Every finding on record at Simpson Place

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 24 residents (Resident # 24 and Resident #3) reviewed for infection control.1) The facility failed to ensure Resident #24's privacy curtains were clean and free of feces on 04/28/2026.2) The facility failed to ensure resident's mattress was cleaned from the urine before putting new fitted sheet on the bed for Resident # 3 on 04/28/26. This failure could place residents at risk for infection and cross contamination of pathogens and illnesses. Findings included: Record review of Resident #24's MDS assessment, dated 03/19/2026, reflected a [AGE] year-old male admitted [DATE]. Diagnoses included Hypertension (elevated blood pressure), Asthma, Chronic obstructive pulmonary disease (breathing difficulty), Morbid (severe) obesity due to excess calories. Resident #24 had a BIMS score of 15 indicating intact cognitive functioning and needed moderate assistance with toileting and personal hygiene. Resident #24 was occasionally incontinent for bowel and urine. Record review of Resident #24's care plan, dated 01/24/26, reflected, Problems/Strengths: Depressed mood, . Interventions: encourage to express self and feelings, 03/23/26 reflected: Problems/strengths: Behaviors Anxiety, takes Xanax. Interventions: calm quiet environment, analyze key times, places, circumstances, triggers, and what de-escalates behavior. Residents needs to be lifted manually with two + person support, with Hoyer lift due to dependent on transfers. During an observation and interview on 04/28/2026 at 01:25 PM, Resident #24 was lying in his bed. Resident #24 stated there was feces on the privacy curtain. Observation revealed dried feces on the privacy curtains on both sides of his bed. Resident #24 stated he had reported this to several employees within the past three months, such as the aides and housekeeping staff (could not provide any names) but they did not do anything. Resident #24 stated he felt uncomfortable seeing the feces on the curtain. During an interview on 04/29/2026 at 02:35 PM , the Housekeeping Supervisor stated she was aware the privacy curtain next to Resident #24 had feces on it. She stated she saw it while she was doing rounds after her staff left for the day on 04/28/2026. The Housekeeping Supervisor stated she told the housekeeping staff on 04/29/2026 about the soiled curtain and they would replace it with a clean one that day. She stated the housekeeping staff were responsible for cleaning resident rooms, checking the curtains regularly and replacing the curtains as needed. She stated the resident did not report to her or any housekeeping staff, or any other staff reported to her about the curtain issue. She stated it was important to have clean curtains because soiled or unclean curtains put residents at risk for infections and they could get sick. She stated all the housekeeping employees received an in-service on infection control every month. She stated the housekeeping staff replaced all resident room privacy curtains with clean ones two weeks ago. During n interview on 04/29/2026 at 03:02 PM, Housekeeper G stated he provided services to Resident #24 within the past week. He stated he was responsible for cleaning the resident room and checking the privacy curtain for any stains/feces on it, he did not see any fees on the curtain recently and Resident #24 did not report to him about this issue. He stated unclean privacy curtains put residents at risk for infections. He stated he received training and in-services on how to properly clean resident rooms and on infection control and prevention almost every month. He stated the housekeeping supervisor informed him that day about the soiled curtain in Resident #24's room and he was going to replace it that day. During an interview on 04/29/2026 at 03:15 PM, the ADON stated she was not aware of the soiled privacy curtain in Resident #24's room. She stated the housekeeping department was responsible for replacing soiled curtains with clean ones and they had changed the curtains of all resident rooms two weeks ago. The ADON stated unclean privacy curtains put residents at risk for infections. During an interview on 04/29/2026 at 03:22 PM, the DON stated the housekeeping department was responsible for cleaning resident rooms, checking the privacy curtains regularly and replacing them with clean curtains. She stated not changing soiled curtains will put residents at risk for infections. She stated all the facility employees received in-service on infection control every month and any staff could report soiled linen/curtain to the housekeeping staff/supervisor directly or using the chat option. The DON stated she was not aware of Resident #24 had feces on his privacy curtains. During an interview on 04/30/2026 at 10:26 AM, Housekeeper H stated she was responsible for cleaning resident rooms and cleaned Resident #24's room within a week. She stated she did not see the feces on the privacy curtain in Resident #24's room and Resident #24 did not tell her about this issue. She stated if she saw stains on a resident's privacy curtain, she would notify her supervisor, as per supervisor's instructions she would replace the curtain. She stated the housekeeping department was responsible for checking and replacing curtains as needed, and that they had replaced all resident curtains within a month. She stated unclean privacy curtains put residents at risk for infections. She stated she received in-services and training on how to properly clean resident rooms and infection control every month. Housekeeper H stated she took down the soiled curtains from resident #24's room yesterday and replaced them with clean curtains. During an interview on 04/30/2026 at 10:41 AM, CNA I stated she had provided care to Resident #24, she would notify the housekeeping staff if she saw stains on a resident privacy curtain. She stated she saw the feces on Resident #24's curtain on 04/24/2026, she verbally notified a female housekeeping staff about it the same day, but she could not remember the staff's name. She stated unclean privacy curtains put residents at risk for infections, and she had received in-service on infection control last week. During an interview and observation on 04/30/2026 at 01:39 PM, Resident #24 stated the housekeeping staff took down both privacy curtains and replaced with clean curtains. Observation reflected both curtains were clean and free of stains. Record review of facility policy titled, Resident room cleaning, Department: Environmental services, dated November 2021. Purpose: To provide a clean, attractive, and safe environment for residents, visitors, and staff. Responsibility: Housekeeping staff. Procedure for cleaning resident rooms. General inspections: . C. inspect the room and report all damage, including to walls, furniture, room divider and window curtains (note cleanliness, resident belongings and sinks. Clean and disinfect resident room furnishings: A. Clean all furnishings in the resident's room including the bed rails, IV poles, doorknobs, wheelchairs, walkers, and all other high contact surfaces. F Pay particular attention to soiled or frequently touched surfaces.J. Windows- clean window tracks and check curtains/blinds for soiling. Report any soiled blinds or curtains to the housekeeping supervisor. 17. Inspect your work: Look over the room carefully and mentally check that you have performed all the required steps and that the room meets your standards. Record review of Resident #3's Quarterly MDS assessment, dated 3/16/26, reflected Resident #3 was a [AGE] year-old male admitted [DATE], diagnoses included morbid (severe) obesity and muscle wasting. Resident #3's BIMS score of 9, which indicated Resident #3' cognition was moderately impaired. The MDS assessment indicated Resident #3 was frequently incontinent of bowel and bladder. During an observation on 04/28/26 at 9:53 AM, reflected CNA D entered Resident #3's room to provide him with incontinent care. Observation reflected she uncovered Resident #3 by removing his blanket and revealed a brief saturated with urine. She removed the saturated brief and cleaned the resident. A ring of urine was observed on the fitted sheet. Observation reflected CNA D removed the soiled linen, including the fitted sheet, and put them in the bag. Observation reflected Resident #3's mattress was contaminated with urine. CNA D put a clean fitted sheet on the urine contaminated urine without cleaning and disinfecting the mattress. During an interview on 04/28/26 at 10:12 AM, CNA D stated she should clean the mattress using sanitary wipes since the old sheet was soiled with urine. CNA D stated it slid from her mind. CNA D stated failing to clean the mattress properly increased risk for contamination and spread of infections. During an interview on 04/30/26 at 11:46 AM, the DON stated if the fitted sheet was soiled with urine or bowel movement, she expected the staff to clean the mattress with wipes before putting on a clean fitted sheet. She stated failure to do so would potentially lead to cross-contamination and spread of infection. She stated the ADON and herself were responsible for ensuring safe practices were utilized to control infection spread by doing routine rounds and random checks. Record review of the facility policy titled, Infection Prevention and Control Surveillance, dated January 2022, did not address the concern.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for the facility's one of one kitchen (only kitchen) observed for food service safety.Facility failed to ensure:Two bags of burger buns stored in the bread crate, outside the walk-in refrigerator was dated and put back in the refrigerator on 04/28/2026.The expired scrambled egg in a plastic bag inside the walking refrigerator was labelled and discarded on 04/28/2026.Three bags of shredded cheese stored inside the walk-in refrigerator were dated 04/28/2026.The dessert cart kept in the walk-in refrigerator was covered on 04/29/2026.These failures could place residents at risk for food borne illnesses and food contamination.Observation on 04/28/2026 at 09:38 AM, in the facility's only kitchen, revealed two bags of burger buns stored in the bread crate outside the walk-in refrigerator, were undated and not put back in the refrigerator.Observation on 04/28/2026 at 09:41 AM, in the facility's only kitchen, revealed scrambled egg in a plastic bag did not have a label and had a use by date of 04/27/2026.During an observation on 04/28/2026 at 09:42 AM, in the facility's only kitchen, revealed three bags of shredded cheese stored inside the walk-in refrigerator, did not have a date it was received, and a use by date.During an observation on 04/29/2026 at 11:57 AM, in the facility's only kitchen, revealed the dessert cart in the walk-in refrigerator was not covered.During an observation and interview on 04/28/2026 at 09:57 AM, the Dietary Aide looked at two bags of burger buns and stated it was missing the date it was received and a use by date. The Dietary Aide stated it was supposed to be put back in the refrigerator. She looked at the plastic bag and stated it was the leftover scrambled egg. She stated the plastic bag had to be labeled and discarded since the use by date was 04/27/2026. The Dietary Aide looked at the three bags of shredded cheese and stated it only had the packed-on date of 03/30/2026, and it was missing the date it was received and a use by date. The Dietary aide stated all the dietary staff were responsible for dating, labeling, putting the leftover food items in the refrigerator and discarding the expired food items. She stated without a label and date, she could not tell exactly what that food item was, when that food item was received or taken out of the main box and when it expired. She stated that not labeling, dating, and discarding expired food items could put residents at risk for food borne illnesses. She stated she received in-service training within the last month about the kitchen and safe food handling.During an interview on 04/28/2026 at 10:16 a.m. the Dietary Manager stated she expected all the food items in the kitchen and refrigerator to be dated and labelled, expired food items to be discarded. She stated the burger buns were taken out of the refrigerator, and the staff were expected to date it and put back the remaining burger bun bags in the refrigerator. She stated all staff were responsible for discarding any food item after the use by date. She stated she put the scrambled egg in the refrigerator, and she was responsible for labelling and discarding it after the use by date. The Dietary Manager stated the kitchen staff were responsible for putting the received and use by date on the three bags of shredded cheese. She stated the cheese bags were taken out of a big box and that was the reason it did not have a use by date. She stated milk products such as unopened cheese would not last more than two weeks in the refrigerator. She stated that not labeling, dating, and discarding expired food items could put residents at risk for food borne illnesses. She stated all kitchen staff received in-services monthly on food handling and infection prevention.During an interview and observation on 04/29/2026 at 11:59 AM, the Dietary Manager looked at the dessert cart in the walk-in refrigerator and stated she expected the dessert cart to be covered with a bun rack cover and that they ran out of the covers. She stated she was responsible for ordering the bun rack covers in a timely manner. She stated not covering the dessert in the cart would put residents at risk for food contamination and food borne illnesses. She stated she discarded all the not dated, expired food items and she would provide in-service to all the kitchen employees on safe handling of food.Record review of facility policy and procedure titled, Food Storage, revision date 02/06/2024, reflected, Policy: Food is stored prepared and transported at an appropriate temperature and by methods designed to prevent contamination. Procedure: Refrigerator . All perishable food is refrigerated immediately to ensure nutritive value and quality. All foods are covered, labelled, and dated.Record review of the Food and Drug Administration Food Code, dated 2022, reflected, 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. (B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on interview and record review, the facility failed to receive registry verification that an individual had met competency evaluation requirements prior to the individual working in the facility as a nurse aide for two of two CNAs (CNA A, and CNA D) and one of one medication aide (MA C) reviewed for training and competency. The facility failed to search the Nurse Aide Registry (NAR) for CNA B, MA C, and CNA D prior to date of hire. This failure could place residents at risk for injury or receiving improper care given by uncertified personnel.Findings included: Record review of Employee Summary, dated 04/28/2026, revealed the following dates of hire:-CNA B date of hire 02/27/2026-MA C date of hire 02/18/2026-CNA D date of rehire 04/21/2026 Record review of CNA B's employee file, dated 02/27/2026, revealed CNA B was hired on 02/27/2026 and attended New Employee Orientation on 02/27/2026. Record review revealed a search of the NAR was conducted on 03/08/2026 for CNA B. Record review of MA C's employee file dated 02/18/2026 revealed MA C was hired on 02/18/2026 and attended New Employee Orientation on 02/18/2026. Record review revealed a search of the NAR was conducted on 02/19/2026. Record review of CNA D's employee file, dated 01/22/2025, revealed CNA D was rehired on 04/21/2026 and attended New Employee Orientation on 04/28/2026. Record review revealed a search of the NAR was conducted on 04/29/2026. Interview with the Human Resources Director on 04/30/2026 at 10:47 AM revealed after interviews were conducted with potential new hires the Administrator conducted a criminal history search. Then the Human Resources Director set up the new employees' dates of hire and set up New Employee Orientation. The Human Resources Director stated that when New Employee Orientation occurred the newly hired employee was considered an employee of the facility. The Human Resources Director stated NAR searches were conducted up to 24 hours after the employee's date of hire. The Human Resources Director stated the criminal background search was completed prior to an offer of employment. The Human Resources Director stated that she did not realize that the NAR searches should be done prior to date of hire or start of employment. During an interview with the Administrator on 04/30/2026 at 11:14 AM revealed after interviews were conducted, she ran the criminal history background before going on to the next step. The Administrator stated she did not know there was a timeframe on completing the NAR searches. The Administrator stated the new employees NAR searches were done prior to the employee working on the floor with residents but that they did attend New Employee Orientation prior to the NAR searches. The Administrator stated that failing to run the NAR searches prior to date of hire could result in hiring someone who was not qualified or had stipulations that would not allow them to work with residents. Record review of the facility policy titled, Abuse, Neglect and Exploitation and Misappropriation of Resident Property, dated 02/12/2020, revealed .PurposeThe purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. All managed healthcare facilities and all management company staff members or third parties providing services to such facilities and/or their residents.4. Screening Potential Facility Employees. The facility will not employ or otherwise engage individuals who: a) have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b) have had a finding entered the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c) have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. To avoid hiring such individuals, all employment offers to facility staff members will be conditioned on satisfactory completion of background checks required by state law and company policy, including screening potential employees for a history of abuse, neglect, or mistreatment of residents or other individuals. Such background screening shall include, but not be limited to, the following:a. attempting to obtain a minimum of two professional reference checks on all candidates prior to employment;b. conducting a criminal background check in accordance with state regulations;c. verifying the licensure and/or certification and good standing of the candidate with the applicable state licensing and certification;d. verifying with the Nurse Aid Registry, Misconduct Registry or similar agency for all non-licensed staff, including certified nurse aides ( CNA) and certified medication aides ( CMA), that the potential employee is not listed on either registry as ineligible for employment; ande. post-offer, pre-employment drug test screening.

