Every finding on record at Wyatt Manor Nursing and Rehab Ctr, Inc

Based on interviews and record reviews, the facility failed to develop a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (#2, #5) of 14 residents reviewed. The facility failed to: 1) develop measurable objectives and timeframes to address Resident #2's wandering behaviors, and 2) develop a care plan to address Resident #5's non-compliance with physician orders.Findings:Resident #2 Review of the medical record for Resident #2 revealed an admission date of 12/03/2020 with diagnoses that included diabetes mellitus, major depressive disorder, schizoaffective disorder, bipolar type, dementia with behavioral disturbance, pseudobulbar affect, and insomnia. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated Resident #2 had severe cognitive impairment with daily decision making. Further review revealed Resident #2 exhibited wandering behaviors 1-3 days a week. Review of the facility's Wandering Data Collection Tool dated 12/22/2025 identified Resident #2 as a wander/elopement risk. Further review revealed Resident #2 wandered ad lib at times in resident rooms and rummaged through resident belongings. Review of Resident #2's potential for elopement care plan revealed interventions that included redirect resident as needed and provide diversional activities as needed. On 03/03/2026 at 3:28 p.m., interview with S3CNA revealed Resident #2 frequently wanders into resident rooms on evening shift. Interview further revealed Resident #2 is easily redirected with diversional activities but redirection was minimally effective. On 03/03/2026 at 4:00 p.m., interview with S2DON was unable to produce documentation to support interventions were measurable with objective timeframes. On 03/04/2026 at 10:14 a.m., S2DON was informed Resident #2's plan of care did not include measurable objectives and timeframes to address Resident #2's wandering behaviors. Resident #5 Review of the medical record for Resident #5 revealed he had an admit date of 12/11/2024 with diagnoses which included diabetes, anxiety and depression. Review of the February and March 2026 medical administration record revealed Resident #5 had refused every by mouth and injectable medication. Resident #5 had also refused every scheduled blood sugar monitoring. Review of the physician orders revealed Resident #5 had lab orders for a complete blood panel, basic metabolic panel, Valporic acid level and hemoglobin A1C to be drawn every 3 months. Review of the lab results revealed they had not been obtained as ordered. Review of Resident #5's Care Plan revealed there was no care plan developed to address the resident's non-compliance with physician orders. On 03/03/2026 at 1:20 p.m., interview with S2DON revealed Resident #5 frequently refuses by mouth and injectable medications, blood glucose monitoring and lab work. She also confirmed Resident #5's plan of care did not address the resident's non-compliance with by mouth and injectable medications, glucose monitoring and lab work.

Based on observations and interviews, the facility failed to maintain a safe, comfortable and homelike environment for 2 (#11, #42) sampled residents reviewed for environmental issues. The facility failed to ensure maintenance services were provided as necessary to maintain a comfortable interior for the residents.Findings:Resident #11Observations on 03/02/2026 at 9:14 a.m. and on 03/03/2026 at 8:45 a.m. revealed Resident #11's window unit air conditioner had a large amount of gray duct tape placed on the window around the outer edges of his window unit.Observation and interview with S1Administrator on 03/04/2026 at 2:55 p.m. confirmed that Resident #11's window unit air conditioner had gray duct tape placed on the window around the outer edges of the window unit. S1Administrator further confirmed the duct tape should not be in place and the unit was in need of repair.Resident #42Observations on 03/02/2026 at 8:52 a.m. and on 03/03/2026 at 8:40 a.m. revealed Resident #42's window unit air conditioner had black duct tape around the top and left side of the air conditioner vent cover. Additionally, there was silver tape and insulation foam noted on the right side between the window and the window unit air conditioner.Observation with S1Administrator on 03/04/2026 at 2:50 p.m. confirmed that Resident #42's window unit air conditioner had black duct tape around the top and left side of the air conditioner vent cover and had silver tape and insulation foam on the right side. S1Administrator further confirmed the duct tape and silver tap should not be present and the unit was in need of repair.

