Every finding on record at Yanceyville Rehabilitation and Healthcare Center

Based on record review, and staff and Psychiatric Nurse Practitioner (NP) interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a new serious mental illness disorder was identified for residents previously determined to have a Level I PASRR status for 4 of 8 residents reviewed for PASRR (Residents #10, #79, #120, #145). 3. Resident #120's Level I PASRR Determination Notification document dated 6/12/25 revealed the document was valid for his stay at the facility. The document further indicated no further PASSR screening was required unless a significant change occurred. Resident #120 was admitted on [DATE] with a diagnosis of major depressive disorder. Review of physician orders revealed an order dated 10/13/25 for Risperidone (an antipsychotic medication used to treat bipolar disorder) 0.5 milligram (mg) at bedtime for mood. Review of a Psychiatric note dated 11/19/25 revealed Resident #120 was assessed by the Psychiatric Nurse Practitioner (NP). The NP diagnosed Resident #120 with bipolar disorder at that time based on his findings. The plan of care was for Resident #120 to continue taking his current order for Risperidone for bipolar disorder. An interview was conducted on 5/28/26 at 3:39 PM with Psychiatric NP. The Psychiatric NP stated Resident #120 was assessed on 11/19 25 and diagnosed with bipolar disorder. The Psychiatric NP indicated at that time the NP continued Resident 120's current Risperidone order for bipolar disorder, instead of insomnia. The Psychiatric NP indicated that when a new diagnosis for a serious mental disorder was added for a resident, a Level II PASSR should have been requested at that time. Resident #120's current medication orders showed an active order dated 5/1/26 for Risperidone 0.25 mg at night for bipolar disorder. Review of Resident #120's diagnosis list revealed a diagnosis of bipolar disorder was added on 2/4/26. Review of a Psychiatric note dated 2/4/26 revealed Resident #120 was assessed by the Psychiatric NP and diagnosed with bipolar disorder at that time. Risperidone was continued for bipolar disorder. The resident was already diagnosed with bipolar disorder on 11/19/25 per the note and the interview. An interview was conducted on 5/28/26 at 2:25 PM with Nurse Manager #1 who entered the bipolar disorder diagnosis for Resident #120 on the diagnosis list on 2/4/26. Nurse Manger #1 indicated the bipolar disorder diagnosis was added after reviewing Resident #120's assessment completed by the Psychiatric NP on 2/4/26. Nurse Manager # 1 indicated she did not review Resident #120's assessment completed by the Psychiatric NP on 11/19/25. She further indicated Resident #120 was not part of her case load and she would have entered the bipolar diagnosis on 11/19/25, if she had reviewed the assessment. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 120 was cognitively intact. The MDS further revealed that Resident # 120 had an active diagnosis of depression and bipolar disorder. Resident #120 received antipsychotic and antidepressant medication daily. The MDS also revealed Resident #120 the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation, or a related condition. The care plan dated 5/26/26 revealed Resident #120 had a focus area for use of psychotropic medications related to bipolar disorder. The interventions included administer psychotropic medication as ordered, monitor for side effects, and observe for adverse reactions. An interview was conducted on 5/29/26 at 9:53 AM with the Social Worker. The SW stated she was responsible for submitting requests for Level II PASRR evaluations for residents with a new mental health diagnosis. She indicated that a Level II PASRR should have been requested for Resident #120 for the new diagnosis of bipolar disorder on 11/19/55 and it was an oversight her on her part. An interview was conducted with the facility's Administrator on 5/29/26 at 4:20 PM who was not aware Resident #120's Level II PASRR had not been completed. The facility's Administrator indicated it was the responsibility of the SW to submit the request for Level II PASSR evaluation. She further indicated the SW should have submitted the request as soon as Resident #120 received the diagnosis of bipolar disorder on 11/19/25. 3. A review of Resident #145's PASRR (Preadmission Screening and Annual Resident Review) determination notification letter dated 12/17/2020 indicated that Resident #145 did not meet the federal definition for mental illness or intellectual disability, and the PASRR number was listed as Level I. Resident #145 was admitted to the facility on [DATE]. At the time of admission, the resident did not have a diagnosis of bipolar disorder. A psychiatric note dated 07/10/2023 stated, in part, that the resident had moderate bipolar disorder, current/most recent episode depressed. A review of Resident #145's diagnosis list showed that he had been diagnosed with bipolar disorder on 08/18/2023. A psychiatry medication reconciliation and monitoring note dated 04/14/2026 also listed moderate bipolar disorder, current/most recent episode depressed under the problem list. Resident #145's quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and exhibited mood symptoms. Further review of the MDS revealed Resident #145 received antidepressants during the assessment period. An interview was conducted on 05/29/26 at 4:38 pm with the Psychiatric Nurse Practitioner, who confirmed that Resident #145 had received a new diagnosis of bipolar disorder on 08/18/2023. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. Attempts had been made to contact the previous Social Worker, but these were unsuccessful. During an interview on 05/29/2026 at 5:00 p.m., the current Social Worker reported that she had started working in the facility in January 2026. She stated that Resident #145 should have had a PASRR review completed when the bipolar disorder diagnosis was made. An interview with the Administrator on 05/29/2026 at 5:06 p.m. revealed that the previous Social Worker was no longer employed at the facility and that a PASRR review should have been completed when Resident #145 received the bipolar disorder diagnosis. Example #1 of 3 The findings included: 1.Resident #10 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder. A Level I PASRR Determination Notification letter dated 12/9/24 revealed Resident #10 had a Level I PASRR with no expiration dated that indicated No further PASRR screening is required unless a significant change occurs with the individual's status which suggests a diagnosis of mental illness or mental retardation or, if present, suggests a change in treatment needs for those conditions. Review of Resident #10's list of diagnoses revealed she was diagnosed with schizophrenia on 8/12/25. Review of physician order dated 8/12/25 indicated olanzapine (Zyprexa) (an atypical second-generation prescription antipsychotic used primarily to treat schizophrenia and bipolar disorder) oral tablet 5 milligrams (MG), give 1 tablet by mouth one time a day for schizophrenia. Review of Psychiatric (psych) Nurse Practitioner (NP) progress note dated 8/12/25 revealed his visit was for psych medication follow-up for bipolar. The resident stated, the voices are little better, but I am still hearing them. The resident was tolerating medication well. Resident had diagnosis of bipolar disorder which was unstable. She was to continue lamictal (a mood stabilizer) for bipolar disorder, Zyprexa for psychotic features, and lithium (prescription mood stabilizer primarily used to treat and prevent manic episodes in bipolar disorder) for bipolar disorder. Review of Psychiatric (psych) Nurse Practitioner (NP) progress note dated 10/13/25 indicated a diagnosis of schizophrenia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact with no behaviors present. Her current diagnoses included bipolar disorder and schizophrenia. She received antipsychotic and antidepressant medications. Review of Resident #10's psychiatry medication reconciliation and monitoring progress note dated 5/11/26 by the Psychiatric Nurse Practitioner (NP) revealed resident had a history of schizophrenia. The resident stated she had fewer auditory and visual hallucinations and fewer delusional thoughts. She had been increasingly less fearful of internal stimuli. The NP note stated Zyprexa for bipolar disorder. A phone interview was held on 5/28/26 at 4:42 PM with Psychiatric Nurse Practitioner (NP). He stated Resident #10 was one of the very few residents he diagnosed with schizophrenia. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. Attempts to reach the previous social worker were unsuccessful. On 5/29/26 at 5:00 PM, an interview was held with the Director of Social Work (SW). She stated the PASRR review should have been entered for a new assessment. The SW stated she just received access to the North Carolina Medicaid Uniform Screening Tool (NC MUST, internet-based application utilized to communicate and manage PASRR requests) in April 2026 to submit for PASRR reviews. Interview with the Administrator was conducted on 5/29/26 at 5:06 PM. The Administrator indicated a new PASRR review should have been completed when a new mental health diagnosis was determined. The Administrator explained the previous SW was the reason the PASRR was not submitted for review. 2. Resident #79 was initially admitted to the facility on [DATE] with no diagnoses of major depressive disorder or bipolar disorder. A Level I PASRR Determination Notification letter dated 10/2/24 revealed Resident #79 had a Level I PASRR with no expiration dated that indicated No further PASRR screening is required unless a significant change occurs with the individual's status which suggests a diagnosis of mental illness or mental retardation or, if present, suggests a change in treatment needs for those conditions. Review of the Psychiatric Nurse Practitioner (NP) progress note dated 6/30/25 indicated the Resident #79 stated, The antidepressant is not working patient complains of mood swings. The resident was tolerating medication well. He complained of depressed mood and mood swings. Resident was on trazodone (an antidepressant) HCl oral tablet 100 MG at bedtime. Discontinue Auvelity (used to treat major depressive disorder (MDD) in adults and agitation associated with dementia). Continue trazodone for insomnia. Start lamictal (a mood stabilizer) for bipolar disorder. Lamictal oral tablet 25 MG, give 1 tablet by mouth two times a day for bipolar disorder. Review of Resident #79's list of diagnoses revealed he was diagnosed with bipolar disorder on 6/30/25. Review of physician order dated 3/16/26 indicated Auvelity oral tablet extended release 45-105 milligrams (MG), give 1 tablet by mouth two times a day for depression related to major depressive disorder. Review of Resident #79's psychiatry medication reconciliation and monitoring progress note dated 4/14/26 by the Psychiatric Nurse Practitioner (NP) revealed resident had a history of mood disorder. Resident #79 to continue to receive Auvelity (used to treat major depressive disorder (MDD) in adults and agitation associated with dementia) for mood and trazadone for insomnia. The quarterly MDS assessment dated [DATE] revealed Resident #79 was cognitively intact with no behaviors present. His current diagnoses included depression and bipolar disorder. He received antidepressant medication daily. A phone interview was held on 5/28/26 at 4:36 PM with Psychiatric Nurse Practitioner (NP). He stated Resident #79 had bipolar disorder. He was on medication Lamictal and resident requested to be taken off that medication. The NP stated he was treating Resident #79 with Auvelity and resident was responding to this medication. The NP stated resident's psychiatric diagnosis was diagnosed by him and while Resident #79 was in the facility. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. Attempts to reach the previous social worker were unsuccessful. On 5/29/26 at 5:00 PM, an interview was held with the Director of Social Work (SW). She stated the PASRR review should have been entered for a new assessment. The SW stated she just received access to the North Carolina Medicaid Uniform Screening Tool (NC MUST, internet-based application utilized to communicate and manage PASRR requests) in April 2026 to submit for PASRR reviews. Interview with the Administrator was conducted on 5/29/26 at 5:06 PM. The Administrator indicated a new PASRR review should have been completed when a new mental health diagnosis was determined. The Administrator explained the previous SW was the reason the PASRR was not submitted for review.