Based on interview and record review, the facility failed to implement written policies that prohibit and prevent abuse, neglect and of exploitation of residents and misappropriation of resident property for five (RN A, CNA B, MA C, CNA D, and LVN E) of six employee personnel files reviewed for pre-employment screening The facility failed to search the Employee Misconduct Registry (EMR) for RN A, CNA B, MA C, CNA D and Nurse Aide Registry (NAR) for RN A, CNA B, MA C, CNA D, and LVN E prior to date of hire. These failures could affect all 47 residents by placing them at risk for abuse, neglect, exploitation and misappropriation of property.Findings included: Review of Employee Summary dated 04/28/2026 revealed the following dates of hire:-RN A date of hire 03/18/2026-CNA B date of hire 02/27/2026-MA C date of hire 02/18/2026-CNA D date of rehire 04/21/2026-LVN E date of hire 03/13/2026 Review of RN A's employee file dated 03/18/2026 revealed RN A was hired on 03/18/2026. RN A attended New Employee Orientation on 03/18/2026. A search of the EMR and NAR was conducted on 03/19/2026 for RN A. Review of CNA B's employee file dated 02/27/2026 revealed CNA B was hired on 02/27/2026. CNA B attended New Employee Orientation on 02/27/2026. A search of the EMR and NAR was conducted on 03/08/2026 for CNA B. Review of MA C's employee file dated 02/18/2026 revealed MA C was hired on 02/18/2026. MA C attended New Employee Orientation on 02/18/2026. A search of the EMR and NAR was conducted on 02/19/2026. Review of CNA D's employee file dated 01/22/2025 revealed CNA D was rehired on 04/21/2026. CNA D attended New Employee Orientation on 04/28/2026. A search of the EMR and NAR was conducted on 04/29/2026. Review of LVN E's employee file dated 03/13/2026 revealed LVN E was hired on 03/13/2026. LVN E attended New Employee Orientation on 03/22/2026. There was no evidence to indicate a NAR search was conducted for LVN E. Interview with the Human Resources Director on 04/30/2026 at 10:47 AM revealed after interviews were conducted with potential new hires the Administrator conducted a criminal history search. Then the Human Resources Director set up the new employees' dates of hire and set up New Employee Orientation. The Human Resources Director stated that when New Employee Orientation occurred the newly hired employee was considered an employee of the facility. The Human Resources Director stated EMR and NAR searches were conducted up to 24 hours after the employee's date of hire. The Human Resources Director stated the criminal background search was completed prior to an offer of employment. The Human Resources Director stated that she did not realize that the EMR and NAR searches should be done prior to date of hire or start of employment. Interview with the Administrator on 04/30/2026 at 11:14 AM revealed after interviews were conducted, she ran the criminal history background before going on to the next step. The Administrator stated she did not know there was a timeframe on completing the EMR and NAR searches. The Administrator stated the new employees EMR and NAR searches were done prior to the employee working on the floor with residents but that they did attend New Employee Orientation prior to the EMR and NAR searches. The Administrator stated that failing to run the EMR and NAR searches prior to date of hire could result in hiring someone who was not qualified or had stipulations that would not allow them to work with residents. Review of Abuse, Neglect and Exploitation and Misappropriation of Resident Property dated 02/12/2020 revealed .PurposeThe purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. All managed healthcare facilities and all management company staff members or third parties providing services to such facilities and/or their residents.4. Screening Potential Facility Employees. The facility will not employ or otherwise engage individuals who: a) have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b) have had a finding entered the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c) have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. To avoid hiring such individuals, all employment offers to facility staff members will be conditioned on satisfactory completion of background checks required by state law and company policy, including screening potential employees for a history of abuse, neglect, or mistreatment of residents or other individuals. Such background screening shall include, but not be limited to, the following:a. attempting to obtain a minimum of two professional reference checks on all candidates prior to employment;b. conducting a criminal background check in accordance with state regulations;c. verifying the licensure and/or certification and good standing of the candidate with the applicable state licensing and certification;d. verifying with the Nurse Aid Registry, Misconduct Registry or similar agency for all non-licensed staff, including certified nurse aides ( CNA) and certified medication aides ( CMA), that the potential employee is not listed on either registry as ineligible for employment; ande. post-offer, pre-employment drug test screening.

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for two of six residents (Resident #21 and #39) reviewed for quality of care. The facility failed to ensure the supplemental oxygen was provided at the physician ordered rate for Residents #21 and #39 This failure could place residents who received oxygen therapy at risk of oxygen toxicity.Resident #21 Review of Record of admission for Resident #21 dated 04/30/2026 revealed Resident #21 was a [AGE] year-old male who was admitted to the facility originally on 09/08/2025 and his most recent admission was on 03/02/2026. Resident #21 was diagnosed with Chronic Obstructive Pulmonary Disease (COPD- progressive, incurable lung disease-primarily caused by smoking or long-term irritant exposure-that restricts airflow, causing chronic coughing, wheezing, and severe shortness of breath). Review of Resident #21's MAR dated April 2026 revealed Resident #21 was prescribed O2 [Oxygen] at 2LPM [liters per minute] by NC [nasal cannula] as needed PRN for shortness of breath as of 04/15/2026.NOTE: There were no additional orders for monitoring oxygen saturations. Review of Resident #21's Physician's Orders dated April 2026 revealed Resident #21 was prescribed O2 [Oxygen] at 2LPM [liters per minute] by NC [nasal cannula] as needed PRN for shortness of breath. Review of Resident #21's Significant Change MDS assessment dated [DATE] revealed .Respiratory Treatments.Oxygen Therapy.1-Checked (Yes). Review of Plan of Care for Resident #21 dated 10/24/2025 revealed Problems/Strengths. Oxygen therapy related to COPD.Goals.Will have no complications from oxygen therapy.Will maintain oxygen saturation >90 per MD [doctor] order.Interventions.Administer oxygen per MD order 2-4 Liters via NC continuously.NOTE: The Plan of Care had been updated but the original date of the goal had not changed. The information in the care plan did not match the orders. Resident #21 was using continuous oxygen and his physician orders and MAR had not been updated. Observation on 04/29/2026 at 9:48 AM revealed Resident #21's oxygen concentrator set between 1 and 1 1/2 lpm via nasal cannula. Resident #21 was not showing any signs of shortness of breath. Interview with RN F on 04/29/2026 at 2:07 PM revealed Resident #21 recently changed from utilizing oxygen as needed to continuous since being readmitted after a hospital stay and after being admitted to hospice on 04/15/2026. RN F stated Resident #21 was ordered 2 lpm. RN F stated that she checked the oxygen settings of her residents every shift about every four hours. RN F stated she had checked on Resident #21 and found no concerns. Observation and interview with RN F on 04/29/2026 at 2:15 PM revealed Resident #21's oxygen concentration set between 2 1/2 and 3 lpm via nasal cannula. RN F confirmed the oxygen concentrator was set on almost 3 lpm. RN F then lowered the concentrator to 2 lpm. RN F stated she did not know why Resident #21's oxygen concentrator settings had been changed. RN F stated a resident getting too little oxygen could cause shortness of breath and a resident receiving too much oxygen could cause the resident to receive more oxygen than needed causing them to breathe harder. Resident #39 Review of Record of admission for Resident #39 dated 04/30/2026 revealed Resident #39 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #39 was diagnosed with Acute Respiratory Failure (critical, rapid-onset condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide). Review of Resident #39's MAR dated April 2026 revealed Resident #39 was prescribed O2 [oxygen] @ [at] 2LPM by NC [nasal cannula] continuous.02 at 2LPM by NC AS NEEDED As needed [sic] anytime.O2 sat [saturation] Check Every Shift.Monitor resident for signs and symptoms of COPD exacerbation: Increased Shortness of breath (More Breathless than usual) Coughing, Chest tightness, Fever and more mucus or change in color of mucus. Review of Resident #39's Physician Orders dated April 2026 revealed Resident #39 was prescribed O2 [oxygen] @ [at] 2LPM by NC [nasal cannula] continuous.02 at 2LPM by NC AS NEEDED As needed [sic] anytime.O2 sat [saturation] Check Every Shift.Monitor resident for signs and symptoms of COPD exacerbation: Increased Shortness of breath (More Breathless than usual) Coughing, Chest tightness, Fever and more mucus or change in color of mucus. Review of Resident #39's admission MDS dated [DATE] revealed .Respiratory Treatments.Oxygen Therapy.1-Checked (Yes). Review of Resident #39's Care Plan dated 04/22/2026 revealed .Problems/Strengths.Ineffective Airway Clearance related to bronchoconstriction.Goals.[Resident #39] will maintain adequate airway clearance next 90 days.Interventions.Assess respiratory rate, breath sounds, and oxygen saturation before and after treatment.Goals.Impaired Gas Exchange related to inadequate oxygenation.Goals.Patient will demonstrate adequate oxygenation at resident and with activity.Interventions.Administer oxygen at prescribed flow rate and delivery device. Observation on 04/28/2026 at 9:42 AM revealed Resident #39's oxygen concentrator was set on 1 1/2 lpm via nasal cannula. Resident #39 was not showing signs of shortness of breath. Observation on 04/28/2026 at 12:44 PM revealed Resident #39's oxygen concentrator was set on 1 1/2 lpm via nasal cannula. Observation and interview with Resident #39 on 04/29/2026 at 9:50 AM revealed Resident #39 stated he thought his oxygen was supposed to be set on 3 liters. Resident #39 indicated he was feeling good at the time. Observation of the oxygen concentrator revealed it was set between 1 and 1 1/2 lpm. Interview with RN F on 04/29/2026 at 2:07 PM revealed Resident #39 was recently admitted to the facility. RN F stated Resident #39 was ordered for continuous oxygen for 2lpm. Observation and interview with RN F on 04/29/2026 at 2:16 PM revealed Resident #39's oxygen was set between 1 and 1 1/2 lpm. RN F stated the oxygen concentrator appeared to be set at just below 2 lpm. Interview with DON on 04/30/2026 at 9:27 AM revealed the facility's policy was for the nurse to verify the oxygen settings each shift to ensure it was set at the right level, based on physician's order. DON stated too little oxygen could result in a resident desaturating, shortness of breath and causing a brain injury. DON stated having too much could cause a resident to have muscle weakness. Review of Apply an Oxygen Deliver Device dated 01/12/2020 revealed .Standard of Practice: Staff will apply oxygen delivery devices accordance with standard practice guidelines.Procedures:.Attach humidified oxygen source if required-Nasal Cannula-Place tips of cannula into the resident's nares.-Loop tubing over the resident's ears.-Adjust lanyard.-Maintain sufficient slack of oxygen tubing.-Observe for proper function of oxygen deliver device.-Verify setting on flowmeter and oxygen source and the prescribed flow rate.