Based on observation, record reviews and interviews the facility failed to have an adequate system in place to ensure residents at risk for elopement are supervised to prevent elopement from the facility for 1 (#1) of 2 (#1 and #2) residents at risk for elopement. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on 9/12/2025 at 2:15a.m. Resident #1 was last observed in the facility on 09/12/2025 at 1:55 a.m. The facility was notified by S3Maintenance Supervisor on 09/12/2025 at 7:30 a.m. when Resident #1 was observed at a gas station approximately 5 miles from the facility via a four lane highway. The local sheriff's office returned Resident #1 to the facility at 7:45 a.m. without injury. Resident #1 exited the building through a coded locked door after entering the code himself at 2:15a.m.The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 09/22/2025. It was determined to be a Past Noncompliance Citation. Findings:Review of the medical record for Resident #1 revealed an admission date of 09/04/2025 with diagnoses that included schizoaffective disorder, bipolar disorder and schizophrenia. Further review of the record revealed Resident #1 was court committed to the facility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #1 had intact cognition for daily decision making. Review of the care plan dated 09/04/2025 revealed Resident #1 had a potential for elopement. Further review of the care plan revealed interventions for visual checks for resident's location every 1 hour, provide diversional activities as needed and to redirect resident as needed. Review of the Wander Data Collection Tool dated 09/05/2025 revealed Resident #1 wandered about the facility and he voiced that he wanted to go home. Resident #1 was placed on every hour census and Resident #1 was assessed as a wander/elopement risk. Review of the Incident/Accident Report dated 09/12/2025 at 7:30 a.m. revealed S3Maintenance Supervisor called the facility and informed S5Licensed Practical Nurse (LPN) that Resident #1 was sitting in between a gas station and the local sheriff's office. Resident #1 reported he threw his belongings over the fence, then climbed over the fence and walked to a local store. S5LPN and S6Certified Nursing Assistant (CNA) immediately went to retrieve Resident #1 in the facility van. Resident #1 was unwilling to be transported in the facility van, but allowed the local Sherriff's officer to transport him back to the facility. Resident #1 did not have any injuries. On 09/22/2025 at 9:00 a.m. observation of the video surveillance with S1Administrator and S2Assistant Director of Nurses (ADON) revealed on 09/12/2025 at 1:55 a.m. S8LPN opened Resident #1's door. Further review of the video surveillance revealed on 09/12/2025 at 2:15 a.m. Resident #1 came out of his room, closed the door behind him entered the code to the exit door and left the building. S1Administator and S2ADON confirmed the last time a staff member saw Resident #1 was on 09/12/2025 at 1:55 a.m. On 09/22/2025 at 9:00 a.m. during observation of the video surveillance, S1Administrator and S2ADON confirmed on 09/12/2025 at 1:55 a.m. was the last time a staff member saw Resident #1. Further interview with S1Administrator and S2ADON confirmed Resident #1 was not monitored every hour for elopement as ordered.Review of the nurses notes dated 09/12/2025 revealed at approximately 7:30 a.m. S3Maintenance Supervisor called the facility to report that a resident was at a gas station. S5LPN and S6CNA left the facility in the van to pick up the resident. Resident #1 refused to get into the facility van so the local Sheriff's department transported Resident #1 back to the facility. Resident #1 arrived back to the facility at approximately 7:45 a.m.On 09/22/2025 at 10:10 a.m. interview with S13LPN revealed she worked on 09/12/2025 from 7:00 a.m. - 7:00 p.m. and received report from S7LPN. S13LPN further revealed when she received report from S7LPN she was not aware that Resident #1 was not in the building. On 09/22/2025 at 2:10 p.m. phone interview with S3Maintenance Supervisor revealed he was at a gas about 5 miles from the facility and saw Resident #1 sitting and smoking a cigarette. S3Maintenance Supervisor revealed he called the facility and told S5LPN that Resident #1 was at the gas station. On 09/23/2025 at 9:00 a.m. a phone interview with S7LPN that was responsible for Resident #1's care on 09/11/2025 from 7:00 p.m. - 7:00 a.m. revealed Resident #1 took his nighttime medications about 7:15 p.m. S7LPN revealed she got busy with other residents and didn't monitor Resident #1's location every hour as ordered. Multiple attempts were made by the surveyor during the survey to contact S24CNA on 09/22/2025 at 2:35 p.m. and 5:30 p.m., 09/23/2025 at 3:26 p.m., and 09/24/2025 at 9:55 a.m. All attempts to call S24CNA were unsuccessful. S24CNA was responsible for the care of Resident #1 on 09/11/2025 on the 11:00 p.m. - 7:00 a.m. shift when Resident #1 eloped from the facility. On 09/23/2025 at 10:09 a.m. interviews with S1Administrator and S2ADON confirmed they were unaware that Resident #1 had the code to the exit door and they were unaware the staff were not visually checking Resident #1's location as ordered. On 09/24/2025 at 10:20 a.m. interview with S4Director of Nursing (DON) revealed she was not aware that the resident or any resident had the code to the exit doors and she was unaware that the staff were not making every 1 hour visualization rounds on Resident #1 prior to this incident. S4DON further confirmed Resident #1 was not monitored every hour as ordered and as stated in the careplan. During the survey, it was determined the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility as evidenced by onsite observations, interviews and record reviews.The facility implemented the following actions with a completion date of 09/16/2025.1. To establish a complete baseline, the ADON did a check for all admitted residents on 09/12/2025 at 7:30 a.m. Fifty-three of the 55 residents were present. 1 resident was inpatient at the local hospital and 1 eloped but was now with staff enroute back to the facility. 2. Resident #1 was placed 1:1 with staff upon return to the facility on [DATE] at 7:45 a.m. until departure at 11:36 a.m.3. The ADON counseled all CNAs and Nurses on 11p-7a shift for their lack of supervision of residents and excessive break time and provided all CNAs and Nurses with a disciplinary write up on 09/12/2025. The ADON and Maintenance Supervisor assessed all exit doors of the building to ensure they were locked and the codes were functioning properly. Codes to the exit doors were updated on 09/12/2025 at approximately 8:00 a.m. 4. The DON inserviced all CNAs and Nurses on 09/12/2025 - 09/16/2025 (all prior to returning to work). At least one CNA must remain on the hall at all times for proper supervision of residents. 5. The DON inserviced all CNAs and Nurses on importance of attentive supervision (every 2 hours rounding during assigned shift), as well as required rounding at each shift change to ensure all residents are safe and accounted for. Inservicing took place from 09/12/2025 - 09/16/2025. All staff was inserviced prior to returning to work. 6. The DON inserviced all staff that door code exits were changed at approximately 8:00 a.m. on 09/12/2025 and the new codes must not be given out to residents or visitors. Inservice also stated that any resident who wished to go outside must be supervised by staff. Inservice took place from 09/12/2025 - 09/16/2025. All staff was inserviced prior to returning to work. 7. To verify understanding of all inservices an elopement questionnaire was developed and administered by DON and ADON and was completed by all nurses and CNAs between 09/12/2025 - 09/16/2025. (All staff inserviced prior to returning to work) 8. On 09/12/2025 all residents were reassessed by MDS and Clinical Care Coordinator (CCC) nurse for baseline to determine any other risk for elopement.9. 09/12/2025 all residents who require every 1 hour visualization are identified by a task on the computer, ordered on Medication Administration Record (MAR), signage above assigned bed, closet care plan and a list posted by the time clock. 10. A construction company was notified by the Administrator that the fence needed improvements at the facility on 09/12/2025.11. A construction company repaired the fence on 09/16/2025.Review of the Quality Assurance Performance Improvement (QAPI) records revealed the following:The DON or ADON will monitor camera footage 3 times a week at random to ensure that CNAs and nurses are not taking excessive break times and that at least one CNA remains on each hall at all times. This monitor will be completed at random 3 times a week for 2 weeks and then 1 time a week for 4 weeks or until compliance is met. Any noncompliance will be addressed. The CNAs and LPNs will rotate every 2 hour rounds through the facility so that all residents have a visual check every 1 hour by staff. CNAs will round on odd hours and nurses will round on even hours. These forms will be turned into the DON and ADON to ensure that this implementation is being followed. Rounding will be completed every 1 hour on all residents for 2 weeks and then will continue on all residents who have a every 1 hour monitor order for 4 weeks but may continue until compliance is met. Residents identified for every 1 hour monitoring are identified by signage above their bed, listed on closet care plan, order in Kiosk for CNAs, order in the computer for nurses, as well as a list by the time clock. Any noncompliance will be addressed. The DON and ADON will visualize rounds with CNAs and LPNs at random times throughout the week to ensure compliance either by in person or reviewing camera footage. This monitor will be completed 3 times a week at random for no less than 6 weeks but may continue weekly until compliance is reached. Any noncompliance will be addressed. An Elopement Questionnaire will be completed with 2 CNAs and 1 nurse at random by the DON or ADON 3 times a week for 2 weeks and then 1 time a week for 4 weeks or until compliance is met. Any noncompliance will be addressed.Validation of Plan of Removal:Review of the Incident log from 05/01/2025 - 09/22/2025 revealed no incidents related to elopement. Review of the census sheet revealed on 09/12/2025 all 53 of the 55 residents were located at the facility. One resident was in a local hospital and one was Resident #1 whom had eloped. Review of the CNA flowsheet dated 09/12/2025 revealed Resident #1 was one on one from 7:45 a.m. until 11:36 a.m.Review of the statement written by S2ADON revealed all exit doors were checked for proper functioning. During the survey the exit doors were functioning properly and were locked. Review of the elopement risk assessments were noted for all residents on 09/12/2025.Review of the disciplinary action forms dated 09/12/2025 the CNAs and nurses that worked 09/12/2025 from 11:00 p.m. - 7:00 a.m. were counseled due to the lack of supervision of residents. Review of the inservice training records from 09/12/2025 - 09/16/2025 revealed in part: -09/12/2025 - 09/16/2025 to CNAs and nurses by S4DON - At least one CNA must remain on the hall at all times for proper supervision of residents. - 09/12/2025 - 09/16/2025 to CNAs and nurses by S4DON - On the importance of attentive supervision (Every 2 hours rounding during assigned shift), as well as required rounding at each shift change to ensure all residents are safe and accounted for. -09/12/2025 - 09/16/2025 to all staff by S4DON - The door codes exits were changed at approximately 8:00 a.m. on 09/12/2025 and the new codes must not be given out to residents or visitors. Inservice also stated that any resident who wished to go outside must be supervised by staff. Review of the facility's QA meeting notes revealed a meeting was held on 09/12/2025 regarding Resident #1's elopement. Review of the monitoring sheets revealed the DON or ADON monitored camera footage 3 times a week at random to ensure that CNAs and nurses were not taking excessive break times and that at least one CNA remained on each hall at all times. Review of the monitoring sheets revealed the CNAs and LPNs rotated every 2 hour rounds through the facility so that all residents have a visual check every 1 hour by staff. CNAs rounded on odd hours and nurses rounded on even hours. Signage was noted above their bed, listed on closet care plan, ordered in the Kiosk for CNAs, ordered in the computer for nurses, as well as a list by time clock was observed. Review of the monitoring sheets revealed the DON and ADON visualized rounds with CNAs and LPNs at random times throughout the week to ensure compliance either by in person or reviewing camera footage. Review of the Elopement Questionnaires revealed they were completed by CNAs and nurses at random by DON or ADON.Review of the invoice from the construction company that repaired the fence on 09/16/2025 revealed the fence was repaired. During the survey observation of the fence revealed no issues were noted. On 09/22/2025 at 9:20 a.m. interview with S9Housekeeping and S10Housekeeping revealed they were inserviced on not to give the code to the doors to anyone, watch for residents that seem like they are trying to get out, no one should be outside without staff. They were aware of the 2 residents that were at risk for elopement. On 09/22/2025 from 9:30 a.m. - 2:30 p.m. and on 09/23/2025 from 8:20 a.m. - 3:45 p.m. interviews with S6CNA, S11CNA, S12CNA, S13LPN, S14LPN, S15LPN, S16CNA, S17CNA, S19CNA, S20CNA, S21CNA, S22CNA, and S23CNA revealed they have recently been inserviced on not giving the door codes to anyone and to watch residents closely for elopement. The staff revealed they were aware that Resident #1 was at risk for elopement prior to his elopement and they were informed to watch him every hour. They document the every 1 hour checks in the computer system and on a form at the nurses station. A closet careplan was located in the closet that tells them all of the help each resident needs and what they are at risk for. Further interview revealed they were not aware that Resident #1 had the code to the door prior to the incident. Observation of the outside fence with S1Administrator on 09/22/2025 at 9:50 a.m. revealed the fence was in good repair. Observation on 09/22/2025 at 8:30 a.m. revealed no residents were observed outside of the building. Observations on 09/22/2025 at 8:45 a.m. and 12:10 p.m. revealed staff were outside in the secured area monitoring the residents. Observations on 09/23/2025 at 8:45 a.m., 12:45 p.m. and at 2:45 p.m. revealed staff were outside in the secured area monitoring the residents. Observation of 09/24/2025 at 8:10 a.m. no residents were observed outside of the building.Observation on 09/24/2025 at 8:45 a.m. revealed staff were outside in the secured area monitoring the residents.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints that were not required to treat a resident's medical symptoms for 1 (#32) of 2 (#5, and #32) residents reviewed for restraint use. Findings: Review of the medical record for resident #32 revealed he had diagnoses which included mood disorder, difficulty walking, muscle wasting and atrophy, seizures and severe intellectual disabilities. On 01/06/2025 at 9:30 a.m. and on 01/07/2025 at 10:10 a.m., resident #32 was observed in a geri-chair with a lap tray. Review of the Pre-Restraining assessment summary dated 11/19/2024 indicated resident #32 could remove the lap tray from the geri-chair. On 01/07/2025 at 12:40 p.m., interview with S4Minimum Data Set (MDS) Nurse revealed the facility did not consider the lap tray to be a restraint because resident #32 could remove the tray. On 01/07/2025 at 12:40 p.m., S4MDS prompted resident #32 to remove his lap tray. The resident was unable to remove the lap tray. On 01/07/2025 at 12:50 p.m., interview with S3Licensed Practical Nurse (LPN) revealed resident #32 was unable to remove the lap tray from the geri-chair On 01/07/2025 at 1:00 p.m., interviews with S5Certified Nursing Assistant (CNA) and S6CNA revealed resident #32 was unable to remove the lap tray from the geri-chair. On 01/08/2025 at 9:20 a.m., interview with S4MDS Nurse confirmed the geri-chair with a lap tray was a restraint for resident #32.

