Every finding on record at The Premier SNF of Alice

Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property for one (Resident #1) of two residents reviewed for misappropriation of property. The facility failed to obtain valid authorization prior to redirecting Resident #1's funds to the facility. This failure could place residents at risk for misappropriation of personal funds. The findings include:Record review of Resident #1's face sheet dated 08/27/26 reflected an [AGE] year-old-female with an admission date of 06/04/26. Diagnoses included dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities). Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 3 (severe cognitive impairment). Record review of Resident #1's Authorization for Payment or [NAME] Services documentation dated 07/02/26 revealed a signature documented as Resident #1's signature. The section designated for the signature of an individual signing on Resident #1's behalf was not completed. During an interview on 08/26/26 at 1:49 p.m., Resident #1's FM stated Resident #1's funds were previously deposited onto a debit card and were then used to pay the facility. The FM stated he later checked the debit card, found no funds available, and discovered Resident #1's funds had been redirected to the facility. The FM stated he was Resident #1's power of attorney and had not signed any documents or provided consent authorizing the facility to redirect Resident #1's funds. The FM stated he believed the BOM signed Resident #1's name on the document. The FM stated the facility received the payment and the remaining funds were provided to him. During an interview on 08/27/26 at 9:13 a.m., the BOM stated Resident #1's funds were transferred to Resident #1's trust account established upon admission. The BOM stated the FM completed the paperwork on 07/02/26 for a resident trust account so the facility could receive payment directly. The BOM stated the FM signed Resident #1's name on the Authorized for Payment and [NAME] Services form and stated she should have ensured the document was completed correctly, including obtaining the FM's signature in the section designated for an individual signing on the resident's behalf. The BOM denied signing Resident #1's name and stated the documentation should have reflected the FM's signature rather than Resident #1's signature. During an interview on 08/27/26 at 1:39 p.m., the ADM stated the BOM was responsible for ensuring Resident #1's trust account documentation was completed accurately and contained the required signatures. Record review of the facility's Abuse, Neglect, Exploitation or Misappropriation Prevention policy dated April 2021 reflected: Policy StatementResidents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on interview, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (Resident #2) of five residents observed for physical restraints.The facility failed to ensure Resident #2 was free from physical restraints on 08/17/26 when staff physically restrained Resident #2 during episodes of physical aggression to complete care. This failure could place residents at risk for physical and psychosocial harm, and decreased quality of life. The findings include:Record review of Resident #2's face sheet dated 08/27/26 reflected a [AGE] year-old-male with an admission date of 01/20/20. Diagnoses included dementia, (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), traumatic subdural hemorrhage (collection of blood that forms between the brain and its outer covering, often due to head trauma), contractures (shortening of the muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to the right elbow, right wrist, right hand, left hand, left hip, and left knee. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 00 (severe cognitive impairment). The MDS reflected Resident #2 had physical and verbal behavior symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) for 4 to 6 days, but less than daily; Resident #2 would reject care (bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goal for health and well-being for 4 to 6 days, but less than daily; and Resident #2 was dependent (helper does all of the effort. Resident #2 does none of the effort to complete the activity. Or the assistance of 2 or more helpers was required for the resident to complete the activity) for oral hygiene, toileting, shower/bathing, dressing, personal hygiene, sit to lying, lying to sitting on side of bed, chair to bed transfer, and was always incontinent of bowel and bladder. Record review of Resident #2's care plan revised on 01/08/26 reflected:Resident #2 had the potential to demonstrate physical behaviors (hitting, kicking, spitting). Resident #2 was resistive to care and would become combative at times due to psychosis, anxiety, and agitation. Interventions included:Provide physical and verbal cues to alleviate anxiety. Give positive feedback, assist verbalization of source of agitation, assist in setting goals for more pleasant behavior, encourage seeking out staff when agitated.When Resident #2 becomes agitated, intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If the response is aggressive, staff should walk away calmly and approach later. During an interview on 08/26/2026 at 11:05am, LVN A stated on 08/17/26 at around 5:45 p.m. she was walking past Resident #2's room when she heard Resident #2 yelling. LVN A stated she heard CNA B say, Oh you don't like it right?. LVN A stated she entered Resident #2's room and observed CNA B and CNA C changing Resident #2's bed linens after completing care. LVN A stated Resident #2 was physically aggressive and was kicking, punching, and spitting. LVN A stated CNA B turned Resident #2 toward CNA C, and she observed CNA C using her weight to hold Resident #2's arms down. LVN A stated she immediately left the room after asking CNA C what she was doing and reported the incident to the ADM.During an observation of incontinent care on 08/26/26 at 11:49 a.m., Resident # 2 was observed displaying physically and verbally aggressive behaviors including jerking his arms, spitting, and cursing. Staff were noted talking with Resident #2, explaining the steps they were doing, and redirected by talking about things Resident #2 enjoys. During an interview on 08/26/26 at 11:59 a.m., CNA B stated that on the day of the incident, she and CNA C were attempting to change Resident #2's brief and bed linens when Resident #2 became physically aggressive. CNA B stated she held Resident #2's hands down briefly to prevent him from hitting her. CNA B stated Resident #2 was strong and was still able to move his arms. CNA B stated staff were not supposed to restrain residents and stated they should have obtained additional assistance. CNA B stated she typically attempted to calm Resident #2 by talking with him about his interests. CNA B stated she held his arms in an attempt to protect Resident #2 and staff.During a phone interview on 08/26/26 at 3:28 p.m., CNA C stated she was no longer employed by the facility and had been terminated following the alleged incident. CNA C stated she and CNA B were in Resident #2's room attempting to change his brief when Resident 32 became physically aggressive. CNA C stated she held both of Resident #2's arms in a crossed position near his chin while he was turned to prevent him from hitting her. CNA C stated LVN A entered the room while she was holding Resident #2's arms. CNA C she applied some weight and continued holding Resident #2 for approximately four to five minutes so care could be completed. CNA C stated Resident #2 remained able to move his arms because he was very strong. CNA C stated that holding Resident #2's arms and hands was an intervention she routinely used while providing care to Resident #2 since he was so combative. CNA C stated she had received training regarding aggressive residents and dementia care but did not recall receiving hands-on training. CNA C stated she should have stopped, backed away, and obtained additional assistance, however, she stated Resident #2 was soaked in urine and needed to be changed immediately. During an interview on 08/26/26 at 3:45 p.m., the DON stated staff should not have physically restrained Resident #2 by holding down his arms or hands. The DON stated staff had received hands-on dementia secure-care training and were knowledgeable regarding appropriate interventions for residents displaying physically aggressive behaviors. The DON stated staff should have stopped care, allowed Resident #2 to calm down, and attempted verbal redirection. The DON further stated an in-service regarding abuse and neglect were conducted following the alleged incident.Record review of abuse and neglect in-service on 08/26/27.Record review of the facility's Use of Restraints policy revised on April 2017 reflected: Policy StatementRestraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. 7. Emergency use of restraints is permitted if their use is immediately necessary to prevent the resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment, and no other less-restrictive interventions are feasible.c. The emergency use of restraints must not extend beyond the immediate episode.9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor).

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, if the alleged violation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for one (Resident #2) of five residents reviewed for reporting alleged allegation of abuse.The facility failed to ensure an allegation of abuse involving Resident #2 was reported to the appropriate State agency withing the required two-hour timeframe on 08/17/26. This failure could place residents at an increased risk for abuse or further potential for abuse due to unreported allegations of abuse and neglect.The findings included:Record review of Resident #2's face sheet dated 08/27/26 reflected a [AGE] year-old-male with an admission date of 01/20/20. Diagnoses included dementia, (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), traumatic subdural hemorrhage (collection of blood that forms between the brain and its outer covering, often due to head trauma), contractures (shortening of the muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to the right elbow, right wrist, right hand, left hand, left hip, and left knee. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 00 (severe cognitive impairment). The MDS reflected Resident #2 had physical and verbal behavior symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) for 4 to 6 days, but less than daily; Resident #2 would reject care (bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goal for health and well-being for 4 to 6 days, but less than daily; and Resident #2 was dependent (helper does all of the effort. Resident #2 does none of the effort to complete the activity. Or the assistance of 2 or more helpers was required for the resident to complete the activity) for oral hygiene, toileting, shower/bathing, dressing, personal hygiene, sit to lying, lying to sitting on side of bed, chair to bed transfer, and was always incontinent of bowel and bladder.Record review of Resident #2's care plan revised on 01/08/26 reflected:Resident #2 had the potential to demonstrate physical behaviors (hitting, kicking, spitting). Resident #2 was resistive to care and would become combative at times due to psychosis, anxiety, and agitation. Interventions included:Provide physical and verbal cues to alleviate anxiety. Give positive feedback, assist verbalization of source of agitation, assist in setting goals for more pleasant behavior, encourage seeking out staff when agitated.When Resident #2 becomes agitated, intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If the response is aggressive, staff should walk away calmly and approach later. Record review of the facility's provider investigation for Resident #2's allegation of abuse reported by the DON reflected:Time and date of incident: 5:44 p.m. on 08/17/26Time and date reported to State agency: 8:53 p.m. on 08/17/26During an interview on 08/26/2026 at 11:05am, LVN A stated she was walking past Resident #2's room when she heard Resident #2 yelling. LVN A stated she heard CNA B say, oh you don't like it right?. LVN A stated she entered Resident #2's room and observed CNA B and CNA C changing Resident #2's bed linens after completing care. LVN A stated Resident #2 was physically aggressive and was kicking, punching, and spitting. LVN A stated CNA B turned Resident #2 toward CNA C, and she observed CNA C using her weight to hold Resident #2's arms down and punch his shoulder. LVN A stated she immediately left the room after asking CNA C what she was doing and reported the incident.During an observation and interview on 08/26/26 at 11:10 a.m., Resident #2 was lying in bed with the sheet over his head. Resident #2 was unable to answer questions about the incident. During an interview on 08/26/26 at 11:59 a.m., CNA B stated that on the day of the incident, she and CNA C were attempting to change Resident #2's brief and bed linens when Resident #2 became physically aggressive. CNA B stated she held Resident #2's hands down briefly to prevent him from hitting her. CNA B stated Resident #2 was strong and was still able to