Based on observation, interview, and record review, the facility failed to ensure that based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for one (Resident #1) of 12 residents reviewed for quality of care. The facility staff failed to follow physician orders for wound care on the left lower extremity for Resident #1. These failures could place residents at risk of not receiving the care and treatment needed to meet their needs and could result in undetected skin issues and delay in treatments.Findings included: Review of Record of admission for Resident #1 dated 04/30/2026 revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 was diagnosed with Cellulitis (common, potentially serious bacterial skin infection affecting the dermis and underlying tissues, causing rapid-spreading red, swollen, hot, and painful skin), Type 2 Diabetes Mellitus (chronic metabolic condition where the body develops insulin resistance and inadequate insulin production, causing high blood sugar levels). Record review of admission MDS assessment for Resident #1 dated 04/09/2026 revealed Resident #1 had a score of 15 on the BIMS [Brief Interview for Mental Status] indicating Resident #1's cognition was intact.Risk of Pressure Ulcers/Injuries.Is this resident at risk of developing pressure ulcers/injuries 1-yes. Unhealed Pressure Ulcers/Injuries.Does this resident has one or more unhealed pressure ulcers/injuries No.Number of Venous and Arterial Ulcers Enter the total number of venous and arterial ulcers present 0.Other Ulcers, Wounds, and Skin Problems.Foot Problems.Diabetic foot ulcer(s) 1-checked (Yes).Application of dressings to feet (with or without topical medications) 1-Checked (Yes). Review of Resident #1's Care Plan dated 02/11/2026 revealed .Problems/Strengths.PVD [Peripheral Vascular Disease-progressive disorder that restricts blood flow to the arms, legs, or other body parts] : Risk for inadequate circulation or ineffective tissue perfusion related to peripheral vascular disease/peripheral arterial disease.Goals.Will not have lower extremity skin breakdown related to poor circulation. Observe skin integrity, report any sores, wounds or ulcerations to MD [Physician] with follow up as indicated Observe color and temperature of limbs, report abnormal findings to MD with follow up as indicated. Review of Resident #1's MAR dated April 2026 revealed Resident #1 was prescribed Soak right lower extremities in warm water for 30 minutes gradually removed [sic] dry crusted flaky skin On Day Shift.Apply Aquaphor ointment or a&d [Vitamin A and Vitamin D] ointment leave open to air. The physician order was from 02/16/2026 and the stop date was 04/03/2026. Review of Physician's Order dated April 2026 revealed Resident #1 had two physician's orders as follows:- .04/07/26 Wound Care 1 Right Heel Every Mon-Wed-Fri [Monday, Wednesday, Friday] Cleanse with vashe [pH-balanced cleanser] pat dry apply foam silicone border to heal on day shift.-.04/07/26 Wound Care Right lower heel every Mon-Wed-Fri 1 cleanse wound with vashe and apply melgisorb plus [highly absorbent, sterile calcium alginate dressing] and ABD [abdominal] pad to open areas, then apply dressing rool [sic] gauze and secure with tape on day shift.NOTE: The second order states Right lower heel but should state right lower extremity. There was an error during transcription. Review of Resident #1's TAR dated April 2026 revealed Resident #1 was prescribed 04/07/26 Wound Care 1 Right Heel Every Mon-Wed-Fri [Monday, Wednesday, Friday] Cleanse with vashe [pH-balanced cleanser] pat dry apply foam silicone border to heal on day shift.04/07/26 Wound Care Right lower heel every Mon-Wed-Fri 1 cleanse wound with vashe and apply melgisorb plus [highly absorbent, sterile calcium alginate dressing] and ABD [abdominal] pad to open areas, then apply dressing rool [sic] gauze and secure with tape on day shift. Review of Wound Note for Resident #1 dated 04/09/2026 revealed .Severe PVD [Peripheral Vascular Disease- slow, progressive circulation disorder involving narrowing or blockage of blood vessels outside the heart and brain, often causing leg pain, numbness, and non-healing wounds].Continue using Aquaphor and wrapping with rolled gauze per previous order.NOTE: Previous order was not restarted after the stop date on 04/09/2026. Observation on 04/28/2026 [Tuesday] at 10:03 AM revealed Resident #1 sitting on his bed, leaning against the wall. Resident #1's right leg was off the edge of the bed with his foot sitting on a towel on the floor. Resident #1 had a skin condition on his right lower extremity and a blister noted on his right shin. Resident #1's leg was open to air. Interview with RN F on 04/28/2026 at 10:20 AM revealed Resident #1 required wound treatments. RN F stated she soaked Resident #1's right lower leg in warm water and then applied a cream. RN F stated she had already completed wound care for the day.NOTE: No information was received that Resident #1 refused his leg to be wrapped. Observation and interview with Resident #1 on 04/28/2026 at 12:45 PM revealed he had been dealing with wounds on his legs for nine years. Resident #1 stated the goal was to get the dead skin off of his leg and stated the problems started when he was burned on both legs years ago. Unfortunately, he had an above the knee amputation after having a aggressive bacteria causing him to have him to undergo the amputation. Resident #1 stated the leg had to be soaked and he usually had the leg wrapped. Resident #1 did not indicate why his legs were not wrapped at this time. Resident #1 stated the nurse had been in this morning and soaked his leg and put on the ointment. Observed Resident #1's leg to be open to air.Interview with DON on 04/30/2026 at 9:27 AM revealed Resident #1 admitted with wounds. The Wound Care Nurse Practitioner showed her that the nurses were to soak warm towels and wrap the legs. After 30 minutes the towels were used to rub and scrape off the dry skin. Then apply cream and wrap the legs. DON stated yesterday, 04/29/2026 she saw a blister and the Nurse Practitioner changed the orders to no longer soak or wrap in the lower extremity in warm towels until the blister was healed. DON stated Resident #1's should have had his legs wrapped on 04/28/2026 and stated RN F reported he refused. DON stated the refusal by Resident #1 should have been documented which she (DON) noted that RN F did not document on the TAR or in a progress note. DON stated there should have been physician orders for daily and PRN treatments if the bandages were soiled. DON stated she entered the physician orders on the evening of 04/29/2026 when she noticed there were no orders. Resident #1 should not have gone without his legs wrapped. DON reviewed the orders and stated the order for the right lower heel should have been clarified and was meant for the right lower extremity. DON stated that failing to follow the physician's orders could result in the wound having delayed healing or other complications. Review of Physician Order policy dated 11/27/2023 revealed .Policy: 1. The licensed nurse will receive and transcribe the physician's orders according to Practice Guidelines. 2. The licensed nursing staff will provide residents with medications and treatments as ordered by his/her physician. Procedure:1. Specific medications or treatment supplies are ordered from the pharmacy via EHR or an established system with pharmacy provider. The order is transmitted via electronic interface with the pharmacy.2. The licensed nurse clarifies and reconciles all orders that may lead to an administration error.3. The electronically entered order will be automatically transcribed onto the Medication admission Record (MAR) or Treatment Record. Date and initials of the transcriber will be automatically recorded.4. If a medication is ordered for a specific number of doses or days, the stop date and hour of the last dose is given, the order will be automatically discontinued on the MAR or TAR.6. Record order changes in Progress Notes. Review of An Overview of Wound Care dated 07/2018 revealed .Purpose.To provide guidance to clinicians for educational purposes about skin and wound care with an emphasis on Pressure Ulcers/Injuries and other common wounds. Monitoring.Staff should remain alert to potential changes in the skin condition and should evaluate, report and document changes as soon as identified. For example, a resident's complaint about pain or burning at a site where there has been pressure or observation during the resident's bath that there is a change in skin condition should be reported so that the resident may be evaluated further.After completing a thorough evaluation, the interdisciplinary team should develop a relevant care plan that includes measurable goals for prevention and management of PU/PIs with appropriate interventions. Many clinicians recommend evaluating skin condition (skin color, moisture, temperature, integrity, and turgor) at least weekly, or more often if indicated, such as when the resident is using a medical device that may cause pressure. Defined interventions should be implemented and monitored for effectiveness.Wounds are not staged using the PU/PI Staging System:The staff will identify these wounds based on appearance and characteristics and not the staging systemfor PU/PI's. Arterial Insufficiency Ulcers Venous Stasis Ulcers Diabetic/Neuropathic Ulcers Traumatic wounds (skin tears, burns and abrasions) Avulsions Lacerations Ecchymosis Surgical Incisions Moisture associated skin damage (MASD) including incontinence associated dermatitis Intertriginous dermatitis (inflammation of skin folds) Medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions)Resident Choices .In the context of the resident's choices, clinical condition, and physician input, the resident's care plan should establish relevant goals and approaches to stabilize or improve co-morbidities, such as attempts to minimize clinically significant blood sugar fluctuations, and other interventions aimed at limiting the effects of risk factors associated with PU/PIs. Alternatively, facility staff and practitioners should document clinically valid reasons why such interventions were not appropriate or feasible. In order for a resident to exercise his or her right appropriately to make informed choices about care and treatment or to decline treatment, the facility and the resident (or if applicable, the resident representative) must discuss the resident's condition, treatment options, expected outcomes, and consequences of refusing treatment. The facility is expected to address the resident's concerns and offer relevant alternatives, if the resident has declined specific treatments. Documentation.Document in the appropriate areas of the EMR on a consistent schedule. Areas include skin data collection modules, wound assessment modules, infection control modules, Care Plans, Nurses' Notes, scanned documents, and physician progress notes.Documentation for the purposes of the MDS may be different than professional practice guidelines (such as down staging). Refer to the Documentation of Wounds related to the MDS 3.0 for information.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #9) of 8 residents reviewed for ADLs. The facility failed to ensure Resident #9 had her fingernails cleaned and trimmed on 4/28/26. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.Findings include: Record review of Resident #9's Quarterly MDS assessment dated [DATE] reflected Resident #9 was a [AGE] year-old female admitted to the facility on [DATE] . Diagnoses included : dementia (a decline in mental ability, reasoning, and communication, severe enough to interfere with daily life) and depression. Resident #9's BIMS score of 3, indicated Resident #9's cognition was severely impaired. The MDS assessment indicated Resident #9 required moderate assistance with personal hygiene. Record review of Resident #9's Care Plan dated 04/06/26, reflected the following: Problem: [Resident #9] requires ADL functions: .Personal hygiene: extensive assist: one person. Goal: will maintain a sense of dignity by being clean, dry, odor free and well groomed . Interventions: . give shower, oral, hair, nail care per schedule and as needed. In an observation on 04/28/26 at 11:36 AM revealed Resident #9 was lying in her bed. The nails on both hands were approximately 0.4cm in length extending from the tip of her fingers. The nails were discolored, tan and had yellow greenish colored residue underside and on the nails' bed. Resident #9 was confused, her answers were not pertinent to the subject. In an interview on 04/28/26 at 11:40 AM, CNA D stated CNAs and nurses were responsible to clean and cut the residents' nails. CNA D stated she did not notice Resident #9's nails. She stated she would do it right then. She stated the risk would be infection control and injury. In an Interview on 04/30/26 at 11:46 AM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated the ADON and the DON would do the routine rounds to monitor. The DON stated residents having long and dirty could be an infection control issue. Record review of the facility's policy Bathing revised 02/12/2020, reflected the following: .Staff will provide bathing services for residents within standard practice guidelines . Perform hand hygiene and perform nail care.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Medication Cart 617 - 631) of 2 carts reviewed for pharmacy services. The facility failed to ensure LVN K and LVN L, responsible for Medication Cart 617 - 631, counted controlled drugs every shift change. This failure could place residents at risk of not having the medication available due to drug diversion. Findings included: Observation on 04/28/26 at 11:13 AM of Medication Cart 617 - 631 with MA M, revealed missing signatures on the narcotic count sheet. Review of the narcotic count sheet revealed missing signatures for Off duty and On duty for 04/03/2026 (6:00 PM to 6:00 AM shift) and 04/13/26 (6:00 PM to 6:00 AM shift) of the narcotic count sheet. During an interview on 04/30/26 at 11:46 AM, the DON stated she expected nurses to sign the narcotic count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated if the staff were not signing the narcotic count sheets, she was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated the ADONs would start checking the narcotic count sheet daily. During an interview on 04/30/2026 at 12:43 PM, LVN K stated he should have signed the narcotic sheet after counting the narcotics, on 4/13/26 at the beginning and at the end of the shift. He stated he got busy and did not go back to sign the count sheet. He stated he knew he was supposed to sign immediately after the count was done. He stated the risk would be potential for drug diversion. During an interview on 04/30/26 at 4:11 PM, LVN L stated he should have signed the narcotic sheet after counting the narcotics on 4/3/26 at the beginning and at the end of the shift. LVN L stated he counted with the other nurse but he did not remember why he did not sign the count sheet. LVN L stated this failure could potentially cause a drug diversion. Record review of the facility's policy titled, Medication Storage - Controlled Medication Storage, dated 01/2028, reflected the following, . At each shift change or when keys are surrendered, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses or approved individuals per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 resident (Resident #1), reviewed for care plan development. The facility failed to ensure Resident #1's comprehensive care plan included a plan of care for ADLs. This failure could place residents at risk of not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Record review of a face sheet dated 03/03/26 revealed Resident #1 was a [AGE] year-old male, who was admitted on [DATE]. Diagnoses included: urinary tract infection (an infection in any part of the urinary system (kidneys, ureters, bladder, or urethra) caused by bacteria, most commonly E. coli [is a group of bacteria that can cause infections in your gut, urinary tract and other parts of your body]); anxiety disorder (excessive, persistent, and uncontrollable worry or fear that interferes with daily life, often causing physical symptoms like rapid heartbeat, chest pain, and dizziness); bipolar disorder (a chronic mental health condition causing extreme, often long-lasting shifts in mood, energy, and activity levels, alternating between high-energy manic/hypomanic episodes and low-energy depressive episodes); schizophrenia (a chronic, severe mental brain disorder affecting about 1% of the population, characterized by delusions, hallucinations, disorganized speech, and cognitive difficulties), and depression (mental health condition). Record review of the MDS assessment dated [DATE] indicated Resident #1's cognition was intact with a BIMS score of 15. Resident #1 required supervision or touching assistance with personal hygiene, including combing hair, shaving, washing/drying face and hands (excluded baths, showers, and oral hygiene). Record review of Resident #1's care plan last reviewed 02/11/26 revealed there was no plan of care that identified measurable objectives, goals, interventions and timeframes for ADLs. During an interview on 03/03/26 at 1:35 p.m., the DON stated every resident should have a plan of care that reflected their likes, dislikes, everyday routine, and anything that affected the residents. She stated the absence of ADLs in the care plan diminished staff communication and knowledge of resident preferences. She stated it was the responsibility of the MDS Coordinator to update residents care plan. The DON stated the facility did not have an MDS Coordinator nurse, and the corporate person did the MDS assessments. The DON stated she was responsible for acute resident care plans. The DON further stated she was doing the care plans for new residents. She stated the risks to residents were decline in ADLs, dignity, and whatever go with it.During an interview on 03/03/26 at 3:16 p.m., the Administrator stated the care plan told a story about the resident's care and preferences. The Administrator stated that without ADLs listed in the care plan, the staff would not know what the residents liked. The Administrator stated the charge nurses were responsible for triggering the acute care plan, and MDS coordinator updated the residents' care plan, but the facility did not have an MDS coordinator.Record review of the facility's Care Plan-Process policy last revised on 02/12/20 and reviewed 04/17/23 revealed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure a resident, who was unable to carry out activities of daily living ,received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Residents #1) reviewed for quality of life. The facility failed to ensure staff provided consistent grooming/shaving for Resident #1. This failure could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity, and self-worth. Findings include: Record review of a face sheet dated 03/03/26 revealed Resident #1 was a [AGE] year-old male, who was admitted on [DATE]. Diagnoses included: urinary tract infection (an infection in any part of the urinary system (kidneys, ureters, bladder, or urethra) caused by bacteria, most commonly E. coli [is a group of bacteria that can cause infections in your gut, urinary tract and other parts of your body]); anxiety disorder (excessive, persistent, and uncontrollable worry or fear that interferes with daily life, often causing physical symptoms like rapid heartbeat, chest pain, and dizziness); bipolar disorder (a chronic mental health condition causing extreme, often long-lasting shifts in mood, energy, and activity levels, alternating between high-energy manic/hypomanic episodes and low-energy depressive episodes); schizophrenia (a chronic, severe mental brain disorder affecting about 1% of the population, characterized by delusions, hallucinations, disorganized speech, and cognitive difficulties); and depression (mental health condition). Review of Resident #1's picture on the face sheet revealed he had a trimmed mustache and clean shaved face. Record review of the MDS assessment dated [DATE] revealed Resident #1's cognition was intact with a BIMS score of 15. Resident #1 required supervision or touching assistance with personal hygiene, including combing hair, shaving, washing/drying face and hands (excluded baths, showers, and oral hygiene). Record review of Resident #1's care plan last reviewed on 02/11/26 revealed there was no plan of care that identified measurable objectives, goals, interventions and timeframes for ADLs. In an observation and interview with Resident #1 on 03/03/26 at 11:15 a.m., the Resident was observed sitting up in his bed, cleaned, and groomed. Resident #1 was observed with a full mustache that was growing over his lip and a chin beard. Resident #1's chin beard was approximately 2 inches long. Resident#1 stated he received shower regularly three times a week, but he wanted his mustache trimmed, and his beard clean shaved. He stated he had been asking to be shaved for weeks, and the staff members were telling him he had to set up an appointment with the beauty salon person in the facility. He stated he could not afford the [NAME] salon services. Resident#1 stated he was not admitted to the facility with a beard, and he used to have a trimmed mustache and clean shaved face. An interview with CNA A on 03/03/26 at 11:17 a.m. revealed she was assigned to Resident #1 that day. She stated she showered Resident #1 on 03/03/26, but had not shaved him, nor had she asked him if he wanted a shave. She stated she was not sure if he wanted to have a beard or if he wanted a shave. She stated she had not asked him or the charge nurse about his grooming preference. She stated it was the responsibility of the CNAs to shave residents on their shower days if the Resident requested to be shaved. She stated this could cause a resident to have a loss of sense of dignity. In an interview with RN B on 03/03/26 at 1:27 p.m., she stated they were responsible for ensuring the residents' showers and ADL care were performed. She stated the CNAs were supposed to let them know if a resident refused ADL care. She stated this week was her first time assigned to Resident #1, and she had not been notified by any of the CNAs that Resident #1 had been asking to be shaved. She stated Resident #1 did not notify her of his desire to be shaved. She stated this could cause a resident to have loss of dignity. In an interview with the DON on 03/03/26 at 1:35 p.m., she stated the CNAs were supposed to perform residents' grooming, such as shaving, nail care, and hair care on shower days. She stated it was the charge nurse for the Hall's responsibility to make sure residents received their care appropriately. She stated she did not know that Resident #1 had been asking to be shaved and that the resident was not shaved. She stated the lack of personal hygiene could lead to skin problems and an overall decline in dignity. In an interview with the Administrator on 03/03/26 at 3:16 p.m., she stated the beauty salon was not responsible for shaving residents in the facility. She stated the CNAs were supposed to perform residents' grooming, such as shaving on shower days. She stated it was the charge nurses, the DON, and her responsibility to make sure residents received their care appropriately. She stated she did not know that Resident #1 had been asking to be shaved and that it was not done. She stated the lack of personal hygiene could lead to an overall decline in dignity. Record review of the facility's policy titled, Hair Care-Combing and shaving, dated January 12, 2018, and revised dated April 22, 2024 reflected, Hair care, combing and shaving will be provided for residents in accordance with standard practice guidelines.

