Based on interview and record review, conducted during a site visit on 05/17/24, it was confirmed the facility failed to ensure service plans were updated quarterly for 1 of 1 sampled resident (#2), whose service plan was reviewed. Findings include, but are not limited to:

A review of Resident 2's service plan indicated the most recent update was on 11/01/23 with a review date of 01/29/24.

In an interview on 05/17/24, Resident 2 stated his/her last care plan meeting was in March 2023 and s/he had not been asked to sign or talk about a new one since.

In an email on 05/21/24, Staff 6 (ED) reported that the nurse had done a care plan update with Resident 2, however, s/he did not document it and was no longer working at the facility.

The findings were reviewed with and acknowledged by Staff 1 on 05/21/24.

It was confirmed the facility failed to ensure service plans were updated quarterly.

Verbal plan of correction: ED will be talking with the team right away to come up with a plan to get everyone's service plans updated and make sure residents and families are invited to care plan meetings.

Based on observation, interview, and record review, it was confirmed the facility failed to ensure that all interior materials and surfaces were kept clean, and all equipment were kept in good repair. Findings include, but are not limited to:

Compliance specialist observed the following on 05/17/24:

·Dining room lights were working and not flickering on and off,

·Red and black stains on the carpet next to the bed in Resident 1's room,

·Dark colored stains on the carpet at the door and by the window and air conditioner in Resident 2's room.

Reviewed invoice dated 01/26/24 indicating an electrician was out to repair lights on 01/11/24.

In an interview with Resident 1 and Witness 1, they stated the floors had not been shampooed since Resident 1 moved there in October 2023.

In an interview with Resident 2, s/he stated the carpets were last cleaned in August 2023. S/He stated they requested the carpets be cleaned two weeks ago when maintenance was walking by.

The findings were reviewed with and acknowledged by Staff 6 (ED) on 05/21/24 via email.

It was confirmed the facility failed to ensure that all interior materials and surfaces were kept clean, and all equipment were kept in good repair.

Verbal plan of correction: Carpet has been replaced in dining room and common areas, facility will address any concerns about carpet or stains when reported and has been transitioning to hardwood floors in the rooms.