Based on record reviews and interviews, the facility failed to ensure resident's drug regimens were free from unnecessary psychotropic medications for 5 (#2, #11, #14, #15, and #33) of 5 residents reviewed for unnecessary medications. Findings: Resident #2 Review of resident #2's record revealed an admitted [DATE] with diagnoses including paranoid schizophrenia, major depressive disorder, acute respiratory failure, other specified extrapyramidal and movement disorders, other psychotic disorder not due to a substance or known physiological condition. Review of resident #2's January 2025 Physician's Orders revealed an order dated 03/15/2024 for Escitalopram Oxalate tab 10 milligrams (mg) give 1 tablet by mouth 1 time a day and Olanzapine tab 10 mg give 1 tablet by mouth 2 times a day (bid). Review of the Pharmaceutical Consultant Report dated 06/13/2024 for resident #2 revealed the pharmacist recommended a gradual dose reduction for Zyprexa (Olanzapine)10 mg bid and Lexapro (Escitalopram Oxalate) 10 mg every day. Further review revealed the physician documented a dose reduction was not appropriate and resident was on the minimal effective dose, but the physician did not provide a handwritten rationale to justify for not reducing the psychoactive medications. On 01/08/2025 at 1:50 p.m., an interview with S2Director of Nursing (DON) confirmed the physician did not document a handwritten rationale as to why resident #2 's psychotropic medications were not reduced on the gradual dose reduction letter. Resident #14 Review of resident #14's record revealed an admitted [DATE] with diagnoses including schizoaffective disorder bipolar type, dementia in other disease classified elsewhere with behavioral disturbance, pseudobulbar affect, bipolar disorder, major depressive disorder, and generalized anxiety disorder. Review of resident #14's January 2025 Physician's Orders revealed the following: 04/25/2022- Trazodone Hydrochloride 100 mg give 1 tablet orally at bedtime (hs), 03/11/2012- Geodon Oral Capsule 80 mg give 2 tablet by mouth one time a day, 04/09/2019- Lorazepam Oral Tablet 1 mg give 1 tablet by mouth two times a day; and 09/27/2012- Zoloft Oral Tablet 100 mg give 1 tablet by mouth one time a day. Review of the Pharmaceutical Consultant Report dated 06/13/2024 for resident #14 revealed the pharmacist recommended a gradual dose reduction for Geodon 160 mg every night, Zoloft 100 mg every day, Ativan (Lorazepam) 1 mg bid, and Trazadone 100 mg at hs. Further review revealed the physician documented a dose reduction was not appropriate and the resident was on the minimal effective dose, but the physician did not provide a handwritten rationale to justify for not reducing the psychoactive medications. On 01/08/2025 at 1:50 p.m., an interview with S2DON confirmed the physician did not document a handwritten rationale as to why resident #14 's psychotropic medications were not reduced on the gradual dose reduction letter. Resident #33 Review of resident #33's record revealed an admitted [DATE] with diagnoses including dementia in other diseases classified elsewhere mild with other behavioral disturbance, dementia in other disease unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, psychotic disorder with delusions due to known phsyiological condition, schizophrenia, Alzheimer's disease, and delusional disorders. Review of resident #33's January 2025 Physician's Orders revealed an order dated 07/01/2024 for Olanzapine oral tablet 10 mg give 1 tablet by mouth at bedtime related to delusional disorders. Review of resident #33's Pharmaceutical Consultant Report letter dated 06/13/2024 revealed the pharmacist recommended a gradual dose reduction for Zyprexa (Olanzapine) 10 mg at hs. Further review revealed the physician documented a dose reduction was not appropriate and the resident was on the minimal effective dose, but the physician did not provide a handwritten rationale to justify for not reducing the psychoactive medication. On 01/08/2025 at 1:50 p.m., an interview with S2DON confirmed the physician did not document a handwritten rationale as to why resident #33's psychotropic medications were not reduced on the gradual dose reduction letter. 41829 Resident #11 Record review revealed resident #11 was admitted to the facility 03/18/2011. Resident #11 diagnoses included paranoid schizophrenia, delusional disorders, manic episode severe with psychotic symptoms, generalized anxiety disorder, insomnia, and major depressive disorder. Review of the January 2025 Physician's Orders included the following psychotropic medications: Abilify 30 mg tablet give one tablet orally at bedtime, Citalopram Hydrobromide 10 mg tablet give 1 tablet orally one time a day, Quetiapine Fumarate 400 mg give 1 tablet orally bid, Lorazepam 0.5 mg tablet give 1 tablet orally three times a day (tid). Review of the Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction letter dated 06/13/2024 revealed a gradual dose reduction was requested for the following medications: Seroquel (Quetiapine Fumarate) 400 mg bid, Abilify 30 mg hs, Celexa (Citalopram Hydrobromide)10 mg daily, and Ativan (Lorazepam) 0.5 mg tid. The physician documented a dose reduction was not appropriate and minimal effective dose. Further review revealed the physician failed to provide a handwritten valid clinical rationale as justification for not reducing the psychotropic medications. On 01/08/2025 at 1:50 p.m., an interview with S2DON confirmed the physician did not document a handwritten rationale as to why resident #11 's psychotropic medications were not reduced on the gradual dose reduction letter. Resident #15 Record review revealed resident #15 was admitted to the facility 07/25/2016. Resident #15's diagnoses included paranoid schizophrenia, insomnia, restlessness and agitation, and generalized anxiety disorder. Review of the January 2025 Physician's Orders included the following psychotropic medications: Risperidone 2 mg tablet give 1 tablet orally one time a day, Risperidone 3 mg tablet give 1 tablet orally at bedtime, and Lorazepam 0.5 mg tablet give 1 tablet orally bid. Review of the Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction letter dated 06/13/2024 revealed a gradual dose reduction was requested for the following medications: Risperdal (Risperidone) 2 mg every day and 3 mg every hs, and Ativan (Lorazepam) 0.5 mg bid. The physician documented a dose reduction was not appropriate and minimal effective dose. Further review revealed the physician failed to provide a handwritten valid clinical rationale as justification for not reducing a psychotropic medication. On 01/08/2025 at 1:50 p.m., an interview with S2DON confirmed the physician did not document a handwritten rationale as to why resident #15 's psychotropic medications were not reduced on the gradual dose reduction letter.

Based on record review, observations, and interview the facility failed to implement a comprehensive person-centered care plan for 1 (#15) of 2 (#13, and #15) residents reviewed for falls. The facility failed to ensure resident #15 had a fall mat in place beside his bed per the physician orders and in accordance with his plan of care. Record review revealed resident #15 was admitted to the facility on [DATE]. Resident #15's diagnoses included muscle wasting and atrophy multiple sites, other abnormalities of gait and mobility, unsteadiness on feet, paranoid schizophrenia, delusional disorders, manic episode severe with psychotic symptoms, generalized anxiety disorder, insomnia, and major depressive disorder. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 9 which indicated moderate cognitive impairment. Resident #15 was unable to ambulate and used manual wheelchair for locomotion. Further review revealed resident#15 required partial/moderate assistance with toileting, showers/bathing, dressing, and transfers. Resident #15 was frequently incontinent of bladder, and always incontinent of bowel. Review of active January 2025 physician orders revealed an order for a fall mat to open side of bed every shift (order start date 07/24/2024) and high risk for falls: resident is on the falling star program. Review of active care plans revealed resident #15 was at high risk for falls. An intervention included for a mat placed to open side of bed. On 01/06/2025 at 1:02 p.m., an observation of resident #15 revealed he was asleep lying in bed. The bed was in the lowest position. The right side of the bed was positioned against the wall. There was no fall mat noted on the floor on the left side of his bed. On 01/07/2025 at 11:40 a.m. an observation of resident #15 revealed he was asleep lying in bed. The bed was in the lowest position. The right side of the bed was positioned against the wall. There was no fall mat noted on the left side of his bed. Further observation revealed there was a blue fall mat lying on the floor underneath resident #15's bed. On 01/07/2025 at 11:56 a.m., an observation of resident #15 with S2Director of Nursing (DON) revealed resident #15 was asleep lying in bed. There was no fall mat on the left side of his bed. There was a blue fall mat lying on the floor underneath resident #15's bed. S2DON confirmed the fall mat should be positioned on the left side of resident # 15's bed according to the physician order and care plan.

Based on observations and interview, the facility failed to ensure the resident's environment remained as free of accident hazards as possible by failing to ensure resident rooms maintained a water temperature of less than 120 degrees Fahrenheit for 1 (#6) of 1 residents reviewed for accident hazards. Findings: On 01/06/2025 at 11:20 a.m. an observation of the water temperature in resident #6's bathroom sink revealed the hot water temperature was 127.6 degrees Fahrenheit. On 01/06/2024 at 12:17 p.m. observation of the water temperature in resident #6's bathroom sink with S1Administrator and S7Maintenance Supervisor, using the facility's thermometer, revealed the water temperature was 127.7 degrees Fahrenheit. S1Administrator confirmed the hot water temperature was too hot and should not be greater than 120 degrees Fahrenheit.