move his arms. CNA B stated staff were not supposed to restrain residents and stated they should have obtained additional assistance. CNA B stated she typically attempted to calm Resident #2 by talking with him about his interests. CNA B stated she held his arms in an attempt to protect Resident #2 and staff.During a phone interview on 08/26/26 at 3:28 p.m., CNA C stated she was no longer employed by the facility and had been terminated following the alleged incident. CNA C stated she and CNA B were in Resident #2's room attempting to change his brief when Resident 32 became physically aggressive. CNA C stated she held both of Resident #2's arms in a crossed position near his chin while he was turned to prevent him from hitting her. CNA C stated LVN A entered the room while she was holding Resident #2's arms. CNA C she applied some weight and continued holding Resident #2 for approximately four to five minutes so care could be completed. CNA C stated Resident #2 remained able to move his arms because he was very strong. CNA C stated that holding Resident #2's arms and hands was an intervention she routinely used while providing care to Resident #2 since he was so combative. CNA C stated she had received training regarding aggressive residents and dementia care but did not recall receiving hands-on training. CNA C stated she should have stopped, backed away, and obtained additional assistance, however, she stated Resident #2 was soaked in urine and needed to be changed immediately. During an interview on 08/26/26 at 3:45 p.m., the DON stated the facility became aware of the allegation of abuse on 08/17/26 at approximately 6:00 p.m. and the alleged incident occurred at approximately 5:44 p.m. The DON stated she reported the allegation to the State Agency by email at approximately 8:51 p.m. on 08/17/26. The DON stated the allegation was not reported within the required two-hour timeframe because she was conducting staff interviews related to the allegation. The DON stated another staff member could have been delegated to make the report however, this was her first time reporting the allegation and she wanted to ensure she had all the necessary information prior to submitting the report. The DON stated the ADM was not in the facility at the time the allegation was reported. Record review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy dated September 2022 reflected: Policy StatementAll reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.If resident abuse, neglect, exploitation, misappropriation or resident property or injury of unknown sources is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:The state licensing/certification agency responsible for surveying/licensing the facility Immediately is defined as:Within two hours of an allegation involving abuse or result in serious bodily injury

Based on observation, interviews and record review, the facility failed to have evidence all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for one (Resident #2) of five residents reviewed for abuse. The facility failed to have evidence that a thorough investigation including a psychosocial exam and monitoring was conducted for Resident #2 following the allegation of abuse on 08/17/26. This failure could place residents at risk of not having their allegations investigated thoroughly or timely, as well as the potential for abuse to continue.The findings included: Record review of Resident #2's face sheet dated 08/27/26 reflected a [AGE] year-old-male with an admission date of 01/20/20. Diagnoses included dementia, (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), traumatic subdural hemorrhage (collection of blood that forms between the brain and its outer covering, often due to head trauma), contractures (shortening of the muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to the right elbow, right wrist, right hand, left hand, left hip, and left knee. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 00 (severe cognitive impairment). The MDS reflected Resident #2 had physical and verbal behavior symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) for 4 to 6 days, but less than daily; Resident #2 would reject care (bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goal for health and well-being for 4 to 6 days, but less than daily; and Resident #2 was dependent (helper does all of the effort. Resident #2 does none of the effort to complete the activity. Or the assistance of 2 or more helpers was required for the resident to complete the activity) for oral hygiene, toileting, shower/bathing, dressing, personal hygiene, sit to lying, lying to sitting on side of bed, chair to bed transfer, and was always incontinent of bowel and bladder. Record review of Resident #2's care plan revised on 01/08/26 reflected:Resident #2 had the potential to demonstrate physical behaviors (hitting, kicking, spitting). Resident #2 was resistive to care and would become combative at times due to psychosis, anxiety, and agitation. Interventions included:Provide physical and verbal cues to alleviate anxiety. Give positive feedback, assist verbalization of source of agitation, assist in setting goals for more pleasant behavior, encourage seeking out staff when agitated.When Resident #2 becomes agitated, intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If the response is aggressive, staff should walk away calmly and approach later. Record review of Resident #2's skin assessment dated [DATE] revealed no noted injuries or discoloration. Record review of LVN A's written statement not dated reflected:LVN A documented she heard Resident #2 repeatedly say fuck you, fuck you, which he usually did when staff would change him. LVN A documented she got up from the nurse's station to go find a paper she had printed. LVN A documented she was walking down the hall towards the front when she heard CNA C state do you want us to change you or not?. LVN A documented when she was walking back, she heard CNA C stated oh, you don't like it right?. LVN A documented she walked into Resident #2's room to see what staff were doing. LVN A documented she pulled the curtain back and stood by the doorway leaning on the wall. LVN A documented she saw CNA B holding Resident #2's arms and was leaning towards him. LVN A documented she could not see Resident #2's face but she could hear him spitting or trying to. LVN A documented CNA C was at the end of the bed putting on the fitted sheet under the mattress. LVN A documented when CNA C was finished, CNA B stated to CNA C to turn Resident #2 towards CNA C. LVN A documented CNA C pulled Resident #2 towards her by grabbing his left shoulder with her left hand and as she turned Resident #2, CNA C punched Resident #2 on the let shoulder with her right hand and put her right knee on him, putting her wight on him. LVN A documented she immediately said don't hit him and CNA C stated she didn't and LVN A stated she had seen her. LVN A documented she went to the ADM's office but he wasn't there so she called him. LVN A documented she went back towards Resident #2's hall and CNA B and CNA C were in the hallways putting linen in the linen barrels. Record review of CNA B's written statement dated 08/17/26 reflected:Resident #2 was being very combative with staff and he began spitting. CNA B documented that she held Resident #2's hands down while CNA C changed his bed linens and brief. CNA B further documented that she held Resident #2's hands down to prevent him from biting staff and continued to hold him down so CNA C could complete care. Record review of the provider investigation report conducted by the DON beginning on 08/17/26. The incident was a self-reported by the facility. During an interview on 08/26/2026 at 11:05am, LVN A stated on 08/17/26 at approximately 5:45 p.m. she was walking past Resident #2's room when she heard Resident #2 yelling. LVN A stated she heard CNA B say, oh you don't like it right?. LVN A stated she entered Resident #2's room and observed CNA B and CNA C changing Resident #2's bed linens after completing care. LVN A stated Resident #2 was physically aggressive and was kicking, punching, and spitting. LVN A stated CNA B turned Resident #2 toward CNA C, and she observed CNA C using her weight to hold Resident #2's arms down and punch his shoulder. LVN A stated she immediately left the room after asking CNA C what she was doing and reported the incident. During an observation and interview on 08/26/26 at 11:10 a.m., Resident #2 was lying in bed with the sheet over his head. Resident #2 was unable to answer questions about the incident. During an interview on 08/26/26 at 11:59 a.m., CNA B stated that on the day of the incident, she and CNA C were attempting to change Resident #2's brief and bed linens when Resident #2 became physically aggressive. CNA B stated she held Resident #2's hands down briefly to prevent him from hitting her. CNA B stated Resident #2 was strong and was still able to move his arms. CNA B stated staff were not supposed to restrain residents and stated they should have obtained additional assistance. CNA B stated she typically attempted to calm Resident #2 by talking with him about his interests. CNA B stated she held his arms in an attempt to protect Resident #2 and staff. During a phone interview on 08/26/26 at 3:28 p.m., CNA C stated she was no longer employed by the facility and had been terminated following the alleged incident following the alleged incident about two or three days after she was suspended on 08/17/26. CNA C stated she and CNA B were in Resident #2's room attempting to change his brief when Resident 32 became physically aggressive. CNA C stated she held both of Resident #2's arms in a crossed position near his chin while he was turned to prevent him from hitting her. CNA C stated LVN A entered the room while she was holding Resident #2's arms. CNA C stated she applied some weight and continued holding Resident #2 for approximately four to five minutes so care could be completed. CNA C stated Resident #2 remained able to move his arms because he was very strong. CNA C stated that holding Resident #2's arms and hands was an intervention she routinely used while providing care to Resident #2 since he was so combative. CNA C stated she had received training regarding aggressive residents and dementia care but did not recall receiving hands-on training. CNA C stated she should have stopped, backed away, and obtained additional assistance, however, she stated Resident #2 was soaked in urine and needed to be changed immediately. Durning an interview on 08/26/26 at 3:40 p.m., the SW stated she did not follow up with Resident #2 regarding the allegation of abuse due to his poor cognition and inability to recall events. The SW stated she did not believe a follow-up with Resident #2 would have provided additional information. The SW stated Resident #2's behaviors were generally consistent, although at times less severe, and she did not believe a change in behavior would have indicated abuse because his behaviors remained consistent. The SW stated Resident #2 was able to answer yes or no questions but did not believe he had the cognitive ability to understand the difference. The SW stated this was her first experience involving an allegation of abuse with a vulnerable resident and that she was not aware of the incident until she overheard someone discussing it. The SW stated she was not familiar with the requirements of the facility's abuse and neglect policy regarding investigations following an allegation of abuse but stated the DON conducted the investigation. During an interview on 08/26/26 at 3:45 p.m., the DON stated staff should not have physically restrained Resident #2 by holding down his arms or hands. The DON stated staff had received hands-on dementia secure-care training and were knowledgeable regarding appropriate interventions for residents displaying physically aggressive behaviors. The DON stated a psychosocial assessment was not conducted for Resident #2 following the allegation of abuse because there were no observed changes in his behavior or emotional status. The DON stated she did not believe his cognition was sufficient to complete the assessment. The DON stated the charge nurses assessed Resident #2 daily however, the assessments were not documented. The DON stated she completed a skin assessment and asked Resident # if he was okay, to which he responded, yeah. The DON stated she did not ask Resident #2 if he felt safe or was scared. The DON stated that after interviewing staff and reviewing witness statements regarding the use of physical restraints, she did not conduct additional staff interviews to determine whether physical restraints were routinely used on Resident #2 or which staff had used them. The DON stated she did not document the incident in Resident #2's chart. Policy StatementResidents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.2. Develop and implement policies and protocols to prevent and identify:a. abuse or mistreatment of residents;.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.9. Investigate and report any allegations within timeframes required by federal requirements.10. Protect residents from any further harm during investigations.