Based on observation and staff interviews, the facility failed to store dry food away from moisture, keep dry goods covered, failed to label and date leftover food stored for use, and discard expired food. This was for 1 of 1 dry goods storage room, 1 of 1 walk-in cooler, 1 of 1 walk-in freezer and 1 of 1 reach-in refrigerator. The facility also failed to maintain the walk in refrigerator floor in a clean and sanitary condition, keep 1 of 4 ice machines clean, and failed to maintain the ceiling above the steam table to prevent peeling paint. These failures had the potential to affect food served to residents.Findings include:1a. On 5/26/26 at 9:20 AM during an observation of the dry storage area with Dietary Manager #1, eight 8 ounce white disposable cups half filled with rice crisp cereal sat on a tray with white powder on the surface. The cups were covered. A second tray was stacked on top of the white disposable cups. The tray also had twelve 8 ounce disposable cups of dry cereal that were covered. The tray also had some white powder on it. None of the cups were labeled or dated. On 5/26/26 at 9:22 AM, during an observation of the air-dry rack, three large plastic bags of dry cereal were observed on the air dry rack near the three compartment sink. Two bags were half filled, and one was full of breakfast cereal. None of the plastic bags were labeled or dated, and the bags were stored next to wet, recently washed dishes.During an interview on 5/26/26 at 9:20 AM, Dietary Manager #1 stated the cereal was used for the morning breakfast tray line.b. On 5/26/26 at 9:25 AM, an observation of the walk-in refrigerator with Dietary Manager #1 revealed the following: A movable cart in the center holding two large pans of green food and one large pan of whitish pink food, all partially covered with parchment paper and not labeled or dated, On a side rack, two trays containing twenty four 6 ounce cups of thickened liquids stacked on top of each other. The trays were wet, and none of the cups were labeled or dated, On another rack, a deep pan containing meat wrapped in foil with pink liquid inside the pan. The pan was labeled Turkey 5/28 lunch. The pan was stored on a middle shelf, Directly beneath the thawing meat, an open cardboard box held fresh cabbage, and a clear 2 gallon plastic bag half filled with shredded cheese stored next to it. The plastic bag was not labeled or dated.During an interview on 5/26/26 at 9:28 AM, Dietary Manager #1 stated the green food was broccoli salad and the whitish pink food was tuna salad, planned for lunch meal use on 5/26/26. He stated he did not know why the turkey was thawing on the middle rack and acknowledged that thawing meat should be placed on the bottom rack with no food stored beneath it. During an interview on 5/29/26 at 1:00 PM, the District Dietary Manager stated the turkey in the pan was precooked, frozen turkey, wrapped in foil and plastic wrap. The District Dietary Manager indicated the staff had placed the precooked frozen Turkey in a pan with water to prevent drying during thawing. c. On 5/28/26 at 11:35 AM, a follow-up observation of the walk-in refrigerator with the District Dietary Manager revealed two trays containing twelve 6 ounce cups each, three quarters filled with thickened liquids. None of the cups were labeled or dated. Staff had stacked two unopened cardboard boxes directly on top of the trays.During an interview on 5/28/26 at 11:37 AM, the District Dietary Manager stated the weekly stock delivery arrived and staff may have placed boxes on top of the trays. She stated she did not see an issue with stacking boxes on the trays because the cups had lids.d. On 5/26/26 at 9:35 AM, an observation of the walk-in freezer with the Dietary Manager #1 revealed the following: A large plastic pan of Brussels sprouts partially covered with cling wrap. Ice had accumulated inside the pan, and the brussels sprouts had ice in between them, were dry with shriveled leaves and pale due to loss of moisture and showed signs of freezer burn Two wet cardboard boxes under the freezer compressor covered in ice, labeled 16 oz pizza dough, A clear open plastic bag containing meat with ice buildup inside it. The meat was dry, pale, had ice crystals on the surface and showed signs of freezer burn. The bag was not labeled or dated. A thin layer of ice on the freezer floor and on the transparent curtain hanging inside the freezer near the door. The curtain was acting as a barrier between the door and inside of the walk-in freezer.During an interview on 5/26/26 at 9:37 AM, Dietary Manager #1 stated the Brussels sprouts should have been fully covered to prevent freezer burn. He stated the meat in the open bag was sausage patties and that open food bags must be closed, labeled, and dated.e. On 5/26/26 at 9:40 AM, an observation of the reach-in refrigerator revealed the following: A 4 quart bin containing yellow pureed food with no label or date, A 4 quart bin half filled with yellowish lettuce and sliced tomatoes labeled 5/21/26, Three unlabeled cups of reddish liquid, One unlabeled cup containing brownish food.During an interview on 5/26/26 at 9:40 AM, Dietary Manager #1 stated the yellow food was egg salad prepared the previous evening but was unsure why it was not labeled or dated. He stated the lettuce and tomatoes were used on 5/21/26 and should have been discarded. He identified the reddish liquid as tomato soup and the brownish food as tuna salad but did not know when they were stored in the refrigerator.During an interview on 5/29/26 at 1:25 PM, the Administrator stated all food must be labeled, dated, covered, and discarded when expired.2. On 5/26/26 at 9:25 AM, an observation of the walk-in refrigerator revealed a wet, dirty floor with brown water.A follow up observation on 5/28/26 at 11:40 AM with the District Dietary Manager again revealed brown water with a muddy floor.During an interview on 5/28/26 at 11:40 AM, the District Dietary Manager stated holes in the refrigerator's floor caused water to rise when someone stepped on it. She demonstrated by pressing her foot on the floor, causing brown water to seep upward. She stated the facility had been aware of the issue for several months.During an interview on 5/29/26 at 11:00 AM, the Maintenance Director stated the refrigerator extended outside the building on a concrete slab placed over mud and grass. He stated previous maintenance staff drilled screws into the diamond metal plate flooring, leaving holes through which rainwater seeped during heavy rainfall. He stated the issue did not occur during dry weather. Maintenance Director stated that there were some heavy rains over the past few days. The Maintenance Director stated that he thinks the entire diamond metal plate on the concrete floor may need to be replaced.During an interview on 5/29/26 at 1:25 PM, the Administrator stated the refrigerator floor should be cleaned daily and that Corporate Maintenance staff would evaluate the issue. She stated kitchen staff should clean the refrigerator frequently to keep it dry.3. On 5/28/26 at 12:00 PM, an observation revealed two ceiling patches-one approximately 2 feet by 2 feet and another 1 foot by 1 foot above the steam table with peeling, hanging paint.During an interview at 12:01 PM, the Dietary Manager stated steam from the steam table caused the paint to peel.During an interview on 5/28/26 at 1:00 PM, the Maintenance Director stated he had painted the kitchen a year earlier and touched up the ceiling three months before. He stated steam and heat from the steam table caused the paint to peel.4. On 5/28/26 at 12:10 PM, an observation of the ice machine in the dining hall with the Registered Dietitian revealed black stains on the lid and inside the machine.During an interview on 5/28/26 at 1:00 PM, the Maintenance Director stated he previously inspected the machine monthly, but the TELS (The Environmental Life Safety system - a digital maintenance and facility management platform) software was changed to require quarterly checks. He stated he could not modify the software. He stated the machine was due for its quarterly cleaning at the end of May 2026 and he had not completed it.During an interview on 5/29/26 at 1:25 PM, the Administrator stated the ice machine was previously cleaned monthly. She stated the facility would reinstate monthly checks and cleaning to prevent the black buildup.

Based on observations, record review, and staff interviews, the facility failed to develop a person-centered care plan for 1 of 4 residents reviewed for activities (Resident #9).The findings included:Resident #9 was admitted to the facility on [DATE] with diagnoses that included legal blindness and adjustment disorder with mixed anxiety and depressed mood.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had severe cognitive impairment. Resident #9's assessment of daily activity preferences revealed it was somewhat important for him to listen to music and to go outside.Review of the care plan last revised on 3/11/26 revealed no goals or interventions related to activities.Review of Resident #9's activity participation documentation for the month of May 2026 revealed self-directed activities included watching tv and relaxing in room, and 1:1 activity noted staff provided hydration and snacks.The Activity Director was interviewed on 5/29/26 at10:30 AM. The Activity Director indicated Resident #9's activity preferences included listening to music and going outdoors but that due to a busy staff schedule, a care plan had not been developed in the area of activities. An interview was conducted with the Administrator on 5/29/26 at 5:20 PM who revealed the Activity Director was responsible for creating the activity care plan for Resident #9 and did not know why this had not been done.

Based on observations, staff interviews and record review, the facility failed to provide an on-going activity program that met the individual interests and needs for 3 of 4 cognitively impaired residents reviewed for activities (Residents #32, Resident #44 and Resident #9). The findings included: 1. Resident #32 was admitted to the facility on [DATE] with diagnoses that included dementia with psychotic behavior and Alzheimer's disease. Review of the Modified Annual Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and dependent on staff for all Activities of Daily Living (ADL). The assessment indicated Resident #32 preferred listening to music, keeping up with news, participating in group activities, and spending time outdoors when the weather was good. Review of the care plan dated 2/13/26 revealed the resident was care planned for activities and was dependent on staff to meet emotional, intellectual, physical, and social needs. Interventions included ensuring activities were compatible with the resident's physical and mental capabilities and aligned with known interests and preferences. The plan also required 1:1 bedside or in room activities when the resident could not attend out of room events, as well as staff assistance and escort to and from activities. The resident enjoyed snacks, music, movies, and spending time outdoors in favorable weather. An activity note dated 3/9/26 showed an activity staff member spent 15 minutes with the resident, discussed the weather, and talked about working in her vegetable garden. The resident asked about the staff member's family and what they did for fun. Record review revealed no activity notes or documentation after 3/9/26 through 5/28/26 showing the resident's participation in activities of interest. Record review also showed that on 5/15/26, the resident transferred from the Life Engagement Unit (LEU) to the 500 hallway (Rehabilitation Unit). Observations on 5/26/26 at 11:26 AM revealed the resident sitting in a wheelchair in the Rehabilitation unit dining room, staring at the table, with no television, music, or staff interaction except for another resident nearby. Continuous observations on 5/27/26 from 11:08 AM to 11:20 AM revealed Resident #32 was in a wheelchair sitting alone near the nursing station, bending down and looking at a white towel on her lap, with no social interaction. On 5/27/26 at 2:40 PM, Resident #32 was observed laying in bed talking to herself while a television played on low volume on the opposite side of the room. The resident was unable to see the television from her bed. The volume of the television was low and could only be heard when someone stood very close to the television Continuous observations on 5/28/26 from 9:23 AM to 9:30 AM revealed the resident in a wheelchair sitting alone in the dining room, staring out the window, with no music, television, or staff interaction. On 5/28/26 at 11:30 AM, the resident was observed sitting in the 500 hallway dining room staring at staff and another resident. No television or music was playing. On 5/28/26 at 2:00 PM, Resident #32 was observed lay in bed, looking toward the hallway and talking to herself. The television volume remained low. During an interview on 5/28/26 at 11:15 AM, Nurse Aide #1 stated that no activity staff came to the rehab unit. She stated Resident #32 was totally dependent on staff for ADL care and could not attend activities without assistance. She stated nurse aides could not take the resident to activities on the other end of the building when they were providing care. She confirmed the resident did not receive 1:1 activities and that there was no music system or television available in the dining room to keep the resident engaged. During an interview on 5/28/26 at 2:44 PM, the Activity Director stated the resident enjoyed preaching, pastor services, color sorting, and matching games. She explained that LEU nursing staff previously assisted activity staff with activities and transport, but staff on the 500 hallway did not. She stated the resident would not be triggered for 1:1 activities until she updated the care plan. She acknowledged no 1:1 activities were completed and no music or television was available in the dining room. She stated the census was large and she needed to determine how to conduct 1:1 activities based on residents and staffing ratio. During an interview on 5/29/26 at 11:24 AM, the Administrator stated that every resident who needed 1:1 activities and could not attend group activities should receive 1:1 activities that enriched them emotionally and intellectually. She stated the resident had been moved from LEU due to declining clinical status. She stated the resident's activity preferences needed review and revision and that activity staff must document all activities provided. 2. Resident #44 was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia, and major depressive disorder. Review of the Annual MDS dated [DATE] revealed the resident was severely cognitively impaired and dependent on staff for all Activities of Daily Living (ADL). The assessment indicated preferred activities such as listening to music, being around pets, attending religious services, participating in group activities, and going outdoors in good weather. Review of the care plan dated 2/25/26 showed the resident required staff support to meet emotional, intellectual, and social needs related to cognitive impairment. Interventions included inviting the resident to activities, ensuring activities matched interests and abilities, and providing assistance or escort to activities. Record review revealed on 12/9/26, Resident #44 was moved from the LEU to the 500 hallway (Rehabilitation unit). Record review revealed no activity notes or documentation. Continuous observation on 5/26/26 from 11:00 AM to 11:07 AM revealed Resident #44 in a wheelchair, sitting in the dining room, staring ahead, with no television, music, or staff interaction. On 5/27/26 at 11:08 AM, the resident was observed in a wheelchair sitting near the nursing station watching therapy staff work with other residents. No staff or resident were interacting with her. Observations on 5/28/26 at 9:23 AM and 11:30 AM revealed the resident sitting in the 500 hallway dining room, staring out the window and looking around, with no television, music, or staff interaction. On 5/28/26 at 2:00 PM, Resident #44 was observed lay in bed while the television played at low volume. The resident appeared disinterested and looked around the room. During an interview on 5/28/26 at 11:10 AM, Nurse Aide #1 stated the resident moved from the memory care unit to the rehab hallway because she required more care. She stated the resident was totally dependent, responded with only simple yes or no answers, and did not receive activities because activity staff never came to the rehab unit. She stated there was no music or television available in the dining room, and although she requested music for the resident, activity staff had not provided it. She stated she could not take the resident to group activities on the other end of the building as she needed to provide care and assistance to other residents. During an interview on 5/28/26 at 2:44 PM, the Activity Director stated Resident #44 preferred music. She stated activity staff conducted 1:1 visits about once per month and acknowledged Resident #44 had not received activities since moving to the 500 hallway. She stated she would educate staff to bring the resident to activities or provide 1:1 visits. She stated the census was large and she needed to determine how to complete 1:1 activities based on staffing. During an interview on 5/29/26 at 11:24 AM, the Administrator stated residents who could not attend group programs should receive 1:1 activities. She stated Resident #44 required updated activity preferences and that activity staff must document resident participation in activities. The findings included: 3.Resident #9 was admitted to the facility on [DATE] with diagnoses that included legal blindness and adjustment disorder with mixed anxiety and depressed mood. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had severe cognitive impairment. Resident #9's assessment of daily activity preferences revealed it was somewhat important for him to listen to music and to go outside. Review of the care plan last revised on 3/11/26 revealed no goals or interventions related to activities. Review of Resident #9's activity participation documentation for the month of May 2026 revealed self-directed activities included watching tv and relaxing in room, and 1:1 activity noted staff provided hydration and snacks. There was no documentation of Resident #9 listening to music or going outside. An observation was completed of Resident #9 on 5/27/26 at 2:55 PM and he was in his room, lying in bed with eyes open facing toward the wall, no music was playing, shared television was not on, and no independent activities were being performed or available in Resident #9's room. An observation was completed of Resident #9 on 5/29/26 at10:25 AM and he was observed in his room lying in bed toward the wall with no music playing and no independent activities available in room and television was not on. An interview was conducted with Nurse Aide (NA) #2 on 5/27/26 at 2:58 PM who revealed Resident #9 was blind and did not like to go to group activities. NA #2 also revealed that she had not seen activity staff provide him with music or assist him with any outdoor activities. The Activity Director was interviewed on 5/29/26 at10:30 AM and she indicated that upon review of Resident #9's activity documentation staff had only provided Resident #9 with snacks and hydration and Resident #9's independent activities in room included relaxing in room and watching television. The Activity Director revealed she was aware that Resident #9's activity preferences included listening to music and going outdoors but that due to a busy staff schedule the staff had not been able to provide Resident #9 with his preferred activities. An interview was conducted with the Administrator on 5/29/26 at 5:18 PM and she indicated that the Activity staff should have provided Resident #9 with activities that met his preferences.