Based on interviews and record reviews, the facility failed to conduct a comprehensive and accurate assessment of each resident's functional capacity by failing to ensure the Minimum Data Set (MDS) Assessment was accurate for 1 (#32) of 2 (#5, and #32) residents reviewed for restraints. Findings: Review of the medical record of resident #32 revealed he had diagnoses which included mood disorder, difficulty walking, muscle wasting and atrophy, seizures and severe intellectual disabilities. On 01/06/2025 at 9:30 a.m., and on 01/07/2025 at 10:10 a.m., resident #32 was observed in a geri-chair with a lap tray. Review of the Pre-Restraining assessment summary dated 11/19/2024 indicated the resident could remove the lap tray from the geri-chair. On 01/07/2025 at 12:40 p.m., interview with S4MDS Nurse revealed the facility did not consider the lap tray to be a restraint because resident #32 could remove the lap tray. On 01/07/2025 at 12:40 p.m. S4MDS prompted resident #32 to remove his lap tray, but the resident was unable to remove the lap tray. Review of the Quarterly MDS assessment dated [DATE] revealed it was not coded accurately to indicate that a restraint was used for resident #32. On 01/07/2025 at 12:50 p.m., interview with S3Licensed Practical Nurse (LPN) revealed resident #32 was unable to remove the lap tray from the geri-chair. On 01/07/2025 at 1:00 p.m, interviews with S5Certified Nursing Assistant (CNA) and S6CNA revealed resident #32 was unable to remove the lap tray from the geri-chair. On 01/08/2025 at 9:20 a.m., interview with S4MDS Nurse confirmed the MDS assessment did not accurately identify the use of a lap tray as a restraint for resident #32.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 5 (#1, #6, #14, #19 and #33) of 5 residents rooms observed. The failed practice was evidenced by residents' air/heating units needed cleaning. Findings: Resident #1 Observations of the air/heating unit on 01/06/2025 at 10:41 a.m., and on 01/07/2025 at 8:28 a.m. located in resident #1's room revealed a buildup of dust and a black substance was observed on the air/heating unit vents. Resident #6 Observations of the air/heating unit on 01/06/2025 at 11:30 a.m., and on 01/07/2025 at 8:40 a.m. located in resident #6's room revealed dirt, dust and a black substance was observed on the air/heating unit vents. Resident #19 Observations of the air/heating unit on 01/06/2025 at 10:29 a.m., and on 01/07/2025 at 8:20 a.m. located in resident #19's room revealed a black substance was observed on the air/heating unit vents. On 01/07/2025 at 8:55 a.m. observation/interview was conducted with S1Administrator. S1Administrator confirmed resident #1, #6, and #19's air/heating units needed to be cleaned. 43405 Resident #33 Observation of the air/heating unit in resident #33's room on 01/06/2025 at 11:50 a.m. revealed a black substance inside the the vent and a dirt buildup surrounding the air conditioner vent. Resident # 14 Observation of the air/heating unit in resident #14's room on 01/06/2025 at 9:30 a.m. revealed a buildup of dust inside and outside of the air conditioner vent. On 01/07/2025 at 8:55 a.m. observation/interview was conducted with S1Administrator. S1Administrator confirmed resident #33 and #14's air/heating units needed to be cleaned.