Based on observations, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 8 residents (Resident #16 and Resident #110) reviewed for pharmacy services in that: The facility failed to notice the narcotic sheet count for Acetaminophen-Codeine (narcotic pain medication) for Resident #110 did not match the remaining number of tablets in the blister pack through 12 administrations of the medication on various dates and times.The facility failed to notice the narcotic sheet count for Acetaminophen-Codeine for Resident #110 did not match the remaining number of tablets in the blister pack when it was set for destruction and locked in the DON's office.The facility failed to document destruction of 1 tablet of Acetaminophen-Codeine properly on 12/03/25.The facility failed to document the time of administration of 1 tablet of Acetaminophen-Codeine to Resident #110 on 01/02/26.The facility failed to administer Resident #16's Ativan (a medication used for anxiety and behavioral outburst) as ordered for the months of March 2026 and April 2026. This failure could place residents at risk for non-therapeutic responses to medications and place residents' medications vulnerable to drug diversion.Findings included: Record review of Resident #110's face sheet dated 04/24/26 revealed an [AGE] year-old female with an admission dated of 11/26/25 and a discharge date of 02/03/26. Pertinent diagnosis included Pain, unspecified. Record review of Resident #110's Discharge MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Record review of Resident #110's comprehensive care plan dated 04/24/26 revealed the focus The resident has a potential for uncontrolled pain. An intervention for the focus included Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Record review of Resident #1's order summary dated 04/24/26 revealed a discontinued order for Acetaminophen-Codeine Oral Tablet 300-30 MG as needed every 6 hours initiated on 12/03/25 and discontinued on 02/03/26. Record review of Resident #110's narcotic sheet for Acetaminophen-Codeine Tablet 300-30 MG revealed 28 tablets were received on 12/03/25 and 16 tablets remained on 01/31/26 after the last administration of the medication. Further review revealed 12 tablets had been administered with 1 tablet administered on each of the following dates and times: 12/5/25 at 8:00 AM 12/10/25 at 4:45 PM 12/11/25 at 1:00 PM 12/17/25 at 2:00 PM 12/18/25 at 6:00 PM 12/24/25 at 8:00 AM 12/25/25 at 10:30 PM 12/26/25 at 10:00 AM 12/28/25 at 8:00 PM 01/02/26 with no time listed 01/27/26 at 6:38 AM 01/31/26 at 11:30 PM During an observation of the lock box containing narcotics set for destruction in the DON's office at 4:09 PM on 04/23/26, the blister pack for Resident #110's order for Acetaminophen-Codeine 300-30 MG contained 14 tablets. Further observation showed 14 bubbles of the blister pack had been opened. In an interview with the DON at 10:41 AM on 04/24/26, the DON stated nurses brought narcotics that were to be destroyed to her and she locked the narcotic sheet along with the blister pack together in a locked drawer in her office. The DON stated there was no way to determine when exactly the narcotic sheet and blister pack for Acetaminophen-Codeine 300/30 MG for Resident #110 was placed in the locked drawer. The DON stated she was supposed to ensure the count matched on the blister pack and narcotic sheet before placing it in the locked drawer. The DON stated she did not specifically remember counting this blister pack and narcotic sheet. The DON stated there were 14 tablets remaining in the blister pack, but the narcotic sheet revealed there should be 16 remaining in the blister pack indicating there were 2 tablets unaccounted for. The DON stated she discovered RN G and LVN H both popped a tablet out of the blister pack but did not sign the narcotic sheet on 12/03/25. The DON stated RN G popped the first one, but accidentally dropped it, so she called LVN H over so they could destroy the tablet together. The DON stated RN G and LVN H did not document on the narcotic sheet that they destroyed 1 tablet together as they were supposed to. The DON stated RN G was called to a meeting by administration leaving LVN H to administer 1 tablet to the resident. The DON stated LVN H then administered 1 tablet to the resident but failed to document it in the narcotic sheet. The DON stated the Acetaminophen-Codeine medication was administered 12 more times to Resident #110 without any nurse reporting the count was off between the narcotic sheet and blister pack. The DON stated it was important to ensure narcotic sheets matched blister packs to ensure all medications were accounted for. The DON stated this medication was a controlled substance and could be abused and impair judgement in people that use them inappropriately. In an interview with RN G at 11:19 AM on 04/24/26, RN G stated on 12/03/25 Resident #110 complained of pain. RN G stated she went to pop 1 tablet of Acetaminophen-Codeine 300-30 MG for Resident #110's pain but accidentally dropped the tablet on the floor. RN G stated she called LVN H over so they could destroy the medication together as per facility policy. RN G stated she dropped the tablet in the drug buster bottle to destroy it. RN G stated she was then called to the DON's office for an unrelated issue. RN G stated she never signed the narcotic sheet for the tablet she popped out of the blister pack and destroyed. RN G stated it was important to keep an accurate log of medications to eliminate medication errors. RN G stated this medication was a controlled substance and could be abused and impair judgement in people that use them inappropriately. In an interview with LVN H at 11:39 AM on 04/24/26, LVN H stated she witnessed the destruction of 1 tablet of Acetaminophen-Codeine 300-30 MG on 12/03/25 with RN G. LVN H stated RN G was then called away to go talk to the DON about something unrelated. LVN H stated she then popped 1 tablet out of the blister pack and administered it to Resident #110 for her pain. LVN H stated she did not sign the narcotic book for either the destruction of 1 tablet or the administration of the other tablet. LVN H stated it was important to keep an accurate log of medications to eliminate medication errors. LVN H stated this medication was a controlled substance and could be abused and impair judgement in people that use them inappropriately. Record review of Resident #16's face sheet, dated 04/22/2026, revealed a [AGE] year-old male with an original admission date of 02/02/2025, and a current admission date of 06/30/2025. Resident #16's pertinent diagnoses included Dementia with other Behavioral Disturbances (a condition which affects memory, thinking, and the ability to perform daily activities, as well as could include symptoms such as agitation, aggression, delusions, and/or hallucinations) and Anxiety (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #16's Quarterly MDS assessment, dated 03/09/2026, revealed Resident #16 had a BIMS of 00, which indicated severely impaired cognition. The MDS also revealed Resident #16 exhibited physical behaviors toward others, verbal behaviors toward others, and other behaviors not directed toward others. Record review of Resident #16's care plan, initiated 02/06/2026, revealed Resident #16 uses anti-anxiety medication. Interventions included give anti-anxiety medications as ordered by the physician. Monitor and document the side effects and effectiveness of the medication. Record review of Resident #16's physician order summary, dated 12/31/2025, revealed apply Ativan 1 MG / 2 ML every 8 hours topically to wrist. Record review of Resident #16's March 2026 and April 2026 MAR revealed Resident #16's Ativan 1 MG / 2 ML was checked as administered every 8 hours up until 04/22/2026 (date of survey). Record review of Resident #16's Ativan Controlled Count Sheets revealed only one syringe, to equal 0.5 MG / 1 ML, was administered every 8 hours beginning 03/07/2026 – 04/22/2026. In an observation on 04/22/2026 at 3:20 PM of the 400 Hall Nurse med-cart, there were two zip-lock bags full of 1 ML syringes prefilled with 0.5 MG of topical Ativan in each syringe. The two bags combined contained 17 prefilled syringes for Resident #16. In an interview on 04/22/2026 at 3:25 PM, LVN-A initially stated Resident #16 was only supposed to have gotten one, 1 ML syringe of topical Ativan every 8 hours, but after reviewing the order and looking at the syringes, he stated the syringes were only 0.5 MG per 1 ML syringe, so Resident #16 needed two syringes each time to equal the correct dosage. He stated he, as well as other nurses, had been giving the medication incorrectly, and Resident #16 was only getting half of the ordered dosage each time. He stated the medication was being utilized for Resident #16's anxiety and behaviors. He stated his behaviors were being controlled for the most part by the partial dosage, and he had not seen Resident #16 have any increase in behaviors or anxiety. In an interview on 04/22/2026 at 3:30 PM, after reviewing the order and looking at the syringes and the controlled count sheets, the DON stated Resident #16 was supposed to be getting 1 MG / 2 ML of topical Ativan, but he had only been getting 0.5 MG / 1 ML of topical Ativan every 8 hours. She stated Resident #16's Ativan was prescribed for anxiety and behaviors. She also stated although his anxiety or behaviors had not changed or increased in severity, they could have since he was not getting the appropriate prescribed dose of the medication. Attempted to interview Resident #16 on 04/22/2026 at 3:40 PM. Resident #16 was unable to answer questions. Record review of the facility's Medication Administration Policy, no date identified, revealed Policy: Medications are administered as prescribed. 16. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. if there is any reason to question the dosage or direction, the physician's orders are checked for the correct dosage schedule. Checklist for completing proper steps in the administration of medication: Adheres to the 6 Rights of Medication Administration: 1) Right Dose, 2) Right Route, 3) Right Resident, 4) Right Medication, 5) Right Time, 6) Right Documentation. Record review of the facility policy Controlled Medications – Administration last revised 04/06/26 revealed the following policy: .6. When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: Date and time of the administration Amount administered Signature of the nurse administering the dose, completed after the medication is actually administered. 7. When a dose of controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. If allowed by your state, they may be destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record on the line representing that dose. 8. At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or nurse and a CMA, QMAP, Med Tech or equivalent as allowed by your State regulatory agency and is documented on an audit record. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: The facility failed to ensure the juicer's dispenser nozzle was clean. This failure could place residents at risk of foodborne illnesses. Findings included: During an observation of the kitchen on 04/22/26 at 10:25 a.m., the juicer's dispenser nozzle had a reddish slimy film in the middle of the nozzle and a hardened yellowish crust that had formed around the nozzle. During an interview on 04/22/26 at 10:27 a.m., [NAME] F said the juicer including the nozzle were cleaned every day. She said the juicer had been used earlier in the day, and that was probably why it was dirty. She tried to remove the yellowish crust but was not able. She could not say how not cleaning the juicer nozzle could negatively affect residents. During an interview on 04/24/26 at 9:35 a.m., DA E said it was the responsibility of all kitchen staff to ensure the kitchen was clean. She said at the end of each shift all kitchen staff were responsible for cleaning their assigned area. She said dietary aides were responsible for cleaning the juicer, which included the nozzle on a daily basis. DA E said she cleaned the juicer on a daily basis but had failed to leave the nozzle soaking in water as she was supposed to. She was not able to say how not cleaning the juicer nozzle could negatively affect residents. Record review of the facility's kitchen Daily Cleaning Scheduled for week ending 04/18/26 and 04/25/26 reflected DA E had cleaned juicer for the past two weeks. During an interview on 04/24/26 at 9:45 a.m., the DM said part of her responsibilities was to ensure the kitchen was clean. She said she had a cleaning log that included all kitchen appliances which included the juice machine. She said all kitchen staff were assigned to clean the appliances on a daily basis. The DM said the juicer nozzle was to be left soaking in water overnight on a daily basis. She said, I'm going to be honest with you, I had not been checking the juicer nozzle to make sure it was clean, I might have overlooked it. She said the negative outcome of not having a clean juicer/nozzle could be foodborne illnesses. Record review of facility's undated Cleaning Schedules policy reflected: The dietary department and all equipment in the dietary department will be cleaned on a regular scheduled basis. Procedure: 3. It is the responsibility of all employees to follow the cleaning schedule, and to initial their assignments when completed. 5. Cleaning schedules are to be individualized to the facility, and it is the responsibility of the DSM to ensure that the assigned tasks are completed when assigned, and in a thorough manner.