Based on observation, record review, resident and staff interview, and Resident Representative (RR) interview, the facility failed to identify hearing aides were missing and determine whether an appointment was needed to maintain hearing abilities for a resident with reported hearing difficulties for 1 of 1 resident reviewed for communication (Resident #81). The findings included:Resident #81 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had severe cognitive impairment and was coded for moderate hearing difficulty with the use of hearing aids.The care plan initiated on 7/25/25 and reviewed on 2/26/26 indicated Resident #81 had a care plan in place for having a communication/hearing impairment and wore bilateral hearing aids. The written interventions included staff to assist Resident #81 daily with putting the hearing aids in every morning and removing them every night and to ensure hearing aids are in place.Review of Resident #81's Medication Administration Record and Treatment Administration Record revealed no entries, or monitoring, for placement, or removal, of the resident's hearing aids.An observation and Interview were conducted on 5/26/26 at 1:07 PM with Resident #81. She was observed to have had one hearing aid in use in her right ear and was not wearing a hearing aid in her left ear. Resident #81 indicated she used to have two hearing aids but one was missing. Resident #81 indicated she would like to have both hearing aids so she could hear better.A telephone interview was conducted with Resident #81's representative on 5/28/26 at 10:56 AM. The Resident Representative stated Resident #81 was admitted to the facility with two hearing aids, but one was lost about six months ago. She further revealed she did not have the funds to pay for a replacement hearing aid and that she had not been contacted by anyone at the facility regarding options to try and replace the hearing aid.An interview was conducted with Nurse #1 on 5/28/26 at 3:14 PM and she indicated she was aware Resident #81 was missing one of her hearing aids but did not know for how long or if it had been reported to a social worker.An interview was conducted on 5/28/26 at 3:30 PM with Nurse Aide (NA) #4 who indicated Resident #81 used to have bilateral hearing aids that were stored in her bedside drawer and staff were responsible for helping Resident #81 to put the hearing aids in each morning and to remove them at night. NA # 4 revealed she had worked for the facility for over six months and was aware that Resident #81 was missing one of her hearing aids but did not know how long the hearing aid had been missing and was not aware if a social worker was made aware of the missing hearing aid.An interview was conducted with the Social Worker 5/29/26 9:15 AM and she indicated she had been in this position since January 2026 and had not been made aware Resident #81 was missing a hearing aid.An attempt was made to interview the former Social Worker on 5/29/26 at 10:17 AM but the attempt was not successful.The Administrator was interviewed on 5/29/26 at 5:15 PM and she stated she was not aware that Resident #81 had a missing hearing aid. She further explained staff should have reported this to the social worker so they could have contacted the family and made the appropriate referral to the audiologist to determine if a replacement hearing aid could have been provided. The Administrator indicated she did not know why this was not done.

Based on observations, record review and staff interviews, the facility failed to provide pureed food items with a pudding like consistency as required. This failure had the potential to affect 11 of 11 residents who had orders for a pureed texture diet.Findings included:1a. A continuous lunch meal observation in the 500 hallway dining room on 5/26/26 from 12:10 PM to 12:20 PM revealed that residents on the 500 hallway received their trays first. Two residents were present in the 500-hallway dining room, each receiving assistance from staff. Both residents had meal tickets indicating a regular diet with pureed consistency.Observation of the residents' trays revealed a lunch meal consisting of pureed tuna salad, pureed broccoli salad, pureed potato salad, and pureed bread. The food was served on a divided plate. Pureed peaches and pears was dessert and served in an individual cup. The pureed food in the divided plated appeared thin and runny, with liquid separating from the solids. When staff tilted the spoon, the food ran off the spoon and did not hold its shape.During an interview on 5/26/26 at 12:10 PM, Nurse Aide #1 stated she frequently assisted the residents with feeding. Nurse Aide #1 stated the pureed food served to the resident was not usually of a pudding consistency. She reported she had notified the Administrator several times, and the Administrator had addressed the concern with Dietary Staff.During an interview on 5/26/26 at 12:12 PM, the Scheduler stated she frequently assisted with feeding and had also noticed the pureed food was thinner than appropriate. She reported she had informed Dietary Staff multiple times.The residents were not feed until the Dietary Manager arrived to the 500 hallway dining room.The Dietary Manager #1 came to the dining hall on 5/26/26 at 12:15 PM, Dietary Manager #1 observed the pureed trays and stated the consistency was incorrect. He confirmed the pureed foods were not of a pudding consistency and that liquid had separated. He stated all pureed items would be remade.At 12:25 PM on 5/26/26, both residents received new trays containing pureed food in the correct consistency.During an interview on 5/26/26 at 2:00 PM, the Dietary [NAME] stated she was the Head [NAME] and had prepared the pureed foods for lunch. She stated she normally prepared pureed foods slightly on the thinner side. She reported she had just been educated by the District Dietary Manager that pureed foods must be of a pudding consistency.During an interview on 5/28/26 at 1:20 PM, the District Dietary Manager stated the menu for the 5/26/26 meal consisted of cold items (tuna and broccoli salads). She stated the hot temperature in the kitchen caused condensation, which thinned the pureed foods.1b. A continuous tray line observation with the District Dietary Manager on 5/28/26 from 12:10 PM to 12:30 PM revealed Dietary Manager #1 was assisting in plating the meal for the resident. The first tray plated on the tray line was a pureed diet plate. The pureed turkey on the first plated pureed tray was not of a pudding consistency. Water was separating from the pureed turkey. Both Dietary Manager #2 and the District Dietary Manager agreed the turkey was not smooth and pudding like. The District Dietary Manager re blended the turkey with thickener to achieve the correct consistency.During an interview on 5/28/26 at 12:12 PM, Dietary Manager #2 stated she was the interim manager. She reported she had prepared the pureed turkey to the correct consistency but believed the condensation from the steam table caused the product to become runny. She stated she had not realized the change in consistency until she plated the first tray.During an interview on 5/28/26 at 1:00 PM, the District Dietary Manager stated pureed foods must maintain a pudding consistency, but the heat in the kitchen and the steam table caused the products to be thin and lose the appropriate texture.During an interview on 5/29/26 at 2:29 PM, the Administrator stated that it was her expectation that the resident received the correct diet with correct diet consistency. Food consistency should be checked when prepared, on the tray line and prior to the tray leaving the kitchen.

Based on observations and staff interviews, the facility failed to keep food preparation areas and food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. The facility failed to clean the ceiling vents located over the food preparation and food service areas. These practices had the potential to affect food served to residents. The findings included: During a kitchen tour on 2/24/25 at 10:32 AM, the following observations were made with the kitchen Regional Dietary Director: a. The 6- stove burners had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were large amounts of burnt foods, dried, encrusted, liquid and splatters throughout the stove area. b. The 2-plate warmers had 2 rows of clean plates stored inside the warmer. The inside of warmer had dried liquid spills and food particles inside and dried liquid spills on the outside. The inside also had old food crumbs all around. c. The 6-compartment steam table had floating food particles in standing water, the lids of the steam table had large volumes of dried food and greasy build up around edges. d. Two open drying racks had dried food and dried liquid on the inside edges where clean lids were stored. e. The 10 meal carts with dry food products stored in them had dried liquids, food crumbs and particles inside. The outside cart also had dried liquids running down the fronts/sides of the cart. A follow-up observation was conducted on 2/25/25 at 9:29 AM, the breakfast meal was served from the meal carts in the main dining rooms and resident halls and the carts had not been cleaned. f. The 6 ceiling vents had large volumes of black dust/debris blowing over the steam table, clean dry dishware storage racks, food service and preparation surfaces. A follow-up observation was conducted on 2/25/25 at 11:20 AM, the ceiling vents had not been cleaned from the initial tour on 2/24/25. Staff were observed preparing meals and dust particles were blowing overtop of the food prep table, steam table, clean dry storage racks. The steam tables continued to have food particles in water, meal carts had not been clean, and meals were still served from the dirty carts. An interview was conducted on 02/25/25 at 12:24 PM, with the Maintenance Director who stated that kitchen vents had not been cleaned in several months and confirmed that they needed to be done and it was an oversight on his part. He further stated he needed to order and replace the current vents. An interview was conducted on 2/25/25 at 1:11 PM with the Regional Dietary Director who stated that the kitchen staff were required to wipe down kitchen equipment after each meal and deep clean weekly in accordance with the kitchen cleaning checklist. The Regional Dietary Director further stated the Dietary Manager was responsible for ensuring the kitchen staff kept the equipment clean and orderly. The Regional Dietary Director acknowledged the identified kitchen equipment, ceiling vents had not been cleaned in several months. An interview on 2/25/25 at 2:30 PM with the Administrator who stated the Dietary Manager was responsible for ensuring the kitchen was cleaned and maintained. The Administrator stated the expectation would be for the Dietary Manager to ensure all kitchen cleaning protocols were in place and followed in accordance with kitchen sanitation guidelines. She further stated the Maintenance Director was responsible for ensuring the kitchen ceiling vents were cleaned monthly.

Based on observations, and staff interviews, the facility failed to ensure the garbage and refuse was contained in 3 of 3 dumpsters and 1 of 1 grease interceptor container and failed to ensure the surrounding area clean and free from debris. This practice had the potential to attract pests and rodents. The findings included: During an initial tour observation on 2/24/25 at 10:45AM, revealed there were 3 dumpsters and 1 grease interceptor container located near a wooded area at the back of the facility that had large amounts trash bags of garbage and refuse overflowing from the tops and loose paper products, boxes, mattresses, furniture old pallets, clothing, blankets and loose food products outside of dumpsters on the ground and surrounding areas. The grease interceptor container was leaking grease on the ground along with the trash onto the parking lot. A follow-up observation was conducted on 2/25/25 at 7:30 AM revealed the trash bags filled with garbage left on the ground overflowing and the surrounding area had not been thoroughly cleaned evidence by the remaining paper and food products, pallets, blankets, clothing, grease was still on the ground around the sides and backs of the dumpsters. An interview was conducted 2/25/25 at 12:24 PM, with the Maintenance Director who acknowledged the condition of the dumpster area and the overflowing grease interceptor container. He stated the dumpster area has been in this condition for some time and the contractor to pick up larger items had not been consistent with pick-ups. He further stated housekeeping, dietary and maintenance was responsible for ensuring the dumpster area was maintained daily. An observation and interview were conducted on 2/25/25 at 1:11 PM with the Regional Dietary Director who stated the housekeeping, dietary and maintenance were responsible for ensuring the dumpster area was cleaned daily. He further stated he was unaware of when grease interceptor container had been cleaned and reported it should have been cleaned monthly. An interview on 2/25/25 at 2:30 PM, with the Administrator who stated housekeeping, maintenance and dietary staff were responsible for keeping the dumpster area cleaned daily.