Based on record reviews, observations and interviews, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility failed to protect resident #1 from physical abuse by resident #2. The deficient practice resulted in an actual harm for resident #1 on 10/05/2024 at 6:37 p.m. when resident #1 sustained injuries to the right and left side of his face from resident #2. Resident #1 was sitting outside when he was hit by resident #2 with an object across the left side of his face. Resident #1 stood up, backed away, raised his hands and attempted to walk away from resident #2. At this time, resident #2 hit resident #1 on the right side of the face. The sheriff's department was notified and came to the facility to start an investigation. Resident #1 was sent to a local hospital for evaluation and resident #2 was sent to a hospital for evaluation and treatment. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. The completion date was 10/07/2024. Findings: Review of the facility's Abuse/Neglect Policy Revision #12 - dated 12/11/2018 revealed the facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean or humiliate a resident(s). Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies, serving the resident, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect and misappropriation of property. Resident #1 Review of the medical record for resident #1 revealed an admitted [DATE] with diagnoses of type 2 diabetes mellitus, syncope and collapse, altered mental status, schizoaffective disorder depressive type, mood disorder, dementia, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a Brief Interview for Mental Status (BIMS) of 9 indicating the resident had moderate cognitive impairment for daily decision making. Further review of the MDS revealed the resident required supervision with one person physical assistance with bed mobility and transfers. Resident #1 did not exhibit any behaviors towards others, hallucinations, or delusions. Review of the physician's progress noted dated 10/01/2024 revealed the resident had schizoaffective disorder depressive type. Further review of the progress note revealed there was no reports of increased behaviors. Review of the hospital notes dated 10/05/2024 revealed resident #1 was diagnosed with an abrasion of the skin, and multiple skin tears. Review of the Computed Tomography (CT) of the maxillofacial report dated 10/05/2024 revealed no evidence of acute fractures. Review of the xray of the facial bones dated 10/11/2024 revealed no obvious orbital or zygomatic fractures were identified. Review of the xray of the mandible dated 10/11/2024 revealed no obvious acute displaced fracture or dislocation. On 10/21/2024 at 1:00 p.m., an interview with resident #1 revealed he was sitting outside in a chair by himself and resident #2 came up to him and hit him with something in the face two times. Resident #1 denied having an argument or a conversation with resident #2 prior to the incident. Resident #1 revealed he and resident #2 were outside smoking earlier on 10/05/2024 and they said hello to each other. Resident #1 revealed he had not had any altercations with resident #2 before. At this time, an observation of resident #1 revealed he did not have any open areas, bruising or swelling on his face. Resident #2 Review of the medical record for resident #2 revealed an admitted [DATE] with diagnoses including alcohol use, major depression severe with psychotic symptoms, anxiety, and major depressive disorder. Resident #2 was discharged to the community on 10/06/2024. Review of the quarterly MDS assessment dated [DATE] revealed resident #2 had a BIMS score of 15 which indicated the resident was cognitively intact for daily decision making. Resident #2 did not exhibit any behaviors towards others, hallucinations, or delusions. Resident #2 required supervision with one person physical assist with bed mobility and transfers. Review of the Incident Report dated 10/05/2024 at 7:10 p.m. revealed resident #1 ambulated to the nurses station bleeding from under his right eye and the bridge on the right side of his nose. A tennis ball sized raised area was noted to resident #1's left lower jaw. Resident #1 stated that skinny person hit me and he needs to go to the mental institution. Each resident was placed on 1:1 with staff. Facial areas cleansed and left open to air. No further bleeding. Review of the Incident Report dated 10/05/2024 at 7:42 p.m. revealed resident #1 had reported to nurses station with facial trauma stating that he had been hit outside. This nurse reported to men's patio to conduct investigation where resident #2 was found sitting in a chair and admitted to the assault. Resident #2 stated I hit that m------ f------ with my fist two times and you can call the law I do not give a f---. Resident #2 was placed on 1:1 observation and assessed for injury. Review of the facility's Investigative Report dated 10/05/2024 at approximately 7:00 p.m. revealed, S5Licensed Practical Nurse (LPN) reported to S2Director of Nursing (DON) that there had been a resident to resident incident. S2DON notified S3Assistant Director of Nursing (ADON) and S1Administrator. S3ADON arrived to the facility at approximately 7:15 p.m. Resident #2 was in his room with S7Cerfified Nursing Assistant (CNA) sitting 1:1. Resident #1 was in the dayroom with a S8CNA sitting upright in a chair awake and alert. S3ADON reviewed the camera footage and at 5:55 p.m. resident #2 and resident #1 were both witnessed by S6CNA sitting near one another on the men's patio during a supervised smoke break. There was no indication that the two may be quarreling. Resident #2 was pleasant and chatting with the staff. Resident #2 was last seen by S6CNA at 6:30 p.m. sitting at a table in the dining room. Camera footage confirms this and shows resident #2 then ambulated to the men's patio where he sat until the incident began at 6:36 p.m. Resident #1 was seen by staff ambulating throughout facility and grounds from 6:00 p.m. - 6:36 p.m. when the incident began. There was no event leading up to the incident. It was seemingly unprovoked. On the men's patio, resident #2 was sitting in a chair, sees resident #1 walk from behind the building and sit down in a chair more than 20 feet away. It does not appear that any words were exchanged at this time. Resident #2 goes inside the building and returned back to the men's patio at 6:37:17 p.m. with a long round object in his right hand and walks directly up to resident #1 who remains seated, and appears to be exchanging words. At 6:37:32 p.m., resident #2 strikes resident #1 with the object across his left face. Resident #1 stands up, backs away, raises hands and attempts to walk away. At 6:37:41 p.m., resident #2 strikes resident #1 again, this time across the right face. Resident #1 continues to try to walk away while resident #2 appears to be shouting at him while holding the object in his right hand in a threatening manner. At 6:38:04 p.m., resident #2 walked back into building to his room. At this time, resident #1 ambulated to a chair on the men's patio and sits down for approximately 2 minutes. Resident #1 then ambulated inside of facility through the back breeze way and ambulated to the nurses station at 6:44 p.m. to self-report incident. Resident #1 complained of pain to the right maxilla and left mandible. There is a superficial laceration over the right maxilla and [NAME] of nose. There is some mild soft tissue swelling to the right maxilla and moderate bruising noted to the right maxilla. There is significant soft tissue swelling noted over the left mandible. Areas were cleansed and patted dry. At 6:57 p.m. S5LPN located resident #2 on the men's patio to begin an investigation. Resident #2 was immediately placed on 1:1 supervision. The physician was notified of the incident. New orders were obtained to send resident #1 to the emergency room for evaluation and treatment and the local Sherriff's department was notified of the incident by S3ADON. Review of the nurses notes dated 10/05/2024 at approximately 6:45 p.m. revealed resident #1 was standing in front of the nurses station. The nurse looked up and saw resident, noted facial bleeding and a tennis ball sized raised area to left cheek, facial area cleansed per nursing home protocol and then noted area under his right eye that measured approximately 3 and a half centimeters and right side bridge of nose that measured approximately 3 centimeters, resident states pain is a 5 on the pain scale of 1 to 10. Review of the nurses notes dated 10/05/2024 at 8:05 p.m. revealed resident #2 stated that peer (referring to resident #1) was walking around with clinched fists stating I am gonna kill someone and he said I walked up to him (referring to resident #1) and hit him in the face with my fist two times. On 10/21/2024 at 11:45 a.m., review of the video recording with S1Administrator revealed resident #2 was seen sitting outside on 10/05/2024 at 6:36 p.m. with two other residents on the patio. Resident #1 walked from the side of the building, resident #2 saw resident #1 and he walked inside the building and came back outside to the patio at 6:37 p.m. with a long round object. At 6:37 p.m., resident #2 walked to the area in which resident #1 was sitting and resident #2 hit resident #1 on the left side of the face with the long round object. Resident #1 stood up and tried to walk away. On 10/05/2024 at 6:37 p.m., resident #2 struck resident #1 across the right side of the face. Further review of the video recording revealed at 6:38 p.m. resident #2 walked inside and resident #1 sat in a chair on the back patio. At 6:44 p.m., resident #1 went inside the building to the nurses station. On 10/22/2024 at 3:16 p.m., interview with S5LPN revealed she didn't know anything about an altercation between resident #1 and resident #2 on 10/05/2024 until resident #1 came to the nurses' station and informed her that the skinny guy hit him. S5LPN revealed she found out that resident #2 was the person that hit resident #1. She found resident #2 on the patio and he told her that he hit resident #1. S5LPN revealed resident #2 was immediately placed on 1:1 observation. The Administrative staff and physician were notified. The ambulance was notified to transport resident #1 to the emergency department. S5LPN revealed the Sheriff's department was notified and they came and escorted resident #2 out of the building to the emergency department for evaluation. On 10/28/2024 at 10:15 a.m., interview with S2DON confirmed resident #2 hit resident #1 two times with a long object causing facial injuries. The Sherriff's department transported resident #2 to the emergency room for evaluation and treatment. Resident #1 was transported by ambulance to the emergency department for evaluation and treatment. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility implemented the following actions with a completion date of 10/07/2024. 1. Resident #1 was placed one on one with a nurse at the nurses' station. 2. Resident #2 was placed one on one with a CNA in his room, no other roommates were in the room at this time. 3. The facility searched for any objects that could be used as a weapon inside the facility and facility outside grounds. (Floor fan rod and fan removed from resident #2's room) 4. Baseline of safety checks conducted by S3Assistant Director of Nursing (ADON) with all residents in the facility. 5. On 10/05/2024, S2DON and S3ADON interviewed all interviewable residents to ensure they felt safe in the facility. 6. On 10/05/2024, S3ADON assessed all non interviewable residents for evidence of injury or trauma. 7. Monitor initiated on 10/05/2024 for monitoring for any object that can be used as a weapon. 8. Monitor initiated on 10/05/2024 to review a random sample of residents to ensure they feel safe in the facility. 9. Monitor initiated on 10/05/2024 to observe for agitation in a random sample of residents. 10. Monitor initiated on 10/05/2024 to review a random sample of nurses' notes on a random sample of residents for documentation of agitation. 11. On 10/06/2024 resident #2 was discharged from the hospital and was sent home with his family. 12. All staff were inserviced on 10/07/2024 by S3ADON discussing recognizing early intervention of the potentially aggressive residents. 13. On 10/07/2024, S3ADON talked to resident #1 whom indicated he no longer feels fearful. Review of the Quality Assurance Performance Improvement (QAPI) records revealed the following: The facility will monitor and interview a random sample of residents to ensure they feel safe in the facility. This monitor will also assess a random sample of non interviewable residents to ensure no evidence of injury or trauma. The monitor will be completed by S2DON or designee at least 3 times a week for 4 weeks, then every month. A monitor was created to observe for agitation in a random sample of residents. The monitor will be completed by S2DON or designee at least 3 times a week for 4 weeks, then every month. A monitor was created to review a random sample of nurses' notes on a random sample of residents for documentation of agitation, arguing and fighting. The monitor will be completed by S2DON or designee at least 3 times a week for 4 weeks, then every month. A monitor was created for each resident's room to be checked for any objects that could be used as a weapon. The monitor will be completed by S2DON or designee one time a week for 4 weeks, then monthly.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (#3) of 1(#3) residents investigated for position and mobility. The facility failed to ensure resident #3 had proper positioning device, foot rest supports for wheelchair, to prevent feet from dangling. Findings: Review of the record for resident #3 revealed an admitted [DATE] with following diagnoses: muscle wasting and atrophy and history of falling. Review of the 11/13/2023 quarterly MDS (Minimal Data Set) assessment for resident #3 revealed mobility devices, wheelchair, used daily. Review of care plan revealed resident #3 was at high risk for falls related to unsteady gait. Falls documented on the following dates: 02/16/2023; 04/23/2023; 05/24/2023 and 07/29/2023. Further review of the care plan for falls revealed approaches included pommel cushion to wheelchair when in wheelchair and lap buddy to wheelchair when in wheelchair. Review of the January 2024 physician orders for resident #3 revealed the following: high risk for falls; lap buddy to wheelchair for positioning, pommel cushion to chair at all times for positioning. Observation on 01/29/2024 at 8:45 a.m. revealed resident #3 sitting in wheelchair in his bedroom. Further observation revealed resident #3 feet were dangling from chair approximately 6 inches off the floor. No foot rest supports were observed on the wheelchair. Interview at this time with S7CNA (Certified Nursing Assistant) confirmed that resident #3's feet were dangling and she was not aware if his wheelchair had any foot rest supports. She reported that she has worked with the resident for about 6 months and had not observed him to have any foot rest supports on the wheelchair. Observation on 01/29/24 at 1:17 p.m. revealed resident #3 in dining area, and sitting in the wheelchair with his legs dangling. No foot rest supports observed. Observation on 01/29/2024 at 3:00 p.m. revealed resident #3 in his room; sitting in the wheelchair and his feet were dangling, not touching the floor. Interview with S5CNA at this time confirmed that resident #3 feet were dangling and that she was unaware of any foot rest supports used for resident #3. Observation on 01/30/2024 at 7:11 a.m. revealed resident #3 in dining area. Resident #3 was observed sitting in the wheelchair with feet dangling, unable to touch the floor. Observation on 01/30/2024 at 9:00 a.m. revealed resident #3 sitting in wheelchair in his room with feet dangling. Resident #3 was fidgeting and mumbling. S8CNA was observed at this time assisting resident #3 with putting on a shirt. Interview with S8CNA at this time revealed that she has worked with resident #3 for 5-6 months. S8CNA reported that resident #3 was supposed to have foot supports/rests on the wheelchair but did not attempt to locate at this time. Observation on 01/31/2024 at 7:50 a.m. of resident #3 revealed sitting up in wheelchair with his feet dangling off the floor; no foot supports in place on the wheelchair. Interview on 01/31/2024 at 7:55 a.m. with S3Therapy Supervisor revealed that the therapy department provided therapy for resident #3 in 08/2023. He reported that nursing placed resident #3 in the wheelchair. He reported that resident #3 should have foot rest supports in place on the wheelchair to prevent feet from dangling. Interview on 01/31/2024 at 8:07 a.m. with S4LPN (Licensed Practical Nurse) confirmed that resident #3's feet were dangling and that he should have foot rest supports in place on the wheelchair to prevent his feet from dangling. Interview on 01/31/2024 at 8:10 a.m. with S2DON (Director of Nursing) confirmed that resident #3's feet were dangling and he should have foot rest supports in place. Surveyor explained that resident #3 has not had foot rest supports in place for the entire survey. It was further explained that 3 CNAs that worked routinely with resident #3 were not aware of foot rest supports ever being used for resident #3 and they did not attempt to notify a nurse or locate any foot rest supports. At this time, S2DON was observed placing foot rest supports on the wheelchair for resident #3.