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #83) residents reviewed for respiratory care. The facility failed to ensure Resident #83's oxygen was administered on 04/23/26 as ordered by the physician. This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #83's admission record, dated 04/23/26, reflected a [AGE] year-old female with an admission date of 02/07/25. Her relevant diagnoses included Alzheimer's disease (a progressive, irreversible neurodegenerative disorder), shortness of breath (the uncomfortable feeling of not getting enough air), and anxiety (mental health condition characterized by excessive, persistent worry and fear that interferes with daily life). Record review of Resident #83's annual MDS assessment, dated 02/20/26, reflected her BIMS score was left blank, which reflected her cognition was severely impaired. Record review of Resident #83's quarterly care plan, dated 04/22/26, reflected [Resident #83] has oxygen therapy, ineffective gas exchange. Date initiated 04/06/26. Interventions included: oxygen at 2 LPM per nasal cannula. Date initiated 04/06/26. Record review of Resident #83's physician summary order, dated 04/23/26, reflected Resident #83 had an order for oxygen LPM: 2 LPM via: nasal cannula, every shift related to shortness of breath with start date of 02/24/26. During an observation on 04/23/26 at 8:06 a.m., Resident #83 was observed lying in bed awake. She had a nasal cannula on, and the concentrator was set at 2.5 lpm. During an interview and observation on 04/23/26 at 8:14 a.m., LVN B was observed as she checked Resident #83's oxygen setting on the concentrator and said it was set at 2.5 lpm. LVN B was observed as she reviewed Resident #83's electronic medical record and said Resident #83 had an O2 order for 2 lpm continuously via nasal cannula. LVN B said her shift had started at 6:00 a.m. but had not checked on Resident #83 yet. LVN B was observed as she checked Resident #83's oxygen using a pulse oximeter and registered at 99%. LVN B said there were no negative outcomes to Resident #83 having her O2 setting at 2.5 instead of 2 lpm as ordered. During an interview on 04/23/26 at 8:14 a.m., the DON said it was the nursing staff's responsibility to ensure a resident's O2 settings were set according to their order. She said nursing staff were supposed to check a resident's O2 settings each time they went into a resident's room. She said Resident #83 had an order for continuous O2 via nasal cannula at 2 lpm. The DON said a negative outcome to Resident #83 not having her O2 set as ordered could be too much oxygen. The DON said nursing staff were regularly in-serviced on oxygen administration. Record review of the facility's Oxygen Administration policy undated, reflected: Oxygen therapy includes the administration of oxygen (O2) in liters/minute (1/min) by cannula or face mask to treat hypoxemic (condition characterized by abnormally low levels of oxygen in the arterial blood) conditions caused by pulmonary or cardiac disease. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. The nasal cannula delivers 22-40 % oxygen and is the most common, inexpensive, and easiest device to use. Common oxygen sources for long-term administration include a cylinder (portable or stationary) or wall system near the resident's bed or concentrator. Goals: 1.The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles 1 of 6 medication carts (Med Aide Cart 1) reviewed for storage. The facility failed to keep Med Aide Cart 1 locked when MA I stepped into room [ROOM NUMBER] to measure a resident's blood pressure during med pass at 7:51 AM on 04/23/26. The failure could place residents in the facility at risk of drug diversion or misuse of medications leading to harm.Findings included:During an observation at 7:51 AM on 04/23/26, Med Aide Cart 1 was unlocked in front of room [ROOM NUMBER]. MA I was inside room [ROOM NUMBER] measuring a resident's blood pressure for approximately 2 minutes, when she came back out of the room at 7:53 AM and noticed she left the medication cart unlocked. During an interview with MA I at 8:45 AM on 04/23/26, MA I stated she was supposed to keep the cart locked whenever she entered a resident's room to check their blood pressure or administer medications. MA I stated if a cart was left unlocked and unsupervised another resident or visitor could have opened the cart and taken medication. During an interview with the DON at 10:41 AM on 04/24/26, the DON stated med aides and nurses should lock their carts before entering a resident's room to check blood pressure or administer medications. The DON stated it was important to keep the cart locked when not supervised to prevent any unauthorized individual from accessing the medication in the cart. Record review of the undated facility policy titled Medication Storage in the Facility revealed the following: .2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on interview, and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 1 (Resident #101) of 3 residents. The facility failed to ensure Resident #101's facility death on [DATE], was accurately documented on his electronic medical record. This failure could place residents at risk of errors by staff when reading information in the clinical record that was inaccurate or incomplete.Findings included: Record review of Resident #101's admission record, dated [DATE], reflected an [AGE] year-old male with an admission date of [DATE] and a discharge date of [DATE]. His relevant diagnoses included chronic obstructive pulmonary disease (a progressive, irreversible lung disease causing restricted airflow and severe breathing difficulties), dementia (progressive decline in mental ability-including memory loss, confusion, and behavioral changes), and seizures (sudden, temporary busts of abnormal electrical activity in the brain). Record review of Resident #101's admission MDS assessment, dated [DATE] reflected a BIMS score of 06, which indicated his cognition was severely impaired. Record review of Resident #101's death in facility MDS assessment dated [DATE], reflected Discharge Status, deceased . Record review of Resident #101's comprehensive care plan dated [DATE], reflected [Resident #101] has an order for Do Not Resuscitate (DNR). Date initiated [DATE]. Interventions included in the absence of b/p, pulse, respirations, and CPR will not be initiated. Date initiated [DATE]. Record review of Resident #101's progress notes reflected the last entry was done on [DATE]. There was no documentation indicating Resident #101's expiration and the action taken on [DATE]. Record review of Resident #101's Death Notice dated [DATE] indicated his remains were released to a local mortuary at 10:29 p.m. signed by Hospice Nurse. During an interview on [DATE] at 9:56 a.m., LVN D said the facility's protocol was when a resident expired in the facility the nursing staff were responsible to thoroughly document how the resident was found, who found them, the presence or absence of vital signs, the resident's code status, all assessments, and actions taken, who was notified, the time of death, and to whom the body was released. LVN D could not say what the negative outcome of not documenting a resident's death on their electronic medical record was but did say, we have to document it. During an interview on [DATE] at 3:22 p.m., the DON said Resident #101 was a hospice resident and had a code status of DNR. The DON said whenever a resident expired in the facility, it was the nursing staff responsibility to document who had found the resident, how they were found, their vital signs if present or not, their code status, all assessment and actions taken, who was notified, their time of death, and to whom the body was released. The DON said nursing staff were regularly in-serviced on the topic of documentation. The DON said the negative outcome of not thoroughly documenting a resident's death in the facility would be that there would be no record of what happened. Record review of the facility's undated Pronouncement of Death policy reflected, Procedure for RN: 3. The nurse will notify the attending physician.Document the date, time, and the physician's statement at notification. Record review of the facility's undated Documentation policy reflected: Documentation is the recording of all information, both objective and subjective in the clinical record of an individual resident and or soft resident file. It may include observations, investigations, and communications of the resident involving care and treatment. It has legal requirements regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes. Goal: 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed. Procedure: 3. Document identifying and statistical information on the proper form or utilizing electronic medical record. 4. Document completed assessments in a timely manner. 5. Complete documentation as needed in a timely manner

Based on observation, interview, and record review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one (Resident #1) of four residents reviewed for skin integrity.The facility failed to ensure on 11/27/2025, NA A failed to follow the facility's procedure when she observed Resident #1's left forearm with 3 brown and yellow skin irregularities. This failure could potentially negatively compromise a resident's well-being by prolonging warranted skin assessments and monitoring. The findings included: Record review of Resident #1's admission's record dated 11/28/2025 revealed Resident #1 was an [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Resident #1 was admitted with multiple diagnoses including severe protein calorie malnutrition, dementia (cognitive impairment), and surgical aftercare following surgery on the digestive system. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1's BIMS score of 99- indicated Resident #1 was unable to complete the interview and needed substantial/maximal assistance with ADLs. Resident #1 was not coded for any skin impairment conditions. Record review of Resident #1's care plan revision date on 07/18/2025 revealed The resident has the potential for pressure ulcer development. The resident will have intact skin, free of redness, blisters or discoloration through review date. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Incontinent care after each episode and apply moisture barrier. Inform the resident/family/caregivers of any new area of skin breakdown. Notify nurse immediately of any new areas of skin breakdown: Open area, Redness, Blisters, Bruises, discoloration noted during bath or daily care. Record review of Resident #1's weekly Skin Assessments dated 11/10/2025, 11/18/2025 and 11/25/2025 there were no skin irregularities noted. Record reviewed Resident #1's progress notes date ranges from 10/29/2025-11/29/2025 revealed no documentation of NA A's 11/27/2025 observation. During an interview and observation on 11/28/2025 at 1:47 p.m., observed Resident #1's left forearm and found 5 skin irregularities on Resident #1 left forearm. The first 4 skin irregularities were clustered together on the top part of Resident #1's left forearm, and each contained red discoloration and were roughly less than a penny in size. The 5th skin irregularity appeared to be a discoloration which was also located on top of Resident #1's left forearm but closer to Resident #1's wrist. The 5th discoloration appeared circular with dark purple discoloration and appeared to be somewhat fresh looking. Resident #1 stated she did not know where the bruises came from, but that no person had ever hit/hurt or scared her. Resident #1 stated the skin irregularities did not hurt. Resident #1 did not appear to be in any distress nor was any indication of malicious intent. During an interview on 11/28/2025 at 1:54 p.m., NA A stated she had observed roughly 3 skin irregularities on Resident #1's left forearm on 11/27/2025 prior to lunch, while she was assisting Resident #1 to dress. NA A stated while she inspected the skin she inquired if Resident #1 knew the origin of the discoloration of skin irregularities, to which Resident #1 could not recall. NA A stated the 3 discolorations were brown and yellow but could not determine circumference nor diameter of the irregularities, however stated they did not look suspicious. NA A stated she did not notify the charge nurse, treatment nurse, ADONs, nor DON as the skin irregularities were not suspicious and did not think it was that serious. NA A stated Resident #1 never presented fearfull of staff nor residents. When NA A was asked if she should have notified the charge nurse when she saw the skin irregularities, NA A reiterated the skin irregularities did not look suspicious and therefore did not think it was serious and did not warrant any notification to the charge nurse. NA A did not verbalize how her inaction to notify her chain of command could have affected Resident #1's well-being. NA A stated she had attended the facility's change in condition in-service as part of her orientation and recalled being educated that she is expected to notify her chain of command when she observes anything abnormal, however NA A reiterated the skin irregularities were not suspicious, Resident #1 never presented fearfully or scared of any person. During an interview on 11/29/2025 at 3:06 p.m., the DON stated she was notified of Resident #1's skin irregularities on 11/28/2025 and immediately directed the treatment nurse to perform a thorough head to toe assessment on Resident #1 and concluded the left arm skin irregularities stemmed from Resident #1's wheelchair arm placement when Resident #1 was attempting to pass through a doorway. The DON stated once NA A observed Resident #1's skin irregularities, she should have immediately notified her charge nurse so that the charge nurse could accurately assess, document, and investigate the origin of the skin irregularities. The DON stated Resident #1's well-being was not compromised, and reiterated NA A should have notified the charge nurse once she saw something abnormal to Resident #1 in congruence with the facility's procedures. The DON stated she had reeducated NA A that her scope of practice does not entail conducting an assessment or determination, and furthermore NA A's scope of practice is to notify immediately when she observes something abnormal. The DON stated she conducted an impromptu one-to-one in-service with NA A and re-educated her that if she was to notice anything abnormal on any resident, she is to immediately notify her chain of command, which includes the charge nurse, ADON, or DON. The DON stated NA A will also be tasked with several on-line training modules that will re-educate NA A on the different types of skin irregularities. Record review of the CNA proficiency competency audit dated 08/22/2025 revealed CNA A was educated to report all changes in condition promptly. Record review of the facility's C.N.A. Proficiency Audit procedure undated revealed C.N.As are to report changes in condition promptly.