Based on observations, staff interviews and record review, the facility failed to provide an on-going activity program that met the individual interests and needs for 4 of 5 cognitively impaired residents reviewed for activities (Residents #29, Resident #52, Resident #137 and Resident #68). The findings included: 1a. Resident #29 was admitted to the facility on [DATE]. The diagnoses included cognitive impairment and dementia. Resident #29 resided on the memory care unit. Resident #29 was coded on the annual Minimum Data Set (MDS) assessment dated [DATE] as having cognition impairment and he needed assistance with activities. The MDS also coded Resident #29's activity interest as very important to participate in favorite activities to include pets, music and news and current events. The annual activity assessment dated [DATE] revealed Resident #29's preferences included listening to music, news, and current events. A focus area on the care plan dated 2/18/25 revealed Resident #29 was dependent on staff for meeting emotional, intellectual, physical, and social needs. The goal included Resident #29 would attend/participate in activities of choice. The interventions included: Staff would ensure that the activities the resident was attending are compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed, compatible with individual needs and abilities; and age appropriate. Introduce Resident #29 to residents with similar backgrounds, interests and encourage/facilitate interaction. Invite Resident #29 to scheduled activities. Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. Provide Resident #29 with materials for individual activities as desired. Record review revealed there were no activity notes or documentation available after the 3/27/24 assessment for Resident #29 through 2/26/25 for Resident#29's participation in activities of interest. Review of the activity calendar for 2/24/25 offered the following activities for the memory care unit: 10:30 AM daily devotion, 11:00 AM table ball and 11:30 senses stimuli. On 2/24/25 a continuous observation was conducted on the memory care unit from 10:30 AM to 11:30 AM. The unit staff and activity staff provided the other residents with a snack in the dining room. The Activity Assistant sat with 3 out of 30 residents in the unit dining room reading a piece of paper (devotion); none of the other residents were provided with the scheduled devotion activities. The Activity Assistant left the unit at 10:45 AM and did not return. The 11:00 AM and 11:30 AM scheduled activities did not occur. Resident #29 was at a table with Residents #52 and Resident #137 with no activity or interaction after the snack was served. Review of the activity calendar for 2/25/25 offered the following activities for the memory care unit: daily devotion at 10:30 AM, puzzles at 11:00 AM and painting with friends at 11:30 AM. On 2/25/25 a continuous observation was conducted on the memory care unit from 10:30 AM to 11:45 AM. The activity staff provided activities for a select few residents. The devotion activity did not involve all the residents on the unit. There were 30 residents in the dining area. Resident #29 was seated in a corner of the room with several other residents that did not have any hands-on activity during the scheduled activities. There were only a few puzzles available for the entire group, and Resident #29 was not provided with the puzzle or the painting materials for the scheduled activity. The activity staff did not actively engage Resident #29 in the dining area. An observation was conducted on 2/26/25 at 10:30 AM of the devotion activity. Resident #29 was in the back corner of the dining room with several other residents at a table with no involvement in the activity. Activity Assistant #2 stated she was trying to go around the room and perform the activity. Activity Assistant #2 had no response as to why the activity was not performed as a group activity as scheduled. 1b. Resident #52 was admitted to the facility on [DATE] . The diagnoses included cognitive impairment, and dementia. Resident #52 resided on the memory care unit. Resident #52 was coded on the annual Minimum Data Set (MDS) assessment dated [DATE] as having cognition impairment and she needed assistance with activities. The MDS also coded Resident 52's activity interest as very important to participate in favorite activities to include music, religious service and outside events. The annual activity assessment dated [DATE] revealed Resident #52 's preferences included listening to music, religious services, pets, outside activities and group activities. A focus area on the care plan dated 2/14/25 revealed Resident #52 was dependent on staff for meeting emotional, intellectual, physical, and social needs. The goal included Resident #52 would attend/participate in activities of choice. The interventions included: Ensure that the activities the resident is attending are compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed, compatible with individual needs and abilities; and appropriate age. Introduce Resident #52 to residents with similar backgrounds and interests and encourage/facilitate interaction. Invite Resident #52 to scheduled activities. Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. Provide the residents with materials for individual activities as desired. Record review revealed there were no activity notes or documentation available after the 6/16/24 assessment for Resident #52 through 2/26/25 for Resident#52's participation in activities of interest. Review of the activity calendar for 2/24/25 offered the following activities for the memory care unit: 10:30 AM daily devotion, 11:00 AM table ball, 11:30 Senses Stimuli. On 2/24/25 a continuous observation was conducted on the memory care unit from 10:30 AM to 11:30 AM. The unit staff and activity staff provided the other residents with a snack in the dining room. The Activity Assistant sat with 3 out of 30 residents in the unit in the dining room reading a piece of paper (devotion); none of the other residents were provided with the scheduled devotion activities. The Activity Assistant left the unit at 10:45 AM and did not return. The 11:00 AM and 11:30 AM scheduled activity did not occur. Resident #52 was at a table with Resident #29 and Resident #137 with no activity or interaction after the snack was served. Review of the activity calendar for 2/25/25 offered the following activities for the memory care unit: daily devotion at 10:30AM, puzzles at 11:00 AM and painting with friends at 11:30 AM. On 2/25/25 a continuous observation was conducted on the memory care unit from 10:30 AM to 11:45 AM. The activity staff provided activities for a select few residents. The devotion activity did not involve all the residents on the unit. There were 30 residents in the dining area. Resident #52 was seated in a corner of the room with several other residents that did not have any hands-on activity during the scheduled activities. There were only a few puzzles available for the entire group, and Resident #52 was not provided with the puzzle or the painting materials for the scheduled activity. The activity staff did not actively engage Resident #52 in the dining area. 1c. Resident #137 was admitted to the facility on [DATE]. The diagnoses included cognitive impairment and dementia. Resident #137 was coded on the admission Minimum Data Set (MDS) dated [DATE] as having cognition impairment and he needed assistance with activities. The MDS also coded Resident #137's activity interest as very important to participate in favorite activities to include music, religious activities, outside activities and group activities. The admission activity assessment dated [DATE] revealed Resident #137 's preferences included listening to music, religious activities, outside activities and group activities. A focus area on the care plan dated 12/13/24 revealed Resident #137 had a functional ability deficit. The goal included encourage Resident #137 to fully participate in activities as much as possible with each interaction and the intervention was to give Resident #137 as many choices as possible about activities. Record review revealed there were no activity notes or documentation available after the 12/13/24 assessment for Resident #137 through 2/26/25 for Resident #137's participation in activities of interest. Review of the activity calendar for 2/24/25 offered the following activities for the memory care unit: 10:30 AM daily devotion, 11:00 AM table ball and 11:30 senses stimuli. On 2/24/25 a continuous observation was conducted on the memory care unit from 10:30 AM to 11:30 AM. The unit staff and activity staff provided the other residents with a snack in the dining room. The Activity Assistant sat with 3 out of 30 residents in the unit in the dining room reading a piece of paper put space here (devotion); none of the other residents were provided with the scheduled devotion activities. The Activity Assistant left the unit at 10:45 AM and did not return. The 11:00 AM and 11:30 AM scheduled activity did not occur. Resident #137 was at a table with Resident #29 and Resident #52 with no activity or interaction after the snack was served. Review of the activity calendar for 2/25/25 offered the following activities for the memory care unit: daily devotion at 10:30AM, puzzles at 11:00 AM and painting with friends at 11:30 AM. On 2/25/25 a continuous observation was conducted on the memory care unit from 10:30 AM to 11:45 AM. The activity staff provided activities for a select few residents. The devotion activity did not involve all the residents on the unit. There were 30 residents in the dining area. Resident #137 was seated in a corner of the room with several other residents that did not have any hands-on activity during the scheduled activities. There were only a few puzzles available for the entire group, and Resident #137 was not provided with the puzzle or the painting materials for the scheduled activity. The activity staff did not actively engage Resident #137. An interview was conducted on 2/26/25 at 6:59 AM, with Nurse Aide #5 who stated if the nurse aides were providing care, they were unable to assist residents at the start of the activity and were only able to take the residents toward the end of the activity. An interview was conducted on 2/26/25 at 7:00 AM, with the Medication Aide #3 who stated the aides had a difficult time assisting with activities at times due to resident care and behaviors. She reported two activity staff were needed at times, because some residents need one on one attention and/or monitoring for behaviors. An interview was conducted on 2/26/25 at 7:15 AM, with Nurse Aide #4 who stated the activities staff had not been consistent in providing activities for residents. Nurse Aide #4 explained when activities staff were on the unit they only worked with a select few residents and other residents were left without activities until staff could assist with the group. An interview was conducted at 2/26/25 5:00 PM, with Nurse #4 who was assigned to the memory care unit who stated activities for the memory care unit had been an on-going concern due to the large number of residents in a group. The activity staff only focused on a few residents at a time and the larger part of the group were not encouraged to participate. When the unit staff were providing care and performing other responsibilities it was difficult to assist with activities. She reported she had asked for additional staff during scheduled activities to help reduce behaviors when the unit staff were attending to behaviors and care while activities were occurring. She reported all activities stopped at 3:30 PM or activity staff don't perform the scheduled activities which resulted in unit staff creating activities when activities should have been done. An interview was conducted on 2/26/25 at 9:30 AM, with Activity Assistant #1 who stated she was unable to provide activities for all residents in such a large group of residents without assistance from the unit staff. She could not recall why she did not do the table ball and sensory stimulation activity on 2/24/25 and may have gotten pulled away to do other tasks. An interview was conducted on 2/25/25 at 4:13 PM with the Administrator and Activity Director. The Administrator stated the expectation was for the activities staff to run the activities program as planned. In addition, all staff were expected to encourage resident participation. The Activity Director stated all activities on the memory care unit should take place according to schedule and when residents were not in group activities the individuals should be provided with one-to-one visits in accordance with the care plan. The Activity Director further stated she was unaware the activities on the memory unit were not being done as scheduled. 38077 1d. Resident #68 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, chronic obstructive pulmonary disease, vascular dementia, and dysphagia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 was assessed as having unclear speech and severely cognitively impaired. The resident was dependent on staff for all Activities of Daily Living. Assessment indicated Resident #68 preferred activities like listening to music: being around animals such as pets, doing things with groups of people, and spending time outdoors. Review of care plan dated 2/13/25 revealed Resident #68 was care planned for activities and was dependent on staff for meeting emotional, intellectual, physician and social needs. Interventions included were ensuring that the activities the resident attended were compatible with physical and mental capabilities and compatible with known interests and preferences. Interventions also indicated the resident needed 1:1 bedside/in-room visits and activities if unable to attend out of room events. Observations made on 2/24/25 at 11:46 AM, on 2/25/25 at 3:30 PM and on 2/26/25 at 10:29 AM revealed Resident #68 was observed lying on her bed. No TV or music playing in the room. Resident #68 was observed staring at the wall. The TV was not connected to the wall. During an interview on 2/26/25 at 1:50 PM, the Activity Director indicated that she was unaware that the TV was not working in Resident #68's room. The Activity Director stated Resident #68 received 1:1 activities and liked to listen to music (country music), when someone read to her and enjoyed having someone in her room. On 2/26/25 at 1:55 PM, the individual participation record from 2/9/25 to 2/16/25 was reviewed with the Activity Director. The participation record indicated Resident #68 received 1:1 daily activities. The record further indicated the resident participated in 1:1 activities like listening to music and listening to Television/radio. The resident was daily involved in talking/conversation/ telephone. The document also indicated Resident #68 independently participated in activities like spiritual/religious, relaxation and sensory activities daily. The Activity Director was asked to explain the 1:1 activities and resident's participation. The Activity Director stated the housekeeping staff spend time with resident for some socialization. The Activity Director added there was a resident in the hallway who carried a boom box, and he played music and would go around the hallway. When asked about specific activities conducted by activity staff, the Activity Director stated that Activity staff could only do some activities with the resident when available. The Activity Director was unable to state what kind of activities were done with Resident #68 by the activity staff. The Activity Director stated she was new to this position and has not completed the assessment or documentation of any activities for the residents. During an interview on 2/26/25 at 3:50 PM, the Administrator stated it was her expectation that the residents received 1:1 activity that enriched her emotionally and intellectually. The Administrator indicated the Activity Director was recently promoted to the position. The Administrator further indicated that Resident #68's 1:1 activities should be reviewed and revised. The Activity Director should document what activities the residents participated in or preferred.