Based on interviews and record review, the facility failed to conduct a comprehensive, accurate assessment within 14 days after the facility determined or should have determined there had been a significant change in the resident's physical or mental condition for 1 (Residents #1) of 2 residents reviewed for Resident Review. The facility failed to complete the significant change MDS assessment for Resident #1 was hospitalized for atypical chest pain, Hypoxia, and altered mental status, and Leukocytosis (elevated white blood cell count) on [DATE].The facility failed to complete the significant change MDS assessment for Resident #1 was hospitalized for Hypernatremia (elevated sodium in the blood) on [DATE]. These failures could prevent residents from obtaining services and equipment to improve and maintain their level of functioning and well-being. Record Review of Resident #1's face sheet dated [DATE], reflected he was a [AGE] year-old male that was admitted on [DATE]. The resident was diagnosed with: Metabolic Encephalopathy (brain disorder that mimics dementia due to memory loss), Diabetic Mellitus ( unstable blood sugar levels) type Hyperosmolality (high concentration in blood.like sodium, sugar, and urea (compound produced by the liver) and Hypernatremia (elevated sodium levels), Acute and Chronic Respiratory failure with Hypoxia (low blood oxygen) . Record Review of Resident #1's MDS, type was left empty, dated [DATE] by LVN-R reflected Section C-Cognitive Patterns the C0500 BIMS Summary score was empty.C0700 Staff assessment of Mental status.Resident short term and long-term memory indicated memory problems. Inattention. Section J- health Conditions.SOB with exertion, when sitting at rest, and when lying flat.Section K-Swallowing and nutritional status .Nutritional approaches parenteral IV feeding while not a resident. Section O for special treatments was left empty, therefore not addressing the resident oxygen and IV use. Record Review of Resident #1's Quarterly MDS dated [DATE] by LVN/MDS R, reflected Section C-cognitive patterns.C0500. BIMS score of 07, indicating he was severely impaired cognitively. Section J-Health Conditions.SOB with exertion, when sitting at rest, and when lying flat.Section K-Swallowing/Nutritional Status.Nutritional approaches.Parenteral/IV feeding. Section O-Special treatments, procedures, and programs, indicating he did not require any special treatments (IV or oxygen). Resident #1 did not have a significant change in condition assessment in his file. Record review of Resident #1's MD orders by MD-J dated [DATE] reflected Admit to skilled care, 2.0 med-pass 90 cc Cal Med Pass (nutritional supplement) 120cc TID three time a day (8:00 AM, 2:00 PM, 8:00 PM.) Order dated [DATE].PRN.Albuterol sulfate 0.63 MG/3ML solution (albuterol sulfate) 3mL inhalation every 6 hours as needed . PRN May resite [Reset] peripheral IV PRN infiltration (you stop the infusion, remove the old IV, assess the tissue damage (swelling, redness, pain), apply compresses (warm/cold depending on fluid), elevate the limb, mark the site, and then start a new IV at a different, healthy location, following facility protocol for managing the infiltrated area.), extravasation (leakage of fluids) as needed any time.Record Review of Resident #1's hospital transfer change in condition dated [DATE] by ADON reflected MD-J and NP admitting.full code CPR (may use AED device that analyzes heart rhythm).Reason for Transfer: abnormal labs (critical labs).Usual mental status. Alert and oriented follows instructions.Specials Treatments.O2 Chronic.Risk Alerts.swallowing precautions.needs meds crushed.aspiration.VS stabilized and follow up plan can be done in NH. Record review of Resident #1 MD progress notes dated [DATE] reflected the following: [DATE] 03:08 PM Category: MD-J and NP here. Made rounds and ordered to start IV fluids: normal saline at 70 cc/hr. for 1 liter and do a stat CMP (blood test measuring in the body). The floor nurse notified Smart Lab to start CMP (blood test measuring in the body). This nurse spoke with [NP] regarding [Resident #1's] thin liquids. She stated that he understands the risk of drinking the thin fluids. This nurse went over with [Resident #1's] t drinking thin liquids. He can have aspiration (choking) pneumonia and can die from this. He understood. This nurse did BIMS, and his score is 15/15. Order written and carried out, notified of new order.Electronically Signed By: [DON] .XXX[DATE] 03:29 PM. Peripheral IV initiated in the right hand using a 20G, 1-inch catheter first attempt. Skin prepped with Chlorhexidine; site clean, dry, intact with no redness/swelling. Transparent dressing applied and labeled. Line flushed with 10mL NS, positive blood return, no resistance. Patient tolerated well, denies pain. Call light within reach, bed in lowest position.Electronically Signed By: [DON]. The MD progress notes were not accessible for the surveyor in the EMR, and the documents were requested from the DON. Record Review of Resident #1's MD visit dated [DATE]. Reflected History and physical examination Complexity level: High.Reason for visit.Examination and medical management of this patient who has multiple significant chronic medical issues, on multiple drugs, with significant potential side effects. Record review of Resident #1's interdisciplinary progress notes dated [DATE] by MD reflected History of Present Illness: Patient HX of chronic respiratory failure on 2L NC (A device used to provide supplemental oxygen), O2, COPD (Disease, a progressive lung condition characterized by airflow limitation, often including emphysema and chronic bronchitis, causing symptoms like shortness of breath, cough, and mucus, primarily due to smoking or long-term exposure.), DM (unstable blood sugar), CKD (loss of kidney function), mood disorder presented to ED on 10/31-11/2 for atypical chest pain and leukocytosis of uncertain etiology (high white blood cell count without an obvious cause.who presented from SNF on [DATE] for hypernatremia in the 170s on routine ELAB (electronic laboratory system) work. This was likely in setting of severe FW (pure water free of pollutes) deficit from noncompliance with thickened liquid diet. Patient stayed 12 days and was needing thickened liquids which may have limited access to free water when at SNF. Patient had NA corrected and AKI (decrease in kidney function) resolved after increased FW deficit. Patient was previously admitted for AMS (changes in awareness) found to have hypoxia to 88% with AMS. CT (Xray) chest showed small PE in segmental and subsegmental pulmonary artery branches. Patient was treated for PE (lung infection), COPD (Disease, a progressive lung condition characterized by airflow limitation, often including emphysema and chronic bronchitis, causing symptoms like shortness of breath, cough, and mucus, primarily due to smoking or long-term exposure.),and respiratory failure with heparin GTT, and then transitioned to Eliquis. Patient was weaned back down to 2L O2 NC (tube used to transport oxygen). Patient was s/p shock and treated for aspiration PNA (lung infection) with pressors, steroids and antibiotics. Patient noted to have GI bleed and treated for it. Patient had AKI (decrease in kidney function), due to shock so was treated and CR (waste product in blood) resolved back to 1.08 baseline. Patient was discharged to [name] SNF for decreasing debility and deconditioning and rehabilitation.Dysphasia c/w soft bite sized solids/honey thickened liquids PO, unable to tolerates has not yet seen patient, Patient wants to sign off on thin liquids for aspiration precautions.Record Review of Resident #1's quarterly care plan dated [DATE] completed by the SW reflected Develop and implement a comprehensive person-centered plan that is consistent with your resident's rights and will meet your medical, nursing, mental and psychosocial needs. Cognitive loss, Dietician referral, Provide diet as prescribed, altered nutrition status related to weight loss.has shortness of breath, at risk of dehydration, oxygen therapy r/t COPD XXX[DATE].Needs total assistance with hygiene after toilet use .NEEDS Assist of 2 staff members for all ADLS r/ bedbound status. Record review of email sent by CRN on [DATE] at 5:23 PM reflected an Admissions MDS dated [DATE] and a Quarterly MDS dated [DATE]. The facility failed to completed a change in condition assessment review for Resident #1. Record review of email sent by CRN on [DATE] at 5:23 PM reflected an Admissions MDS dated [DATE] and a Quarterly MDS dated [DATE]. The facility failed to completed a change in condition assessment review for Resident #1. During an interview on [DATE] at 10:30 AM with CRN-R he needed to check the MDS's that were updated. He stated that Resident #1 was hospitalized several times returning with clinical changes to diet approaches of thickened liquids, respiratory treatments and IV. During an interview on [DATE] at 1:10 PM the DON stated that the MDS should accurately reflect the residents' current care status and needs. She stated that Resident #1's change in diet, treatments for IV and respiratory should have been coded to reflect care and treatment. DON stated that it was ADON, MDSC, and DON's responsibility to ensure that assessments were completed timely and accurately. She said failing to complete an accurate MDS the resident at risk of clinical care and task. During an observation and interview with Resident #1 on [DATE] at 3:00 PM when asked about recent hospitalization, oxygen treatments and thickened water, he said whatever they said. Resident #1 did not provide any additional information. During an interview on [DATE] at 4:40 PM with ADM, stated that facility recently terminated the MDSC after observing a pattern of failing to complete timely and accurate assessments for the residents. ADM said the DON was responsible for monitoring and ensuring that the MDS was updated. The ADM requested staff to provide an updated copy of Resident #1's most recent MDS to reflect MDS completion for Resident #1. The ADM did not provide any additional information regarding the change in condition. During an interview on [DATE] at 4:45 PM with CRN stated that Resident #1 had updated MDS in the facilities EMR. He was informed that there was no change in condition MDS located in the EMR. CRN left to search for MDS. CRN provided no additional information about the change in condition MDS. Record review of facility policy titled: change of Condition.Clinical Operations.dated [DATE] and revised on [DATE].reflected Policy: The primary goal of identifying Acute Changes of Condition (ACOCs) is to enable staff to evaluate and manage a patient at the community and avoid transfer to a hospital or emergency room (ER). To achieve this goal, the community's staff and practitioners must recognize an ACOC and identify its nature, severity, and cause(s). Examples of circumstances of when it is appropriate to communicate information to these parties may include, but are not limited to: Diagnosis of a new condition or a significant change in diagnosis.Transfer of a patient to another healthcare community for assessment, treatment, or care.Unexpected deterioration in condition or status.Significant injury or illness.Definitions: An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death.

Based on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the status for 1 (Resident #1) of 4 residents reviewed for accuracy of assessments in that: Resident #1's quarterly MDS dated [DATE], did not address his diet in Section K with changes to thickened liquids and his respiratory treatments in Section O. The failure place residents at risk for missed treatments, aspiration, and changes in health that could result in death.Record Review of Resident #1's face sheet dated 01/15/2026, reflected he was a [AGE] year-old male that was admitted on [DATE]. The resident was diagnosed with: Metabolic Encephalopathy (brain disorder that mimics dementia due to memory loss), Diabetic Mellitus ( unstable blood sugar levels) type Hyperosmolality (high concentration in blood.like sodium, sugar, and urea (compound produced by the liver) and Hypernatremia (elevated sodium levels), Acute and Chronic Respiratory failure with Hypoxia (low blood oxygen) Record Review of Resident #1's MDS, type blank dated 09/09/2025 by LVN-R reflected Section C-Cognitive Patterns the C0500 BIMS Summary score was empty.C0700 Staff assessment of Mental status.Resident short term and long-term memory indicated memory problems. Inattention. Section J- health Conditions.SOB with exertion, when sitting at rest, and when lying flat.Section K-Swallowing and nutritional status .Nutritional approaches parenteral IV feeding while not a resident. Record Review of Resident #1's Quarterly MDS dated [DATE] by LVN/MDS R, reflected Section C-cognitive patterns.C0500. BIMS score of 07, indicating he was severely impaired cognitively. Section J-Health Conditions.SOB with exertion, when sitting at rest, and when lying flat.Section K-Swallowing/Nutritional Status.Nutritional approaches.Parenteral/IV feeding. Section O-Special treatments, procedures, and programs, indicating he did not require any special treatments (IV or oxygen).Section Z-Assessment Administration.Z0500.Signed by RN-L, 12/23/2025. Resident #1's last MDS was on 09/09/2025, and the type of assessment was not documented. He was admitted to the hospital on [DATE] and 12/2/2025. Resident #1's quarterly MDS did not address the need for thickened liquids in Section K and respiratory treatments in Section O Record Review of Resident #1's quarterly care plan dated 01/14/2026 completed by the SW reflected Develop and implement a comprehensive person-centered plan that is consistent with your resident's rights and will meet your medical, nursing, mental and psychosocial needs. Cognitive loss, Dietician referral, Provide diet as prescribed, monitor weight, altered nutrition status related to weight loss, extensive assistance with 2 person support on toilet, has shortness of breath, at risk of dehydration, oxygen therapy r/t COPD 12/23/2025.Needs total assistance with hygiene after toilet use .NEEDS Assist of 2 staff members for all ADLS r/ bedbound status. Resident recently received thin liquids and is slowly trying to feed himself. Residents is progressing in speech. Record review of email sent by CRN on 01/15/2026 at 5:23 PM reflected an Admissions MDS dated [DATE] and a Quarterly MDS dated [DATE]. The facility failed to completed a change in condition assessment review for Resident #1. During an interview on 01/15/2026 at 10:30 AM with CRN-R he needed to check the MDS's that were updated. He stated that Resident #1 was hospitalized several times returning with clinical changes to diet approaches of thickened liquids, respiratory treatments and IV for enteral feeding. During an interview on 01/15/2026 at 1:10 PM the DON stated that the MDS said care clinical assessments and plan should be updated to reflect the resident's current. The DON stated that it was ADON, MDSC, and DONs to ensure that all resident records were completed timely and accurately. She said failing to complete or update MDS assessments place the resident at risk of missing individualized clinical care, treatment; and task. She stated that Resident #1 was prescribed thickened water and oxygen treatment PNA and aspirations (accidental inhalation of food, liquids in the airway). The DON was asked to provide the progress notes on changes, due to the surveyor not having access to all areas of the EMR. During an observation and interview with Resident #1 on 01/15/2026 at 3:00 PM when asked about recent hospitalization, oxygen treatments and thickened water, he said whatever they said. Resident #1 did not provide any additional information. During an interview on 01/15/2026 at 4:40 PM with ADM, stated that facility recently terminated the MDSC after observing a pattern of failing to complete timely and accurate assessments for the residents. ADM said the DON was responsible for monitoring and ensuring that the MDS was updated. The ADM requested staff to provide an updated copy of Resident #1's most recent MDS. The ADM did not provide any additional information regarding the change in condition. During an interview on 01/15/2026 at 4:45 PM with CRN stated that Resident #1 had updated MDS in the EMR. He was informed that there was no change in condition MDS located in the EMR. CRN left to search for MDS. CRN provided no additional information about the change in condition MDS. Record review of facility policy titled: Resident assessment.clinical operations.dated 09/13/2017 and revised on 01/12/2020.MDS 3.0. reflected Purpose: To assess each residents strengths, weaknesses, and care needs.use this assessment data to develop a person-centered comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible.To enter this assessment data into a computerized format that will be transmitted to the.(CMS).Standard of Practice:.facility to conduct, initially and periodically, a comprehensive, accurate assessment of each resident's functional capacity utilizing the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual.Procedure: A registered nurse will coordinate each assessment.and shall sign to certify the completion of each assessment in item Z0500. Each resident will be scheduled for an assessment period. with the frequency and type of assessment being determined according to the guidelines in the RAI Manual. Comprehensive assessments will be completed not less often than once every 12 months (366 days), within 14 calendar days after admission, or within 14 days of a significant change determination. Quarterly assessments will be conducted not less often than once every 3 months (92 days).