Based on record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for one resident (Resident #1) of three residents reviewed for skin assessments. The facility failed to ensure on 11/17/2025 around 9:00 p.m., LVN A failed to accurately document the description of three discolored dots on Resident #1's left forearm as well as light brown/purple bruise on the top of Resident #1's right forearm. This failure could place residents at risk of having incomplete and accurate records and not receiving appropriate treatment and services. The findings included: Record review of Resident #1's admission's record dated 11/28/2025 revealed Resident #1 was an [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Resident #1 was admitted with multiple diagnoses including severe protein calorie malnutrition, dementia (cognitive impairment), and surgical aftercare following surgery on the digestive system. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1's BIMS score of 99- indicating Resident #1 was unable to complete the interview and needed substantial/maximal assistance with ADLs. Resident #1 was not coded for any skin impairment conditions. Record review of Resident #1's care plan revision date on 07/18/2025 revealed The resident has the potential for pressure ulcer development. The resident will have intact skin, free of redness, blisters or discoloration through review date. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Incontinent care after each episode and apply moisture barrier. Inform the resident/family/caregivers of any new area of skin breakdown. Notify nurse immediately of any new areas of skin breakdown: Open area, Redness, Blisters, Bruises, discoloration noted during bath or daily care. Record reviewed of Resident #1's weekly Skin Assessments dated 11/10/2025, 11/18/2025 and 11/25/2025 revealed, there was no skin irregularities noted. Record reviewed Resident #1's progress notes date ranges from 10/29/2025-11/29/2025 revealed no documentation of LVN A's 11/17/2025 observation. During an interview on 11/28/2025 at 2:44 p.m., CNA A stated while she was working on 11/17/2025 she entered Resident #1's room with LVN A and assisted LVN A with redirecting Resident #1 as LVN A was attempting to provide enteral nutrition. CNA A stated while she was redirecting Resident #1, she noticed Resident #1's right forearm had a yellowish-brown bruise-like discoloration roughly 3inches in length and roughly 1inch in width. CNA A stated simultaneously LVN A saw the discoloration as well and commenced an assessment on Resident #1's skin irregularity. CNA A stated she did not notify any other nurse as LVN A was the charge nurse on 11/17/2025 and had fulfilled her scope of practice. During an interview on 11/28/2025 at 3:22 p.m., LVN A stated while she was working on 11/17/2025 she entered Resident #1's room with CNA A to perform enteral nutrition. LVN A stated while she was with Resident #1, she noticed Resident #1 had light brownish/light purple bruise-like discoloration on Resident #1's right forearm that was no more than the size of a quarter. LVN A stated she additionally observed two unmeasurable little dots on Resident #1 left forearm. LVN A stated she followed the facility's protocol and notified the DON of the skin irregularities but missed the documentation aspect of the protocol. LVN A stated she should have documented her observable findings to ensure accurate monitoring of the observed skin irregularities. LVN A stated she should have documented the findings to monitor if the skin irregularities progressed to ensure the well-being was not compromised, but reiterated the skin irregularities had resolved, but going forward she will be more intentional and document accurately and in a timely manner. During an interview on 11/29/2025 at 3:06 p.m., the DON stated once LVN A recognized the skin irregularities on Resident #1 on 11/17/2025 she should have documented the observed findings as part of the facility's protocol. The DON stated the reason she should have documented the skin assessment on 11/17/2025 was to ensure accurate monitoring of the skin irregularities to prevent any further progression of any compromising skin integrity issue. The DON stated Resident #1's well-being was not compromised as the skin irregularities had resolved with no evidence of any malice intent. The DON stated the discoloration could have stemmed from when Resident #1 attempts to pass through doorways with her wheelchair. The DON stated going forward, the facility has planned to conduct an as needed in-service regarding documenting skin assessment. Record review of the facility's Skin Assessment undated revealed 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission.The assessment may also be performed after a change in condition or after any newly identified pressure injury. h. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. 7. Documentation of skin assessment: b. Document observations (e.g. skin conditions.).

Based on record reviews and interviews the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 1 of 5 CNAs (CNA A) reviewed for CNA certification. The facility failed to ensure CNA A's certification was current before allowing him to care for residents. CNA A worked in the facility providing resident care, on a full-time basis, with an expired certification during the period from [DATE] to [DATE]. This failure could place residents who received care from CNA A at a risk of decreased physical, mental, and psychosocial well-being.Findings included:Record review of CNA A's certification on [DATE] revealed the certification expired on [DATE]. In an interview with the DON at 12:16 PM on [DATE], the DON stated she was not aware CNA A's certification had expired. The DON stated each employee was responsible to ensure their license or certification was current. The DON stated HRC was responsible for reviewing the licenses and certifications of staff periodically and ensuring they were current. The DON stated an active certification showed the employee was capable and deemed fit to practice as a CNA. The DON stated a staff member without the proper certification or license may accidentally harm a resident. The DON stated CNA A was one of the best CNAs at the facility and he constantly got compliments from residents and their families. In an interview with the HRC at 12:30 PM on [DATE], the HRC stated she had been in her current role since [DATE]. The HRC stated it was her responsibility to track licensures and certifications of the staff. The HRC stated she ran audits of the employees periodically to ensure they were current. The HRC stated the last time she ran an audit was around [DATE]. The HRC stated she missed CNA A's certification had expired when she reviewed the audit. The HRC stated it was important to ensure all necessary staff were licensed or certified to keep the residents as safe as possible. In an interview with CNA A at 12:35 PM on [DATE], CNA A stated he had worked at the facility for approximately five years. CNA A stated he was not aware his certification had expired. CNA A stated when he first acquired his certification in 1988, the instructors told him as long he kept working then his certification would be automatically renewed. CNA A stated he thought the facility would maintain his certification. CNA A stated it was important for a CNA to be certified so they could provide the best possible care to a resident. Record review of page 26 of the Employee Handbook revealed the following paragraph: All professionally registered, licensed and certified staff is [sic] required to maintain current licensure, registration and/or certification. A copy of the current documentation must be submitted to your department head for inclusion in your personnel file. Failure to provide the documentation or failure to maintain status may result in suspension and/or termination. The cost for renewal is the responsibility of the employee. Record review of the signature page of the Employee Handbook revealed the form was signed and dated by CNA A on [DATE].

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for sanitation. The facility failed to properly label and date open, shelf stable food. The facility failed to dispose of expired shelf stable and refrigerated food. The facility failed to ensure items were stored properly in a refrigerator instead of on a pantry shelf. The facility failed to ensure the large containers of cooking oil were free from cracks or holes and not leaking on the floor. The facility failed to maintain and assure all chemicals in the kitchen area were labeled appropriately. These failures could place residents at risk of foodborne illnesses, as well as place residents and staff at risk for falls and injuries. Findings were: Observations and initial tour of the kitchen on [DATE] at 8:10 AM revealed a half-used jug of lemon juice labeled as refrigerate after opening was being kept on a pantry shelf; a large container of cooking oil on a bottom shelf in pantry that had leaked all over the floor and under shelving; an opened meat product, thawing in bloody water, past the hand written expiration date; three Ziploc bags of dry goods that were all past the hand written expiration date. Observation on [DATE] at 8:25 AM of the supply closet in the kitchen that houses the cleaners and chemicals revealed a large spray bottle with a light-yellow liquid or chemical inside it. Liquid or chemical had a very strong odor, and there was no label or writing on the bottle. In an interview on [DATE] at 8:25 AM with the Dietary Manager, he stated the unlabeled bottle had Clorox cleaner in it, and it should have been labeled or discarded. In an interview on [DATE] at 8:29 AM, housekeeping stated that labels should be put on the bottles by whoever pours the chemical into the bottle. She stated that it was not safe to have unlabeled chemicals sitting around because staff could use them without knowing what they were using, or a resident could get ahold of it and really hurt themselves if they drank it or got it on their skin. She also stated that it was not safe to leave spills, whether oil or something else, on the floor as someone could slip in it and hurt themselves. She stated it should be cleaned up as soon as the spill or mess was noticed. In an interview with the Dietary Manager on [DATE] at 08:55 AM, he stated serving expired food could cause residents to become ill, and If items were not being refrigerated like they should, this could also cause residents to become ill. He also stated that the oil had been leaking, and needed to be transferred to a different container and cleaned off the floor so an accident did not occur. He also stated that the person who transferred the chemical should have added the labels to the bottle, and if a chemical was not labeled appropriately, it could be hazardous if used for something else or if a resident got ahold of the chemical, it could cause harm to them. He stated that he was ultimately responsible for things being labeled or disposed of appropriately in the kitchen. In an interview with the Dietary Aide on [DATE] at 09:10 AM, she stated if food was used past the expiration date it could cause the residents to get sick. She also stated if things were not stored properly, they could go bad, and the residents could get sick from this as well. She also stated the person who opened and poured chemicals into a bottle was the person who would label the chemicals. She stated the staff or manager needed to dispose of the chemicals since there was no label or you could get it confused with other things. She also stated that a resident could have drunk the chemical or gotten it on their skin not knowing what it was, and it could have harmed them, and in regard to the oil all over the floor, whoever saw or noticed the oil spilled in the floor should have attended to it and cleaned it up, but that the Dietary Manager was ultimately responsible for everything in the kitchen. In an interview with the Administrator on [DATE] at 9:29 AM, he stated that the person who transferred the chemicals should have labeled it, but the Dietary Manager was ultimately responsible for everything in the kitchen, including labeling and discarding chemicals. He also stated that they do not have a policy regarding labeling chemicals or keeping chemicals labeled. He stated he was told that they teach and preach to label chemicals, but they do not have a specific policy for it. He also stated the Dietary Manager was ultimately responsible for getting rid of any expired food, and that serving expired food to the residents could cause them to become sick. He also stated that storing food improperly could cause it to go bad and could cause sickness as well if served; The Administrator also stated that the Dietary Manager was responsible for cleaning the oil off the kitchen floor, and if not cleaned up, someone could slip and fall. In an interview with the DON on [DATE] at 09:18 AM, she stated that serving expired food to the residents could cause them to get sick, and it was all kitchen staff's job to discard of expired food, but it was ultimately the Dietary Manager's responsibility to check to see if anything was expired. She also stated if food items or products were being stored improperly and served to the residents, this could also have caused them to get sick. The Dietary manager would be ultimately responsible for making sure if something was not labeled, it was discarded. The DON stated that the person who transferred the chemicals into the bottle should have labeled the bottle. If they did not label the bottle a resident could get injured or have poisoning if they had ingested the chemical. She stated the dietary manager was ultimately responsible for making sure something was labeled or was discarded, as well as should keep the oil contained, and the floor cleaned up because someone could slip and fall and become injured. Record review of the Food Storage and Supplies policy from the Dietary Services Policy and Procedure Manual 2012 revealed all facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas were clean and organized. If perishable food items were not stored at the proper temperature, spoilage bacteria could grow faster than anticipated and food becomes spoiled and should not be served. Record review of an email dated [DATE] at 10:38 AM from the Director of Environmental Services revealed they teach and preach to label chemicals, but there was no policy.