Based on observations, record reviews, and interviews, the facility failed to provide necessary care and services that is in accordance with professional standards of practice for 3 (#29, #32, and #202) of 3 residents reviewed for respiratory care. The facility failed to 1) properly change the humidifier bottle and nasal cannula and label them with the date it was changed for residents #29, #32, and #202 and 2) post No Smoking signs at the entrance to their rooms for residents #32 and #202 per the oxygen administration policy. The facility failed to properly change the nebulizer tubing and mask per the plan of care for resident #202. Findings: Review of the facility's policy regarding oxygen therapy revealed: While oxygen is in use, No Smoking, signs will be posted at the entrance to the room. Humidifier bottles, cannulas and oxygen tubing will be changed at least once weekly and dated. Resident #29 Observations of the resident's room on 12/05/2022 at 9:45 a.m., 12/06/2022 at 10:55 a.m., and on 12/07/2022 at 9:20 a.m., revealed the resident's humidifier bottle and oxygen tubing was not labeled with a date. Review of the resident's medical record revealed he had a diagnosis of Chronic Obstructive Pulmonary Disease and Lung Cancer. He also had an order for oxygen to be administered at 2 liters per minute. On 12/07/2022 at 10:20 a.m., interview with S4LPN (Licensed Practical Nurse) confirmed the resident's oxygen tubing and humidifier bottle was not labeled with a date. Resident #32 Observations of resident #32 on 12/05/2022 at 9:50 a.m., on 12/06/2022 at 10:50 a.m., and on 12/07/2022 at 9:00 a.m. revealed the resident's humidifier bottle and oxygen tubing was not labeled with a date and a No smoking sign was not posted near the entrance to the room. Review of the resident's record revealed he had a diagnosis of lung cancer and an order for oxygen to be administered at 2 liters per minute. On 12/07/2022 at 10:25 a.m., interview with S3LPN confirmed the oxygen tubing was not dated and a no smoking sign was not posted at the entrance to the room. 19256 Resident #202 Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, pulmonary embolism and infarction, morbid obesity, atherosclerotic heart disease, congestive heart failure, and supplemental oxygen dependence. Review of the current physician orders revealed the following orders: 1) oxygen at 3 L (Liters) per minute continuously, utilize portable unit for bathing, toileting, and transport in hallways and common areas and 2) Ipratropium 0.5 mg (milligrams) - albuterol 3 mg/3 milliliters nebulization solution - 1 vial per handheld nebulizer inhalation as needed four times a day when necessary for shortness of breath or wheezing. Review of the care plan revealed: potential for impaired gas exchange - shortness of breath related to diagnosis of chronic obstructive pulmonary disease, chronic allergies, and shortness of breath. Review of the interventions revealed oxygen at 3 Liters per minute continuously, utilize portable unit for bathing, toileting, and transport in hallways and common areas, change oxygen tubing and humidifier bottle weekly and clean filter, change handheld nebulizer tubing and mask every week. Review of the Medication Administration Record for November 2022 revealed the resident received a nebulizer treatment on 11/27/2022. Review of the nurses' notes for December 2022 revealed the resident received a nebulizer treatment on 12/01/2022. Observation on 12/05/2022 at 9:50 a.m. revealed the resident was up in her wheelchair at the nurses' station with portable oxygen at 3L per nasal cannula. The oxygen tubing was not labeled with a date. Observation at 10:00 a.m. of the resident's room revealed there was not a No smoking sign at the entrance of the resident's room and there was an oxygen concentrator in the room with the nasal cannula on the bed. The humidifier bottle and oxygen tubing was not labeled with a date. There was also a mask nebulizer on the bedside table that was not labeled with date. Observation on 12/06/2022 at 2:00 p.m. and 12/07/2022 at 9:10 a.m. revealed the resident was in her room with her oxygen at 3 L per nasal cannula. The resident's humidifier bottle and oxygen tubing was not labeled with a date. An interview with S3LPN on 12/07/2022 at 10:30AM confirmed the oxygen tubing, humidifier bottle and nebulizer mask were not labeled with dates. On 12/07/2022 at 10:35 a.m., an interview with S2DON (Director of Nursing) confirmed the oxygen tubing and humidifier for residents #29, #32, and #202 should be labeled with a date and changed weekly and the nebulizer mask and tubing for resident #202 should be labeled with a date and changed weekly. S2DON further confirmed the No Smoking signs should be posted on residents #32 and #202's doors.

Based on record review and interview the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#1) of 5 (#1-#5) sampled residents by: 1. Failing to timely report to the physician when Resident #1's sacral area pressure ulcer began to deteriorate and show signs of infection and 2. Failing to identify an unstageable pressure ulcer to Resident #1's right heel. This failed practice resulted in an actual harm for Resident #1 on 02/25/2022 at 6:03 PM when Resident #1's sacral area pressure ulcer was found to have a moderate amount of yellow drainage, an odor present and painful. At that time, the resident's physician nor the DON (Director or Nurses) were notified of the changes in the condition of the pressure ulcer by S2 LPN (Licensed Practical Nurse). The physician was not notified of the changes until 02/28/2022 when the DON first became aware of the change. On 02/28/2022 after notification, the physician ordered Resident #1 to be sent out for wound care. The resident was admitted to a specialty hospital on 03/01/2022 for wound care treatment and intravenous antibiotics for the pressure ulcers. Findings: Review of the record for Resident #1 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS (Minimum Data Set) dated 02/13/2022 revealed a BIMS (brief interview for mental status) score of 13 which indicated the resident was cognitively intact. Further review of the MDS revealed the resident required extensive assistance by two persons with bed mobility, transferring, and toilet use. Further review of Resident #1's record revealed an assessment by S1 DON on 02/23/2022 of an unstageable pressure ulcer to right buttock that was identified on 02/23/2022. S1 DON described it as having scant serous drainage with no infection or pain and measured 8 cm (centimeters) x 5 cm x 0.10 cm. S1 DON documented notifying the nurse practitioner and obtaining wound care treatment orders. On 02/23/2022, the nurse practitioner ordered to cleanse the unstageable pressure ulcer to the sacrum with wound cleanser, pat dry, apply Santyl (product used to aid in healing ulcers) to the wound bed and cover with [MEDICATION(S)] (a foam absorbent dressing) bordered gauze every day until healed. Review of Resident #1's nurses' notes revealed the following entry: 02/25/2022 at 6:03 PM: Upon performing wound care, noted that skin has sloughed away at areas spanning from left buttock across sacrum to right buttock. Light pink granulation tissue noted to direct wound edges. Edges are not even. Eschar noted to center of left buttock approximately 2 cm in diameter. Yellow slough to sacral area and scattered to bilateral buttocks. Moderate amount of yellow drainage. Odor present. No heat to area. Painful. Monitoring for changes and will report to MD (Medical Doctor) as needed or as directed. Signed by S2 LPN (Licensed Practical Nurse). In an interview at 2:42 PM on 03/21/2022, S2 LPN confirmed when she performed Resident #1's sacral pressure ulcer wound care on 02/25/2022, the pressure ulcer had continued to enlarge since her return to the facility 02/11/2022. S2 LPN reported it had grown to both buttocks and was now shaped like a butterfly with wings on each buttock. She confirmed it was now draining yellow drainage and had an odor. S2 LPN reported it was now painful to the resident because Resident #1 was grimacing when wound care was performed on 02/25/2022. S2 LPN reported she did not call the physician to report the changes and doesn't remember if she reported it to S4 ADON (Assistant Director of Nurses) or S1 DON. S2 LPN confirmed the facility did not have a wound care nurse and all wound care was performed by the floor nurse caring for the resident. Review of a wound assessment by S1 DON dated 02/28/2022 revealed the following: Right buttock Pressure Ulcer identified on 02/23/2022, which was not present on admission has deteriorated. Unstageable due to slough/eschar; serous, scant drainage. No infection. Pain with treatment-yes; pain intensity-moaning, grimacing; measured 15 cm x 8 cm x 0.1 cm; 20% epithelial tissue and 80% granulation tissue; Physician notified 02/28/2022. Additional notes: Wound is now malodorous. Dr. ______ aware. Will refer for wound care. In an interview on 03/22/2022 at 11:30 AM, S1 DON reported on 02/28/2022 she was asked by S3 LPN to go assess Resident #1's pressure ulcer. S1 DON reported the pressure ulcer was malodorous and the top skin was gone from cheek to cheek. S1 DON reported she called Dr. _____ and received an order to send the resident out for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . S1 DON confirmed she was not notified by S2 LPN of Resident #1's change of the sacral pressure ulcer on 02/25/2022 and first became aware of the change on 02/28/2022 when S3 LPN asked her to assess the wound. She confirmed Resident #1 needed an intervention on 02/25/2022 but she nor Dr. ______ were made aware until 02/28/2022. She reported if she had been notified on 02/25/2022 of the drainage, odor, and pain she would have told staff to send Resident #1 to the hospital for treatment. She further confirmed when she called Dr. _____ on 02/28/2022 about the changes, he reported he was not aware of the change in the condition of the wound either. Review of the hospital records for Resident #1's revealed an admit wound assessment dated [DATE] at 1PM which noted a right heel DTI (deep tissue injury) that measured 3 cm x 6.5 cm x 0 cm and an unstageable wound to coccyx/bilateral gluteal that measured 4.5 cm x 13 cm x 0 cm that were documented as present on admission. Further review revealed the pressure ulcer to the coccyx/bilateral gluteal area had a moderate amount of purulent drainage and an odor present. Review of the Physician's admit History and Physical revealed the plan for Resident #1 included antibiotics and wound care. Review of facility policy titled Ulcer Management revealed the following: C. Monitoring . 3. Discharge Procedure: A full body skin audit will be conducted and documented by a nurse prior to discharge to a hospital (if time permits) and prior to an extended home leave. The audit should focus on observation for new wounds not already being treated, as well as current problem areas. Other Treatment Considerations and Protocols: a) MD Notification: The MD will be notified of the development of a pressure area or of a significant change in an existing area so that orders for treatment may be obtained or plan of care changed. In an interview at 2:00 PM on 03/22/2022, S4 ADON confirmed a discharge full body skin audit was not performed on Resident #1 prior to discharge on 03/01/2022. Review of Resident #1's medical record failed to reveal any evidence or documentation of a deep tissue injury to the right heel. In an interview at 2:00 PM on 03/22/2022, S1 DON confirmed she was unaware Resident #1 had a deep tissue injury to her right heel.