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1, and Resident#3) of two residents observed for infection control during incontinent care. 1-The facility failed to ensure LVN A, CNA C, CNA D, CNA E wear proper PPE while caring for Resident#1 in EBP Isolation. 2-The facility failed to ensure CNA F performed hand hygiene between glove changes, and LVN B did not put the dirty linen on the floor while providing incontinent care to Resident #3. These failures could place residents at risk for spread of infection through cross-contamination.1- A record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including obstructive uropathy (a condition where urine flow is blocked, leading to the accumulation of urine in the urinary tract), and cancer (a group of diseases characterized by uncontrolled cell growth and the ability to invade and spread to other parts of the body). Resident #1 had a BIMS score of 09 which indicated Resident #1's cognition was moderately impaired. He required extensive assistance of two-person physical assistance with bed mobility and transfer. Resident #1 had a supra pubis catheter (a urinary drainage tube inserted through a small incision in the lower abdomen, just above the pubic bone, into the bladder). Record review of Resident #1's care plan dated 06/26/25 reflected, Problem: Enhanced Barrier Precautions related to suprapubic catheter and wounds. Goal: Prevent/manage the likelihood of complications due to isolation over the next 90 days. Interventions: Contact Isolation Precautions are to be used during all aspects of care. handwashing Educate resident and family members on standard precautions and the importance of.Observation on 10/15/25 at 7:38 AM revealed LVN A was in the process of changing the nephrostomy (a surgical procedure that creates a temporary or permanent opening in the kidney to drain urine directly into a collection bag) exit site dressing, and supra-pubic catheter exit site dressing for Resident#1 with gloved hands and without wearing a gown. CNA C with gloved hands, and without wearing a gown was providing Resident#1 morning care and got him ready to sit in a Geri-chair (a supportive, reclining chair designed for individuals with limited mobility, offering more comfort and stability than a traditional wheelchair). CNA E entered Resident#1's room, washed hands, put on clean gloves, but she did not put on a gown. CNA E proceeded to help CNA C put resident lift sling under Resident#1. CNA D got the Geri-chair and the Mechanical lift and entered Resident#1's room.She washed her hands, put on clean gloves but did not put on a gown. The three CNAs maneuvered the Mechanical left, the Geri chair, and put Resident#1 on the Geri chair. The three CNAs removed gloves, washed hands and exited the room. There was a PPE supplies cart in front of the room, but no EBP isolation signage.In an interview on 10/15/25 at 07:45 AM, LVN A stated she was supposed to wear a gown while performing high contact procedure with Resident#1 who was in EBP isolation. She stated, she was about to go home at the end of her night shift, when she found out that Resident#1 had to get up and ready for a doctor appointment. She stated she was in rush and forgot to put on proper PPE (gloves and gown). She stated the risk spread of infection.In an interview on 10/15/25 at 07:55 AM, CNA C stated she did not know that she supposed to wear gown while performing morning care for Resident#1. She stated she saw the supplies cart in front of the room but did not know what it was for. She stated the risk spread of infection.In an interview on 10/15/25 at 08:12 AM, CNA D stated she did not know that she supposed to wear gown while helping with Resident#1's transfer. She stated she saw the supplies cart in front of the room but did not know what it was for. She stated the risk spread of infection.In an interview on 10/15/25 at 10:22 AM, CNA E stated she was supposed to wear gown while helping to get Resident#1 up in his Geri chair. When asked how she knew Resident#1 was in EBP isolation, she replied by the PPE supply cart in front of the resident's room, and the name of the resident written on blue paper vs the white paper for non-isolation residents. She stated the risk would be the spread of infection. 2-Review of Resident #3's quarterly MDS assessment, dated 07/04/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: type 2 diabetes, hypertension, morbid obesity due to excess calories. Review cognitive patterns reflected a BIMS of 15, which meant Resident #3's cognition was intact.Observation on 10/15/25 at 11:51 AM revealed CNA F with the help of LVN B entered Resident#3's room to do incontinence care. CNA F washed her hands using soap and water and donned clean gloves. LVN B washed hands and put on clean gloves. CNA F unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe and discarded, she then wiped the folds of skin at left and right groin area using a new wipe. CNA F with the help of LVN B turned the resident on the left side. She cleaned the buttocks area with a disposable wipe. CNA F then removed the soiled brief and discarded it into a trash bag. CNA F rolled the linen (draw sheet and fitted sheet) and pushed it under Resident#3. CNA F changed her gloves without performing any form of hands hygiene (CNA F did not wash her hands or use had sanitizer between glove change). CNA F put a clean brief on Resident #3. Both staff turned Resident#3 to right side. LVN B removed the dirty linen and put it in a pillowcase and put it on the floor. CNA F and LVN B finished putting brief on Resident#3. LVN B removed gloves, took the dirty linen and exited the room, disposed of it in the dirty linen hamper in the Hallway, and sanitized hands. CNA F removed gloves, washed hands, and left the room. In an interview on 10/15/25 at 12:19 PM, CNA F stated she was supposed to perform hand hygiene in the beginning and at the end of the incontinent care procedure, and between change of gloves. She said she did not do it this time because she was nervous. CNA F stated the dirty linen was not supposed to be on the floor. CNA F stated the dirty linen was supposed to be in a plastic bag at the foot of the bed. She stated the risk would be the spread of infection.In an interview on 10/12/25 at 12:24 PM, LVN B stated, the staff were not allowed to bring the dirty linen hamper in front of the residents' room. LVN B stated putting the dirty linen in the pillowcase and on the floor was not an issue. LVN B stated the dirty linen will be washed anyway. She stated the risk was the spread of germs.In an interview on 10/15/25 at 12:58 PM, the administrator stated all the staff were supposed to perform hand hygiene before any contact with the residents, and between change of gloves. She stated the dirty linen was supposed to be put on a plastic bag not on the floor. She stated the risk would be the spread of infection.In an interview on 10/14/25 at 02:13 PM, the DON stated the expectation was for the staff to wear proper PPE while taking care of the residents, and for EBP isolation the staff were supposed to wear gowns, and gloves for any high contact care with the residents. When asked about some staff who did not know about EBP isolation, she replied the facility just had annual skills faire, and they talked about EBP isolation. The DON stated her expectation for the CNAs and nurses to perform hand hygiene before and after any care, and any time after removing dirty gloves. She stated if the staff hands were visibly soiled, they were to clean with soap and water, otherwise, they could use hand sanitizer. The DON stated the dirty linen was not supposed to be put on the floor. She stated the CNAs and nurses were trained to put the dirty linen on a plastic bag. The DON stated the risk could be cross-contamination. Review of the facility's policy titled Hand Hygiene for Staff and Resident reviewed January 2022 revealed, . 1. Hand hygiene is done: . After: . H. removal of medical/surgical or utility gloves.At the date and time of exit on 10/15/25 at 3:00 PM the facility did not provide the linen handling policy.Review of the facility Policy titled Enhanced barrier precaution dated April 01, 2024 revealed .This facility utilizes EBP as a strategy to decrease transmission of MDROs when Contact Precaution do not apply. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact care activities that provide opportunities for transfer of MDROs to staff hands and clothing.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one resident (Resident #1) reviewed for catheter care. The facility failed to ensure CNA C maintained Resident #1's indwelling urinary catheter (a tube that drains urine from the bladder) drainage bag below the bladder level during transfer from bed to Geri-Chair (a supportive, reclining chair designed for individuals with limited mobility, offering more comfort and stability than a traditional wheelchair) on 10/15/25. This failure placed residents at risk for infection. A record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including obstructive uropathy (a condition where urine flow is blocked, leading to the accumulation of urine in the urinary tract), and cancer (a group of diseases characterized by uncontrolled cell growth and the ability to invade and spread to other parts of the body). Resident #1 had a BIMS score of 09 which indicated Resident #1's cognition was moderately impaired. He required extensive assistance of two-person physical assistance with bed mobility and transfer. Resident #1 had an indwelling catheter. Record review of Resident #1's care plan dated 06/26/25 reflected, Problem: Urinary catheter (SUPRAPUBIC) . Goal: Resident will be free of complications of indwelling catheter . Interventions: . Complications can include an increased risk of urinary tract infection, blockage of the catheter with associated bypassing of urine, expulsion of the catheter . Observation on 10/15/25 at 07:38 AM revealed CNA C, CNA E were in the process of getting Resident #1 transferred from bed to Geri chair. CNA C unhooked the catheter bag from the bed rail. CNA C put the catheter bag flat on the foot of the bed, above the resident's bladder. CNA C and CNA E hooked the transfer sling to the Mechanical left. CNA C took the foley catheter bag and hung it to the shaft of the Mechanical left. The two CNAs maneuvered the mechanical left and get Resident#1 on the Geri chair. During the procedure urine was observed flowing back toward the resident's bladder. After lowering Resident#1 to the Geri chair, CNA C hooked the catheter bag onto the Geri chair frame. In an interview with CNA C on 10/15/25 at 07:55 AM, she stated she was trained to always keep the catheter drainage bag below the bladder. She stated she put the bag on the bed to prevent it from pulling. She stated having it above the bladder could possibility cause the urine to run backwards, which could cause an infection. In an interview with the Administrator on 10/15/25 at 12:58 PM she stated her expectations were for the staff not to put the foley catheter bag on the bed because the flow could go back and cause the Resident to develop infection. In an interview with the DON on 10/15/25 at 2:13 PM she stated any resident with a foley catheter should always have the bag and tubing below the bladder. She stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of urinary tract infection and cross contamination. Review of the facility's policy titled, Care and Removal of an Indwelling Catheter, revised 01/12/2020 did not address the concern.