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a residents medical, nursing, mental, and psychosocial needs, for 2 (Resident #5 and Resident #44) of 12 Residents reviewed for care plans in that: 1. The facility failed to implement a comprehensive person-centered care plan for Resident #5 to maintain the call light within reach of Resident #5. 2. The facility failed to ensure Resident #44's foley catheter ordered on 11/27/24 was care planned. This deficient practice could place residents at an increased risk of decline, and diminished quality of life. The findings included: 1. Record review of Resident #5's face sheet dated 02/03/25 revealed a [AGE] year-old male with an admitted [DATE]. Pertinent diagnoses included unspecified dementia, traumatic subdural hemorrhage (bleeding between the brain and the skull), and unspecified psychosis. Record review of Resident #5's comprehensive MDS dated [DATE] section C, cognitive function, stated Resident #5's BIMS score was 99, which indicated the resident was unable to complete the interview. Section GG, functional abilities, scored Resident #5 as a 1 (Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for eating, oral hygeine, toileting hygeine, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygeine. Record review of Resident #5's care plan revealed the focus [Resident #5] has impaired communication due to impaired cognition and unclear speech initiated on 03/01/21 and revised on 05/12/21. One Intervention listed associated with the focus included: Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation initiated on 03/01/21. During an observation inside Resident #5's room and interview on 02/03/25 at 9:36 AM, Resident #5's call light was hung up on the wall, out of reach of Resident #5. Resident #5 was not interviewable. During an observation inside Resident #5's room on 02/03/25 at 1:20 PM, Resident #5's call light was hung up on the wall, in the same position it was in during the previous observation. In an interview with CNA A on 02/03/25 at 1:24 PM, CNA A stated a resident's call light should be within arms reach or clipped onto the bed. CNA A stated the staff went in Resident #5's room frequently. CNA A stated Resident #5 was not able to get up and walk around. CNA A stated Resident #5 can only move around in bed a little bit. This state surveyor and CNA A walked into Resident #5's room and CNA A stated Resident #5's call light was currently on the wall. CNA A stated Resident #5 will swing his call light around sometimes. CNA A stated they will sometimes put it out if reach for a few minutes and redirect him from swinging it around, before putting his call light back within reach. CNA A stated it was important for residents to be able to reach their call light in case they needed assistance going to the bathroom or if they needed anything. In an interview with LVN B on 02/03/25 at 1:31 PM, LVN B stated residents should have their call light within arm ' s reach. LVN B stated she was in Resident #5's room approximately 30 minutes ago and his call light was draped over the back of his bed at that time. LVN B stated Resident #5 had a family member with him in his room at that time. LVN B stated Resident #5's call light was within reach as well during her morning rounds around 6:30 AM. LVN B stated she had not seen Resident #5 swing his call light around before but had heard about it from other CNAs and nurses. This state surveyor and LVN B walked into Resident #5's room and LVN B stated Resident #5's call light was not currently within reach. LVN B stated it was important for residents to be able to reach their call lights in case they needed anything from staff. In an interview with the DON on 02/03/25 at 4:45 PM, the DON stated the call light should always be within reach of the resident unless otherwise stated. The DON stated she was not aware of any residents in the facility that should not have their call light within reach. The DON stated the only signaling system residents used in the facility were call lights. The DON stated she had never heard of Resident #5 swinging his call light around. The DON stated she had not heard of any issues with Resident #5 regarding his call light. The DON stated it was important for residents to have their call lights within reach so they could voice their needs if they had any. 2. Record review of Resident #44's face sheet date 2/4/25 reflected an [AGE] year-old-female with an original admitted [DATE] and a re-admitted [DATE]. Diagnosis included chronic obstructions pulmonary disease (characterized by persistent respiratory symptoms like progressive cough and breathlessness) and type two diabetes (insufficient insulin production in the human body). Record review of Resident #44's orders dated 11/27/24 reflected: Urinary Foley Catheter 20F/10cc to gravity drainage every shift related to obstructive and reflux uropathy (blockage in your urinary tract). Record review of Resident #44's care plan initially dated 8/23/24 did not reflect foley care. Record review of Resident #44's Admission/Medicare MDS dated [DATE] reflected a BIMS of 14 (cognition intact) and indicated the resident had an indwelling catheter. In an interview on 02/04/25 at 02:47 PM LVN C stated she was unable to locate Resident #44's foley catheter care plan. LVN C stated Resident #44's foley catheter should have been care planned to ensure foley catheter care was being done and so direct care staff could monitor for infection. LVN C stated Resident #44's foley catheter instructions were on the medication administration record and treatment administration record. In an interview on 02/04/25 at 02:52 PM the MDS Coordinator stated Resident #44's foley care was not on the care plan. The MDS Coordinator stated it should have been care planned since it was part of Resident #44's plan of care. The MDS Coordinator stated she was not sure why foley care was not care planned. The MDS Coordinator stated it was a team effort to make sure the care plans are not overlooked and accurate. In an interview on 02/04/25 03:16 PM the DON stated Resident #44's foley should be care planned to ensure the proper plan of care was in place for Resident #44 and so staff were aware of the foley being in place. The DON stated it was a team effort to ensure the care plans are up to date and Resident #44's foley care plan was over looked. Record review of the facility's Comprehensive Care Planning policy not dated stated: The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the 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 comprehensive assessment. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. 50039

Based on observation, interview, and record review, the facility failed to review and revise the care plans for 1 of 5 residents (Resident #232) whose care plans were reviewed, in that: The facility failed to ensure Resident #232's care plan was revised to accurately reflect current urinary or foley catheter status. These failures could place residents at risk of receiving inadequate individualized care and services. Findings included: Record review of Resident #232's face sheet revealed an [AGE] year-old male with an admitted [DATE]. Record review of Resident #232's Comprehensive MDS dated [DATE] revealed Resident #232 was unable to respond or answer questions, or rarely or never understood, so the brief interview for mental status was not performed. MDS also reflected Resident #232 was dependent with toileting hygiene, oral hygiene, showering/bathing and dressing. Record review of Resident #232's care plan revealed resident was care planned for an indwelling catheter on 1/14/25, and it was revised on 2/4/25 to still show indwelling catheter with 7 different interventions to meet urinary and catheter goals. Record review of Resident #232's physician orders revealed Foley catheter and Foley catheter care discontinued on 1/16/25. Record review of Resident #232's progress notes dated 1/13/25 revealed Resident was admitted from the hospital with the foley catheter. No other progress notes make a reference to having or removing a foley catheter. In an observation on 2/3/25 at 4:40 PM, Resident #232 was observed lying in bed with feeding tube attached and family at bedside. He would not wake to answer questions. No Foley catheter was observed. In an interview on 2/3/25 at 4:40 PM, Resident #232's daughter stated that her dad did have a foley catheter, but they removed it not long after he was admitted to the facility. In an interview on 2/4/25 at 12:12 PM with the Regional Nurse Consultant, she stated that care plans were updated typically by either the DON, ADON or MDS nurse. In an interview on 2/4/25 at 5:05 PM the DON stated that per the physician's orders, the foley catheter was discontinued on 1/16/25, and catheter and urinary status should have been removed from the care plan, especially since it was revised by someone today. In an interview on 2/5/25 at 9:29 AM with the Administrator, he stated that the DON normally initiates the care plans, then they were reviewed, revised, or updated by anyone on the Interdisciplinary Team. He stated that if care plans were not implemented or revised correctly, resident could end up getting improper care. Record Review of the Care Plan Policy, undated, revealed each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. The resident's care plan will be reviewed after each admission, quarterly, annual and/or significant change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person centered care plan that included services to be furnished to attain or maintain the resident highest practicable well being for one resident (R#1) of 4 residents reviewed for skin care. A focus item of wound care treatment for Resident #1 was not listed on the care plan for over a month (from June to July). This failure could place Resident #1 at risk for lack of appropriate interventions and goals for the resident to meet their highest practicable level of care. This failure could lead to infection, progression of the growth, missing Dermatology and other specialty appointments and observations, and the excision of the growth. Findings were: Observation of Resident #1's wound care treatment with LVN #1 on 7/19/2024 at 1:46 p.m. This growth is softball sized with a rough textured surface. Wound care orders reviewed with LVN#1 and followed: clean area with wound cleanser and 4x4, pat dry, and cover with bordered gauze once daily. Aseptic technique was maintained during wound treatment. Record review of Resident #1's face sheet dated 7/22/24 indicated Resident #1 was [AGE] years old and admitted on [DATE] with diagnoses of Dementia (disorder that affects a person's ability to perform everyday activities), Hypertension (high blood pressure), Depression, Anxiety, and Cerebral Infarction (a pathologic process that results in an area of necrotic tissue in the brain). Record review of Resident #1's annual MDS assessment dated [DATE] and a quarterly MDS assessment dated [DATE] indicated Resident #1 has a BIMS of unable to complete. MDS indicated this resident is not coherent enough to complete this form. MDS does not indicate any skin issues currently. A record review of a Nursing Home visit by Resident #1's physician dated 6/7/2024 stated Large golf-ball sized left neck mass. Necrotic in appearance. Record review of Resident #1's care plan updated 7/19/2024 revealed this resident has a growth to the neck. The care plan does not indicate when this growth was first noted by a physician. The care plan indicated the resident is at risk for infection and complications due to the resident itching and scratching the site. A review of the Wound Care policy updated October 15, 2016, revealed Care planning in response to risk prediction must be completed. During an interview on 7/23/2024 at 9:35 a.m., LVN A verbalized Resident #1 could have been put on the Wound Care doctor's list for review. This is not an intervention listed in the care plan because the growth was not care planned until 7/19/2024. LVN A verbalized Resident #1 may have benefitted from being on the Wound Care doctor's list but is unsure how this would have benefitted the resident. During an interview on 7/23/2024 at 11:23 a.m., DON stated, Anything that has a doctor's order should be care planned. DON also stated there was no harm done or that could have been done to Resident #1t for lack of the growth being care planned because the wound care was being completed and the growth is scheduled to be removed.