Based on observations, record review and staff interviews, the facility failed to promote care in a dignified manner for 3 of 3 residents who were assisted with meals. Staff were observed standing beside the side of the residents' beds while feeding assistance was provided (Resident #62, Resident #14 and Resident # 68). Findings included: 1. Resident #62 was admitted on [DATE]. Review of the significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was assessed as moderately cognitively impaired. The assessment indicated Resident #62 was dependent on staff for eating and was on a therapeutic diet. The assessment indicated the resident had a significant weight loss and was under hospice care. During a continuous lunch meal observation on 2/24/25 from 1:15 PM to 1:20 PM, Resident #62 was observed in bed and Nurse Aide (NA) #2 was observed standing beside Resident #62's bed, leaning over and assisting the resident with eating. There was one chair on the other side of the resident's room. The chair had the resident's roommate's personal item and pillow on it. During an interview on 2/24/25 at 1:20 PM, NA #2 indicated the Resident #62 needed assistance with feeding. NA #2 stated there was no chair in the room, so she continued to feed the resident while beside his bed. NA #2 stated she frequently assisted Resident #62 with feeding. NA #2 indicated depending on the day or if there was a chair available in residents' room, she would either sit or stand and feed the resident. NA #2 further indicated she just didn't think about sitting down while assisting Resident #62 with feeding. 2. Resident #14 was readmitted to the facility on [DATE]. Review of the admission MDS dated [DATE] revealed Resident #14 was assessed as having unclear speech and severely cognitively impaired. The assessment indicated the resident was dependent on staff assistance for eating. During a continuous meal observation on 2/24/25 from 1:22 PM to 1:30 PM, NA #1 stood beside Resident #14's bed and assisted Resident #14 with eating while Resident #14 was in bed. There was no chair observed in the resident's room. During an interview on 2/24/25 at 1:25 PM, NA #1 stated Resident #14 needed assistance with feeding. NA #1 indicated there were no chairs in resident's rooms, so he was feeding the resident while standing beside her bed. 3. Resident #68 was readmitted to the facility on [DATE]. Significant change MDS dated [DATE] revealed Resident #68 was assessed as severely cognitively impaired. The resident was dependent on staff assistance for eating. Physician orders dated 2/18/25 revealed regular diet with pureed texture, and honey consistency liquids. The order also indicated double protein with meals for risk of malnutrition and compromised skin integrity. During a continuous observation on 2/24/25 from 1:32 PM to 1:40 PM, Resident #68 was observed lying in bed. Resident #68's meal tray was brought into the room by NA #2. The meal was placed beside the bedside table and NA #2 started feeding the resident. NA #2 was observed standing beside Resident #68's bed, leaning over and feeding the resident. Observation of the room revealed that there was no chair in the room. During an interview on 2/24/25 at 1:40 PM, NA #2 indicated the resident needed assistance with feeding and she frequently assisted the resident with feeding. NA #2 stated there was no chair in the room and hence she was standing and feeding the resident. During an interview on 2/26/25 at 10:06 AM, the Administrator stated all nursing staff were frequently trained to sit beside the resident while feeding or while assisting resident with eating. The Administrator indicated all nursing staff would be retrained to ensure the residents who needed feeding assistance were fed with dignity. She acknowledged that no staff should be standing beside the residents' bed while assisting them with eating.

Based on record review, and resident and staff interviews, the facility failed to facilitate a resident's participation in the development of their plan of care for 1 of 29 residents reviewed for comprehensive care plans (Resident #110). The findings included: Resident #110 was admitted to the facility on [DATE] with diagnosis that included Diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 was cognitively intact. Record review of copies of the care plan invitation letters sent to the resident revealed Resident #110 was scheduled for care plan meetings on 1/28/24, 5/7/24, 8/29/24, and 1/28/25 but there was no documentation that Resident #110 participated. During an interview on 2/24/25 at 1:53 p.m. Resident #110 revealed he had not attended his care plan meetings since admission to the facility. Resident #110 revealed he had always received invitation letters from the Social Worker Assistant, but the dates came and went without anyone coming to get him to the meeting. During an interview with the Social Work Assistant on 2/25/25 at 2:14 p.m. she revealed that she expected Resident #110 to reach out to her to choose a time slot he would be available to participate in his care plan meeting. She further stated it was a miscommunication between her and Resident #110 because he did not come to her to choose a time slot for his meeting. The Social Work Assistant stated that she did not follow up with Resident #110 after handing him the care plan meeting invitation letter to confirm his participation. The Social Work Assistant stated that Resident #110's care plan meetings usually went on without his participation. In an interview with the Administrator on 2/26/25 at 1:31 p.m. she revealed there was a miscommunication between Resident #110 and the Social Work Assistant. She further stated that the Social Work Assistant will receive an in-service to ensure residents who are able to participate in their care plan meetings are in attendance.

Based on record review, and staff, Adult Protective Services Social Worker (APS-SW), family and the Arresting Officer interviews, the facility failed to protect a resident's right to be free from misappropriation of property leading to a suspected monetary loss of $11,670.68. The deficient practice was for 1 of 1 resident reviewed for misappropriation of resident property (Resident #400). Findings included: Resident #400 was admitted to the facility on [DATE] and discharged on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #400 was cognitively intact. The initial allegation report dated 2/18/25 stated that it was brought to the facility's attention by the Police Department that Nurse Aide #7 was allegedly using a resident's credit card without permission. The report stated that the family of Resident #400 noted charges on a credit card when the monthly bill was received on 2/18/25 and the family notified the local Police department on 2/18/25 and the police initiated an investigation. The report stated Nurse Aide #7 was suspended. A review of the 5-day investigation report dated 2/21/25 revealed that on 2/18/25 the Administrator and the Assistant Director of Nursing (ADON) were visited by a local County Deputy [NAME] who stated that Nurse Aide #7 was under investigation for using Resident #400's credit card. The investigation report stated that the Deputy Sheriff stated that the charges on Resident #400's credit card are from 2 days after she was admitted at the facility on 1/14/25. The investigation report stated the family contacted the police when they received Resident #400's credit card statement and saw the suspected charges. The Deputy Sheriff stated that Nurse Aide #7 was under investigation and would be charged in court the following week. The investigation report stated that the Administrator and ADON called Nurse Aide #7 on the phone, and she adamantly denied the allegations, stating it was not her. The investigation report revealed the Administrator explained to Nurse Aide #7 that she could not work or enter the facility until the courts decided on her guilt or innocence. Attempts made to contact Nurse Aide #7 by phone on 2/25/25 and 2/26/25 were unsuccessful. During an interview on 2/25/25 at 11:23 a.m. with the APS-SW he revealed that he had received a complaint from the bank via fax on 2/18/25 about the unauthorized use of a credit card belonging to Resident #400 in the amount of approximately $11,670.68. The APS-SW revealed the investigation was still ongoing. Attempts to speak with Resident #400 by phone on 2/24/25 and 2/25/25 were unsuccessful. In an interview on 2/27/25 at 9:31 a.m. with Resident #400's family member, he revealed that the charges on the credit card occurred while Resident #400 was at the facility. He further revealed that the missing funds were reimbursed to Resident #400 by credit card company. According to family memebr of the resident, she did not make any purchases or cash withdrawals using her credit while she was hospitalized or admitted at the facility and discharging home on 2/10/25. During an interview on 2/27/25 at 10:39 a.m. with the Arresting Officer he revealed Nurse Aide #7 was arrested in connection with the unauthorized credit card use. The Arresting Officer stated that he was still working on the case. During an interview with the Business Office Manager on 2/27/25 at 9:36 a.m. she revealed that she was not aware Resident #400 had a pocketbook and a credit card on her during admission. She revealed they discouraged residents from having cash or credit cards on their person but do provide lock boxes for safe keeping of valuables. During an interview with the Assistant Director of Nursing (ADON) on 2/26/25 at 8:26 a.m. she stated that she became aware of the theft of funds from Resident #400's credit card on 2/18/25 when the police came to the facility seeking to arrest Nurse Aide #7. She further revealed that Nurse Aide #7 was suspended from work until determination of the court process. In an interview with the Administrator on 2/26/25 at 1:42 p.m. she revealed that she was not aware that Resident #400's credit card was missing or used by a staff member until the police showed up looking to arrest Nurse Aide #7 on 2/18/25. She stated that the police informed her that the credit card was used from 2 days after Resident #400 was admitted to the facility. She further revealed she contacted Nurse Aide #7 who denied using Resident #400's credit card. She revealed she contacted Resident #400 on 2/18/25 who expressed shock that Nurse Aide #7 had been arrested for using her credit card. The Administrator revealed Resident #400 had stated that her credit card was in her bookbag while she was at the facility. The Administrator revealed that Nurse Aide #7 who had worked at the facility for several years, was suspended pending the court system outcome. The Administrator stated that she revealed she apologized to the family of Resident #400. NA #7 allegedly used the card from 1/14/25 through the first week of February 2025. The facility provided the following corrective action plan with a completion date of 2/22/25. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. -An investigation was conducted on 2/18/25 on Resident #400 whose credit card had been misappropriated. Resident #400 was awarded back the funds that had been charged on her credit by the credit company with no financial hardship. -Incident was reported to Adult Protective Services by the Administrator on 2/18/25. -The Administrator filed a 24-hour report with NCDHHS on 2/18/25 at 3:41 p.m. -The ADON suspended Nurse Aide #7 on 2/18/25. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. -The Administrator stated that the Business Office Manager will complete inventory of cash and credit and debit cards on new residents starting on 2/18/25. As of 2/18/25 the Business Office Manager reported no residents had a credit or debit card in the facility. - During the investigation from 2/18/25 through 2/21/25, alert and oriented residents in the facility were interviewed by Business Office Manager , Social Work Assistant and ADON concerning missing money or belongings for a refund or replacement and no concerns/claims noted. -100% of audit of trust funds by the Business Office Manager for all residents regarding any missing money on 2/18/25. Business Office Manager audited all receipts for purchases made for alert and oriented residents by the activities department. Business Office Manager reported no concerns were identified. -Responsible parties for non-alert and oriented residents were contacted and interviewed concerning missing money or belongings with no concerns noted on 2/18/25 by Social Work Assistant and ADON. -discharged residents/responsible parties from 1/14/25 to 2/18/25 were also contacted and interviewed concerning missing money or belongings with no concerns noted. -Staff members who worked in the facility from 1/14/25 through 2/18/25 when the credit card was taken were interviewed by ADON to see if they had noticed anyone going through resident belongings or any other suspicious activity. No concerns were reported. Address what measures were be put into place or systemic changes made to ensure that the deficient practice will not recur. -During the investigation ADON conducted in-service education with all staff in all departments regarding misappropriation of resident money from 2/18/25 through 2/21/25. Staff are required to report to management immediately if they see a credit card lying around. -The Administrator reported that all newly hired staff will be educated on Abuse, Neglect, and misappropriation of property and policies during the orientation process by the Social Services Director/designee beginning 2/18/25. -On 2/18/25 the Administrator directed the ADON to provide Abuse, Neglect, and Misappropriation of property in-service education to any agency staff prior to working their first shift-presently no agency staff is being used at this facility. -The Administrator reported that a decision was made during the Ad Hoc QAPI meeting on 2/18/25 for facility to procure a safe box with a key for each resident with credit cards or cash for safekeeping and monitoring of their use by the Business Office Manager. The Administrator reported they expect the safe boxes to arrive in a week's time and they shall provide education for alert and oriented residents. -During the investigation from 2/18/25 through 2/21/25, the Business Office Manager performed new background checks on all staff. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. -Administrator or DON will conduct a random interview of ten residents weekly for four consecutive weeks, fifteen residents bi-weekly for 2 months and then twenty residents monthly for 2 months. These residents will be interviewed about experiencing misappropriation of funds. -Any deficient practice found during the audits will be corrected immediately and education and/or corrective action done by the Administrator as appropriate. -The audit findings will be reported to the monthly QAPI meeting by the Administrator for a minimum of 3 months. -The Administrator stated she was the individual responsible for compliance with this POC. Corrective action completion date: 2/22/25. Validation: Onsite validation of the corrective action plan was completed on 2/27/25. Interviews with staff in all departments in the facility confirmed they received in-service training on Misappropriation of resident funds, property, abuse, neglect, and reporting of alleged violations. A review was completed on the training sign-in sheet dated 2/18/25 for all staff, the call logs by the Social Work Assistant to Responsible parties, and all staff background checks done by the Director of Human Resources on 2/18/25. The compliance date of 2/22/25 was validated.