Based on interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of five residents reviewed for catheter and incontinence care. The facility failed to ensure CNA G provided timely incontinence care for Resident #2 on 10/14/25. This failure could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infectionRecord review of a face sheet dated 10/14/25 revealed Resident #2 was a [AGE] year-old female who was admitted on [DATE]. Resident #2 had a BIMs score of 15, which indicated she was cognitively intact. Resident #2's diagnoses included other idiopathic peripheral autonomic neuropathy (damage to the nerves that control involuntary bodily functions), depression (mental health condition), secondary hypertension (high blood pressure), unspecified atrial fibrillation (an irregular rapid heart rate), and chronic diastolic congestive heart failure (the heart muscle is unable to relax properly). Record review of Resident #2's most recent MDS dated [DATE] indicated: Section H (Bladder and Bowel): H0300-Urinary Continence reflected Frequently incontinent. H0400-Bowel Continence reflected Frequently Incontinent. An interview with Resident #2 on 10/14/25 at 10:50am revealed she had not had a diaper change all morning. Resident #2 stated her call light had not worked for 2 months but she had a bell to alert staff. An interview with CNA G on 10/14/25 at 10:58am revealed Resident #2 was not changed since her shift began at 6:00am. CNA G stated she had to get 4 to 5 residents up for breakfast when she arrived for her shift and another resident needed a shower. CNA G stated she was responsible for 16 residents this day. CNA G stated incontinent care was expected to be provided every 2 hours or when requested. CNA G stated incontinent care delay resulted in skin breakdown or rawness for the resident. An interview with LVN K on 10/14/25 at 11:59am revealed residents were expected to be changed every 2 hours or when needed. LVN K stated delayed incontinent care caused skin breakdown or depression. An interview with the DON on 10/15/25 at 1:53pm revealed the expectation for incontinence care was every two hours for residents or when the call light was pressed for care. The DON stated the risk of incontinent care delay was potential infection, UTIs, and skin breakdown. Record review of the facility's policy titled, Perineal Care/Incontinent Care effective April 2012, reflected, staff will perform perineal/incontinent care with each bath and after each incontinent episode.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 1 resident (Resident #2), reviewed for care plan development. The facility failed to ensure Resident #2's comprehensive care plan included a plan of care for ADLs. This failure could place residents at risk of not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.Record review of a face sheet dated 10/14/25 revealed Resident #2 was 90-years-old and was admitted on [DATE] with diagnoses including other idiopathic peripheral autonomic neuropathy (damage to the nerves that control involuntary bodily functions), depression (mental health condition), secondary hypertension (high blood pressure ), unspecified atrial fibrillation (an irregular rapid heart rate), and chronic diastolic congestive heart failure (the heart muscle is unable to relax properly). Record review of the most recent MDS dated [DATE] indicated Resident #2 was cognitively intact with a BIMS score of 15. Section GG (Functional Abilities) reflected Resident #2 required substantial/maximal assistance for toileting hygiene, shower/bathe self, partial/moderate assistance with upper body dressing and set up or clean up assistance with eating and oral hygiene. Record review of Resident #2's care plan last reviewed 09/08/25 revealed there was no plan of care that identified measurable objectives, goals, interventions and timeframes for ADLs. During an interview on 10/15/25 at 12:59 p.m., the Administrator stated the care plan told a story about the resident's care and preferences. The Administrator stated that without ADLs listed in the care plan, the staff won't know what the residents like. The Administrator stated the MDS nurse was responsible for the comprehensive care plan. During an interview on 10/15/25 at 1:53 p.m., the DON stated every resident should have a plan of care that reflected their likes, dislikes, everyday routine, and anything that affected the residents. She stated the absence of ADLs in the care plan diminished staff communication and knowledge of resident preferences. She stated she was unsure why ADLs were not included in the care plan. She stated the MDS Coordinator was responsible for writing the care plans. During an interview on 10/15/25 at 01:43 p.m., the MDS Nurse stated she was responsible for updating the care plan. She stated the care plan reflected a picture of the resident's functioning, preferences, and how much assistance was needed to meet their needs. She stated it was important to have an accurate care plan because it reflected the resident's level and any improvement. Record review of the facility Care Plan-Process policy last revised on 02/12/20 and reviewed 03/27/23 revealed: The interdisciplinary team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required time frames. 4) Interdisciplinary Team meets and reviews the care plan as follows: Quarterly and annually 5) The team directs care planning toward attaining and maintaining the highest optimal physical, psychosocial, functional status including Advance Directives, and signs the approved plan of care.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items in the facility kitchen had use-by date. This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: In an Observation on 02/11/25 at 10:00 AM of the facility walk in refrigerator revealed two packets of liquid eggs were opened but did not have use by date. In an interview and observation on 2/11/25 10:05 AM with the Dietary Manager revealed liquid egg packets were opened but not dated. She stated that all open items need to have 'open date' and 'used by date' depending on the food item. She stated that liquid eggs were open for breakfast on 2/11/25 and should have had use by date of 2/14/25 since liquid eggs were good for consuming for 3 days after opening. She stated that everyone in the kitchen including Cooks, Dietary aide and herself were responsible for dating food items in the kitchen. She stated risk of not dating was possible risk of food borne illness to the residents. In an interview on 02/12/25 12:07 PM with Dietary Aide E revealed everyone working in the kitchen was responsible for dating open food items. She stated for any food item that was open, it should have an open date and use by or expiry date. She stated risk of not dating food items was possibility of getting residents sick. In an interview on 2/12/25 12:54 PM with [NAME] D revealed everyone in the kitchen was responsible for dating food items. She stated that liquid eggs had use by date of 3 days after opening. She stated that opened, not dated food items posed a risk to residents since kitchen personnel were not sure how long food items have been opened and can make residents sick if they were spoiled. She stated that they received in-services from the Dietary Manager often about dating and labeling food items. Record review of the facility's policy titled, Food Storage policy revised February 6, 2024, reflected, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination 2. Refrigerator .All foods are covered, labeled, and dated. Defrosting meat, eggs and milk shakes are labeled with date pulled for thawing . Review of the Food and Drug Administration Food Code, dated 2022, reflected, .Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 24 residents (Resident #1), reviewed for care plan development. The facility failed to ensure Resident #1's comprehensive care plan included a plan of care for dialysis. This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. The findings included: Record review of a face sheet dated 02/12/25 revealed Resident #1 was an [AGE] year-old male and was admitted on [DATE] with diagnoses including peripheral vascular disease (a circulatory condition), hypotension of hemodialysis (occurs when a large amount of blood is rapidly filtered during dialysis), muscle wasting and atrophy (a decrease in muscle mass and strength), and enterocolitis due to clostridium difficile (inflammation of the intestines). Record review of the most recent MDS dated [DATE] indicated Resident#1 was cognitively intact with a BIMS score of 15. Record review of Resident #1's care plan initially reviewed on 01/22/25 at 10:45 an revealed dialysis was not addressed in the plan of care prior to entry date of survey date (02/11/25) and time (9:08am). Record review of Resident #1's physician order summary revealed an order with a start date of 01/23/25 for Dialysis, M-W-F. During an interview on 02/13/25 at 8:50 a.m., the DON stated the resident was admitted to the facility as a dialysis patient. The DON stated every resident should have a plan of care. The DON stated anything that affected the resident should be care planned. She stated she was unsure why dialysis was not care planned prior to 02/11/25. She stated the MDS Coordinator was responsible for writing the care plans. During an interview on 02/13/25 at 01:48 p.m., the MDS Coordinator stated she did not see the plan of care addressed dialysis. She stated although there was a new system, it was already in effect when the resident was admitted . She stated she usually care planned the physician orders. She stated it was important to have an accurate care plan because it reflected what the facility was doing for the patient. Record review of the facility Care Plan-Process policy last revised on 02/12/20 and reviewed 03/27/23 revealed: The interdisciplinary team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required time frames

Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 residents (Resident #30 and Resident #19) of 5 residents reviewed for ADLs. The facility failed to ensure Resident #30, and Resident #19 had their fingernails cleaned and trimmed on 2/11/25. These failures could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: 1- Resident #30 Record review of Resident #30's Quarterly MDS assessment dated [DATE] reflected Resident #30 was [AGE] year-old male with initial admitted to the facility of 02/28/2024. His diagnoses included stroke (interrupted blood flow to the brain leading to partial or complete brain damage), hypertension (high blood pressure), hyperlipidemia (high lipid levels), and anxiety. Resident #30 had BIMS of 15 which indicated Resident #30 had intact cognition. Resident #30 was totally dependent on staff for personal hygiene. Record review of Resident #30's Comprehensive Care Plan revised on 11/03/2024 reflected, .Problem: Fall Risk related to amputation. Intervention: . Assist [Resident#30] with ADLs as needed . In an observation and interview on 02/11/25 at 11:37 AM revealed Resident #30 had dirty and jagged nails. The nails on both hands were approximately 0.4 cm in length extending from the tip of his fingers. Resident #30 stated he would like his nails to be clipped and cleaned. He stated that he was dependent on staff for nailcare, and he did not have clippers to cut his nails. 2- Resident #19 Record review of Resident #19's Quarterly MDS assessment dated [DATE] reflected Resident #19 was [AGE] year-old male with initial admitted to the facility of 03/20/2019. His diagnoses included Fractures and other multiple traumas, Hypertension (high blood pressure), Peripheral vascular disease (decreased blood flow to the limbs), hyperlipidemia (high lipid levels), Schizophrenia (chronic mental condition affecting the thought process and perceptions). Resident #19 had BIMS of 15 which indicated Resident #15 had intact cognition. Resident #19 needed moderate assistance for personal hygiene. Record review of Resident #19's Comprehensive Care Plan revised on 11/13/2024 reflected, , .Problem: Fall Risk related to history of peripheral vascular disease. Intervention: . Assist [Resident#19] with ADLs as needed . In an observation and interview on 02/11/25 12:07 PM revealed Resident #19 sitting in the dining room. Resident #19 had long, jagged nails with black discoloration underneath the nailbed. The nails on both hands were approximately 0.3 cm in length extending from the tip of his fingers. Resident #19 stated that he could use help to cut nails. He also stated that the staff have clippers, and they clip his nails, however his nails had not been clipped for several days. In an observation and interview on 02/11/25 02:21 with CNA H stated CNAs and Nurses were responsible for nailcare. She stated nail care was performed on shower days and as needed. She said if a resident had diabetes, then nurses trimmed their fingernails. She stated that if nails were long and dirty, residents may be at risk of infection. She added Resident #30 refused nail care at times. She stated if ADLs were refused, she informed the Charge Nurse about refusals. CNA H then approached Resident #30 in the activity area and asked if he would like his nails cleaned and trimmed after he was done with the activities. Resident #30 stated he would like them to be clipped. In an interview and on 02/11/25 02:43 PM with RN G stated that both nurses and CNAs were responsible for doing nail care for the residents. She stated that fingernails should be trimmed and cleaned on shower days and as needed. She stated that dirty, jagged nails could lead to risk of increased infections. In an interview on 02/11/25 03:01 PM with the DON she stated nail care was the responsibility of all CNAs and Nurses. The DON stated nails should be observed daily. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated she and management personnel conducted routine rounds to monitor ADL care. The DON stated residents having long and dirty could cause skin integrity to be broken and cause bleeding or infection. Record review of the facility policy titled, Bathing (not partial or complete bed bath) dated February 12, 2020, reflected, Nail care is given to clean and keep the nails trimmed . o Perform hand hygiene and perform nail care

Based on interview and record review, the facility failed to ensure a discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for two (Resident #23 and Resident #43) of two residents reviewed for discharge assessments. The facility failed to complete and transmit Resident #23's and Resident #43's discharge MDS assessment within 14 days of completion. This failure could place the residents at risk of having incomplete records. Findings include: Review of Resident #23's face sheet, dated 02/13/25, reflected Resident #23 was an [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #23's facility death record, dated 02/13/25, reflected Resident #23 date of death [DATE]. Review of Resident #23's MDS assessments on 02/12/25 revealed Resident #23 did not have a discharge MDS assessment completed. This MDS record was identified as greater than 120 days late on the resident assessment facility task. Review of Resident #43's face sheet dated 02/13/25 reflected Resident #43 was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #43's Against Medical Advice form dated 09/30/24, reflected Resident #43 discharged on [DATE]. Review of Resident #43's MDS assessments on 02/12/25 revealed Resident #43 did not have a discharge MDS assessment completed. This MDS record was identified as greater than 120 days late on the resident assessment facility task. In an interview on 02/13/25 10:21 AM with MDS Nurse F revealed Resident #23 and Resident #43 should have had discharge assessments. She stated that they had a change in the electronic health record system in November 2024 and was unable to see previous assessments. She stated that she was responsible for completing all MDS assessments. She stated the transmission of MDS assessment to CMS was conducted by the Regional MDS coordinator. She stated the timeframe for completing and transmitting discharge assessments was within 14 days of discharge or death. In a phone interview on 02/13/25 11:49 AM with the Regional MDS RN stated that all discharge or death assessment should be completed and transmitted to CMS within 14 days of discharge or death. She stated that Resident #23 had Quarterly MDS assessment dated [DATE] and Resident #43 had Admission MDS assessment dated [DATE] in the EHR. She stated that she could not find any discharge MDS assessment for Resident #23 and Resident #43 either in the previous or new EHR nor could she find MDS transmission records for the same. She stated that facility MDS nurse was responsible for completing all MDS assessment in timely manner. She stated she will contact the MDS Nurse F in the facility to complete MDS assessments for Resident #23 and Resident #43 after the interview. In an interview on 02/13/25 12:39 PM with the Administrator stated that Facility MDS Nurse was responsible for completing all MDS assessment in timely manner and it was her expectation that all the MDS assessments were completed and transmitted to CMS within the stipulated time frame. She stated that failure to do so will lead to CMS not being aware if the resident was still residing in the facility. Review of facility's policy titled Resident Assessment revised on January 12, 2020 reflected, . It is the Standard of Care at this facility to conduct, initially and periodically, a comprehensive, accurate assessment of each resident's functional capacity utilizing the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual .Comprehensive assessments will be completed not less often than once every 12 months (366 days), within 14 calendar days after admission, or within 14 days of a significant change determination . Tracking records and OBRA assessments will be transmitted electronically, in a CMS specified format, within 14 days of the assessment completion. MDS transmission Validation Reports will be saved electronically.

Based on observation, interview, and record review, the facility failed to keep residents free from physical abuse for 1 (Residents #1) of 4 residents reviewed for safety. The facility failed to implement interventions for Resident #1's safety related to wandering. Resident #1 sustained a closed fracture of the alveolar process and mandible and a bloody mouth from a physical altercation with Resident #3 The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 12/01/22 and ended on 12/30/22. The facility had corrected the noncompliance before the survey began. Resident #1 was placed on 1:1 , with no other incidents and staff were reeducated regarding Abuse and Neglect and Behavioral Management on 12/30/22, and the facility had pending transfer to another facility that could better meet the resident's needs. This failure could place residents at risk of injury and lack of supervision. Findings included: Review of Facility Policy and Procedure NO.: NSG-5.003 entitled Abuse, Neglect and Exploitation and Misappropriation of Resident Property dated 2/12/20 reflected the following: Policy: 1. Each resident has the right to be free from abuse .2. Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect .5. Training. The facility will conduct staff member training regarding abuse, neglect .to include prevention, intervention, detection, reporting .d. working with residents with dementia and cognitive impairment .e. Techniques for management of difficult residents .g. Assessment of staff responses to aggressive or hostile behaviors .k. Appropriate interventions that are implemented to deal with aggressive and/or catastrophic reactions of residents .m. Behavioral interventions that can be used for inappropriate resident behaviors .6.2 A committee selected and chaired by the Administrator/Abuse Coordinator or designated representative will function as the Quality Assurance and Performance Improvement (QAPI) Committee and meet monthly upon the availability of the interdisciplinary team. The Committee will a) analyze the occurrences to determine what changes are needed, in any to policies and procedures to prevent further occurrences, and b) review/evaluate, identify trends in situations in which abuse, neglect or misappropriation, exploitation and mistreatment of resident/property is more likely to occur. This includes an analysis of: .e. the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents who have behaviors such as entering other resident's rooms. Record review of Resident #1's face sheet dated 1/26/23 revealed that he was a [AGE] year-old male with an admitted [DATE] and a discharge date of [DATE]. Diagnosis included: Dementia with Behavioral Disturbance; Depression; Anxiety; Major Neurocognitive Disorder; Cognitive Decline; Vascular Dementia (Dementia caused by an impaired supply of blood to the brain), mild, with Mood Disturbance; Legal Blindness as defined in the USA; Type 2 Diabetes mellitus without complications; Insomnia; Unspecified Mood Disorder and Transient Ischemic Attack (Stroke). Record review of Resident #1's MDS assessment dated [DATE] revealed that he was unable to complete the Brief Interview for Mental Status, and his eyesight was highly impaired. Resident #1 was unable to complete the Resident Mood Interview, and he was positive for hallucinations under Section E0100 Potential Indicators of Psychosis. Resident #1 required a wheelchair as a mobility device and required partial to moderate assistance for transfers to and from his wheelchair and was occasionally incontinent of bowel and bladder. Record review of Resident #1's Progress Notes dated 11/20/22 at 8:22 PM, written by LVN A, revealed Resident #1 wandered into Resident #2's room and an altercation ensued resulting in Resident #1 receiving a small scratch on Resident #1's eyelid. Resident #2 had no injuries noted. Record review of Resident #1's orders dated 11/21/22 at 4:17 PM revealed that Resident #1 was transferred to In-service Psychiatric Service with a diagnosis of violent behavior. Order end date 11/26/22. Record review of Resident #1's Psychiatric Subsequent assessment dated [DATE] at time unknown, written by Psychiatrist D revealed that Resident# 1 had his medications adjusted from Ativan (anxiety) 0.5mg daily to 0.5mg twice daily and Divalproex Sprinkle (anxiety) 125mg twice daily to Divalproex 250mg twice daily. Record review of Resident#1's Progress Notes dated 12/1/22 at 3:22 PM written by LVN B, revealed Resident #1 wandered into Resident #3's room and an altercation ensued resulting in Resident #1 receiving a closed fracture of the alveolar process of mandible (between the bottom of the nose and upper lip) and a bloody mouth. Record Review of Hospital Record After Visit Summary dated 12/1/22, no time noted, reflected that Resident #1 was diagnosed with a closed fracture of the Alveolar Process of Mandible (a fracture between the bottom of the nose and upper lip). Record review of Resident #3's Face sheet revealed that he was a [AGE] year-old male with an admitted [DATE], his diagnosis included: Blindness Left Eye Category 5 (blindness-irreversible blindness with no light perception), Low Vision Right Eye category 1 (moderate visual impairment), Cerebral Infarction, unspecified (stroke), End stage Renal Disease (kidneys no longer function well enough to meet the body's needs), and Hemiplegia (partial paralysis of one half of the body). Record review of Resident# 3's MDS dated [DATE] revealed that he had a Brief Interview for Mental Status score of 15 (no cognitive impairment), and that he used a wheelchair for ambulation. He required partial to moderate assistance with transfers and bathing and that he was always continent of bowel and bladder. Record review of Resident #1's Progress Notes dated 12/2/22 at 3:13 PM, written by RN C, revealed that Resident #1 was to return to the facility that day and was now on 1:1 and required hourly behavioral monitoring. Record review of Resident #1's Progress Notes dated 12/2/22 at 5:23 PM, written by LVN E, revealed that Psychiatric D had been contacted and orders given to continue 1:1 monitoring and document behaviors every shift. Record review of Resident #1's Progress Notes dated 12/8/22 at 4:14 AM, written by RN F, revealed that Resident #1 was on 1:1 monitoring. RN F was called away to another resident in distress to suction a trach. RN F reported that CNA G took over for RN F for 1:1 monitoring of Resident #1. Resident #1 wandered into Resident #3's room and an altercation ensued, resulting in Resident #1 receiving an abrasion to the left foot, no injuries were noted for Resident #3. Record review of Resident #1's Progress notes dated 12/8/22 at 1:53 PM written by DON revealed that Resident #1 explained what happened (he mistook Resident #3's room for his restroom), DON assessed Resident #1 and the skin abrasion to Resident #1's left foot had healed. Record review of Resident #1's Psychiatric Subsequent assessment dated [DATE] at time unknown, written by Psychiatrist D revealed that no changes were made to Resident #1's medications. Record review of Resident #1's Progress Notes dated 12/26/22 at 8:02 AM, written by DON revealed Resident #1 was adjusting well, no behaviors noted during previous shift. Will wean Resident #1 off 1:1 on first shift and continue to have 1:1 on 2-10 and 6-10 shift and slowly wean off if behaviors appropriate. Will continue to monitor. Record review of Resident #1's Progress Notes dated 12/27/22 at 10:22 PM, written by LVN B revealed that Resident #1 continue on 1:1 monitor during this shift No behavior issues noted this shift. Resident #1 adjusting well. Will wean Resident #1 off 1:1 on first shift and continue to have 1:1 on 2-10 and 10-6 shift and wean off if behaviors appropriate. Record review of Resident #1's Progress Notes dated 12/29/22 at 9:39 PM, written by DON revealed Resident #1 showing no behavior issues with less wandering throughout the day and doing well. Able to be redirected when wandering and staying mostly in dining room or by nurses' station and common area. Will try to wean off 1:1 supervision on 2-10 shift and place on 30-minute checks for 2-10 shift and remain 1:1 on 10-6 shift at this time. Will continue to monitor residents' behavior. NP H aware and in agreement. Record Review of Resident # 1's check sheet entitled Every 15 Minute Check Sheet Dated 12/29/22 and signed by DON revealed that 30-minute checks were conducted. Record review of Resident #1's Progress Notes dated 12/29/22 at 9:30 PM, written by LVN B revealed Resident #1 wandered into Resident #4's room and an altercation ensued. No injuries were noted for both Resident #1 and Resident #4. NP H notified. Resident 1 monitored through the shift for any behaviors or wandering. Record review of Resident #1's Progress Notes dated 12/30/22 at 6:36 PM, written by DON revealed the DON talked with NP H and in agreement to have Resident #1 on 1:1 supervision for wandering every shift for the safety of the resident. In an interview on 1/25/23 at 9:15 AM with the ADM he stated Resident #1 was scheduled for discharge on 1/25/23 to another facility and Resident #1 was not the aggressor in all of the altercations, that Resident #1 was a sundowner and wandered into other resident's rooms by accident. In an interview on 1/25/23 at 10:12 AM with Resident #4 he stated that Resident #1 came into his room and started to move stuff around, that he asked Resident #1 to leave their room and when Resident #1 did not leave he slapped him on the back of the head. He stated that the nurses came very quickly and broke them up. He further revealed he was offered psychological counseling and he felt safe in the facility. In an interview on 1/25/23 at 10:24 AM with Resident #2 he stated Resident #1 came into his room in his wheelchair and called him a white boy. He further stated that he did not hit Resident #1, but they wrestled a bit and the nurses came quickly. He further revealed that they had offered him psychological services and that he felt safe at the facility. In an interview on 1/25/23 at 11:02 AM with CNA I she stated she had worked with Resident #1 on many occasions and Resident #1 was easy to redirect when he first came to the facility, but redirecting had become harder because Resident #1 seemed more confused. She stated that she had been with Resident #1 for 1:1 and that 1:1 meant they were not to let the resident out of their sight and to always be very close to the resident to prevent him from getting into any more trouble. CNA I stated that they had received training in Abuse and Neglect and Resident Behavior and Management. In an interview on 1/25/23 at 12:14 PM with Resident #3 he stated the first time Resident #1 came into his room Resident #1 tried to take a swing at him, so he hit him in self-defense. The second time Resident #1 came into his room Resident #1 was completely naked and he was touching his private parts. He stated that he was completely blind in their left eye so that he did not see Resident #1 come into his room and Resident #1's appearance completely startled him and that he hit Resident #1 completely out of reflex. Resident #3 further stated that the nurses came and stopped the fights quickly and he had been offered psychological services and felt safe at the facility. In an interview on 1/25/23 at 12:48 PM with DON, they stated that 1:1 supervision meant someone had to be with Resident #1 at all times, even when Resident #1 was sleeping. Responsibility for 1:1 was listed on the staffing sheets. She further stated that on the morning of 12/8/22 RN F was listed as the staff member that was responsible for 1:1 with Resident #1 but RN F had an emergency with another resident involving suctioning a trach. RN F was away from Resident #1 for just a few minutes when the altercation happened. In an interview on 1/25/23 at 1:05 PM with RN C she stated that 1:1 supervision meant continuous observation even while the resident is sleeping. Her understanding was that on the overnight shift the RN and the aides have a rotating schedule for 1:1. She had been instructed to document all of Resident #1's behaviors every shift change or every time he had a behavior. She stated that she had received training in Abuse and Neglect and Resident Behavior and Management. In an attempt to interview Resident #1 on 1/25/23 at 1:30 PM Resident #1 stated that he had come to the facility around June, that he had no problems with any of the residents there, he was not sure why he was in other people's rooms, that he had just got to the facility that day. He further stated that he could not see out of his right eye and that he had gone to a hospital for his jaw and that it was good now. In an interview on 1/25/23 at 2:56 PM with CNA J she stated that she had been instructed that 1:1 meant they had to be within arm's reach of the resident at all times even if the resident was sleeping. She stated that she had received training in Abuse and Neglect and Resident Behavior and Management. In an interview on 1/25/23 at 3:33 PM with CMA K she stated that she had been instructed that 1:1 supervision meant that the resident had to be accompanied at all times even if they were sleeping. CMA K stated she had been one on the staff members that helped break up the altercation on 12/8/22 and that Resident #1 appeared to have had a bloody mouth and that Resident #3 seemed to be uninjured. In an interview on 1/25/23 at 3:53 PM with RN F she stated that she was the only RN on duty with CNA G and CNA L during the morning of the 12/8/22 when the altercation between Resident #1 and Resident #3 occurred. RN F stated she had been 1:1 with Resident #1 at that time and Resident #1 had been asleep when RN F had been notified of another resident in distress with a trach that required her to go and attend to the resident in distress. She stated that she had instructed CNA G to be with Resident #1 while she attended to the resident in distress and that while she had been suctioning the trach for the resident in distress, she had heard some commotion coming from further down the hallway. RN F stated that while CNA G was on his way to attend 1:1 for Resident #1, CNA G heard another resident call out for help in the room next to Resident #1's room. RN F stated that she had heard some yelling while suctioning the trach and when she had been able, she found that Resident #1 had gotten up and had wandered into Resident #3's room. She noted that Resident #1 was partially clothed, and that Resident #1 told her that he had been looking for his bathroom. She stated that she had assessed both residents, contacted the physician and family and that Resident#1 had a abrasion to his left foot and that Resident # 3 had no injuries noted. In an interview on 1/25/23 at 4:14 PM with CNA G he stated that the had been instructed on 1:1 and that he understood that 1:1 meant he had to be with Resident #1 even if the resident had appeared to be sleeping. He stated he had received training in Abuse and Neglect and Resident Behavior and Management. CNA G stated he had been told by RN F to assume 1:1 of Resident#1 while RN F attended to another resident in distress, but that on the way to his room the resident in the room next door to Resident #1's room had yelled out for help. During the few minutes of attending to the resident yelling out for help, Resident #1 went into Resident #3's room and an altercation happened. In an interview on 1/26/23 at 11:40 AM with Physician M he stated had been notified every time there was an incident with Resident #1, and that he had increased Resident #1's medications in response to Resident #1's wandering behavior. He stated Resident #1 had a diagnosis of Vascular Dementia and that made it difficult to isolate a cause, and that the facility had been attempting to get Resident #1's diagnosis switched to a psychiatric one, because the facility was unable to provide Resident #1 with the care that Resident #1 needed in accordance with his diagnosis. Physician M stated that on the medical side he had tried to make sure Resident#1's medications were providing as much help to reduce his wandering. He had stated that the medications had appeared to have started to work and he had eventually released Resident #1 from 1:1 to 30-minute observations but another altercation had happened within a few days. Resident #1 was placed back on 1:1 supervision. Physician M further stated that Resident #1 really needed a facility with a psychiatric care unit that was equipped to provide 1:1 supervision. In an interview on 1/26/23 at 11:46 AM with NP H she stated that Resident #1 had Vascular Dementia and that caused him to go into other resident's rooms by accident. Resident #1's cognition was becoming worse, and the facility was actively trying to find another facility better suited to Resident #1's needs. Resident #1's medications were adjusted in response to his behaviors, and Resident #1 had shown some improvement in his behaviors. She stated that did not write his orders to be taken off of 1:1, that had been a nursing staff call. She further stated that there had always been an effort to get Resident #1 the care he needed but his cognition had appeared to have gotten worse and that another facility, namely a facility with a memory care unit or a psychiatric unit would be better to provide the care Resident#1 needed. In an interview on 1/26/23 at 11:51 PM with Psychiatrist D she stated that the facility notified her of any incidents that had involved Resident #1 and that she had been updated within 24 hours of each altercation. Psychiatrist D stated that Resident #1 had both medical and psychological problems and that Resident #1's blindness and Vascular Dementia compounded his anxiety and wandering behaviors. Psychiatrist D stated she had been very involved with Resident #1's 1:1. The 1:1 and the adjustment in Resident #1's medications had been good for him and he had started to show improvement and Resident #1 had been put on 30-minute observations. Psychiatrist D also stated that she had recommended for Resident #1 to go to a secured facility where he could have access care more appropriate for his conditions. In an interview on 1/26/23 at 12:26 PM with LVN N she stated that 1:1 meant that the staff member had to be with the resident at all times and that a staff member had to be within line of sight at all times. She further stated that Resident #1's wandering behavior seemed to increase over time and that he appeared to gravitate towards the ends of the hallway. She stated that she had received training in Abuse and Neglect and Resident Behavior and Management. In an interview on 1/26/23 at 1:06 PM with SW she stated that Resident #1 she had contacted Resident #1's family on 12/14/22 about the move to another facility and that Resident #1 had not been very mobile when he first came to the facility but that he had become more mobile as his health had improved. SW further stated that proper discharge protocol was that the family had to be informed and that the discharge had to be safe. In an interview on 01/26/23 at 1:30 PM with the DON they stated that Resident #1 had been discharged from the facility to another facility. In an interview on 01/26/23 at 1:56 PM with the DON they stated that the facility had always had only three staff members on overnight because on the overnight shift there were generally no issues. She further stated that she believed there had been enough coverage on the overnight shift to facilitate 1:1 for Resident #1 as long as the 1:1 duty was rotated between staff members. She stated that before 11/20/22 Resident #1 had been more easily redirected, but after 11/20/22 something had changed in Resident #1 that made had made him less re-directable. DON further stated that she did not have a policy on 1:1 and that she had just trained the nurses and the CNAs on what was expected. In an interview on 01/26/23 at 2:40 PM with ADM he stated that 1:1 means that a staff member must always be in the line of sight of a staff member. The purpose of 1:1 would be for the safety of the resident and other residents. Resident #1's wandering behavior mainly seemed to manifest after 6 PM. He further stated that now the incident on 12/08/22 had occurred because the staff working that night had been called away for a resident in distress, he had not considered an extra intervention of adding more personnel to the overnight shift to stop Resident #1's behavior. ADM further stated that because of the lapse in 1:1 protocol on 12/08/22 it did cause the residents involved undue harm and duress. He added that having another staff member added to the overnight shift may have been a solution. In an interview on 01/26/23 at 3:13 PM with CNA O she stated that she had been working the overnight shift on 12/08/22 when the altercation with Resident #1 and Resident #3 occurred, but that she had not seen the altercation happen because she had been on the other end of the hallway changing another resident. She further stated that she had been on 1:1 with Resident # 1 in the past and that 1:1 meant that the staff member had to be with the resident at all times even if the resident was sleeping. CNA O stated that she had received training in Abuse and Neglect and Resident Behavior and Management. 1:1 was in place from 12/1/22 to 12/26/22, with the lapse in 1:1 on 12/8/22. Psychiatrist recommended that Resident#1 was responding well to meds/treatment, and orders were given to have resident placed on one shift of 30 min obs. starting 12/26/22, with the other two shifts being 1:1. On 12/29/22 during the shift that was 30-min observations, Resident #1 wandered into another resident #4's room, yelling and pushing occurred, no injuries noted. Resident #1 was immediately placed back on to 1:1, no other incidents occurred from that time. Resident #1 discharged from the facility to another facility on 1/26/23. Record review of Resident #1's Care Plan dated 1/20/23 reveled that Resident #1 had been Care planned for: Cognitive Deficit/ Decision Making evidenced by BIMS Score (8-12), Short term Memory loss; Visual Impairment evidenced by Highly Impaired Vision, Legally Blind, Blind In Right Eye, Decreased Vision Left Eye; Behavioral Changes related to Mood Disorder, Trauma Event-Captivity, Trauma Event-Physical Assault, evidenced by Verbally Abusive, Traumatic Experience Does Not Bother Resident At This Time; Mood Changes related to History of Depression; Non Compliance evidenced by Cognitive Ability varies Throughout the Day; Verbally Aggressive evidenced by Easily Annoyed/Angered; Wandering evidenced by Blindness, Cognitive Ability Varies Throughout the Day. In-Service for Abuse and Neglect and Behavioral Management was completed with nursing staff on the following dates: 11/21/22, 12/2/22, 12/9/22 and 12/30/22. Monthly QAPI meetings addressing the incidents regarding Resident #1 were conducted on the following dates: 11/4/22, 12/2/22/ and 1/6/23. Resident #1 was observed several times throughout the day to make sure the 1:1 was being enforced. During observations the resident did not have any obvious bruising/lacerations/skin tears/abrasions in the following observations: 1/25/23 at 9:25 AM: Resident #1 was observed accompanied by two staff members while the resident received a shave in the facility barber shop. 1/25/23 at 9:50 AM: Resident #1 was observed in a supine position in bed in his room accompanied by a staff member sitting next to Resident #1's bed. 1/25/23 at 10:10 AM Resident #1 was observed in the common area of the facility accompanied by a staff member engaged in simple exercises. 1/26/23 at 8:23 AM observed Resident #1 in the dinning area sitting comfortably in a wheelchair at a table eating breakfast accompanied by a staff member sitting in a regular chair next to Resident #1. 1/26/23 at 10:21 AM observed Resident #1 in a supine position accompanied by a staff member sitting in a chair next to his bed, conversing quietly with the staff member. Review of Policy and Procedure Document, entitled Behavior Management Clinical Operations Effective January 12, 2018, Revised February 12, 2020, revealed that: Staff will utilize the Behavior Management Guidelines in order to improve the resident's quality of life through therapeutic interventions and addressing behavioral concerns .Procedures: I. Primary Interventions: A. Anticipating Behaviors 1. Staff is responsible for preempting behavior problems before they occur .rule out any unmet needs such as: a) The need to eliminate .e0Physiological/medical problems .Commonly Used Behavior Interventions .Meet the residents physical needs: toileting, hunger, thirst, pain .1:1 The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 12/01/22 and ended on 12/30/22. The facility had corrected the noncompliance before the survey began. Resident #1 was placed on 1:1 , with no other incidents and staff were reeducated regarding Abuse and Neglect and Behavioral Management on 12/30/22, and the facility had pending transfer to another facility that could better meet the resident's needs.

Based on observation, interview and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as was possible for one (Resident #1) of four residents reviewed for falls and safety. Resident #1 had a fall while walking in the dining room unattended which resulted in Resident #1 sustaining a cervical fracture and scalp laceration. This failure placed all residents at risk of accidents resulting in the potential for serious injury and hospitalization . Findings included: Record review of Resident #1's face sheet dated [DATE] revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease, cervical disk displacement, [CONDITION(S)] heart disease, [CONDITION(S)], and [CONDITION(S)]. Record review of Resident #1's quarterly MDS assessment, dated [DATE], revealed she was sometimes understood, and she had the ability to usually understand others. Her BIMS was 99 indicating the resident was severely cognitively impaired. The resident required limited assistance of one staff in the areas of bed mobility, transfers, walk in room, walk in corridor, eating, toileting, and personal hygiene. Her balance during transition and walking was not steady, she was only able to stabilize with staff assistance, no equipment was used by the resident Record review of Resident #1's Care Plan, dated [DATE], updated [DATE], revealed the resident was care planned for falls, wandering, and behavior problems related to: Alzheimer disease and aggressive behavior. Her RP was informed and involved in the care plan. The interventions in place for falls, were to administer medications as ordered and monitor for side effects/effectiveness; explain all procedures before starting to help resident adjust to changes; assess contributing factors related to fall history; activities; encourage rest periods; obtain lab and x-ray as order; use of a wheelchair; awaiting closed back shoes from the family; redirection; therapy referral; and weight scale was removed and place in a closed area. Interventions for behavior problems, approach and speak in a calm manner; divert attention; activities; assess for contributing factors; explore the source of agitation; activities of living needs; give resident choices; and evaluate if side effects of medications. The resident was noted as wandering. Interventions were to redirect, distract resident, offering diversion, and safe walking path. Record review of the facility's Incident Accident Reports revealed on [DATE] Resident #1 was walking in dining room unassisted and fell receiving a laceration to the back of the head. Further review of the description of incident revealed Resident #1 was wandering in the hallway to the dining room when she stumbled on the weight scale and fell hitting the back of her head on the wall. Emergency services was called and compressed pressure was applied to stop bleeding. Review of the facility's Incident Accident logs dated ,d+[DATE] through ,d+[DATE] reflected Resident #1 had 23 falls. Further review reflected multiple interventions had been put in place to include; low bed, request for new shoes, therapy evaluation, and staff to monitor and redirect the resident. At the time of the fall on [DATE] the intervention that was for all staff to redirect. Review of Resident #1's nurse's notes, dated [DATE], reflected the same information that was indicated on the incident accident report. Review of Resident #1's Hospital Record, dated [DATE], reflected Resident #1 admitted to the hospital with the diagnosis of C1 cervical fracture and scalp laceration, due to a mechanical ground fall. Resident #1 had been then transferred to a in hospital Hospice of the families choice, where she later died . In an interview on [DATE] at 11:00 a.m. and 2:25 p.m. with the Housekeeping Supervisor revealed she was cleaning in a resident's room on [DATE]. She stated Resident #1 attempted to come into the room and the Housekeeping Supervisor redirected her. The Housekeeping Supervisor said Resident #1 turned and left the room and went back out in the hallway and she did not see where she went. She said within moments she heard a loud thudding noise and ran out of the room. The Housekeeping Supervisor said she was the first staff member to enter the dining room and Resident #1 was lying on the floor on her back with her head about a foot away from the weight scale. The Housekeeping Supervisor said the nurse came immediately and began to assess the resident. The Housekeeping Supervisor said she was asked to move the weight scale and she noted there was no blood on the scale. The Housekeeping Supervisor said there was blood and an indentation on the wall where Resident #1 had hit her head. The Housekeeping Supervisor was asked, by the investigator, when she entered the dining room was there anyone in the room, she said, no. In an interview on [DATE] at 11:00 a.m. with MA C revealed she had assisted with Resident #1 since she had lived at the facility. MA C said Resident #1 was a confused resident who had to be constantly redirected. She said the resident was easily redirected most of the time, by just telling her to turn around, but could get aggressive at times. MA C said the resident walked all the time, to the point of being so weak she would sit down in the hallway. MA C said it took the entire staff to watch her because she was constantly moving, they could get her to sit for a short period, but if they did not stay with her she would get up. MA C was asked if the resident was unsteady and she said yes, she shuffled and leaned forward sometimes when she walked. MA C was asked if she had seen the weight scale in the dining room, and she said yes in the past, but had been off when Resident #1 fell and the scale was gone by the time she had come back. Observation and interview on [DATE] at 2:25 p.m. with the Housekeeping Supervisor revealed there was no scale in the dining room and there was an indentation in the wall approximately an inch in length and one-half inch in diameter. The Housekeeping Supervisor said she had to clean the blood off the wall and the floor at the time Resident #1's fall. The Housekeeping Supervisor was asked how long had the weight scale been in the dining room prior to Resident #1's fall, she said ,d+[DATE] days, but it was moved the same day the fall occurred and she had not seen the weight scale in the dining room after that . The Housekeeping Supervisor said the weight scale was just inside the opening of the dining room door, up next to the built in shelves. She said if you walked in the opening of the doorway you could have tripped or even walked up on the scale and then off, but she did not know if that was what the resident had done. In an interview on [DATE] at 1:25 p.m. and 3:42 p.m. with CNA A revealed she weighed all the residents monthly, weekly, and daily. CNA A said she had been working at the facility since [DATE]. CNA A said she was working the day that Resident #1 had fallen, and the weight scale had been left in the dining room unattended while she went to lunch . She could not recall how long she was gone, but when she returned Resident #1 had fallen. CNA A said she was told to remove the weight scale and place the scale in a closet on the hallway. She was given a one on one in-service concerning the weight scale and given a key to the closet and told never to remove the scale from the closet. CNA A said that she was responsible for central supply and when she had begun work at the facility she had asked the Administrator to clean the closet out and put the weight scale in there, but had not had time to do that since she had to assist on the floor to care for residents. CNA A was asked where was the weight scale located at that time of the fall, other than the ding room. she said it had been moved all over the facility because there was no place for the weight scale to go. I had not been able to clean out the supply closet and the unit for readmits to the building was there also. Observation on [DATE] at 10:00 a.m. revealed there was no weight scale in the dining room and at 1:25 p.m. with CNA A the weight scale was in a locked closet. In an interview on [DATE] at 11:30 a.m. with the Administrator revealed the weight scale had been placed in the dining room, because he had no place to put it. He said after Resident #1's fall he had CNA A clean out the closet and place the weight scale in that room. The Administrator said the dining room was not in use for residents and was still not in use for residents . The Administrator said Resident #1 wandered all the time and she wanted to walk there was no stopping her from doing that. The Administrator was aware that Resident #1 had multiple falls but did not know how many. The Administrator said he could not prove in his investigation that the resident had fallen over the scale, the way her body was laying he thought she lost her balance. He said she walked with a unsteady gait sometimes moving very fast and he knew that different shoes had been requested by the nursing staff. In an interview on [DATE] at 11:45 a.m. with the DON revealed she had been working at the time of Resident #1's fall. The DON said she had recently requested different shoes, that were not slip on, for the resident but had not received the shoes form the family. The DON said the fall was an unwitnessed fall and the resident had a history falls with many interventions, including; activities, therapy, toileting program, naps, and redirection by the staff. The DON said when she had come to work at the facility, she had previously spoken to the family about possibly moving her to a secured unit, since she was wandering so much, and the family refused. The DON said she had given an in-service concerning documentation and falls following the fall of Resident #1, because she realized that the nursing staff had documented, the resident had tripped over the scale. The DON said she found education was more effective and professional than having the staff make a late entry in the clinical record. The DON was asked about the weight scale in the dining room and she said it was moved the day Resident #1 fell and placed in a locked closet. When the DON was ask about how long the weight scale had been in the dining room and why it had been moved there, she said that it was the shoes that were the problem, not the weight scale. When ask why the shoes she said they were not stable enough they were open at the back of the foot. In an interview on [DATE] at 3:30 p.m. with LVN B revealed she had been the nurse in charge when Resident #1 had fallen. She said she had assessed her and noted the laceration to the back of her head and called 911, sent her out to the hospital. LVN B was asked about Resident #1 and she said she was a wandering, confused resident that constantly had to be redirected. LVN B was asked had there been a witness to the fall and she said the Housekeeping Supervisor told her about the fall. LVN B said later she found out the Housekeeping Supervisor was not in the dining room and the fall was not witnessed. When she was asked why she had documented that the resident had tripped/stumbled over the weight scale, she replied, I know that was a possibility but no one saw her, I thought since the weight scale was there it just made sense. LVN B said she received an in-service by the DON after the incident on documentation and change of condition. Record review in-service, dated [DATE], given by the ADON for the nursing staff, including LVN B reflected documentation and change of condition. In an interview on [DATE] at 3:46 p.m. with the ADON revealed she was no longer working at the facility, but she was working there when Resident #1 fell , but was not in the building at the time of the fall. She said she had given in-services to the staff concerning falls and documentation after the resident had fallen, but the DON had given in-services about falls and documentation before this fall involving Resident #1. The ADON was asked about Resident #1, she said the resident had lived there for over a year and she had been a wanderer the entire time, she had a history of falls and the facility staff tried very hard to keep her safe with many different interventions, including activities therapy and asking the family for a different type of shoes. When the ADON was asked about the weight scale and the location she replied it had been in the dining room for a couple of days . In an interview on [DATE] at 12:00 p.m. with RN D (Hospice) revealed she had received a phone call from the facility she thought it was around [DATE] but could not be sure concerning Resident #1 and a fall. RN D said she was informed the resident had been sent to the hospital. RN D said Resident #1 had a history of falls and she was a confused wanderer. RN D said the facility had many interventions to try and keep her safe, including therapy. RN D said the resident was fast at times, she gave an example that she was at the nurses station and a CNA had placed Resident #1 in her bed for a nap and before the CNA could get back to the nurses station, Resident #1 was already at the nurses station. RN D said he felt the nursing staff had taken very good care of her and tried everything they could to keep her safe . In an interview on [DATE] at 10:29 p.m. with the Director of Rehabilitation revealed the therapy department had screened, assessed and treated Resident #1. The DOR said the resident had just completed services on [DATE], prior to her fall on [DATE]. She had been screened after that, when she had falls but she had no change in her baseline , she still confused and unable to use any equipment. The Director of Rehabilitation said that Resident #1 wandered all the time thought the hallway and was redirected by the staff. The Director of Rehabilitations said that Resident #1 remained unsteady at times with her mobility since she would walked all the time and got tired. In an interview on [DATE] at 2:30 p.m. with CNA E revealed she had worked at the facility since [DATE]. CNA E said she had taken care of Resident #1. CNA E said Resident #1 walked a lot on the evening shift, all over the hallway and in and out of other resident's rooms, she was easily redirected, and it took the entire staff to keep up with her. CNA E said she was not working the day that she fell , but she had seen the weight scale in the dining room, but she could not recall when. In an interview on [DATE] at 2:45 p.m. with CNA F revealed she had assisted in redirecting Resident #1; the entire staff did. CNA F said Resident #1 walked a lot on the evening shift, and she could become very tired and would sit down in the hallway sometimes. She said she had never been at the facility when the resident had fallen, but she had seen the results of some her falls, with bruising on her face and arms. CNA F said Resident #1 was unsteady at times when she was walking would bend over and walk forward, she would stumble sometimes, but catch herself and not fall. In an interview on [DATE] at 8:40 a.m. with the Administrator revealed there was no witness to Resident #1's fall and he had found that out during his investigation for his self-report. The Administrator said he was aware of the history of the resident's unsteady wandering. When the Administrator was asked about the documentation stumbled on the weight scale and fell hitting the wall to the back of the head, in the incident accident report on the nurses notes he replied he felt that the nurse was trying to make sense out of the fall. Record review of the facility's Fall Prevention policy titled: Fall Management, revised February 2020, revealed in part, . The community will manage falls by providing an environment that is free from potential hazards