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 of 24 residents (Resident #20, Resident #49, Resident #36, Resident #40 and Resident #58), reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #20 (R#20) in that: -Care plan did not address R#20's dominant left sided weakness. The facility failed to implement a comprehensive person-centered care plan for Resident #49 (R#49) in that: -Care Plan was not updated in regard to his diet. The facility failed to implement a comprehensive person-centered care plan for Resident #36 (R #36) in that: -Care plan did not include the resident's sleep/wake preferences. The facility failed to implement a comprehensive person-centered care plan for Resident #40 (R#40) in that: -Care plan did not state family occasionally brings R #40 outside food (R #40 was on pureed diet with nectar liquids). The facility failed to implement a comprehensive person-centered care plan for Resident #58 (R#58) in that: -The resident's diet changed from a regular diet to a g-tube/enteral feedings only. These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs. Findings included: 1.) Record review of Resident # 20's face sheet documented a [AGE] year-old female with an original admitted [DATE] and a re-entry date of 04/17/22. Diagnoses included a stroke with paralysis and weakness affecting the left non-dominant side, diabetes, depression, anxiety, high blood pressure, heart failure, reflux, and lung disease. Record review of R #20's MDS dated [DATE] revealed R #20 had a BIMS of 15 indicating cognitively intact, was left-handed, required 1 person assistance with ADL's, and was able to feed herself with adaptive equipment. Record review of R #20's comprehensive care plan dated 05/20/2021 documented R #20 had left sided hemiplegia (paralyzed) but did not address anything about R #20 having been left hand dominant, or resident centered focus, goals, and interventions for activities. Record review of R #20's Kardex did not address anything about R #20 having been left hand dominant, resident centered focus, goals, or activities. Interview with the AD on 11/09/23 at 10:32 AM stated R #20 only liked to play bingo or [NAME]. The AD stated she encourages R #20 to do what she likes to do. The AD stated she tells her residents it's good exercise for their fingers. The AD did not know if anything was being done to address the resident's left dominant paralysis and was unaware R #20 was left-handed. Interview with the DOR on 11/09/23 at 10:38 AM stated R #20 was on Occupational Therapy (OT) services which she got every 3 months and had started OT on 10/29/23. Prior to that, she came off skilled services on 01/10/23. The DOR stated R #20 told her she wanted to start signing her name on Tuesday, 11/07/23, and that was the first time she had mentioned wanting to do something. The DOR stated R #20 had ROM in her left shoulder and much less in her left fingers. The DOR stated there had not been much progress because R #20 had come from another facility and there were a few years since her stroke and R #20 was not motivated to rehab. The DOR stated when they picked up R #20 here, she wanted to participate and get up out of bed. The DOR stated R #20 wanted to go home but family member said no-she needs too much care for them to handle. The DOR stated adaptive equipment should be care planned. The DOR did not know if the resident could hold or activate the call light with her left hand. The DOR stated she could not find anything about adaptive equipment in the orders or the care plan, as she scoured the electronic medical record. The DOR stated there should be something addressing R #20's left dominant paralysis, other than the hemiplegia and requiring assistance from staff. The DOR stated R #20 had a nosey cup and a plate guard. The DOR stated R #20 took her meals in her room because she spilled a lot. Interview with the MDS Coordinator on 11/09/23 at 01:07 PM stated the IDT (interdisciplinary team) care plan as needed and nurses communicate with administration when there were changes in resident care. Interview with the DON on 11/09/23 at 02:15 PM, stated care plans were done by the MDS Coordinator quarterly, for any acute changes, and any resident updates. The Don stated staff utilized a 24-hour communication binder located at each nursing station that was utilized for resident changes and concerns. The DON stated when morning meetings were conducted with staff, resident changes were discussed with the MDS Coordinator present so any changes could be updated immediately. The DON stated possible negative outcomes for R #20 would be, direct care staff would not know to make sure the call light was properly positioned, or her food tray was set up properly. The DON stated she was responsible for making sure the MDS Coordinator was updating care plans by doing audits during care plan meetings but did not recall if she checked to see if R #20, #49, and #36's care plans were updated, and the care plan updates were just missed. The DON stated, moving forward, daily audits of care plans would be conducted, would make sure direct care staff would be using the 24-hour communication binder, and charge nurses would be updating direct care staff of any and all resident updates. Record review of R #49's face sheet documented a [AGE] year-old male with an original admitted [DATE] and a re-entry date of 04/12/23. Diagnoses included a traumatic neck fracture and spinal cord injury with weakness affecting all limbs (quadriplegia), diabetes, low blood pressure, reflux, muscle spasms, depression, and neuromuscular dysfunction of the bladder requiring an indwelling catheter. Record review of R #49's MDS dated [DATE] revealed R #49 had a BIMS of 15 indicating he was cognitively intact. R #49 required assistance with ADLs, toileting, and mobility. Record review of R #49's comprehensive care plan dated 03/01/21 documented R #49 a potential risk for malnutrition date initiated 08/19/22 with an intervention including update food preferences as needed date initiated 08/19/22. Resident's diet order is mechanical ground meats, uses weighted utensils and plate guard with meals due to weakness and stiffness to his upper extremities. Date Initiated: 06/15/2021. Intervention included Determine food preferences and provide within dietary limitations. Date Initiated: 06/15/2021. There were no revision date(s) regarding R #49's food preferences. Record review of R #36's face sheet dated 06/16/23 documented a [AGE] year-old female with an initial admission of 06/16/23. Diagnoses included Lupus (when the immune system attacks its own tissues, causing inflammation, and can cause permanent tissue damage affecting the skin, joints, heart, lung, kidneys, blood cells, and the brain), reflux, arthritis, depression and anxiety, lung disease, insomnia, and chest pain. Record review of R #36's MDS dated [DATE] revealed R #36 had a BIMS of 15 indicating intact cognition. R #36 required minimal-1 person assistance/supervision in all areas. Record review of R #36's comprehensive care plan dated 06/19/23 did not document R #36's preferences for sleep/wake times. Interview with R #36 on 11/07/23 at 1:45 PM, revealed mornings were chaotic, and they want to wake me up at the crack of dawn! R #36 stated she had to tell staff repeatedly not to wake her up in the early mornings, and she preferred to wake up around 11:00 AM. Record review of R #36's comprehensive care plan dated 06/13/23 revealed preferences for sleeping until 11:00 AM were not Care planned. Interview with the ADON and the DON on 11/08/23 at 2:59 PM, both stated R #36's preferences should probably be care planned. Interview with the DON on 11/09/23 at 2:14 p.m. revealed care plans were reviewed quarterly and/or for any changes. The DON could not answer why revisions and changes were not made. The DON stated if something was not care planned, not everyone would know how to care for the residents. The DON stated the MDS was ultimately responsible for updating care plans. The DON stated she ensured the MDS made changes via a daily 24-hour report. The DON stated she did not recall Resident #49 coming up in the daily meetings. She stated there needed to be a daily review of care plans. Record review of R #49's face sheet documented a [AGE] year-old male with an original admitted [DATE] and a re-entry date of 04/12/23. Diagnoses included a traumatic neck fracture and spinal cord injury with weakness affecting all limbs (quadriplegia), diabetes, low blood pressure, reflux, muscle spasms, depression, and neuromuscular dysfunction of the bladder requiring an indwelling catheter. Record review of R #49's MDS dated [DATE] revealed R #49 had a BIMS of 15 indicating he was cognitively intact. R #49 required assistance with ADLs, toileting, and mobility. Record review of R #49's comprehensive care plan dated 03/01/21 documented R #49 a potential risk for malnutrition date initiated 08/19/22 with an intervention including update food preferences as needed date initiated 08/19/22. Resident's diet order is mechanical ground meats, uses weighted utensils and plate guard with meals due to weakness and stiffness to his upper extremities. Date Initiated: 06/15/2021. Intervention included Determine food preferences and provide within dietary limitations. Date Initiated: 06/15/2021. There were no revision date(s) regarding R #49's food preferences. Record review of R #36's face sheet dated 06/16/23 documented a [AGE] year-old female with an initial admission of 06/16/23. Diagnoses included Lupus (when the immune system attacks its own tissues, causing inflammation, and can cause permanent tissue damage affecting the skin, joints, heart, lung, kidneys, blood cells, and the brain), reflux, arthritis, depression and anxiety, lung disease, insomnia, and chest pain. Record review of R #36's MDS dated [DATE] revealed R #36 had a BIMS of 15 indicating intact cognition. R #36 required minimal-1 person assistance/supervision in all areas. Record review of R #36's comprehensive care plan dated 06/19/23 did not document R #36's preferences for sleep/wake times. Interview with R #36 on 11/07/23 at 1:45 PM, revealed mornings were chaotic, and they want to wake me up at the crack of dawn! R #36 stated she had to tell staff repeatedly not to wake her up in the early mornings, and she preferred to wake up around 11:00 AM. Record review of R #36's comprehensive care plan dated 06/13/23 revealed preferences for sleeping until 11:00 AM were not Care planned. Interview with the ADON and the DON on 11/08/23 at 2:59 PM, both stated the resident's preferences should probably be care planned. Interview with the DON on 11/09/23 at 2:14 p.m. revealed care plans were reviewed quarterly and/or for any changes. The DON could not answer why revisions and changes were not made. The DON stated if something was not care planned, not everyone would know how to care for the residents. The DON stated the MDS was ultimately responsible for updating care plans. The DON stated she ensured the MDS made changes via a daily 24-hour report. The DON stated she did not recall Resident #49 coming up in the daily meetings. She stated there needed to be a daily review of care plans. 2.) Record review of Resident #40's face sheet dated 11/09/2023 documented an [AGE] year-old male with an initial admitted [DATE] and a readmitted [DATE]. Diagnoses include Cerebral Infarction (type of stoke caused by impaired blood flow to the brain), Type 2 Diabetes (insufficient production of insulin in the body), Hypertension (high blood pressure), Stage 4 pressure ulcer (deep wound that exposes underlying muscle, tendon, cartilage or bone), right leg above knee amputation, Dysphasia (difficulty swallowing), Heart Failure, and Gastronomy (an opening in the stomach from the abdominal wall made surgically for the introduction of food). Record review of R #40's MDS dated [DATE] revealed R #40 had a BIMS of 3 (Severe Impairment), had a feeding tube, and required extensive assistance with bed mobility, transfer, dressing, personal hygiene, and toilet use. Record review of R #40's comprehensive care plan dated 7/5/2022 documented R #40 had pleasure feedings of purred with nectar liquids. Record review of R #40's physician orders dated 7/3/2023 documented R #40 had enteral feedings and pureed texture, nectar consistency diet. Record review of R #40's nursing documentation dated 10/12/2023 documented resident's (R #40) spouse was feeding resident a sandwich. educated her on his diet. notified RP. RP stated that they have been giving him tacos once in a while. Interview on 11/09/23 at 01:01 PM, the DON stated R #40's family had brought in regular food that contradicted with R # 40's MD dietary orders. The DON stated the MDS Coordinator did care plans for residents and should have been care planned and updated when the change had occurred. Interview on 11/09/23 at 01:05 PM, the ADON printed out R #40's care plan, dated 11/9/2023, that reflected, family occasionally brings outside food to resident (R #40). This surveyor informed ADON that previous care plan for R #40 was saved on 9/9/2023 at 9:24 AM. by this surveyor and did not reflect the changes on the care plan. The ADON stated that she was not sure what the previous care plan for R #40 documented since current care plan does reflect the change. Interview on 11/09/23 at 01:07 PM, the MDS Coordinator stated the IDT (interdisciplinary team) care plan as needed and nurses communicate with administration when there are changes in resident care. Interview on 11/09/23 at 02:15 PM, the DON stated care plans are done by the MDS Coordinator quarterly, for any acute changes, and any resident updates. The Don stated staff utilized a 24-hour communication binder located at each nursing station that is utilized for resident changes and concerns. The DON stated when morning meetings are conducted with staff, resident changes are discussed with MDS Coordinator present so any changes could be updated immediately. The DON stated possible negative outcomes for R #40 would be, direct care staff would not know that family was bringing in outside food to R # 40 and staff would not know to monitor R #40's for any changed condition if outside food was eaten. The DON stated she is responsible for making sure the MDS Coordinator was updating care plans by doing audits during care plan meetings but did not recall if she checked to see if R #40's care plan was updated, and R #40's care plan update was just missed. The DON stated, moving forward, daily audits of care plans would be conducted, would make sure direct care staff would be using the 24-hour communication binder, and charge nurses would be updating direct care staff of any and all resident updates. 