Based on observation, record review, and interview, the facility failed to ensure a resident maintained acceptable parameters of nutritional status by failing to implement the Registered Dietitian's recommendations and provide all ordered supplements for a resident with significant weight loss for 1 (#47) resident out of 1 resident reviewed for nutrition. Findings: Resident #47 During an observation on 01/03/2022 at 9:44 AM, Resident #47 was sitting in a wheelchair in her room. Resident #47's legs were noted to be very thin. Review of Resident #47's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS (Minimum Data Set) dated 12/14/2021 revealed Resident #47 had severely impaired cognitive skills and never or rarely made decisions. Further review of the MDS revealed Resident #47 required extensive assistance with eating. Review of Resident #47's medical record revealed the following weights: 08/02/2021-133.4 pounds 09/08/2021-130 pounds 12/16/2021-105 pounds, which represented a significant weight loss of 21% over a 4 month period Review of the nurses' notes revealed the following entries by S2 RD (Registered Dietitian): 10/22/2021: Weight is 120 pounds with a 10 pound weight loss (8%) noted since 09/08/2021 . Recommendations: Begin House Supplement 2.0, 90ml (milliliters) three times per day to help prevent further weight loss 11/05/2021: Weight is 112 pounds with a 16% weight loss noted times 6 months and an 8# (6.5%) weight loss noted since 10/06/2021.Recommendations: Begin House Supplement 2.0 60 ml three times per day to help prevent further weight loss and provide extra nourishment. Will continue to monitor and make further recommendations as needed. Review of Resident #47's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 12/03/2021: Give 4 ounces of ice cream or pudding with all meals and document intake. 11/17/2021: House Supplement 2 cals/cc (calories per cubic centimeter) give 240 cc by mouth with med pass three times per day to aid in nutritional status. Document percentage of intake. Review of the MARs (Medication Administration Records) for 10/2021 and 11/2021 revealed the house supplement ordered by S2 RD on 10/22/2021 and 11/05/2021 was never initiated or given to Resident #47. Further review of the MARs revealed a house supplement was first given to Resident #47 on 11/17/2021 after it was ordered again by the nurse practitioner. During an observation on 01/04/2022 at approximately 11:50 AM, Resident #47 was being assisted with lunch by S3 CNA (Certified Nursing Assistant). Resident #47's lunch tray was noted to have a mechanical soft diet with roast, sweet potatoes, okra and tomatoes, cornbread, and bread pudding. The tray was noted to have ice tea but no ice cream or pudding. S3 CNA confirmed she feeds the resident whatever is on the tray by dietary. She confirmed there was no ice cream or pudding on the lunch tray. During an interview on 01/04/2022 at 12:58 PM, S1 ADON (Assistant Director of Nurses) confirmed S2 RD's recommendations to add the house supplement on 10/22/2021 and 11/05/2021 had not been implemented timely and should have been. S1 ADON further acknowledged there was no ice cream or pudding on Resident #47's lunch tray today, as ordered.

Based on observation, record review, and interview the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 1 (#20) of 4 (#20, #35, #40, and #51) residents reviewed for activities of daily living. The facility failed to ensure Resident #20's fingernails were cleaned and trimmed in a timely manner. Findings: Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS (Minimum Data Set) dated 10/26/2021 revealed BIMS (Brief Interview for Mental Status) score 15 which represented he was cognitively intact. Review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan revealed self-care deficit: Resident will receive person centered care. Resident needs assistance with bathing, hygiene, dressing, and grooming. Intervention include check, clean, and or trim fingernails and toenails weekly by LPN. On 01/03/2022 at 9:25 AM an observation of Resident #20 revealed fingernails on both hands were long with brownish colored grime noted under fingernails. Resident #20 reported that he was diabetic and the nurse trims his fingernails. On 01/04/2022 at 11:28 AM an observation of Resident #20 revealed he was lying in bed watching television. Further observation revealed his fingernails on both hands were long. Resident #20 reported that is has been a while since the nurse has trimmed his fingernails. On 01/04/2022 at 1:08 PM an interview conducted with S1 ADON (Assistant Director of Nurses) in Resident #20's room revealed his fingernails were long and needed to be trimmed. S1 ADON confirmed that Resident #20's fingernails were long and needed to be cleaned and trimmed.

Based on interviews and observations, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of flies. This deficient practice had the potential to affect all 50 residents residing in the facility. Findings: During the initial tour of the facility on 07/06/2021 at 9:30AM, there were multiple flies in every resident room. There were also multiple flies in the hallways, whirlpool room, and dining room. Further observation in the dining room revealed the air fan at the exit door where the residents exit to one of the smoking areas was off. There was one fly strip in the facility located in the dining room. An interview on 07/06/2021 at 10:00AM with S3Certified Nursing Assistant revealed the facility has a problem with flies at this time. An interview on 07/06/2021 at 11:00AM with resident 7 who is independent with daily decision making revealed the facility has trouble with flies. The resident reported the flies are crazy around here. An interview on 07/06/2021 at 12:00PM with resident 6 (who is the resident council president and is alert and oriented) revealed the facility has a problem with flies. An interview on 07/06/2021 at 1:00PM with S1Administrator revealed the facility usually has a problem with flies from April to October. He reported pest control sprays every month. An interview on 07/06/2021 at 1:15PM with the pest control employee revealed he has been servicing the facility every month since January 2021. He reported the spray he uses outside is more effective than the inside spray, but he didn't do it last month because it was raining too badly. He reported legally they can spray inside and outside every 14 days. An interview on 07/07/2021 at 8:40AM with resident 1 revealed the flies bother her. An interview on 07/07/2021 at 9:00AM with S4Registered Nurse revealed the facility does have quite a bit of flies. An interview on 07/07/2021 at 12:25PM with S2Director of Nursing revealed the flies were an issue. An interview on 07/07/2021 at 12:45PM with resident 8 who was alert and oriented revealed the flies were bad. An interview on 07/08/2021 at 9:00AM with S1Administrator revealed they have not addressed the fly issue in their Quality Assurance meetings.

Based on review of the activity calendar, record review, interview, and observation, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community by not offering scheduled activities on the weekends. There are 52 residents able to attend scheduled activities. Findings: Resident #24 Review of the medical record for resident #24 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident had independent cognitive skills for daily decision making. Further review revealed the resident had signs and symptoms of [MEDICAL CONDITION] and mood disorder. Further review revealed the resident required supervision for bed mobility, transfer, dressing, and personal hygiene. Review revealed one person limited assistance with toilet use. The resident was occasionally incontinent of bladder and always continent of bowel. Review of the careplan revealed potential for social isolation related to facility admission. Further review revealed the following approaches: provide resident verbal reminders of upcoming activities, reinforce attendance at activities with verbal praise, invite family/friends to attend selected activities with resident, where possible allow resident to select seating location at activities, post personal activity schedule in resident's room, visit with resident and assist as needed with selecting the activities that the resident is interested in and will plan to attend. Review of the 12/03/19 activity progress notes revealed today visit resident in her room, resident is an unsafe smoker that requires supervision via staff during scheduled smoke breaks, she spends one third to two thirds times in her room or moving about the facility and one third to two thirds of her time in activities. she naps 15-30 minutes during the daytime, she particularly enjoys writing in notebooks and looking up words in her dictionary, resident will participate in food socials with passive participation but has recently started to attend more scheduled activities and the participation level is gradually increasing, resident recently started attending morning exercise class once or twice a week with active participation. Observation on 0[DATE] revealed there were no scheduled activities offered. Observation of the Activity Calendar for February revealed on Saturdays the calendar stated, Free Choice and on Sundays the calendar stated, TV time. Observation on 0[DATE] at 11:00AM revealed there was not an activity calendar posted in the resident's room. Observation on 0[DATE]20 at 10:19AM revealed the resident was participating in the exercise activity. Observation on 02/18/2020 at 1:45PM revealed the resident was at the Mardi Gras craft activity in the dining room. An interview with S11Activity Director on 0[DATE]20 at 11:10AM revealed the weekend Registered Nurse volunteered to help with activities on the weekend. There are games available and movies to pick from to watch. There are not any scheduled activities on the weekend. An interview with S1Administrator on 0[DATE]20 at 2:00PM confirmed there were no scheduled activities on the weekend. Resident #26 Review of the medical record revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required supervision with bed mobility and eating. The resident required one person limited assistance with transfers, dressing and personal hygiene. The resident required one person extensive assistance with toilet use and bathing. Review of the careplan revealed depression, anxiety, socially inappropriate behavior at times, this is her usual baseline status, impaired psychological well-being and activity intolerance related to [MEDICAL CONDITION]. Further review revealed the following approaches: escort to activities per resident request, encourage to attend activities as offered, encourage activities and relationships with other residents, provide 1:1 visits when chooses to avoid group programs, schedule time to pursue activities of choice, observe/monitor interest/participation in activities, encourage and assist resident to day or activity room, provide music and TV daily, encourage to talk, and walk and to get out of room. Review of the activity progress note dated 0[DATE]20 revealed: today visit resident in the resident's room, resident does not use tobacco products of any kind she spends one third to two third times in activity and one third of her time in her room or socializing with others, resident naps 15-30 minutes per day, resident very willing to try new activities with some cuing and is cooperative in following directions, activity participation is generally active but needs cueing at times, resident enjoys playing bingo, attending parties, or church and going on outings, she also attends morning exercise three days a week which she enjoys, resident is generally cheerful in passing and in all activities. Observation on 0[DATE] revealed there were no scheduled activities offered. Observation of the Activity Calendar for February revealed on Saturdays the calendar stated, Free Choice and on Sundays the calendar stated, TV time. Observation on 02/18/2020 at 1:45PM revealed the resident was at the Mardi Gras craft activity in the dining room. An interview with S11Activity Director on 0[DATE]20 at 11:10AM revealed the weekend Registered Nurse volunteered to help with activities on the weekend. There are games available and movies to pick from to watch. There are not any scheduled activities on the weekend. An interview with S1Administrator on 0[DATE]20 at 2:00PM confirmed there were no scheduled activities on the weekend. Resident #51 Review of the medical record for resident #51 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident had modified independent cognitive skills for daily decision making. The resident required supervision and set up for transfers, bed mobility, dressing, eating, personal hygiene, toilet use and bathing. The resident was always continent of bowel and bladder. Review of the careplan revealed potential for [MEDICAL CONDITION] and potential for social isolation related to paranoid [MEDICAL CONDITION]. Further review revealed the following approaches: encourage resident to participate in activities during the day, post activity calendar next to dining room for visibility, assist resident with selecting appropriate activities, provide resident with verbal reminders of upcoming activities, offer verbal praise to reinforce positive social behavior in group activities settings, if resident unable to tolerate group activities setting, provide one to one visits and individualized activities program, and until resident can resume participation in group activities settings. Review of the activity progress note dated [DATE]20 revealed: today visit resident in her room, resident is a unsafe smoker that requires supervision via staff during scheduled smoke breaks, she spends one third to two thirds time in activity and one third time to two thirds time ambulating around the facility and visiting with other residents, she goes on some outings, plays games, likes to watch TV and listen to music. She is very eager to help and participate in activities but prefers afternoon activities. She naps 15 to 30 minutes during daytime. she is very persistent in keeping up with activities and has recently began attending exercise class a couple times a week. She is sometimes quick to remind staff of schedule. resident actively participates in all that she attends with a cheerful disposition. Observation on 0[DATE] revealed there were no scheduled activities offered. Observation of the Activity Calendar for February 2020 revealed on Saturdays the calendar stated, Free Choice and on Sundays the calendar stated, TV time. Observation on 0[DATE]20 at 10:19AM revealed the resident was participating in the exercise activity. Observation on 02/18/2020 at 1:45PM revealed the resident was at the Mardi Gras craft activity in the dining room. An interview with resident #51 on 02/18/2020 at 11:00AM revealed she likes to play Bingo. She further stated that there are not any activities on the weekends. She stated that she would participate in Bingo on the weekend if it was offered. An interview with S11Activity Director on 0[DATE]20 at 11:10AM revealed the weekend Registered Nurse volunteered to help with activities on the weekend. There are games available and movies to pick from to watch. There are not any scheduled activities on the weekend. An interview with S1Administrator on 0[DATE]20 at 2:00PM confirmed there were no scheduled activities on the weekend.

Based on record review and interview, the facility failed to ensure a potential allegation of abuse was thoroughly investigated and reported to the appropriate individuals and agencies. This deficient practice involved 1 of 1 (#11) residents reviewed for potential abuse, out of a total sample of 25 residents. Findings: Review of the medical record for resident #11 revealed he was a [AGE] year old male with an admission date of [DATE]. Review of the [DIAGNOSES REDACTED]. Further review of record for resident #11 revealed current BI[CONDITION] (brief interview for mental status) score of 9 which indicates modified independent cognitive skills for daily decision making. Review of the facility's investigative report for resident #11 dated 02/02/2020 at 8:00PM revealed resident #11 had been hit by another resident (Resident #53). Interview on 02/18/2020 at 11:00AM with S1 Administrator revealed that he was not notified of incident regarding resident #11 until 02/03/2020. Further interview with S1 Administrator revealed that no abuse investigation was completed regarded this incident and that no SI[CONDITION] (state incident management system) report was initiated. S1 Administrator also stated that the local police was not notified regarding this incident on 02/02/2020.

Based on observation, record review and interview the facility failed to provide appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1(#23) of 1 (#23) residents reviewed for range of motion and mobility out of a total sample of 19 residents. Findings On 01/14/19 at 01:52PM resident # 23 was observed having a right hand contracture without an anti-contracture device (splint) in place. On 01/15/19 at 02:47PM resident # 23 was observed sitting up in a geri chair at the bedside in his room with no anti-contracture device noted in right hand. Resident answered simple questions appropriately. Resident acknowledged that a splint or hand roll had not been placed in his right hand in a long time. On 01/16/19 at 09:43AM resident # 23 was observed sitting up in a geri chair at the bedside with no anti-contracture device noticed to right hand. Record review revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Further review of the MDS (Minimum Data Set) dated 10/12/10 under section G (functional abilities) revealed resident # 23 had impairment of one side of upper extremities. Further record review revealed two specific active orders dated 05/09/17 as follows: 1) Place cone shaped anti-contracture device in right hand at 8 AM daily 2) Remove contracture orthosis from right hand q (every) 4 PM Further review of the MAR (medication administration record) dated 01/01/19 through 01/16/19 revealed documentation that a cone-shaped anti contracture device had been placed in the right hand every morning at 08:00AM and was removed at 4 pm every day. The MAR indicated [REDACTED]. On 01/16/19 at 10:59AM an interview with S5LPN confirmed that the cone shaped anti-contracture device had not placed in right hand at 08:00AM everyday as documented.

Based on observation, record review, and interview the facility failed to ensure that 1(#13) of 3 (#13, #34, #43) sampled residents reviewed for accidents received adequate supervision. The facility failed to identify hazards in the kitchen environment and to evaluate and implement interventions to prevent resident #13 from entering unsafe areas including the kitchen. There were 19 sampled residents reviewed during the survey. Findings: Record review for resident #13 revealed an admitted [DATE] that included [DIAGNOSES REDACTED]. Review of the 10/26/18 plan of care for resident #13 revealed a problem of physical mobility impaired due to the resident's primary mode of mobility is a wheelchair; requires extensive staff assist times two with bed mobility and transfers. Further review of care plan revealed no specific problem or approach addressing the resident's wandering behaviors. Review of the 10/26/18 Wander Data Collection Tool for resident #13 revealed summary of findings that include: propels self independently in wheelchair. Does not wander. No elopement attempts noted- not a wander/elopement risk. On 01/14/19 at 02:54 PM observation revealed resident#13 wandering in different rooms with no staff observed trying to redirect the resident. Further observation revealed resident #13 was loud, incoherent, mumbling, and ambulating per wheelchair with his feet. On 01/15/19 at 10:35AM, an observation revealed resident #13 ambulating per wheelchair and entered the kitchen area. The resident was observed entering the kitchen via an open door and he continued to ambulate until he was next to the stove and deep fryer, which was in use. Further observation revealed that kitchen staff was cooking and unaware that resident #13 entered the cooking area. A certified nursing assistant was then observed to enter the kitchen and remove resident #13. The door to the kitchen remained open after resident #13 was removed from the area. Further observations on 01/15/19 revealed resident #13 ambulating per wheelchair throughout the facility and entering into other residents' rooms without staff noticing or trying to re-direct the resident. On 01/15/19 at 1:30PM, interview with S4 Dietary Supervisor confirmed that resident #13 entered the kitchen cooking area this morning during lunch meal preparation. S4 Dietary Supervisor confirmed that residents are not supposed to enter the kitchen area at any time due to safety issues. On 01/15/19 at 1:41PM, Interview with S3CCC (Clinical Care Coordinator) revealed no care plan for wandering behavior for resident #13. Further interview with S3 CCC confirmed that resident #13 does ambulate in other bedrooms and areas in facility. On 01/17/19 at 8:45AM, interview with S5LPN confirmed that resident #13 ambulates per wheelchair throughout the facility and constantly enters other residents rooms.