Based on record review, and Resident Representative and staff interviews, the facility failed to provide the resident and Resident Representative with a written notification of transfer or discharge including notification of appeal rights when the resident was discharged for 1 of 2 residents reviewed for hospitalization (Resident #200). The findings included: Resident #200 was originally admitted to the facility on [DATE]. The discharge Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #200 had severe cognitive impairment. The discharge was coded return not anticipated. A review of the medical record revealed Resident #200 was transferred to the hospital on 4/3/24 for psychiatric evaluation and involuntary commitment. Resident #200 was transferred back to the facility on 4/7/24 and then discharged on 4/7/24. There was no documentation a notice of transfer/discharge was provided to Resident #200 or the Resident Representative. A telephone interview was conducted on 2/25/25 11:32 AM with the Resident Representative who stated when Resident #200 was discharged on 4/7/24, she nor the resident received a written notice of transfer or discharge. An interview was conducted on 2/25/25 at 12:27 PM with Social Worker #1 who stated the discharge process on 4/7/24 was handled by nursing and the Administrator and she was unaware of what notification was provided when the resident was discharged home. An interview was conducted on 2/27/25 at 9:07 AM, with the Administrator who stated the family was notified by telephone on 4/7/24 of Resident# 200's discharge home and she was unaware the resident and resident representative had to be notified in writing every time a resident was discharged to the hospital or community.

Based on record reviews, and Resident Representative (RR), hospital Case Manager, Physician, and staff interviews, the facility failed to permit a resident to remain in the facility after the hospital assessed Resident #200 as returning to her baseline and discharged her back to the facility for 1 of 2 residents reviewed for discharge (Resident #200). The findings included: Resident #200 was originally admitted to the facility on [DATE] with multiple diagnoses including anxiety, depression, schizophrenia and bipolar disorder. The discharge Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #200 had severely impaired cognition. The discharge was coded as planned with return anticipated. Review of the nurses' note dated 4/3/24 revealed that Resident #200 needed to be involuntarily committed due to threat to self, staff and other residents. Exhibiting aggressive behaviors and outbursts and refusing all medications. The provider was notified of the resident's behavior and gave orders to have resident involuntarily committed for one day. Review of the transfer/discharge form dated 4/3/24 revealed (involuntary commitment) was written on the form and the reason for transfer/discharge: The safety of individuals in this facility is endangered due to the clinical or behavioral status of the resident; The health of individuals in this facility would otherwise be endangered. Review of the hospital Discharge summary dated [DATE] read in part: revealed Resident #200 was admitted on [DATE] and discharged on 4/7/24. Review of the hospital course revealed Resident #200 was seen in the emergency room on 4/3/24 for noncompliance with medications, delusional thought process, hallucinations. The facility staff reported that the resident was currently a safety risk to herself and others at the facility, displaying aggressive behaviors toward self and other residents, both physically and verbally and non-compliant with medications. The facility management stated the resident may return to the facility once mentally stable. Discharge assessment and plan: Resident #200 improved and was taking her medications without issues. She was at her baseline and could return to her skilled nursing facility (SNF). There were no threats to herself or others and no hallucinations. The treatment plan included restarting medications and discharge Resident #200 back to the facility. On 2/25/ 26 and 2/26/25 attempts were made to contact the hospital nurse and discharge staff to confirm the discharge plan, however, individuals who were involved in the admission and discharge process were unavailable for interview. Review of a nurses' note dated 4/7/24 at 5:11 PM revealed emergency medical service (EMS) here and with the resident (Resident #200). The report has not been called in. The officer here telling me to move out of the way so EMS can put her in her bed. Facility was not made aware that she was returning. Resident, RP (Resident Representative), and Provider updated. Review of the nurses' note dated 4/7/24 at 5:17 PM revealed the Resident was refusing to take her medication. Resident, RP, and Provider updated. Review of the nurses' note dated 4/7/24 at 5:22 PM revealed 911 was called to take her back to the hospital. Resident, RP, and Provider updated. Review of the nurses' note dated 4/7/24 at 6:40 PM revealed the nurse spoke with another family member. She stated that they were on their way here to pick up Resident #200. Resident, RP, and Provider updated. Review of the nurses' note dated 4/7/24 at 5:59PM revealed Resident refusing to go with them. A [family member] was notified to come pick up resident. Resident, RP, and Provider updated. Review of the nurses' note dated 4/7/24 at 7:40 PM revealed Resident #200 wants to go home. Refusing all meds. Refusing supper and liquids. Resident, RP, and Provider updated. Review of the nurses' note dated 4/7/24 at 8:13PM revealed Resident #200 took bedtime meds. Resident, RP, and Provider updated. Review of the nurses' note dated 4/7/24 at 10:30 PM revealed Resident #200 arrived via emergency medical services (EMS) at 5:00 PM without report and without facility accepting her back. EMS called the sheriff. The Assistant Director of Nursing (ADON) was notified that the resident had returned to the facility. Family called to make aware of return. The [family member] stated that she was coming to pick up the resident. The provider gave an order to discharge resident with resident representative. Resident Representative and a gentleman came and picked up resident. The resident left the facility in good condition. Resident, RP, and Provider updated. Review of the nurses' note dated 4/7/24 at 10:49 PM revealed the Resident Representative here to take Resident home. Resident, RP, and Provider updated. Review of the nurses' note dated 4/7/24 at 11:41 PM revealed the Resident left with resident representative in good condition. Took all belongings. Resident, RP, and Provider update. A telephone interview on 2/26/25 at 1:47 PM, with Nurse #5 who stated she was unaware Resident #200 was returning until EMS arrived at the facility with the resident on 4/7/24. The nurse further stated EMS dropped the resident off and left, she was not sure if the EMS brought paperwork back to facility. Nurse #5 stated she called the hospital and was told Resident #200 was stable. Nurse #5 did not indicate whether she asked for the discharge orders. She then called the Assistant Director of Nursing and informed her the resident had returned. Nurse #5 further stated the Assistant Director of Nursing told her Resident #200 would not be accepted back to the facility due to the facility being unaware Resident 200's discharge from the hospital; the facility did not have any paperwork and was no longer a resident of the facility and there were no beds available and to call the family and inform them they needed to pick up Resident #200. Nurse #5 stated she called the family member and Resident Representative of Resident #200's return to the facility and the reason why Resident #200 was not accepted back in the facility was based on the instruction of the ADON. Nurse #5 indicated Resident #200's initial response when she returned to the facility she refused her medication. The ADON wanted Resident #200 to return to the hospital and the resident refused. EMS called the police who came to the facility and stated the resident would remain in the facility and allow the resident to return to her room, there was nothing that would be done by the police. Nurse #5 stated she contacted ADON, the provider and the resident representative, and informed her of the status of Resident #200. She indicated the family had asked if Resident #200 could remain in the facility overnight and they were told no by the instructions of the ADON. The family member and Resident Representative stated they had to make the arrangements to pick-up Resident #200 and were on their way. She indicated Resident #200 took her evening medications and did not have any behavior issues. Nurse #5 stated when the family arrived, she reviewed the medication list with them, and they took her personal belongings. An interview was conducted on 2/25/25 at 2:20 PM with the Assistant Director of Nursing (ADON), who stated she received a call from Nurse #5 and stated Resident #200 returned to the facility on 4/7/24 without discharge paperwork from the hospital. She stated the facility was not made aware of Resident #200's discharge from the hospital. The ADON stated she instructed Nurse #5 not to accept the resident back without the proper paperwork and to contact the family and inform them Resident #200 had returned to the facility and would not be accepted back because she was not readmitted to the facility and the resident representative needed to come pick-up Resident #200. The ADON indicated she was informed the resident was exhibiting behaviors of medication refusal and insisting on going home. She further stated based on the behaviors she wanted Resident #200 to return to the hospital, but EMS refused to return resident to the hospital. The police were also called to assist with the transfer back to the hospital and indicated there was nothing they could do if the resident refused. The ADON stated she did not have the actual discharge summary on hand when she made the decision not to transfer or readmit Resident #200. The ADON was unable to provide documentation of behaviors that were not manageable in the facility when Resident #200 returned to the facility on 4/7/24. The Assistant Director of Nursing reviewed the medical record and confirmed Resident received her antipsychotic medication and remained calm until family arrived. She indicated that no written notice or discharge plans were made due to the Resident Representative agreement to take resident home. The ADON stated she did not contact the hospital about discharge orders until the next morning. The discharge Minimum Data Set (MDS) assessment dated [DATE] indicated discharge return not anticipated. A telephone interview was conducted on 2/24/25 at 12:31 PM with the Case Manager at the receiving hospital on 4/7/24. The Case manager stated Resident #200 arrived at the emergency room after midnight with the resident representative for admission. The resident representative reported she received a call from the skilled nursing facility to come and pick up Resident #200 because she was no longer a resident of the facility and there was no bed available. The Case Manager stated Resident #200 and Resident Representative was very upset about the discharge process. Resident #200 was very upset and did not want to return to the skilled nursing facility. The resident representative stated she did not agree to take the resident home because she had just learned the resident had returned to the facility following a hospital stay. The resident representative stated she had no place to take Resident #200 due to her health and age she could provide care for Resident #200, so they took her to the emergency room. The Case Manager stated Resident #200 was admitted to the hospital for multiple health conditions until placement could be found. The family was very upset about the entire discharge process. A telephone interview was conducted on 2/24/25 at 11:32 with Resident #200's Resident Representative (RR) who stated she received a call from the facility to inform her the resident was discharged from the hospital but was not accepted back to the facility due to no beds being available. In addition, the hospital failed to send discharge paperwork for Resident #200 to be readmitted and the family needed to come pick up the resident. The Resident Representative further stated they requested for the resident to remain in the facility and was told by the facility nurse Resident #200 could not stay without the paperwork from the hospital. The Resident Representative stated she did not tell the facility they wanted to take Resident #200 home, she stated she was unable to care for the resident due to age and health. The RR stated she felt pressured to take Resident #200 home. She further stated they were not familiar with the area and there were no arrangements made for placement, so they brought Resident #200 to the emergency room in their hometown. She indicated the facility did give her a list of Resident #200's medication and she gave the information to the emergency room staff. Review of the Nurse Practitioner discharge summary note dated 4/18/24 for Resident #200 revealed the chief complaint / nature of presenting problem: Discharge to family care. History Of Present Illness: When the resident returned to the facility from the hospital, the family was made aware that the resident returned. The Resident Representative stated that she was coming to pick up the resident. This provider gave orders to discharge the resident with the resident's representative. Resident Representative and a gentleman came and picked up resident. The resident left the facility in good condition. discharged . Belongings provided to family. discharge: Facility Course: discharged to care of family, no prescriptions provided and no care services. Unplanned discharge. The Nurse Practitioner was contacted multiple times and was unavailable for interview. A telephone interview was conducted on 2/26/25 at 2:21PM with the Physician who stated he received a call from the facility Administrator and Assistant Director of Nursing on 2/25/25 to discuss the discharge of Resident #200 4/7/24. He stated the initial discharge on [DATE] was appropriate based on the behaviors exhibited at the time. He stated he reviewed the hospital discharge summary that revealed the resident was clinically stable for discharge. The Physician reported he was not informed Resident #200 had any behaviors when she returned to the facility on 4/7/24. He stated the information presented to him by the facility staff that the discharge was based on the family agreement to take Resident #200 home. He further stated there was no clinical reason why Resident #200 was not readmitted to the facility. An interview was conducted on 2/25/25 at 12:27 PM with Social Worker #1 worked with Resident #200 at the time of discharge on [DATE] and return on 4/7/24. Social Worker #1 stated the discharge process on 4/7/24 was handled by nursing and the Administrator and she was unaware of what notification was provided when the resident was discharged home. A telephone interview was conducted on 2/27/25 at 2: 47 PM with the former Social Worker who stated previous discussions had been held with Resident #200 and the Resident Representative about Resident #200 returning home. The Resident Representative was able to provide support in the past, however due to her age and health she was no longer able to assist and support the resident. The former Social Worker stated attempts were made to seek placement in Resident #200's hometown to be closer to the family, but facilities of interest declined admission. She further stated that because she was not directly involved in the readmission process, she was not aware of all the events that took place as to why the resident was not accepted back to the facility. She stated after speaking with the nurse in charge at the time readmission on [DATE] the nurse informed the family of Resident #200's the return to the facility and the management decision not to accept the resident back to the facility. The nurse was following the instruction of the Assistant Director of Nursing. She stated the Resident Representative did call back with questions about the discharge process and she was referred to nursing and the Administrator since they handled the discharge. An interview was conducted on 2/27/25 at 9:07AM, in conjunction with a record review with the Administrator who stated beds were available at the time of Resident #200's return. Resident #200 was discharged to the hospital on 4/3/24 as an involuntary commitment with no intent for readmission based on resident safety and involuntary commitment status. The Administrator further stated after she reviewed the record there was no clinical reason the resident for the resident to not be readmitted and that a discharge planning meeting should have been held before resident went home.

Based on observations, record review and staff interviews, the facility failed to complete an admission Minimum Data Set (MDS) and failed to complete the Care Area Assessments (CAA) within 14 days of admission for 1 of 3 sampled residents reviewed for comprehensive assessments (Resident #15). The findings included: a. Resident #15 was admitted to the facility on [DATE]. An admission MDS with an Assessment Reference Date of 12/11/24 was completed on 12/24/24. b. The CAA for Resident #15 included fall potential related to medications, neuromuscular issues, incontinence and Parkinson's Disease; nutritional problems related to swallowing issues; hydration issues related swallowing issues; and potential for skin breakdown and pressure ulcer development due to incontinence. The CAA was not completed until 12/24/24 and the care plan decisions were not completed until 12/30/24. The MDS nurses were interviewed on 2/26/25 at 11:02 AM. MDS Nurse #1 reported she was the MDS Director. MDS Nurse #1 reported during December 2024, the MDS staff was low, and the department had difficulty completing assessments on time. MDS Nurse #2 reported the admission MDS assessment and CAA should have been completed 14 days after admission. The Administrator was interviewed on 2/27/25 at 1:08 PM. The Administrator reported the assessment was late because the facility had a lot of assessments during December 2024 and the MDS department staffing was low. The Administrator reported she was not aware the MDS assessment for Resident #15 was late and she expected the admission MDS assessments and CAA to be completed 14 days after admission to the facility.

Based on observations, record review and staff interviews, the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of the Assessment Reference Date for 1 of 3 sampled residents reviewed for significant change assessments (Resident #61). The findings included: Resident #61 was admitted to the facility on [DATE]. Review of Resident #61's MDS assessments revealed a significant change MDS assessment with an Assessment Reference Date of 12/13/24. The MDS assessment was signed off as completed on 12/29/24, 16 days after the assessment reference date. The MDS nurses were interviewed on 2/26/25 at 11:02 AM. MDS Nurse #1 reported she was the MDS director. MDS Nurse #1 reported during December 2024, the MDS staff was low, and the department had difficulty completing assessments on time. MDS Nurse #2 reported the significant change MDS assessment should have been completed 14 days after the Assessment Reference Date for Resident #61. The Administrator was interviewed on 2/27/25 at 1:08 PM. The Administrator reported the assessment was late because the facility had a lot of assessments during December 2024 and the MDS department staffing was low. The Administrator reported she was not aware the significant change MDS was late for Resident #61, and she expected significant change assessments to be completed within 14 days.

Based on observation, record review and staff interviews, the facility failed to secure smoking materials, specifically, a lighter for 1 of 4 residents (Resident #16) reviewed for safe smoking. Findings included: Resident was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease with exacerbation, diabetes mellitus type 2, and nicotine dependence. Review of the safe smoking screening assessment dated [DATE] revealed the staff reviewed the policy related to smoking times and storage of smoking materials with the resident and resident acknowledged understanding. Resident was assessed as safe smoker and could smoke independently. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was a tobacco user. A review of the most recent quarterly MDS dated [DATE] revealed Resident #16 was assessed as cognitively intact. Review of the assessment indicated the resident exhibited verbal behavior towards others and exhibited rejection of care. Resident #16 required partial/ moderate to substantial / maximal assistance with most activities of daily living. The MDS also revealed the resident was able to use her wheelchair for ambulation. Review of the care plan (last reviewed/ revised on 1/21/25) revealed Resident #16 was care planned to smoke independently per her smoking assessment. The goal was for the resident to be an unsupervised smoker and be free of any injuries related to unsafe smoking practices. Interventions, included the residents' smoking supplies, will be stored at the nurse's station. Charged nurse would be notified if it is suspected that Resident #16 had violated the smoking policy. Resident #16 did not require supervision while smoking. During a continuous observation on 2/24/25 from 11:20 AM to 11:25 AM, Resident #16 was observed in her wheelchair and smoking outside. Medication Aide (MA) #1 was observed supervising the resident during smoking. During an interview on 2/24/25 at 11:25 PM, MA #1 stated Resident #16 was a safe smoker and did not need supervision for smoking but added the Resident was on contact precaution and hence has been supervised. During an observation on 2/24/25 at 11:28 AM, Resident #16 and staff were observed coming inside the building. MA #1 assisted the Resident inside the room. MA #1 went to her medication cart once the resident was in her room. During an interview on 2/24/25 at 11:30 AM, MA #1 indicated she did not take the Resident's smoking material (cigarettes and lighter) from Resident #16 as the Resident was a safe smoker. MA #1 reiterated that some safe smokers could hold their own smoking material including the lighter. Resident #16 was one of the safe smokers who was allowed to keep her smoking material with her. MA #1 stated she was unsure who gave the resident her lighter. During an observation and interview on 2/24/25 11:40 AM, the Assistant Director of Nursing (ADON) was observed going into Resident #16 room. The ADON was observed requesting the Resident to hand over her smoking material (cigarettes and lighter). The ADON was observed coming out of the room with 2 packs of cigarettes. One pack had cigarettes, and another had cigarettes and lighter. During an interview, the ADON indicated a staff member notified her about the resident keeping her smoking materials. The ADON further indicated Resident #16 was assessed as a safe smoker. ADON further indicated Resident #16 was holding her lighter and it was in one of the cigarette pack. The ADON stated she was unsure if Resident #16 was one of the safe smokers who could keep smoking materials on her. The ADON further stated she needed to check the resident's medical records to ensure if she could keep her smoking material. During an interview on 2/25/25 at 2:45 PM, the Assistant Social Worker indicated Resident #16's last smoking assessment was completed on 10/9/24 and the Resident was assessed as safe smoker. The Assistant Social Worker further stated that residents who were assessed as safe smokers could keep their cigarettes with them. The Assistant Social Worker further stated no residents were allowed to keep any lighters on them. All residents who smoked should be assisted with lighting their cigarettes. She confirmed Resident #16 could keep her cigarettes but her lighter or match that can strike a fire should be stored at the nursing station. During an interview on 2/26/25 at 9:50 AM, the Administrator stated the safe smokers could keep cigarettes with them, as the residents could go to the smoking area at their will. The Administrator further stated that smoking residents were not allowed to have any lighter or matches that could light fire with them. Staff assisted residents with lighting their cigarettes. The Administrator indicated Resident #16 was assessed as safe smoker and should only be having her cigarettes with her and not any lighter.

Based on observations and staff interviews, the facility failed to keep food preparation areas, food storage areas and food service equipment clean, free from debris, grease buildup, and/or dried spills on the floor during two kitchen observations. The facility failed to clean the ceiling vents and air condition units located over the food prep and food service area. This practice had the potential to affect food served to all residents. The findings included: 1.During a kitchen tour on 11/14/23 at 10:00AM, the following observations were made with the dietary manager: a. The 6- stove burners had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were large amounts of burnt foods, dried, encrusted, liquid and splatters throughout the stove area. The inside and outside of the combination stove and oven doors had grease buildup, dried foods, and liquid spills. b. The 4-compartment ovens had a heavy grease buildup, dried food, and liquids on the inside and outside. The grease buildup was encrusted on doors/shelves where food was being cooked. There was a dried grease buildup observed on the fronts of the ovens and on the walls on the inner walls of the oven or on the walls behind the oven. c. The 5 compartment steam tables had large volumes of leftover food in standing water. Under the steam table there were 9 clean steam table lids stored on dirty surfaces where foods crumbs d. The 8 ceiling vents and 1 air conditioner had large volumes of black dust/debris blowing over food service and prep surfaces and clean dishes area. e. The 3 -compartment plate warmer had 3 rows of clean plates stored in the warmer. The inside of warmer had dried liquid spills and food particles inside and dried liquid spills on the outside. The inside also had old food crumbs all around. f. The floor underneath the stove, fryer, steamer, and ovens had large amounts of dried food, grease puddles and paper products. An interview was conducted on 11/14/23 at 10:15 AM, the Dietary Manager stated staff were required to wipe down all kitchen equipment and floors after each meal and deep clean the equipment weekly. The Dietary Manager acknowledged the identified kitchen equipment, ceiling fan and air condition units had not been cleaned in several months. The DM state staff were expected to sign off the task was clean according to the checklist. The Dietary Manager stated the maintenance staff were responsible for cleaning the ceiling vents. A follow-up observation conducted was done with the Dietary Manager (DM) and Kitchen Supervisor on 11/16/23 at 11:14 AM, of the identified kitchen equipment and concerns. The equipment remained the same as on the initial tour on 11/14/23. Some areas have been worked on but not yet complete. The Kitchen Supervisor further stated she was responsible for ensuring the kitchen staff kept the equipment clean and orderly during her monthly inspections. All staff were responsible for ensuring kitchen equipment was wiped down daily and cleaned weekly in accordance with the kitchen cleaning checklist. The maintenance staff was responsible for cleaning ceiling vents/fans. An interview was conducted on 11/17/22 at 7:30 AM, the Administrator stated the Dietary Manager and Kitchen Supervisor was responsible for ensuring the kitchen was cleaned and maintained. The expectation would be for the Dietary Manager to ensure all kitchen cleaning protocols were in place and followed in accordance with kitchen sanitation guidelines. The Administrator stated the kitchen staff were responsible for ensuring the venting system was clean in the kitchen. An interview was conducted on 11/17/23 at 1:10 PM, the Maintenance Director stated maintenance staff was responsible for changing the filters, the kitchen staff responsible for keeping the vents clean.

Based on resident and staff interviews and record review, the facility failed to resolve repeated concerns with scheduled smoking and diet preferences voiced during 2 of 5 months of consecutive Resident Council Meetings reviewed May 2023, thru October 2023. Findings included: The Resident Council Minutes for the period August 2023 through October 2023 were reviewed and revealed the following. The Resident Council minutes dated August 2023: * The staff did not take smokers out on schedule. * The preferences were not changed on the diet slips. The Resident Council minutes dated September 2023: * Smoking issues regarding scheduled times and staff availability were not resolved. * The dietary preferences were not resolved. The Resident Council Minutes for October did not address any concerns or old business. An interview on 11/15/23 at 11:40 AM with the interim Activity Director revealed that the previous Activity Director did not leave Resident Council minutes. She stated the resident council minutes were typed up from notes she found. She did not know if any if the grievances had been resolved or had a response. A Resident Council meeting was conducted 11/17/23 at 10:40 AM the Resident Council President and 10 residents reported ongoing issues with smoking times and staff being available to take them out in the morning and evening. The group stated that the diet slips were incorrect. They were getting the same food every week. The group stated that the facility failed to respond and resolve any of the group's concerns. The Resident Council President revealed that old business was not discussed during the meetings. There was no resolution. A review of the grievance logs for the period May 2023 through October 2023 revealed that there were no grievances filed on behalf of the Resident Council members' concerns regarding smoking schedules and dietary preferences. Interview with Dietary Manager 11/17/23 at 2:30 PM revealed she had not been made aware of any concerns voiced by the Resident Council about food preferences. Interview with the Administrator on 11/17/23 at 2:40 PM revealed that the Central Supply clerk had been the interim the Activity Director resigned abruptly in October. She further indicated the previous Activity Director did not communicate with specific departments related to the Resident Council. grievances. She stated that she knew there were concerns with the smoking times. She had the staff inform the smokers that they had to follow the designated times and could not go out earlier.

Based on observations, resident and staff interviews and record reviews, the facility to follow the menu for 1 of 1 meal observations for 4 of 4 residents(Resident #7, #58, #109 and #49). During the lunch meal the facility ran out of chicken thighs. The findings included: Review of the facility's lunch meal menu and spreadsheet revealed residents were to receive rancher's chicken thigh, country style tomatoes, black-eyed peas, dinner roll and pumpkin pie and there was no alternate indicated on the menu or on the resident meal ticket on 11/16/23. The entire facility resident meal tickets all read the main meal with no alternate. Observation of the tray line was conducted on 11/16/23 at 11:40 AM- 12:48 PM, the cook, dietary manager and kitchen supervisor were present when the cook ran out of chicken for the residents who received a regular diet. The cook began to serve up an alternate meal of Quiche which was not listed on the facility menu or spreadsheet. The Dietary Manager and Kitchen Supervisor both stated the cook probably had not followed the menu correctly to ensure there was enough food per the recipe. There was no explanation offered by the dietary manager or kitchen supervisor why there was not enough chicken to serve all the residents. Review of the meal tickets there were 11 residents that did not receive the chicken thigh. An interview was conducted on 11/16/23 at 11:50 AM, the Kitchen Supervisor stated she was responsible for monthly kitchen inspections and her last visit was on 10/31/23. She indicated the dietary manager was responsible for checking behind the staff to make sure things were done and the cooks were following the corporate menus and ordering food/supplies weekly. Observation was conducted at 1:00 PM on 11/116/19 in the main dining room revealed several voiced concerns about the meal served was not on the menu. a.Resident #7 was admitted to the facility on [DATE]. Review of Resident #7's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #'7s ate independently and his cognition was intact. The November 2023 physician order revealed a carbohydrate-controlled, regular diet and thin liquids. An observation and interview were conducted on 11/16/23 at 1:15 PM, Resident was observed not eating what was served on the tray. Resident #7 stated he was looking forward to the chicken and he did not know why he got the eggs. Resident #7 further stated he was told by the aide the kitchen ran out of chicken. He indicated everyone gets the same food and the residents did not have a menu to select from. Everyone just eats what was served. b. Resident #58 was admitted to the facility on [DATE]. Review of Resident #58's quarterly Minimum Data Set(MDS) dated [DATE], revealed Resident #58's cognition was moderately impaired with supervision during meals. The November 2023 physician order was heart healthy, regular diet and thin liquids with supervision during meals. An observation and interview were conducted on 11/16/23 at 1:16 PM, Resident #58 was observed only eating the dessert on the tray and not the other items on the tray. She stated she wanted the chicken and was not sure why she did not receive the chicken and she did not want eggs. c. Resident #109 was admitted to the facility on [DATE]. Review of Resident #109's significant change Minimum Data Set(MDS) dated [DATE], revealed Resident #109 cognition was moderately impaired with supervision during meals. The November 2023 physician order revealed a carbohydrate-controlled, regular diet and thin liquid. An observation and interview were conducted on 11/16/23 at 1:17 PM, Resident #109 was observed not eating the meal served. He stated he did not want breakfast for lunch and the board said chicken. Resident #109 further stated he asked the aide what happened with the chicken and was told they probably ran out of chicken, so he got the substitute. d. Resident #49 was admitted to the facility on [DATE]. Review of Resident #49's significant change Minimum Data Set(MDS) dated [DATE], revealed Resident #109 cognition was moderately impaired with supervision during meals. The November 2023 physician order revealed a no added salt regular texture diet and thin liquids. An observation and interview were conducted on 11/16/23 at 1:18 PM, Resident #49 stated he was looking forward to the chicken and the aide told him they were out of chicken. Resident #49 stated the residents never knew what the meal choice were because everyone was getting the same food even if we they did not like it. They seem to run out of food so often. He reported he ate what was given. An interview was conducted on 11/17/22 at 7:30 AM, the Administrator stated the Dietary Manager and Kitchen Supervisor was responsible for ensuring there was enough food in accordance with the menus, physician orders and resident diets.

Based on observations, record review, and staff interviews, the facility failed to protect a resident from slipping in water, by leaving the resident unattended. The resident had a fall, sustaining an Acute Right Patellar Fracture, and required surgical repair. This was evident in 1 of 3 sampled residents (Resident #1) who were reviewed for falls. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the Falls Risk assessment dated ,[DATE] /14 revealed Resident #1 was a high risk for falls. Review of the initial Minimum Data Assessment (MDS) with an Assessment Reference Date(ARD) of 05/07/14 indicated Resident #1 had behaviors that put the resident at significant risk for physical illness or injury, which included wandering. The resident required limited assistance with one person physical assist for bed mobility, transfers, locomotion on and off the unit, and required extensive assistance with toilet use and personal hygiene. Review of the Care Area Assessment (CAA) Summary dated 05/13/14 for Resident # 1 indicated the following care areas were triggered to proceed to the resident ' s care plan: Cognitive loss/dementia, urinary incontinence, behavioral symptoms, falls, and psychotropic drug use. Review of the Care Plan dated 5/13/14 revealed Resident #1 was, " At risk for falls related to : mental status, new admission, psychotropic medication use, ambulatory/incontinent, osteoporosis. " The approaches included: " Observe for potential patterns of falls to identify possible causes, observe for potential medication related causes, encourage resident to ask for assist, ensure resident has proper footwear as indicated and accepted, orient resident to environment, place call light within reach, offer/assist resident to toilet frequently and as accepted, and place frequently used items within reach. " Record review revealed Resident #1 had five falls in June of 2014. A fall occurred on 06/21/14 when the resident was left unattended by staff, and slipped due to water on the floor. Review of the nurses notes dated 06/21/14 at 7:45 AM read, " Resident found lying in a puddle of water with knees pulled up to the chest. Upon getting the resident up, the resident was noted to have a limp to the right leg, when walking. The right knee was noted to be reddened and bruised. " A staff interveiw conducted 10/2/2014 at 10:35 AM with the 3rd shift Charge Nurse (Nurse #1) regarding the fall sustained by Resident #1 on 6/21/14. Nurse #1 revealed " I was on the secured unit around 6:00 AM on 6/21/14. I heard water running, and I went in the bathroom in (Resident #1 ' s) room, and the water was overflowing from the sink. I turned the water off, and I helped (Resident #1) into the dining area. I assigned (NA#4) to stay with (Resident #1) and the roommate in the dining area, while I got towels and blankets to soak up the water. I called housekeeping and no one responded to the call, because there was no housekeeping staff in at that moment. The water had flowed from the bathroom to the resident ' s room near the window. I then went out of the unit, and found a housekeeping aide, who came to the unit approximately 15 -20 minutes later to mop up the water. When I went back to the unit, housekeeping was mopping up water that had flowed into the hallway, and I was told by (NA #2) that (Resident #1) had slipped in the water and had fallen. I assessed the resident, and I noticed both knees were red, and the right knee was more reddened and swollen. The knee cap was sunken in. I called the Doctor and received an order for [REDACTED]. Interview with the Housekeeping Aide and the Housekeeping Supervisor conducted on 10/01/14 at 2:00 PM regarding what was done related to the water overflow in Resident #1 ' s room on 6/21/14. The Housekeeping Aide stated, " I came in at 6:00 AM. Before shift change, I was called to the 600 hall. (Nurse #1) called me because there was a flood in room 607 (Resident #1 ' s room). I started mopping the water up, and I was putting down bath blankets to absorb the water. About 7:00 AM, I went to get some more blankets to put down. When I left the 600 hall, it was still a little wet, and there was water at the nurse ' s station. " A direct care staff interview conducted with NA #4 on 10/01/14 at 2:10 PM regarding the the fall for Res. #1. NA #4 stated, " I was on third shift, working between 200 hall and 600 hall. When I got to 600 hall, I was assigned by (Nurse #1) to monitor (Resident #1) and three other residents in the dining area until first shift. When (NA # 2)(my relief ) came, she took over the residents, and I clocked out. When asked what it meant to monitor the residents, NA #4 stated, " To monitor means you can ' t leave them by themselves, someone has to be with them, watching them. If they are a fall risk patient, they are subject to fall, and you have to be by their side to assist them walking. If they have a yellow band on, they are considered a fall risk. (Resident #1) was a fall risk at the time. " A direct care interview was conducted with NA #2 on 10/1/14 at 3:00 PM, regarding the circumstances surrounding Resident #1 ' s fall of 06/21/14. NA #2 indicated, " When I came in about 6:56 AM, NA #4 was with (Resident #1) in the hallway in front of the resident ' s room. Water was still on the floor. (NA #4) left the resident with me, because (NA #4) had to clock out. I told the resident to go in the opposite direction down the hallway, and I started my rounds. I left the resident alone, while I went to do my rounds. I was there by myself for about 5 minutes, then everybody else(referring to Nursing and Nursing Assistant staff) started coming in. I had started rounds with my first resident, when (NA # 3) came and got me out of the room and told me (Resident #1) was on the floor. Me (NA#2) and (NA #3) ambulated (Resident #1) and took (Resident #1) into the dining room. We noticed (Resident #1) was not ambulating well, and when I pulled the gown back to check, I noticed the whole right knee was pushed in and flat, the knee cap was higher than where it was supposed to be. (NA#3) got (Nurse #1) off the main hall. (Nurse #1) assessed (Resident #1), and told me to sit with (Resident #1), until (Nurse #1) could call and get an X-Ray done for the knee. The doctor looked at the X-Ray, and sent (Resident #1) to the hospital. " When asked about the facility protocol for a resident who is at risk for falls on the secured unit, NA #2 stated, " We are supposed to keep them out of harms way, and monitor the fall risk residents by walking the resident with use of a gait belt to make sure they don ' t fall, and also observing the residents during activities and /or sit with the resident. I know we are not supposed to leave them alone. " Review of the hospital record for the admission of 06/21/14 revealed Resident #1 sustained an acute fracture of the right knee patellar and had an open reduction internal fixation surgery on 6/22/14 to repair the fracture. A direct care staff interview was conducted on 09/30/2014 at 4:25 PM with Nurse # 2 regarding the current monitoring needs of Resident #1. Nurse #2 indicated, " (Resident #1) is on close supervision because of being a falls risk, and a nursing assistant has to stay with (Resident #1) when in the dining room. " A direct care staff interview conducted on 09/30/14 at 4:30 PM with Nursing Assistant (NA #5) indicated Resident #1, " Can now walk and is total care. " When asked how NA #5 prevented the resident from having further falls, NA #5 revealed, " We walk with (Resident #1), there is an alarm on the bed, and a fall mat beside the bed when the resident is in bed. " Observation of Resident #1 ' s room on 09/30/14 at 4:45 PM verified the use of an alarm on the bed, with the bed in low position. A fall mat was observed stored behind the bed. Resident #1 was observed in the dining room seated at the dining table. A staff member was observed seated next to the resident. Interview with the Administrator and the DON conducted on 10/1/14 at 3:15 PM revealed the facility recognized a problem with falls the first of June, 2014. The Administrator indicated, " We had a lot falls in May, when I first got here. In June we started a different method of investigating falls, with actually looking at the root cause of the falls. " The DON stated, " I don ' t know what date we actually started monitoring. " The Administrator stated, " There is a Performance Improvement Plan for residents at risk for falls. The Quality Assurance Program is done during the morning Interdisciplinary meeting when all falls are reviewed, then we have several meetings throughout month for reviewing at risk residents (At Risk Review Meeting) when each resident is discussed , then we discuss the trends bimonthly with the Medical Director and the entire Interdisciplinary team. For instance, with falls, the falls started to decline in June, and we have continued to trend down. This month, we did not flag for falls. " Interview with the Administrator conducted 10/1/14 at 4:40 PM indicated, " There is no documentation of monitoring for residents at risk for falls on the secured unit. We will need to change that. " Review of the facility in-service dated 6/25/14 entitled, " In-Service with 600 Hall Staff " presented by the DON included: Cleaning up spills as soon as noted, fall interventions, alarms on and answering alarms and call lights, rounds, reducing falls, and non-skid socks available. Interview conducted with the Administrator on 10/2/14 at 4:40 PM revealed the expectations of the Administrator regarding falls in facility included : " To have immediate corrective action after assessment for need, look at the root cause of the fall to make sure no one else is harmed, look at who else/other residents would be affected by the situation, look at our present systems and evaluate for effectiveness, and implement additional interventions as needed, monitor the systemic change to see if its working, and make adjustments as needed. " Interview with the Administrator on 10/1/14 at 2:30 PM revealed, " NA #2 (the assigned NA) was not following protocol to monitor the resident prior to the fall. "