3.) Record review for R #58's admission record dated 11/7/23 revealed R #58 was admitted to the facility initially on 09/20/2023, was a [AGE] year-old male. R #58's diagnoses included unspecified protien-calorie malnutrition , Parkinson's (degenerative disorder of the central nervous system that mainly affects the motor system), Pneumonia due to inhalation of other solids and liquids, lack of coordination, and history of falls. Record review of R #58's care plan dated 10/05/23 indicated R #58 was changed to a NPO diet, NPO texture, NPO consistency however the care plan was not updated to implement that the resident could no longer receive food or fluids other than enteral feed. The care plan stated that R #58 could have a snack and it was encouraged to offer the resident drinks to maintain hydration. Observation on 11/7/2023 at 10:35 PM of R #58 in his room. R #58 was in his bed and had just finished physical therapy. R #58 noted with no drinks or food in sight. R #58 appeared calm, with pale skin. R #58 was nonverbal and could not express whether he was able to eat or drink anything or what was acceptable in his diet. This surveyor observed R #58 receiving an enteral feeding. Interview with CNA A and CNA B stated they were working the 500 hall on 11/8/23 at 2:08 PM. CNA A and CNA B stated they were not sure of the diet for R #58. This surveyor asked how do they know what R #58 can or cannot eat. CNA A and CNA B stated the charge nurse was the one that fed R #58 and they believed R #58 was fed only through R #58's g-tube but may be able to be pleasure fed. This surveyor asked CNA A and CNA B what could happen if they gave the R #58 food or drink because they were not sure of the R #58's diet. CNA A and CNA B stated R #58 could become very sick or even die if R #58 choked. Interview with the charge nurse for the assigned floor was on 11/8/23 at 2:32 PM, stated R #58's diet was an NPO diet and they had not changed it on R #58's care plan because R # 58's family member was not accepting of the diet change. This surveyor asked the LVN A where in the Care Plan can I find that R #58's family member had not been accepting of the diet and reason for not updating the plan? LVN A could not give this surveyor an answer. LVN A stated, I don't know. This surveyor asked if there was a reason why CNA A and CNA B did not know what the diet was for R #58. LVN A stated that CNA A and CNA B did not know R #58's diet and CNA A and CNA B could have simply gone to the Kardex to verify, but CNA A and CNA B may have been nervous to answer or say they needed to check. Interview with the DON on 11/9/23 at 2:30 PM, revealed care plans began upon admission, quarterly, and updated as needed. The DON stated staff utilized a 24-hour communication binder located at each nursing station that was utilized for resident changes and concerns. The DON stated when morning meetings are conducted with staff, resident changes are discussed with the MDS Coordinator present so any changes could be updated immediately. The DON stated possible negative outcomes for R #58 would be that direct care staff could had given R #58 food or something to drink by accident because the care plan stated that it was encouraged. The DON stated she was responsible for making sure the MDS Coordinator was updating care plans by doing audits during care plan meetings but did not recall if R #58's care plan had been updated recently. The DON stated, moving forward, daily audits of care plans would be conducted. The DON stated she would make sure direct care staff would be utilizing the 24-hour communication binder, and charge nurses would be updating direct care staff of any and all resident updates. Review of Care Planning Policy not dated states: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will; a. Include measurable objectives and timeframe b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. Record review of facility Comprehensive Care Planning Policy not dated stated; The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the 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 comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goal, and address the resident's medical, physical, mental, and psychosocial needs. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representatives, if applicable, so that changes can be reflected in the comprehensive care plan. A comprehensive care plan will be- Developed with 7 days after completion of the comprehensive assessment The resident's care plan will be reviewed after each Admission, Quarterly, Annually and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. 46038 48118

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to label and date items in the nutrition rooms 2. The facility failed to maintain cleanliness of the ice machine in the nutrition room 3. The facility failed to dry storage items sealed 4. The facility failed to keep personal items out of the prep area These failures could place residents at risk of foodborne illnesses. Findings include: Initial tour of the kitchen on [DATE] beginning at 10:55 AM with the DS revealed a 16 oz. bag of potato chips in the dry storage area that was open to air. There was a 12 oz. bag of powdered gravy in the dry storage area that was open to air. Observation of the kitchen and interview with the DS on [DATE] at 11:25 AM, revealed a large personal container of a clear beverage on the prep table next to the stove, that belonged to one of the cooks. The DS told her there were no personal drinks allowed in the kitchen area due to the risk of cross contamination. Observation of the east wing nutrition room on [DATE] at 2:00 PM, revealed 4, 14 oz. containers of pudding expired [DATE], 1, 7.23 oz. bag of chocolate rice cakes expired [DATE], 1, 7.5 oz. bag of sugar free candies expired [DATE], 2, 7.5 oz. bag of sugar free candies expired [DATE], 1, 2 oz. opened, half empty and unlabeled bag of cheese flavored snacks. The ice machine had a thick, white cheesy substance on the ice chute. Interview with the cook on [DATE] at 11:25 AM, revealed having her cup in the prep area was not allowed and it just slipped her mind. The cook stated personal items were not allowed in the prep areas because cross-contamination could occur from touching the item, then touching something in the kitchen used to prepare food for the residents. It could make the resident sick. Interview with the DS on [DATE] at 2:10 PM, revealed floor staff were responsible for stocking, maintaining, and cleaning the nutrition rooms. Interview with the DON on [DATE] at 2:14 p.m., revealed floor staff were responsible for stocking, maintaining, and cleaning the nutrition rooms. A record review of in-services and training for the kitchen staff revealed [DATE] covered correct serving spoons, [DATE] tardiness, [DATE] handwashing, [DATE] dress code/jewelry, [DATE] harassment/cell phone use, [DATE] code of conduct, [DATE] professionalism/code of conduct, [DATE] handwashing, [DATE] legionella.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet measurable objectives and timeframe to meet a resident's medical needs for 1 of 5 residents (Resident # 1), reviewed for care plans in that: MDS (minimum data set) Coordinator did not list the objective and timeframe for [MEDICATION(S)] levels ordered by the Physician for Resident #1 This failure could result in residents not receiving the care and treatments ordered by the physician which are documented in the comprehensive person-centered care plan; and could lead to a diminished quality of life, and not attaining medical, nursing, and mental and psychosocial needs. Findings were: Record review of Resident #1 's face sheet, dated 3/30/22 and EMR (electronic medical record) revealed, the resident was readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a female; age 66. Advanced Directive was Full Code. RP (responsible party) was listed as: Resident. Record review of Resident #1's Quarterly MDS (minimum data set), dated 12/20/21 revealed: o BIMS (brief interview of mental status) Score was 3 (severe impairment ). o ADLs (activities of daily living): B/B (bowel and bladder) incontinent. Transfer was extensive one/two staff member assistance. Bed Mobility was extensive one/two staff members assistance. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MAR (medical administration record) March 2022 revealed, the resident was administered [MEDICATION(S)] daily three times per day from March 01-22, 2022. Record review of Resident #1's Care Plan, undated, revealed, no goal for [MEDICATION(S)] levels and no interventions. No documentation made about [MEDICATION(S)] levels. The care plan was completed by the MDS(minimum data set) Coordinator, LVN A. Record review of PASRR (preadmission screening and resident review) II (10/14/21) revealed the resident triggered for ID (intellectual disability) and MI (mental illness). Record review of order summary for Resident #1, March 2022, read, CBC (complete blood count), CMP (complete metabolic panel), Hemoglobin A1C (diabetes), [MEDICATION(S)] level, [MEDICATION(S)] level Q 3 (every three months) (anticonvulsive/[CONDITION(S)] [CONDITION(S)]) (October, January, April, July). Record review of labs for [MEDICATION(S)] revealed: 3/11/22 level was 0.5 (0.6-1.1) resident not toxic (toxic after 1.2) 2/8/22 level was 1.05 (within range) 1/28/22 level was 0.67 (within range) During an interview on 3/30/22 at 11:58 AM, LVN (licensed vocational nurse) A (MDS Coordinator) confirmed that [MEDICATION(S)] levels ordered by the physician and the need to take labs was not present in the comprehensive person-centered care plan for Resident #1. LVN A stated, Typically, the care plan should say 'monitor labs as ordered' and not present .it might have been an oversight .[MEDICATION(S)] levels need to be checked to prevent toxicity and to ensure the medication is within therapeutic ranges .the care plan captures all the assessments .missing information might lead to an oversight on interventions . During an interview on 3/30/22 at 12:14 PM, the DON (director of nursing) stated, . As for [MEDICATION(S)], she (Resident #1) was never toxic and she was tested on [DATE] and she was within range she was hospitalized for behavior issues and need for medication adjustment .she was having aggressive and having outbursts .we sent her to the hospital on 3/14/22 for medication adjustments and they (hospital staff) hospitalized her .it had nothing to do with [MEDICATION(S)] .we wanted to find the medications that would settle her outburst .she (Resident #1) is still in the behavioral health hospital . During an interview on 3/30/22 at 1:30 PM, the DON stated, not aware that labs interventions for [MEDICATION(S)] and the other meds ordered by the MD (medical doctor) were not incorporated into the Care Plan .the Care Plan serves as communication for all staff .the MDS nurse is responsible ensuring the correctness of Care Plan . During an interview on 3/30/22 at 1:34 PM, SW (social worker) stated, resident (#1) was sent to Hospital to assess the resident's medications and to assess her aggressive behaviors .she became more verbal .and also threw a remote at a TV . Record review of SW progress note 3/14/22 revealed, Resident #1 was referred to a behavioral Hospital for medication adjustment and psychiatric evaluation. During an interview on 3/30/22 at 1:40 PM, LVN B stated, we monitored her medications and side-affects monitored labs and kept MD informed of any changes to include behavior changes .she received the care she needed monitoring is found in the lab results in Resident #1's clinical record . Record review of facility's Comprehensive Care Planning policy, undated, read, .The facility will develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs .'

Based on interview and record review, the facility failed to allow the resident and or the resident representative the right to participate in the development and implementation of the person-centered care planning process for one (Residnet#44) of 24 residents reviewed for individualized person-centered care plan. The facility did not include Resident #44 or her representative(s) in her initial care plan meeting. This deficient practice could affect residents and place them at-risk by contributing to inadequate care. The findings included: Review of Resident #44's Face Sheet dated 6/24/20 documented an [AGE] year-old female admitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated FM A as Responsible Party whom signed all of Resident #44's admission documents and consents. Review of Resident #44's Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #44: -had a brief interview of mental status score of 14- cognitively intact -required limited assistance with one - two person physical assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. During an interview on 6/21/21 at 3:26 p.m., Resident #44 denied ever attending any care plan meetings, stated. I didn't know there was such a thing. Record review of Resident #44's medical record on 6/24/21, revealed that there had not been any care plan meetings for the time Resident #44 had been at the facility. During an interview on 6/24/21 at 10:30 a.m., DON said Resident #44 had attended the care plan meeting, and FM A was on speaker phone. DON and MDS coordinator were both in agreement that a care plan meeting had been held. DON stated, I can't believe Resident #44 said she has never attended any care plan meeting when we discussed all her doctor's orders and her plan of care with her which took a long time. During an Interview on 6/24/21 at 11:15 a.m., with MDS coordinator stated, she could not find any documentation regarding the care plan meeting for Resident #44, and that a care plan meeting had been done. MDS coordinator said she called FM A and asked him if he could remember being in attendance in the care plan meeting. MDS coordinator said FM A told her he was not because FM A had asked for it to be rescheduled from 5/14/21. MDS coordinator stated, but I recall having the Care Plan meeting on 5/14/21 at 4:30 p.m., but I can't find any notes regarding the meeting of who was in attendance. During an interview on 6/24/21 at 1:19 p.m. with DON stated she was aware that there was no documentation of a care plan meeting taken place for Resident #44. DON acknowledged if there was no documentation the care plan meeting did not occur. DON stated, I recall having the meeting and even what Resident #44 was even wearing that day but, I do understand, if there isn't any documentation it didn't happen. During an interview on 06/24/21 1:33 PM over the phone with FM A, RP stated, I was supposed to have had a care plan meeting on 05/14/21 at 4:30 p.m. but, I never heard back from the facility. FM A said the facility never schedule the care plan meeting and he never received a letter or a call notifying him regarding the meeting. FM A stated, I never heard from them until this morning (6/24/21). They just called me this morning and asked me if I had remembered being in attendance at the care plan meeting on (05/14/21), but I told her you all never got back with me to tell me about the meeting. FM A said MDS Coordinator just now (6/24/21) scheduled a time for the care plan meeting for 07/16/21 at 1:00 p.m. Review of the facility's undated Comprehensive Care Plan Policy and Procedure documented Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, address the resident's medical, physical, mental and psychosocial needs. Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. A comprehensive care plan will be - Developed within 7 days after completion of the comprehensive assessment. Prepared and /or contributed to by an interdisciplinary team, that includes but is not limited to- - The attending physician. - A registered nurse with responsibility for the resident - A nurse aide with responsibility for the resident. - A member of food and nutrition services staff. - To the extent practicable, the participation of the resident and the resident's representative(s). An explanation will be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. - Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Review of the facility's undated Comprehensive Care Plan Policy and Procedure documented Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .