Every finding on record at Alhambra Rehab & Healthcare

Based on observation and interview, the facility failed to properly label medications for 3 (R2, R11, R19) of 3 residents observed for proper medication storage in a sample of 27.Findings Include: 1.) R2's Undated Face Sheet documents R2 was originally admitted to the facility on [DATE], and has medical diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, Malignant Neoplasm of Connective and Soft Tissue, Hypertension, and Peripheral Vascular Disease.R2's Minimum Data Set (MDS), dated [DATE], documents R2 is severely cognitively impaired.R2's Physician Order, dated 5/7/25 at 9:44 AM, documents Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject per sliding scale subcutaneously three times a day.R2's Physician Order, dated 2/3/26 at 12:47 PM, documents Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 5 unit subcutaneously three times a day.R2's Physician Order, dated 5/28/26 at 12:00 AM, documents TobraDex ST Ophthalmic Suspension 0.3-0.05 % (Tobramycin-Dexamethasone) Instill 1 drop in both eyes four times a day for Eye Inflammation for 10 Days.On 6/9/26 at 3:19 PM, the Facility's A/B Hall medication cart was observed with V6, Registered Nurse (RN). The medication cart contained an open undated bottle of TobraDex ST Ophthalmic Suspension 0.3-0.05 % eye drops and an open undated Insulin Aspart (Novolog) pen.2.) R11's Undated Face Sheet documents R11 was originally admitted to the facility on [DATE], and has medical diagnoses of Hypothyroidism, Heart Failure, Type 2 Diabetes Mellitus, Hypertension, and Acute Kidney Failure. R11's MDS, dated [DATE], documents R11 is moderately cognitively impaired.R11's Physician Order, dated 2/18/25 at 10:03 AM, documents NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject per sliding scale subcutaneously with meals.On 6/9/26 at 3:22 PM, the Facility's A/B Hall medication cart was observed with V6. The medication cart contained one opened undated NovoLOG FlexPen for R11. 3.)R19's Undated Face Sheet documents R19 was originally admitted to the facility on 1/2023, and has medical diagnoses of Cerebral Palsy, Paraplegia, Ankylosing Spondylitis Lumbar Region, Cervicalgia, and Hypertension.R19's MDS, dated [DATE], documents R19 is cognitively intact.R19's Physician Order, dated 4/29/26 at 11:07 PM, documents Dorzolamide HCl Solution 2 % Instill 1 drop in both eyes in the morning.R19's Physician Order, dated 4/29/26 at 11:14 PM, documents Latanoprost Solution 0.005 % Instill 1 drop in both eyes at bedtime.R19's Physician Order, dated 4/29/26 at 11:34 PM, documents Timolol Maleate Ophthalmic Solution 0.5 % (Timolol Maleate (Ophth) Instill 1 drop in both eyes in the morning. On 6/9/26 at 3:23 PM, the Facility's A/B Hall Medication Cart observed V6. The medication cart contained an opened undated bottle of Dorzolamide Hcl Solution 2%, an opened undated bottle of Timolol Maleate Ophthalmic Solution 5%, and an opened undated bottle of Latanoprost Solution 0.005% for R19.On 6/9/26 at 3:25 PM, V6 stated she dates everything when she opens it to be safe, and the facility asks staff to date insulin and eye drops with the date they are opened.On 6/11/26 at 1:57 PM, V2, Director of Nursing, stated she expects staff to label eye drops and insulin with the date they are opened. V2 stated she has a list of all insulins documenting how long the insulin is good for once it is opened and all nursing staff have been educated on it.The Facility's Undated Common Insulins-Room Temperature (Out of Refrigerator) Stability List documents Insulin Aspart's (Novolog) room temp stability (after first use) is 28 days.The Facility's Administering Medications Policy, revised 4/2019, documents Medications are administered in a safe and timely manner, and as prescribed. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

A. Based on Observation, Interview, and Record Review, the facility failed to establish and maintain a system of surveillance to identify communicable diseases or infection. This has the potential to affect all 38 residents in the facility. Findings include: On 8/1/2024 Facility Infection Control log documents on 7/21/2023 R196 Urinary Infection. No culture done. On 8/1/2024 Facility Infection Control log documents on 10/10/2023 R195 Urinary infection. No culture done. R195's Physician Order Sheets dated 10/2024 has no documentation of culture and sensitivity. R195's Physician Order Sheets dated 10/10/2023 documents Bactrim DS 800MG-160MG Tablet: Administer 1 tablet by mouth at 8am and 8pm everyday x 7 days related to UTI, Urinary Tract Infection. R195's medication administration record dated 10/2024 documents Bactrim DS 800mg-160MG Tablet. Administer 1 tablet by mouth at 8AM and 8PM. Everyday x 7 days related to UTI, Urinary Tract Infection. Order Date 10/10/2023. Start Date 10/10/2023. Stop Date 10/17/2023. Sulfamethoxazole/Trimethoprim. Administration dates document 10/10/2023 at 8PM. 10/11/2023-10/16/2023 at 8AM and 8PM. 10/17/2023 at 8AM. R196's Physician Order Sheets dated 7/2023 has no documentation of culture and sensitivity. R196's Physician Order Sheets dated 7/21/2023 Cephalexin 500MG Capsule: Administer 500mg oral at 8am, 12pm, 5pm every day. Stop date 7/28/2023. Generic: Cephalexin. R196's medication administration records dated 7/2023 document Cephalexin 500MG Capsule. Administer 500 MG oral at 8AM, 12PM, 5PM Everyday. Order date 7/21/2023. Start date 7/21/2023. Stop date 7/28/2023. Administration dates document 7/22/23-7/28/2023 8AM,12PM,5PM. Facility infection control log dated 6/9/2023-7/1/2024 contains no documentation of infection tracking for 7/2024. On 8/1/24 at 3:10 PM, V3, Infection Preventionist, IP, stated she just took over the role in October 2023. She tracks and trends facility infections with the floor plan, but has not yet started July 2024. She stated she had a floor plan for tracking organisms for previous months but it will take her a while to find them because her office has been moved and they are in boxes. On 8/2/2024 at 10:00AM V4, Regional Director of Clinical Operations, stated I would expect cultures to be completed prior to antibiotic administration. I would expect infection surveillance to be conducted throughout the facility. Facility policy date 2001 states Surveillance for Infections: The Infection preventionist will conduct ongoing surveillance for Healthcare Associated Infections and other epidemiologically significant infections that have substantial impact on potential resident outcome an that may require transmission based precautions and other preventative interventions. 34964 B. Based on observation, interview and record review, the facility failed to maintain Enhanced Barrier precautions and perform appropriate hand hygiene to prevent spread of infection for 1 of 6 residents (R32) reviewed for infection control in the sample of 29. Findings include: On 8/1/24 at 1:05 PM V18, Licensed Practical Nurse (LPN) provided pressure ulcer treatment of R32, assisted by V20, Certified Nursing Assistant (CNA) for turning and positioning. They both washed their hands and donned gloves. V20 rolled R32 onto his right side and unfastened his adult diaper to expose his buttocks. R32 did not have a treatment on his stage 2 pressure ulcer in his gluteal cleft as ordered and he was incontinent of feces which was smeared over his exposed pressure ulcer. V18 stated the old dressing must have come off when they did R32's incontinent care around lunch time. V20 used disposable wipes and wiped feces from area of his pressure ulcer and around the pressure ulcer, and wiped most of the feces from his rectal area and buttocks, but left some feces on both buttocks. V20 then placed the soiled diaper with soiled wipes inside of it and some feces exposed on the outside of the diaper on the bed. This soiled diaper was sitting right next to the area V18 was performing pressure ulcer care. After V20 cleansed most of fecal material off R32's buttocks, V18 cleansed his pressure ulcer with wound cleanser, then applied a piece of calcium alginate above the pressure ulcer and secured it with a bordered dressing. She removed gloves and donned new gloves without performing hand hygiene. V18 handed V20 a pair of gloves and told him to change your gloves, but he did not perform hand hygiene before donning the gloves. After V18 finished pressure ulcer care, V20 applied a new adult diaper on R32 without washing the feces off his buttocks or cleansing his scrotum, penis or groin. V18 and V19 did not wear appropriate Personal Protective Equipment (PPE) to maintain enhanced barrier precautions while providing pressure ulcer treatment and incontinent care. Neither wore a gown during care and neither hand sanitized when changing gloves during care. On 8/2/24 at 9:50 AM V4, Regional Director of Clinical Operations, stated if staff are providing incontinent care to a resident who had been incontinent of bowel and bladder, that staff should ensure all areas touched by incontinence are thoroughly cleaned before putting on a new adult diaper. V4 stated V18 and V20 should have worn a gown and gloves while performing wound care and incontinent care per the enhanced barrier precautions. V4 stated any time a staff changes gloves while providing care they should hand sanitize with alcohol gel or wash their hands with soap and water before donning new gloves. The facility's policy, Enhanced Barrier Precautions Policy, revised 3/28/24 documents, Enhanced Barrier Precautions (EBP) expand the use of PPE and refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. The use of gown and gloves for high-contact resident care activities is indicated for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC- targeted or other epidemiologically important MDRO when contact precautions do not otherwise apply. Wounds generally include chronic wounds, not shorter lasting wounds such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. The facility's policy, Handwashing/Hand Hygiene, revised August 2015, documents, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Wash hands with soap and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea, including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: g. before handling clean or soiled dressings, gauze pads etc; and m. after removing gloves.

Based on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 38 residents living in the Facility. Findings Include: The Facility's July 2024 RN (Registered Nurse) and LPN (Licensed Practical Nurse) schedule documents the Facility did not have a RN on 7/9/24, 7/19/24, 7/24/24, 7/27/24, or 7/28/24. The Facility provided time cards documenting V6, Registered Nurse (RN) and Minimum Data Set (MDS) Coordinator, worked on 7/9/24, 7/19/24, and 7/24/24, and V2, Director of Nursing (DON) worked on 7/27/24. The Facility was unable to provide documentation that a RN worked for at least eight hours on 7/28/24. On 7/31/24 at 7:52 AM, V2, Director of Nursing (DON), stated staffing has been an issue, and they have been trying to hire more nurses. On 8/1/24 at 10:10 AM, V13, Regional Director of Operations, stated the Facility does not have a policy regarding RN staffing, and they just follow the federal guidelines. The Facility's Long-Term Care Facility Application For Medicare and Medicaid dated 7/30/24 documents there are 38 residents living in the Facility.

Based on observation, interview, and record review, the Facility failed to properly store and medications and discard expired medications. This has the potential to affect all 38 residents living in the Facility. Findings include: On 7/31/24 at 8:35 AM, the medication cart on A Hall was inspected with V3, Licensed Practical Nurse (LPN). The cart contained one opened bottle of over the counter liquid protein that was not dated upon opening and one opened bottle of over the counter cough syrup that was not dated upon opening. V3, LPN, stated the liquid protein had a label, but it must have worn off. She stated none of the residents use the cough syrup, so she will just throw it away. On 7/31/24 at 8:40 AM, the medication room on A Hall was inspected with V3, LPN. The refrigerator in the room contained one opened unlabeled multi dose Tubersol vial. V3, LPN, stated the vial should be dated upon opening, so she will get rid of it and order a new vial. She stated all residents receive Tubersol on admission and yearly. On 8/2/24 at 9:55 AM, V4, Regional Director of Clinical Operations, stated she expects the Facility to date medications upon opening and follow the medication storage policy. The Facility's Storage of Medications Policy revised April 2007 documents, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. The Facility's Tubersol package documents the product should be discarded 30 days after opening. The Facility's Long-Term Care Facility Application For Medicare and Medicaid dated 7/30/24 documents there are 38 residents living in the Facility.

Based on interview and record review, the Facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 2 of 4 residents (R195, R196) reviewed for antibiotic stewardship in the sample of 29. Findings include: 1-The Facility's Infection Control Log lists No culture done for R195's 10/10/23 urinary infection. On 7/31/24 at 7:45 AM, requested culture and sensitivity for R195's 10/10/23 urinary infection from V4, Regional Director of Clinical Operations. On 8/2/24 at 10:00 AM, no culture and sensitivity was received. R195's October 2023 Physician Orders document an order for the antibiotic Bactrim DS 800 mg (milligram) - 160mg tablet with instructions to take one tablet twice daily for seven days for UTI (Urinary Tract Infection). R195's October 2023 Medication Administration Record (MAR) documents R195 received 14 doses of Bactrim DS. 2-The Facility's Infection Control Log lists No culture done for R196's 7/21/23 urinary infection. On 7/31/24 at 7:45 AM, requested culture and sensitivity for R196's 7/21/23 urinary infection from V4, Regional Director of Clinical Operations. On 8.2.24 at 10:00 AM, no culture and sensitivity were received. R196's July 2023 Physician Orders document an order for the antibiotic Cephalexin 500 mg capsule with instructions to take 500 mg three times daily. R195's July 2023 MAR documents R195 received 21 doses of Cephalexin. On 8/2/24 at 9:55 AM, V4, Regional Director of Clinical Operations, stated she expects the Facility to obtain urine cultures prior to starting antibiotics. The Facility's Antibiotic Stewardship Policy revised December 2016 documents, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on observation, interview and record review, the facility failed to provide pressure ulcer treatment as ordered for 1 of 4 residents (R32) reviewed for pressure ulcers in the sample of 29. Findings include: On 8/1/24 at 1:05 PM V18, Licensed Practical Nurse (LPN) provided pressure ulcer treatment for R32, assisted by V20, Certified Nursing Assistant (CNA) for turning and positioning. They both washed their hands and donned gloves. V18 explained what she was going to do to R32 and (resident) stated, It's embarrassing. She reassured him it would not take too long and that his treatment needed to be done. V20 rolled R32 onto his right side and unfastened his adult diaper to expose his buttocks. R32 did not have a treatment on his stage 2 pressure ulcer in his gluteal cleft as ordered and he was incontinent of feces which was smeared over his exposed pressure ulcer. V18 stated the old dressing must have come off when they did R32's incontinent care around lunch time. V20 stated he had not provided care for R32 before this today and that he thinks one of the other CNAs would have changed him around lunch time. After V20 cleansed most of fecal material off R32's buttocks, V18 cleansed his pressure ulcer with wound cleanser, then applied a piece of calcium alginate above the pressure ulcer and secured it with a bordered dressing. She removed gloves and donned new gloves without performing hand hygiene. The pressure ulcer was still completely uncovered after V18 placed the treatment on R32's buttock. V18 then confirmed she was done with the dressing and removed her gloves. Writer informed her the pressure ulcer is not covered and V18 stated, yes it is,, and V20 confirmed that he could still see the pressure ulcer also as it was not covered with the dressing. V18 pulled the dressing off and attempted to put that same dressing over the pressure ulcer, but the edges became stuck together and she discarded it and got a new piece of calcium alginate and a new bordered foam dressing and applied them to the pressure ulcer. The calcium alginate was not completely covering the wound bed, but the bordered gauze did cover the ulcer. On 8/1/24 at 1:35 PM V21, CNA stated she had changed R32 before breakfast and around lunch time. She stated R32 did not have a treatment in place to his pressure ulcer on his coccyx either time that she provided incontinent care to him today. V21 stated she did not report to his nurse that he did not have a treatment in place. R32's Face Sheet documents his diagnoses include Adult Failure to Thrive, Malignant Neoplasm of Prostate, and Unspecified Dementia. R32's Minimum Data Set (MDS) dated [DATE] documents R32 is severely cognitively impaired, is occasionally incontinent of bladder and always incontinent of bowel and had on unhealed Stage 2 pressure ulcer at the time of this assessment. R32's Physician Order Summary Report dated 8/1/24 documents the order: 7/17/24: Clean wound with NS (normal saline) or WC (wound cleanser) cover with calcium alginate and border gauze once a day or prn (as needed) one time a day. R32's Care Plan focus dated 7/17/24 documents: (R32) has pressure area to his sacral/coccyx area r/t (related to) weakness, end of life care. The goal for this care plan documents, (R32) will have no complications r/t pressure area of the sacral/coccyx area until the next review dated. Interventions for this care plan include: Administer medications as ordered. Monitor/document for side effects and effectiveness. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Document location of wound, amount of drainage, peri-wound area, pain, edema, and circumference measurements (weekly). Encourage good nutrition and hydration in order to promote healthier skin. Evaluated wound for : size, depth, margins: peri wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. Float heels while in bed as tolerated. Monitor dressing when providing care to ensure it is intact and adhering. Report loose dressing to the nurse. Monitor pressure areas for changes in color, sensation, temperature and report any change to the nurse. Monitor/document/report to MD (Medical Doctor) prn for s/s (signs and symptoms) of infection: green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever. Pressure redistributing mattress on bed. R32's Skin and Wound Evaluation dated 7/17/24 documents he has an unstageable pressure ulcer with slough and/or eschar that was acquired in-house and first observed on 7/17/24 that measured length-1.7 centimeters (cm) by width-1.0 cm by depth-not applicable. It described wound bed as eschar 50 %. This assessment described the surrounding skin as fragile. Per this assessment, this is a new area and R32's Power of Attorney, MD and hospice were notified of new pressure ulcer. R32's Skin and Wound Evaluation dated 7/24/24 documents the pressure ulcer measurements as 1.4 cm by 0.8 cm with 50% granulation tissue and 50% slough. On 8/2/24 at 9:50 AM V4, Regional Director of Clinical Operations stated staff should ensure a treatment is done as ordered and make sure that treatment is in correct place when doing pressure ulcer treatment. She stated if a CNA is providing care for a resident and discovers a treatment fell off or becomes dislodged during care, that CNA should inform the nurse that the treatment is off so it can be replaced. The facility's policy, Treatments/Wound Care, revised October 2010 documents, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 2. Wash and dry hands thoroughly. 3. Position resident. Place disposable cloth next to resident, (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing if applicable. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly or use hand sanitizer. 6. Put on gloves. Gown will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. 10. Wear gloves when touching the wound or holding a moist surface over the wound. 11. Wash tissue around wound that is usually covered by the dressing, tape, or gauze with antiseptic or soap and water. Remove gloves, perform hand hygiene, and replace gloves. 12. Apply treatments as indicated.

Based on observation, interview and record review the facility failed to provide complete incontinent care for 1 of 2 residents (R32) reviewed for incontinent care in the sample of 29. Findings include: On 8/1/24 at 1:05 PM V18, Licensed Practical Nurse (LPN) provided pressure ulcer treatment of R32, assisted by V20, Certified Nursing Assistant (CNA) for turning and positioning. They both washed their hands and donned gloves. V20 rolled R32 onto his right side and unfastened his adult diaper to expose his buttocks. V20 used disposable wipes and wiped feces from area of his pressure ulcer and around the pressure ulcer, and wiped most, but not all of the feces from his rectal area and buttocks. V20 then placed the soiled diaper with soiled wipes inside of it and some feces exposed on the outside of the diaper on the bed. After V18 finished pressure ulcer care, V20 applied a new adult diaper on R32 without washing the feces off his buttocks or cleansing his scrotum, penis or groin. R32's Face Sheet documents his diagnoses include Adult Failure to Thrive, Malignant Neoplasm of Prostate, Urinary Tract Infection (1/12/24) and Unspecified Dementia. R32's Minimum Data Set (MDS) dated [DATE] documents R32 is severely cognitively impaired, is occasionally incontinent of bladder and always incontinent of bowel and had on unhealed Stage 2 pressure ulcer at the time of this assessment. R32's Care Plan did not include a focused care plan regarding his incontinence or assistance he requires for Activities of Daily Living (ADLs). On 8/2/24 at 9:50 AM V4, Regional Director of Clinical Operations stated if staff are providing incontinent care to a resident who had been incontinent of bowel and bladder, that staff should ensure all areas touched by incontinence are thoroughly cleaned before putting on a new adult diaper. The facility's policy, Perineal Care, revised February 2018, documents, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. For a male resident, b. Wash perineal area starting with urethra and working outward. K. Ask resident to turn on his side with his upper leg slightly bent, if able. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus and the buttocks.

Based on interview and record review, the Facility failed to ensure residents were free from abuse for 2 of 4 residents (R23, R36) reviewed for abuse in the sample of 29. Findings include: 1-R23's Face Sheet documents R23 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, major depressive disorder, and cognitive communication deficit. R23's Minimum Data Set (MDS) dated [DATE] documented R23 was severely cognitively impaired and ambulated via walker. R23's Care Plan printed 7/30/24 documents R23 has aggressive behaviors toward others. 2-R36's Face Sheet documents R36 was admitted to the facility on [DATE] with diagnoses including depression, hypertension, and cerebral infarction. R36's MDS dated [DATE] documented R36 was cognitively intact and independent with ambulation. R36's Care Plan printed 7/30/24 documents R36 has both verbally and physically aggressive behaviors. The Facility's Initial Report sent to the Illinois Department of Public Health (IDPH) on 5/7/24 documents, Administrator notified of incident between resident (R36) and (R23), with unwanted contact made between the two residents. Resident's {sic} immediately separated and assessed for injuries. PCP (Primary Care Physician) and POAs (Power of Attorneys) notified of incident. Investigation has begun with final investigation to follow. R23's Incident Investigation by V2, Director of Nursing (DON), dated 5/7/24 documents, Resident entered into TV area and appeared to be speaking as she was entering. She sat down in the rocking chair and began rocking. (R23) on occasion was seen looking to other residents and sitting on the couch area and appeared to be speaking. Another resident stood up from the couch and walked over to (R23) and placed his hand on the back of the chair which stopped the rocking motion of the chair. He bent down to a face to face level and pointed his figer {sic} at her and appeared to verbalize something to her. The two continued to make verbalizing gesture to each other as (R23) stood up holding onto her walker. She began to back up as the other resident was in front of her. She raised her hand toward his face and he swiped his hand up to her hand and appeared to touch her arm in the process. (R23) back into a wheelchair behind her. Both residents continued to make verbal gestures as (R23) left the area. The nurse immediately intervened and assessed the situation. Both residents were separted {sic} for the rest of the evening. (R23) has a ST (Skin Tear) to Right forearm. On 8/1/24 at 2:45 PM, V2, DON, stated she watched the video of the altercation between R23 and R36. She stated R23 has behaviors and was antagonizing R36. R23 sat next to R36 on the couch, got in his face, and was pointing at him. R23 got up and moved, then paced around for a while and sat down in the rocker. R23 continued to say things and was looking directing at R36 and pointing at him. The video tape does not have sound, so she could not tell what R23 was saying, but R23 generally curses at whoever she comes across. After R23 sat down, R36 stood up and walked over to R23 and pointed at her. Then R23 stood up with the walker and tried to knock R36's hand away. V2 stated R36 has longer nails, so his hand might have caught her arm, but R23 also lost her balance and bumped into a wheelchair of a resident coming down the hall. V2 stated she was unable to tell from the video whether the skin tear came from R36's nails or the other resident's wheelchair. R23's Post-Incident Actions dated 5/7/24 documents, Narrative of incident: Resident engaged in a verbal confrontation {sic} with (R36). At that point (R23) started pointing her finger/hand in (R36)'s face. (R36) raised his hand/arm to protect himself causing (R23) to loose {sic} her balance and fall against someones wheel chair resulting in a skin tear to her right forearm. Immediate Post-Incident Action: Resident immediately separated {sic} and assessed for injuries. Kept one on one until behaviors ceased. Residents then monitored and kept distanced. R23's Incident Follow Up dated 5/7/24 documents, 24 Hour condition and injury appearance: St (Skin Tear) to rt (right) upper forearm. 8 steri strips with xeroform and dry dressing in place. All edges of ST approximated and without drainage. R23's 5/8/24 Progress Note by V14, LPN, documents (unknown) Certified Nursing Assistant (CNA) brought R23 to her with a large skin tear to right forearm, stating resident just had an altercation with another resident. The skin tear measured 7.5 cm (centimeters) and was treated with rolled gauze and tape to secure. V14 went to the tv area where the incident occurred. Resident R21 stated she was there and R23 was yelling at everyone and calling names, then R36 tried to diffuse the situation. R23 became more angry and put fingers in R36's face, then R36 grabbed her arm to protect himself. V14 then went to interview R36 who told her he did not grab R23's arm, but threw up his own arm to move her hand away, causing her to lose her balance and falling against someone's wheelchair. On 8/1/24 at 1:10 PM, attempted to contact V14, Licensed Practical Nurse (LPN), by phone and left voicemail requesting call back. As of 8/2/24 at 10:00 AM, no return call from V14, LPN, was received. On 8/1/24 at 9:37 AM R21 stated she could not recall the 5/7/24 incident between R23 and R36. On 7/31/24 at 9:10 AM, R23 was unable to provide any information regarding the 5/7/24 incident with R36. R36's Incident Investigation dated 5/7/24 documents, Resident was in tv area sitting on couch when another resident entered the area. The other resident was reported to have been having verbal aggressive behavior throughout the evening. (R36) walked over to the rocking chair where the other resident was sitting and placed his hand on the back of the chair which stopped the chair from rocking. He then bent over, looking the other resident in the face, and pointed his finger at her face. A motion of verbalization appeared to take place between the two residents. The other resident stood up from her chair and as the two continued to have gestures of verbalization, She began to back away and she reached up to his face. (R36) pushed her hand away and his hand appeared to touch her arm. This caused her to back into a wheelchair behind her. The residents continued to have verbalization between each other as she was leaving the area. (V2) had conversation with (R36) related to interactions between himself and other agitated residents. He agreed not to be aggressive toward {sic} other residents. On 8/1/24 at 2:20 PM, V6, Regional Minimum Data Set (MDS), stated she spoke with R36 who stated R23 was trying to move out of his way, but he did not hit her. On 8/1/24 at 9:47 AM, R36 stated R23 was sh*t talking on 5/7/24, but was unable to recall detailed information from the incident. On 8/1/24 at 9:39 AM V1, Administrator, stated that the injury to R23's arm did occur as a result to the altercation with R36. The Facility's Final Report sent to IDPH on 5/13/24 documents, (R36) was in TV area sitting on couch when another resident entered the area. (R23) was reported to have been loud verbally throughout the evening time and had entered the TV area where (R36) was located. (R36) walked over to where (R23) was sitting, pointing at her while she was sitting down. (R23) stood up as the two began to exchange words. She began to back away but reached her hand up to his face in a gesture. As (R36) tried to push away her hand, his hand did touch her arm, causing her to bump into wheelchair that was behind her. Residents were immediately separated and nurse notified of incident. Nurse assessed both residents. Evaluation of (R23) showed a scratch to her arm which needed in-house treatment of steri strips. No injury to (R36) noted. On 8/2/24 at 9:55 AM, V4, Regional Director of Clinical Operations, stated she expects the Facility to keep residents free from abuse. The Facility's Abuse Prevention Policy dated 8/16/19 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment.

Based on interview, observation and record review, the facility failed to provide complete incontinence care to prevent urinary tract infections for 2 of 5 residents (R2, R4) reviewed for incontinence care in the sample of 10. Findings include: 1. On 2/14/24 at 9:39 AM, V7, Certified Nurse Aide (CNA) and V8, CNA, took R2 to the restroom, gait belt applied, and with a 2 person assist R2 was placed on toilet. R2's incontinent brief was wet with urine. V8, with a piece of toilet paper, swiped R2's rectal area once, a new incontinent brief and pants were pulled up. R2 was then placed in her wheelchair. R2 was then returned to the living room. V8 failed to cleanse R2's peri-area or R2's buttocks. R2's Face Sheet, print date of 2/14/24, documents that R2 was admitted on [DATE] and has diagnosis of Alzheimer's Disease and Dementia. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 is severely cognitively impaired, dependent on staff for toileting hygiene, requires substantial assistance from staff for mobility, and is always incontinent of bowel and bladder. 2. On 2/14/24 at 9:28 AM, V7, CNA and V8, CNA took R4 to restroom, gait belt applied, and with a 2 person assist R4 was placed on toilet. R4's incontinent brief was wet with urine. V7, with a piece of toilet paper, swiped R4's rectal area twice. V7 did not cleanse R4's peri-area or the buttocks. R4's new incontinent brief and pants were pulled up. R4 was then placed in wheelchair and assisted to bed. R4's Face Sheet, dated 2/14/24, documents that R4 was admitted on [DATE] and has diagnoses of Epilepsy and intellectual disabilities. R4's MDS, dated [DATE], documents that R4 is severely cognitively impaired, dependent on staff for toileting needs, and is frequently incontinent of bowel and bladder. On 2/14/24 at 3:30 PM, V1, Administrator stated that if an incontinent brief is soiled full incontinent care should be provided. The facility's Urinary Incontinence policy, dated 4/2018, did not document the process of incontinent care.

Based on interview and record review, the Facility failed to answer call lights in a timely manner for 3 of 3 (R1, R5, R6) residents reviewed for call lights in the sample of 6. Findings include: 1. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including hypertension, muscle weakness, depression, urinary retention, dysphagia, displaced intertrochanteric fracture of left femur, and unspecified abnormalities of gait and mobility. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was moderately cognitively impaired and ambulated via wheelchair and walker. R1's Care Plan dated 4/14/23 documents R1 has a self-care deficit and assistance will be provided to meet needs, including assistance with dressing/undressing, assistance with meals as needed, and assistance with oral/dental hygiene. On 2/1/24 at 1:00 PM, R1 was sitting in her wheelchair in her room. She stated call light response times vary, but sometimes they take a really long time. 2. R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, obstructive sleep apnea, hypertension, and depression. R5's MDS dated [DATE] documented R5 was cognitively intact, ambulated via wheelchair and walker, and required partial/moderate assistance with oral hygiene, toileting, bathing and dressing. R5's Care Plan dated 1/16/24 documents R5 requires assistance with mobility. On 2/2/24 at 6:18 AM, R5 stated sometimes call lights take a long time and usually take around 30 minutes to get a response. 3. R6's Face Sheet documents R6 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, anxiety, muscle weakness, hypothyroidism, hyperlipidemia, need for assistance with personal care, and other abnormalities of gait and mobility. R6's MDS dated [DATE] documented R6 was cognitively intact, ambulated via wheelchair, and required substantial assistance with rolling left to right and transfer. R6's Care Plan does not address need for assistance with personal care. On 2/2/24 at 7:10 AM, R6 stated sometimes call lights take up to an hour to be answered. The Facility's Resident Council Meeting Minutes dated 11/22/23 document, Issues/Concerns: Too long to answer call lights. The Facility's Resident Council Meeting Minutes dated 12/28/23 document, Issues/Concerns: Call light response time. On 2/2/24 at 5:50 AM, V16 and V17, Certified Nursing Assistants (CNA's) stated they try to answer call lights as quickly as possible. On 2/2/24 at 7:23 AM, V5, CNA, stated she answers call lights as quickly as she can. On 2/2/24 at 8:10 AM, V1, Administrator, stated he has done several in-services on call light response, and his goal is for call lights to be answered within 3-5 minutes. The Facility's Resident Rights Policy revised 12/2016 documents, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: A dignified existence; be treated with respect, kindness, and dignity; communication with and access to people and services, both inside and outside the facility.

Based on interview and record review the facility failed to keep a resident free from abuse for 1 of 5 residents (R1) reviewed for abuse in the sample of 5. Findings include: Facility Abuse Investigation: 1/4/24 - Initial report: R2 was in R1's room having a verbal altercation. After a very short time went by R2 pushed R1 into the hallway and R1 fell down. Residents were separated and the investigation started. Final investigation: It was reported on 1/4/24 that resident R2 with identified behaviors for physical/verbal aggression toward staff and resistant to care has allegedly made physical contact with resident R1. R1 had noted skin tear to left elbow with minor bruising noted to shoulder. R1's Face Sheet to include diagnosis of muscle weakness and depression. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately impaired and has physical/verbal behaviors directed towards others. R1's Care Plan dated 12/14/23 documents R1 Displays episodes of physical aggression towards others by evidence of attempting to hit nursing staff (swinging at them and also verbally threatening to hit them). Resident displays episodes of verbal aggression towards others by evidence of yelling at, name calling, and threatening nursing staff. Interventions in place and are personalized to this resident. R1's Behavior Tracking documents: Physical aggression: resident will threaten to hit staff, swing to hit staff. R1's Nursing Note dated 01/04/2024 at 12:49 PM documents, Writer summoned to B Hall at 5:57AM, staff observed resident lying on left side on floor. Mid hallway by room [ROOM NUMBER]. Resident vocal, stated he threw me. Writer observed other resident standing in hallway. Small amount blood noted to resident's 3rd finger left hand, refused assessment did not want to do ROM (Range of Motion), Resident stated just leave me lay here and call my son. Resident remained alert and conscience while lying on floor. Staff kept resident immobile until EMS arrived. No distress, no guarded behavior no grimacing noted. Writer called ambulance 911. Call placed to son, message left for administrator to call facility. 6p to 6a nurse called DON (Director of Nursing). R1's Nursing Note dated 01/04/2024 at 3:16 PM documents, MD notified of resident being on floor this am and sent to ER given report that there no findings at hospital, notified of skin tear to left elbow 1.2 cm (centimeters) x 0.7cm x 0.1cm, shearing to mid back and bruising with small amount bleeding to 2nd finger left hand. Resident did return. On 1/5/24 at 8:25am R1 When asked about the incident with R2, resident stated I'm not talking to you without my lawyer present. All R1 would say is that he was on the ground because of R2. R2's Face Sheet to include diagnosis of Alzheimer's Disease, Unspecified Dementia Without Behavioral Disturbance. R2's MDS dated [DATE], not completed, documents R2 has severe impairment. R2's Care Plan dated 1/3/24 documents, Resident frequently wanders throughout the facility and is at risk for elopement as he makes statements of wanting to get out of this place and lingering near exits, also at times into other resident rooms. 1/2/24 - Resident has a diagnosis of Dementia/Alzheimer's and may experience disorientation, loss of self-awareness, difficulty making decisions, and may be startled/display agitation by loud noises. 1/2/24 - Per interviews with spouse/POA (Power of Attorney), resident may display episodes of increased agitation surrounding assistance with care tasks/ADLs. Interventions in place with no concerns. R2' Behavior Tracking: Resident may become agitated or restless wondering where he is/what to do. Interventions in place with no concerns. R2's Nurses Notes dated 1/4/24 at 4:13 PM document, Observed standing in hall after altercation with another resident. Staff attempted multiple times to redirect resident away from the other resident. Resident placed on 1:1 supervision with a staff member until EMS arrived. EMS placed resident on stretcher and he was transferred to the hospital for abnormal aggressive behaviors. Wife called and notified of transfer. On 1/5/24 at 8:30 am V5, Registered Nurse, stated she did not witness the incident between R1 and R2, it happened before she got to the facility. Stated she heard that R2 pushed R1 down. Stated R2 has only been at the facility for a couple of days and was at home prior to coming to the facility. Stated the wife told her he could be aggressive with her at times and wanders. Stated other than wandering, he hadn't displayed any behaviors when she was working. Stated R2 was very forgetful and that upset him and if he did have agitation, it was probably due to being in a new environment. On 1/5/24 at 8:55 am V1, Administrator, stated R2 was ok until last night (1/4/24), he became aggressive and pushed R1 down. Neither R1 or R2 sustained any injuries. Stated R1 was sent out to the hospital for evaluation and returned to the facility. V1 stated R2 was placed on 1:1 supervision until EMS came. Stated R2 was sent to the hospital and they were planning on taking R2 back but his family decided to send him to an Alzheimer's unit at another facility. Stated R2 was a new resident and was only in the building for about 72 hours.

Based on observation, interview and record review, the facility failed to provide Personal Privacy/Confidentiality for 1 of 3 residents (R2) reviewed for dignity and respect in the sample of 13. Findings include: R2's Face Sheet, not dated, documents, that R2 was readmitted to the facility on [DATE] with diagnosis of Pressure ulcer of sacral region, unspecified stage listed as diagnosis. R2's Care Plan, dated 10/10/2023, documents, Pressure Ulcer: Unstageable (Slough and/or eschar) to Sacrum. R2's Minimum Data Set, dated dated [DATE], documents that R2 is severely impaired cognitively and never/rarely made decisions. On 10/30/2023 at approximately 10:10 AM V16, LPN, stated, that she is the Nurse on the hall and also helps with the wounds. V16 stated, that she does take pictures of wounds for treatment purposes. V16 stated, that she sends those pictures to V2, Director of Nurses, and V17, Wound Nurse (from outside company). On 10/30/2023 at approximately 11:00 AM. V2, Director of Nurses, stated that the facility does not take pictures of wounds in the facility. V2 stated, that this is not a requirement of the Wound Nurse. V2 stated, that they do not have a policy on taking photos of wounds, because this is not something that is done at this facility. V2 stated, that he is not aware of staff taking pictures of residents and or resident wounds on their personal phone. On 10/30/2023 at approximately 11:30 AM V18, R2's daughter, stated that she was not aware of facility staff taking pictures of R2's wound. V18 stated that she did not give permission for staff to take pictures of residents wound on her coccyx. On 10/30/2023 at 4:07 PM V15, R2's Daughter-in-law, stated that she came in to visit R2 in the afternoon. R2 stated that R2 was soiled with bowel. V15 stated that she pulled the call light and waited for staff. V15 stated that she waited a little while and then went to the Nurse. V15 stated that she voiced her concerns to the Nurse. V15 stated that she informed V16, Licensed Practical Nurse, that R2 was sitting in stool. V15 stated that she asked V16 how was R2's wound supposed to heal if R2 is sitting in stool for over 2 hours. V15 stated that V16 informed V15 that R2's wound was improving. V15 stated that V16 then pulled out her phone and showed V15 a picture of R2's coccyx wound when R2 was first admitted and the wound at a later date. V15 stated, that V16 scrolled through her personal photos of her family and children and then showed the photos of the wound on the coccyx. V15 stated that anyone looking at her pictures would see R2's wound on her buttocks. V15 stated that R2 can't say anything at this point, but that R2 would not like that. V15 stated that R2 would not have given the ok to take pictures and keep them in their personal phone. V15 stated that if she gave the phone to someone to look at her photos R2's coccyx wound would be seen. V15 stated that R2 would be embarrassed. V15 stated that she asked V16 why she had pictures of R2's coccyx wound. V15 stated that V16 informed her that she sends the pictures to her Director of Nurses. V15 stated now V2 has pictures of R2's coccyx wound and rear end in his personal phone. V15 stated that I don't know if this is how things are done, but I do know that R2 would not be ok with this. On 10/31/2023 at 11:01 AM V17, APRN FNP-BC, stated, that she is the (Wound Management Company), Wound Nurse. V17 stated that the normal process of new admits with wounds is the staff will describe the wound to her and then review the current orders if any and then either continue the current order or change it. V17 stated that this will treat the wound until she sees the wound on Tuesday. V17 stated that she did receive a picture of R2's wound from V16. V17 stated that R2 was admitted from the hospital. V17 stated per R2 the wound was worse than what was reported from the hospital. V17 stated that V16 sent V17 the picture of the wound. V17 stated that the picture did not identify the area of the body. V17 stated that she had to respond to V16 and ask where the wound was and who was the resident. V17 stated that V16 did respond. V17 stated that she gave direction and orders for R2. V17 stated that this is not the normal way of communicating. V17 stated that V16 was having a difficult time describing the wound and sent the picture. V17 stated that she felt it was ok, because the location was unidentifiable. V17 stated that she would expect that the picture be deleted immediately. On 10/31/2023 at approximately 2:50 PM V16 stated, that she did take a picture of R2's wound on her coccyx with her personal phone. V16 stated that she was notified of R2 had a stage 4 wound on her coccyx the day before admission. V16 stated that she was aware of the wound. V16 stated that she had not had any visual of the wound. V16 stated that in report from the Hospital on the day of admission she was again notified of the stage IV pressure ulcer to R2's coccyx. V16 stated that when R2 was admitted the wound was different that she expected and did not know what to do. V16 stated that she notified the (V2) Director of Nurses and they both looked at the wound. V16 stated that at that time she took a picture of the wound and sent it to V17 for guidance. V16 stated that V2 was with her when she took the picture. V16 stated that she deleted the picture immediately. When asked if she showed a picture of the wound to the family? V16 denied. V16 stated that she did not discuss with the family a picture of the wound. When asked how would the family know that pictures were taken by V16 and visually seen them? V16 stated that she does not know. On 10/31/2023 at approximately 3:00 PM V2 stated that V16 did take the picture of R2's coccyx wound. V2 stated that he went down to the room. V2 stated that the facility does not have wounds of this caliber. V2 stated that upon admission (V2 ) and V16 looked at the wound. V2 stated that they were unsure if the treatment was the correct one and did not know how to proceed with this wound treatment. V2 stated at that time V16 took a picture of the wound, with V16's personal cell, and sent it to V17 cell. V2 stated that it was easier to show her then try to describe what was being seen. V2 stated that he thought the photo was deleted and would have expected it to be deleted. V2 stated that this is the not normal practice but felt this was an extenuating circumstance. When asked what was the extenuating circumstance? V2 stated that the wound was different than what was received in report. V2 stated that the expectation would be that the Nurse would delete the photo and not keep it in her personal phone. The Illinois Long Term Care Ombudsman Program Residents Rights for people in Long-Term Care Facilities, dated 11/18, documents as Long-term care resident in Illinois, you retain the same rights as every citizen of Illinois and the United States. It also documents, your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. It continues, Your medical and personal care are private. Facility must respect your privacy when you are being examined and given care.

Based on interview, record review, and observation the facility failed to provide nonpharmacological interventions for one of three resident (R33) reviewed Psychotropic medications in the sample of 18. Findings Include: R33's Minimum Data Set, (MDS), dated [DATE] documents, R33's cognitive skills for daily decision making is severely impaired, and she rarely makes decisions. R33's MDS also, documents R33 has diagnoses of Schizophrenia, Alzheimer's, and Dementia. R33's Behavior Tracking for the month of May documents, R33 has history of mental illness requiring the use of Antipsychotic medications - monitor for any episodes, such as yelling and crying Goal: maintain absence of behavior/mood swings. Behavior tracking was not done every day. Interventions: 1. report any episodes to nurse 2. encourage activities 3. Provide consistent and clear feedback in non-threatening behavior. (No specific interventions for psychotic behavior were listed on the behavior tracking, and no specific mental illness behaviors were listed.) On 06/07/23 02:24 PM V18 Certified Nursing Assistant, (CNA), She sees things that are not there reaching on the table for things. On 06/07/23 at 2:26 PM V19 CNA yes, she is always reaching for things that are not there She is always talking to people. On 06/07/23 at 2:35 PM V20 Licensed Practical Nurse, (LPN), No Psychosis I haven't noticed her talking to self. She is usually sleeping. On 06/07/23 at 2:40 PM V11 CNA, she talks to self and grabs things out of the air that are not there. She talks to herself. (None of them had any interventions for the above behaviors). On 06/08/24 at 12:50 AM V10 LPN stated, it depends on the day talking to her baby doll in her room. Sometimes she is talking to herself. 90% of the time she can be redirected or reproached. She has a diagnosis of Dementia. She does have verbal aggression not toward anybody. On 6/8/23 at 12:52 PM V22 CNA stated, no behaviors with me. she has fits with other aides. We try to do an activity or watch TV (television). Sometimes it works. V3 MDS stated, I saw it (the schizophrenia diagnosis) in the computer. I don't know how it got there. When she came, she had behavior. V7 CNA Coordinator stated, we just leave her (R33) alone. Let her calm down. She has a baby doll 06/07/23 11:15 AM R33 is very confused her husband was pushing her around the facility she has a flat affect. 06/07/23 11:50 AM R33 is sitting in the dining room. Mumbling to herself. The facility policy dated 10/1/20 entitled Behavioral Assessment, Intervention, and Monitoring. the facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and Psychosocial well-being in accordance with comprehensive assessment and plan of care.

Based on interview, record review, and observation the facility failed to properly assess before giving a diagnosis of Schizophrenia for the administration of Antipsychotic medications for one of one resident (R33) reviewed for diagnosis without assessment in the sample of 18. Findings Include: R33's Local Hospital Record Adult Hospitalist Service History and Physical dated 4/13/23 documents in part R33 as having diagnoses of Alzheimer's Disease, Dementia in senility without behavioral disturbances, Memory Loss, Depression. R33's Adult Hospitalist Service History does not document a diagnosis Schizophrenia, but her home medications documents Risperidone 1mg (milligrams) take 1.5 tablets nightly at bedtime. The patient (R33) was taking differently take 1mg by mouth nightly at bedtime. R33's Electronic Health Record/ Diagnoses document on 5/25/22 the diagnosis of Schizophrenia was added to her diagnosis list. R33's Electronic Health Record/Physician Order Sheet (POS) dated 11/3/22 documents R33 has an order for Risperidone 0.5mg daily at 12:00 noon. R33's Electronic Health Record POS dated 5/26/23 documents Risperidone 1mg daily at 6:00 PM was added to the resident regimen with the diagnosis of Schizophrenia Unspecified. R33's Electronic Health Record/Antipsychotic drug use: At risk for side effects Care Plan does not document an assessment, goals, or interventions concerning her diagnosis of Schizophrenia. The undated facility policy entitled Physician Services documents the physician will perform pertinent, timely medical assessments prescribe an appropriate medical regimen; provide adequate timely information about the resident's condition and medical needs, visit the resident at appropriate intervals and ensure adequate alternative coverage. The medical director will identify attending physician qualifications and responsibilities based on clinical and regulatory requirements and the recommendations of relevant professional associations.

Based on observation, interview and record review, the facility failed to provide assistance with bathing, grooming, and hygiene to dependent residents for 6 of 7 residents (R2, R3, R4, R5, R6, R8) observed for activities of daily living (ADLs) in the sample of 7. Findings include: 1. R2's Electronic Medical Record, documents R2's diagnoses as Gastrointestinal (GI) Hemorrhage, Urinary Tract Infection (UTI), Dysphagia, Anemia, Cognitive communication deficit, COVID-19, Malignant neoplasm of upper lobe lung, Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), left femur fracture. R2's Care Plan, dated 8/10/22, documents (R2) has a self-care deficit. Interventions: Assist with ambulation, transfers, and locomotion as needed, assist with dressing/undressing, assist with oral/dental hygiene, encourage resident to perform self-care if able. It continues (R2) has Excoriation. Interventions: Provide prompt attention to incontinent episodes, assess wound healing weekly, full skin evaluation with bath/shower, assess skin daily with routine care, perform skin care with attention to keeping skin folds clean and dry. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 is cognitively intact and requires total dependence on one staff member for bathing, total dependence of two staff members for toileting, limited assistance from one staff member for personal hygiene, extensive assistance from one staff member for dressing. R2's MDS documents R2 is frequently incontinent of urine and always continent of bowel. On 4/18/23 at 2:05 PM, R2 was sitting in wheelchair and hair messy. On 4/18/23 at 2:10 PM, R2 stated I only get one shower a week. They have too many residents and not enough helpers. I would prefer to have two a week because it's relaxing. No one helps me with oral care on me. I only have four teeth left and no one ever offers to brush those teeth or even rinse my mouth out. I will sometimes use a washcloth to wipe out my mouth. On 4/19/23 at 8:40 AM, R2 stated I did not get cleaned up since Tuesday (4/18/23). I sometimes just ask for a washcloth to at least wash my face because I have to wait a week to get a shower. R2's Electronic Medical Record, Resident Care Tasks, documents that R2 is scheduled for a bath on Tuesdays and Fridays. The Facility's Shower Schedule, documents that R4's showers are on Tuesdays & Fridays. The Facility's shower sheets with staff signatures along with the staff schedules were reviewed. R2's Shower sheets appeared to have the same handwriting. V4, Certified Nurse's Assistant (CNA), was documented as providing R2 showers on the following days 3/21, 3/24 and 3/31/23. R2's Shower Sheets for 3/28, 4/14 and 4/17/23 documented that V7, Registered Nurse, gave R2 showers. The staff schedule for these dates documented that V7 did not work these days. R2's Shower Sheets for 4/4 documented V8, Licensed Practical Nurse/LPN, gave R2 the shower. The staff schedule for that date documented V8 did not work this day. R2's Shower Sheet for 4/7/23 documented V9, RN, gave R2 the shower; however, the staff schedule for that date documented V9 did not work that day. 2. R3's Electronic Medical Record, documents that R3's has diagnoses of Encephalopathy, Anemia, Dysphagia, Anxiety Disorder, Atrial-Fibrillation (A-Fib), Cervicalgia, Chronic Pain, Diabetes Mellitus (DM), Gastroesophageal Reflux Disease (GERD), Falls, Osteoarthritis, COPD, Major Depressive Disorder, Congestive Heart Failure (CHF), Methicillin-resistant Staphylococcus aureus (MRSA), Cardiomyopathy, Chronic Kidney Disease (CKD)-stage 3, Pulmonary Embolism (PE), Radiculopathy lumbar, Spinal stenosis lumbar, Morbid obesity, Prurigo Nodularis, Pleurodynia, Left Knee replacement, HTN. R3's Care Plan, dated 4/9/23, documents (R3) is at risk for alteration in skin integrity. Interventions: Incontinence care, apply barrier cream, pressure reducing cushion to wheelchair and mattress. It continues (R3) has a new skin tear noted to coccyx. Interventions: Full skin evaluation with bath/shower. R3's MDS, dated [DATE], documents R3 is cognitively intact with Basic Interview for Mental Status (BIMS) of 15. R3's MDS documents requires total dependence of two staff members for bathing, toilet use, and transfers. R3's MDS documents R3 requires dependence on one staff member for personal hygiene and extensive assistance from two staff members for dressing, has a urinary catheter and is frequently incontinent of bowel. On 4/18/23 at 2:15 PM, R3 was lying on her side in bed, on top of covers, appears to have clean clothes on, hair messy. On 4/18/23 at 2:28 PM R3 stated I get one shower a week. I am supposed to get one on Fridays too, but I never get one then. I think they are just too busy. I would prefer to have a shower every other day but that won't happen here. My last shower was last Tuesday (4/11/23) and I am supposed to get one tonight. I have to use mouthwash in the mornings when they get me out of bed to try and keep my mouth clean. On 4/19/23 at 8:28 AM, R3 stated They put clean clothes on me this am, but I have not had a shower. R3's Electronic Medical Record, Resident Care Tasks, documents that R3 is scheduled for a bath on Tuesdays and Fridays. The Facility's Shower Schedule, documents that R3's showers are on Tuesdays & Fridays. The Facility's shower sheets with staff signatures along with the staff schedules were reviewed. On 3/28/23 and 4/14/23, the CNAs listed as performing R3's shower were not scheduled that day and were signed by V2, Director of Nursing/DON. 3. R4's Electronic Medical Record, documents R4's diagnoses of UTI, HTN, Gout, Osteoarthritis, Atherosclerotic Heart Disease (ASHD), Type 2 DM, Morbid Obesity, Irritable Bowel Syndrome (IBS), A-Fib. R4's Care Plan, dated 1/2/23, documents (R4) requires assistance for all ADLs. Interventions: Refer to Occupational Therapy to work on ADL re-training, give verbal cues to help prompt, give verbal cues to help prompt, give verbal cues to help prompt. It continues (R4) has a self-care deficit related to fracture of left lower leg. Interventions: Assist with ambulation, transfers, and locomotion as needed, assist with dressing/undressing, assist with oral/dental hygiene. R4's MDS, dated [DATE], documents R4 is cognitively intact and requires total dependence on two staff members for bathing, toileting, and transfers. R4 requires extensive assistance from one staff member for dressing, and limited assistance from one staff member for personal hygiene. R4 is occasionally incontinent of urine and always continent of bowel. On 4/18/23 at 2:28 PM, R4 was sitting in her wheelchair in her room, appears to have clean clothes on, hair messy. On 4/18/23 at 2:30 PM, R4 stated I was just elected president of the resident council meeting. We have a meeting once a month and there were several residents complaining of not getting their showers. I only get one shower a week, but I would prefer to have at least two of them. I had a CNA came in this morning and gave me a shower in my room. I have asked for two showers a week and was told that they barely have enough staff to give everyone one shower a week. On 4/19/23 at 8:55 AM, R4 stated I do get clean clothes to put on every day, but I am hoping for another shower yet this week. R4's Electronic Medical Record, Resident Care Tasks, documents that R4 is scheduled for a bath on Tuesdays and Fridays. The Facility's Shower Schedule, documents that R4's showers are on Tuesdays & Fridays. R4's Shower Sheets, dated 4/4/23 and 4/14/23, documented that V4 provided R4 with a shower. 4. R5's Electronic Medical Record, documents R5's diagnoses of Acute/Chronic Respiratory Failure, Anemia, Arthritis, A-Fib, HTN, Malignant neoplasm of breast, Morbid Obesity, Type 2 DM, Osteoarthritis. R5's Care Plan, dated 4/9/23, documents (R5) requires assistance for all ADLs. Interventions: Give verbal cues to help prompt, give verbal cues to help prompt, give verbal cues to help prompt. It continues (R5) has a self-care deficit. Interventions: Assist with ambulation, transfers, and locomotion as needed, assist with dressing/undressing, assist with oral/dental hygiene, encourage resident to perform self-care if able. R5's MDS, dated [DATE], documents R5 is cognitively intact with BIMS 15. R5 requires total dependence on one to two staff members for bathing, transfers, and personal hygiene. R5's MDS documents R5 requires extensive assistance from one to two staff members for dressing and toilet use. R5's MDS documents R5 is frequently incontinent of urine and always continent of bowel. On 4/18/23 at 3:35 PM, R5 was seen sitting in her wheelchair next to her bed, husband at bedside. Appears to have clean clothes on, hair brushed straight back and slightly greasy. On 4/18/23 at 3:38 PM, R5 stated I only get a shower once a week. I am supposed to get one tonight, but we will see if that happens. I think having two showers would be nice, especially at night. On 4/19/23 at 9:05 AM, R5 stated I did get a shower last evening (Tuesday). I'm hoping for another one on Friday, but I doubt it. R5's Electronic Medical Record, Resident Care Tasks, documents that R5 is scheduled for a bath on Tuesdays and Fridays. The Facility's Shower Schedule, documents that R5's showers are on Tuesdays & Fridays. The Facility's shower sheets with staff signatures along with the staff schedules were reviewed. The shower sheet, dated 3/24/23, showed the CNA listed as performing R5's shower was not on the schedule that day. The Shower sheets dated 4/4/and 4/14/23, documented V4 gave these showers. 5. R6's Electronic Medical Record, documents R6's Diagnosis include: Need for assistance with personal care, Cognitive communication deficit, Obesity, Hyperlipidemia, Peripheral Vascular Disease (PVD), Seizures, Middle cerebral artery syndrome, Subarachnoid hemorrhage, Alzheimer's Disease, Right arm fracture, Falls, Dementia. R6's Care Plan, dated 1/23/23, documents (R6) has a self-care deficit. Interventions: Assist with ambulation, transfers, and locomotion as needed, assist with dressing/undressing, assist with oral/dental hygiene, encourage resident to perform self-care if able. R6's MDS, dated [DATE], documents R6 has a severe cognitive impairment and requires total dependence of one staff member for bathing, and limited assistance from one staff member for all other ADLs. R6's MDS documents R6 is occasionally incontinent of urine and always continent of bowel. On 4/18/23 at 3:32 PM, R6 was seen lying in bed, hair appears greasy and pulled straight back and put into a bun/ponytail on back of her head. Appears to have clean clothes on. On 4/18/23 at 3:35 PM, R6 stated I can do just about everything myself and I don't really need their help. I only shower once a week but would like one twice a week. They don't give me one twice a week, and they really don't tell me why not. On 4/19/23 at 9:00 AM, R6 lying in bed with her hair still slightly greasy and pulled up into a ponytail. On 4/19/23 at 9:02 AM, R6 stated I did get a shower this past Monday (4/17/23) but I never get one on Thursdays, but I am hoping I get one this Thursday. R6's Electronic Medical Record, Resident Care Tasks, documents that R6 is scheduled for a bath on Mondays and Thursdays. The Facility's Shower Schedule, documents that R6's showers are on Mondays and Thursdays. The Facility's shower sheets with staff signatures along with the staff schedules were reviewed: R6 has shower sheets with staff names that performed the showers on the following dates. The Shower sheets, dated 3/22,3/27, 4/7/23 and 4/12/23, documented staff that were not working that day per schedule. The shower sheets, dated 3/20 and 3/29 and 4/3/23, documented that V4 gave R6 showers. 6. R8's Electronic Medical Record, documents that R8's has diagnoses of Sepsis, COVID-19, COPD, Benign prostatic hyperplasia, GERD, Major Depressive disorder, Anxiety disorder, Malignant neoplasm of rectosigmoid junction, Myalgic encephalomyelitis, Anemia, Urine retention, Hypothyroidism, Generalized Anxiety disorder, CKD, Need for assistance with personal care. R8's Care Plan, dated 4/19/23, documents (R8) has a self-care deficit. Interventions: Assist with ambulation, transfers, and locomotion, assist with dressing/undressing, assist with oral/dental hygiene, encourage resident to perform self-care if able. R8's MDS, dated [DATE], documents R8 is cognitively intact with BIMS 15. R8 requires total dependence of two staff members for bathing. R8 is independent for all other ADLs. On 4/18/23 at 2:45 PM, R8 was wheeling himself around his room in wheelchair, with his hair messy and appeared slightly greasy under his ballcap. On 4/18/23 at 2:48 PM, R8 stated I only go to the main shower in the facility once a week because they are too busy to do it more and I want more than one shower a week. Now I use my own shower in my room. Whenever I want a shower, I ask them to help me get into the shower in my room and then I can clean myself up. I do that about every other three days. R8's Electronic Medical Record, Resident Care Tasks, documents that R8 is scheduled for a bath on Wednesdays and Saturdays. The Facility's Shower Schedule, documents that R6's showers are on Wednesdays and Saturdays. The Facility's shower sheets with staff signatures along with the staff schedules were reviewed: R8 has shower sheets with staff names that performed the showers. The shower sheets, dated 3/22/23, 3/25/23, 3/29/23, 4/5/23 and 4/15/23, documented V4 gave R8 showers. On 4/19/23 at 8:25 AM, V1, Administrator, stated Our residents should be getting two showers a week. That is what is expected. I have not heard otherwise that they are not getting them twice a week. I know of one instance where an employee was on their cell phone while trying to transfer a resident, but nothing about a shower. On 4/19/23 at 8:30 AM, V2 provided the residents shower sheets. All writing on the sheets appears to be in the same handwriting and appears to be the same ink pen used. There are a couple of residents who have duplicate shower sheets for the same date but have different staff names on each one. When comparing a signature of one staff member, it appears different on a different page. On 4/19/23 at 9:30 AM, V1, Administrator, stated I have to agree that the handwriting and signatures look very similar on each page. Some of the signatures don't match each other. On 4/19/23 at 9:40 AM, V4, stated I work Monday through Friday from 6:00 AM, until 2:00 PM. I use the list of residents who require a shower that day and go down the list. I can only do so many showers in my time, so there are some that might not get done. I will give a resident a shower and when finished, I will complete the shower sheet, sign it and give it to the nurse on duty to sign. On 4/19/23 at 9:58 AM, V4 stated That is not my handwriting or my signatures on those shower pages. These pages are made up. I do not ever give (R5) her shower because she only lets one CNA give her one. This one shower sheet for (R6) shows a CNA on 3/27/23, and I doubt that CNA did that one because she rarely works here and usually does not do the showers. (V2) has never given me a log-in in the electronic medical record to document showers given. I have been here since January and have never documented in the computer. They are making all of these shower sheets up because again, that is not the way I print or sign my name. On 4/19/23 at 10:28 AM, V4 stated The Regional Nurse asked me if I document in the computer when showers are given, and when I said no because I have not received a log-in, (V2) stated that she sent it to me via messenger, we both looked at our phones and (V2) stated, my bad, I guess I didn't. On 4/19/23 at 2:12 PM, V5, CNA Supervisor, stated This is a good facility, and our staff work hard for our residents. We only have a couple of shower aides that try hard to keep up with the showers. If we are not keeping up and the residents are complaining, then we should just confess to that. I was a little upset when I found out that our shower sheets are getting filled out with our names on it without us knowing about it. On 4/19/23 at 2:38 PM, V6, Regional Nurse, stated We have a couple issues that need to be worked on here. Showers are one of them. The Facility's Activities of Daily Living (ADLs), Supporting, Policy, dated 3/2018, documents Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).

Based on interview, observation and record review, the facility failed to secure medications appropriately and count controlled substances to ensure accurate reconciliation and accountability of those medications. This failure has the potential to affect all 39 residents residing in the facility. Findings include: 1. On 8/17/22 at 11:45 AM, V6, Registered Nurse (RN), was observed during medication administration. V6 had the medication cart sitting in the hallway outside of the dining room. V6 left the medication cart to administer medications in a resident room, left the medication cart unlocked and out of V6's view. At 12:00 PM, V6, returned to where the medication cart was located. 2. On 8/17/22 at 1:05 PM, the medication storage refrigerator was checked. The refrigerator contained a plastic container with a yellow plastic tie on it. The label on the container documented [MEDICATION(S)] (controlled substance) 2 milligrams(mg)/milliliter(ml), 5 vials and [MEDICATION(S)] 2mg/ml, 30ml was inside the container. Neither the refrigerator nor the plastic container had a lock to ensure safe control of those medications. On 8/17/22 at 2 PM, V6, RN and V14, Licensed Practical Nurse (LPN) were observed completing a shift-to-shift count of the controlled substances. Neither V6 nor V14 checked or counted the [MEDICATION(S)] located in the medication storage refrigerator. On 8/17/22 at 2:05 PM, V14 states only the nurses have a key to the storage room where the refrigerator is located that has the [MEDICATION(S)] stored. V14 states when pharmacy sends the containers with the controlled substances in them, the containers have a red tag on them, when the nurses get into the container, they fill out a form, send it to pharmacy and replace the red tag with a yellow tag. V14 states the nurses do not count or check the tag on the container to ensure there is a correct count during the shift-to-shift controlled substance count. On 8/18/22 at 3:47 PM, V2, Director of Nurses, states she would expect the nurses to lock the medication arts when out of view. The Storage of Medications policy, dated 4/2017, documents 7. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended, if open or otherwise, potentially available to others. The Controlled Substance policy, dated 12/2012, documents 5. Controlled substances must be stored in the medication room in a locked container for any non-controlled medications. This container must remain locked at all times, except when it is accessed by the nurse. 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing. The Resident Census and Conditions of Residents for CMS-672, dated 8/16/22, documents the facility has 39 residents residing in the facility.

Based on observation, interview, and record review, the Facility failed to ensure food was prepared and served in a manner that prevents potential contamination. This has the potential to affect all 39 residents in the facility. Findings include: On 8/16/2022 at 11:20 AM, V10 pulled down her face mask with gloved hands to speak, then replaced mask and rubbed hands on her shirt. V10 did not change gloves or perform hand hygiene. On 8/16/2022 at 11:30 AM, V10 began serving resident meals. On 8/16/2022 at 11:33 AM, V10 adjusted her face mask. She did not change gloves and continued to serve food. V10 placed dinner rolls on resident plates with her hands while wearing these same gloves. On 8/17/2022 at 11:30 AM, V5, Dietary Manager, was serving food in kitchen with face mask worn below her nose. On 8/17/2022 at 11:42 AM, V12, Certified Nursing Assistant (CNA), adjusted her face mask with gloved hands in the dining room. She did not change gloves and carried a lunch tray to R34. V12 then removed silverware from R34's napkin and cut up R34's food. On 8/17/2022 at 11:43 AM, R34 began eating with the fork that V12 used to cut up her food. On 8/17/2022 at 3:05 PM, V1, Administrator, stated, I would expect food service staff to wear masks covering the nose while serving food. I expect all staff to follow our policies. The Facility's Personal Protective Equipment - Using Face Masks Policy revised in September 2010 documents, Objectives: To prevent transmission of infectious agents through the air. Be sure that the face mask covers the nose and mouth while performing treatment or services for the patient. Never touch the mask while it is in use. Avoid any unnecessary handling of the mask. The Facility's Preventing Foodborne Illness - Food Handling Policy revised in July 2014 documents, Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. The Facility's Resident Census and Condition of Residents Form (CMS 672), dated 8/16/22, documents that the facility has 39 residents living in the facility.

Based on interview, observation and record review, the facility failed to provide range of motion (ROM) for 3 of 4 residents (R9, R11 and R15) reviewed for ROM in the sample of 25. Findings include: 1. On 8/17/22 at 8:27 AM, R9 was observed with an inability to fully move both of her lower extremities independently to maintain/improve ROM in her joints. R9's face sheet, undated, documents R9 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R9's Minimum Data Set (MDS), dated [DATE], documents R9 has impairment in ROM in both lower extremities. 2. On 8/16/22 at 9:47 AM, R11 states she is unable to move her joints like she used too and would like to do exercises to improve on this. R11 was observed and was unable to fully move both of her upper and lower extremities independently to prevent a decrease in ROM. R11's face sheet, undated, documents R11 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's MDS, dated [DATE], documents R11 has impairment in ROM in both of her lower extremities. 3. On 8/16/22 at 9:08 AM, R15 was observed moving both upper and lower extremities, R15 was unable to fully move her joints independently to maintain/improve ROM. R15's face sheet, undated, documents R15 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R15's MDS, dated [DATE], documents R15 has impairment in ROM in one of the lower extremities. On 8/17/22, V2, Director of Nurses (DON), states R9, R11 and R15 do not have a ROM program in place. The Range of Motion Exercises policy, dated 10/2010, documents The purpose of this procedure is to exercise the joints and muscles.

Based on observation, interview and record review, the facility failed to provide timely toileting and complete and thorough incontinent care to prevent urinary tract infections ([CONDITION(S)]) for 1 of 4 residents (R12) reviewed for Urinary Tract Infections ([CONDITION(S)]) in the sample of 25. Findings include: On 8/17/22 at 1:00 PM V12, Certified Nursing Assistant (CNA) and V13, CNA transferred R12 from her wheelchair to her bedside commode. R12's pants were visibly wet at the tops of her legs. V13 donned gloves and pulled down R12's pants and adult diaper which was completely saturated with yellow urine. V13 stated the last time R12 was toileted was around 8:30 AM this morning. V12 and V13 both stated incontinent residents should be checked for toileting needs or incontinent care every two hours. V13 removed R12's soiled diaper and pants, and then R12 was lifted with sit to stand lift to standing position and V12 provided incontinent care. V12 sprayed no-rinse peri-wash onto the first wet wash cloth and wiped R12's perineal area from front to back between her buttocks. V12 then repeated the same action with two more washcloths but did not use any peri-wash on the other two cloths, and she re-wiped the same area. V12 then changed her gloves without sanitizing her hands and pulled up R12's diaper and pants, and then she and V13 transferred R12 into her recliner. V12 did not cleanse R12's labia, groin, thighs, lower abdomen or buttocks, which had all been visibly wet with urine. On 8/17/22 at 2:15 PM V15, who is a private caregiver hired by R12's family to sit with R12 during the day, stated she writes down what time she puts on the call light for staff to assist R12 with toileting, and what time the staff actually come to help R12. She stated today the CNAs did pretty good when she called them at 8:30 AM to assist R12 to the commode. V15 stated they answered the call light at 8:47 AM and assisted R12 onto the commode. V15 stated R12 was dry at that time and did not do anything on the commode after about 10 minutes of sitting on it. V15 stated the staff do not check and change R12 unless she or the other private caregiver call them. V15 stated R12 still has the sensation when she must urinate and if they would toilet R12 every two hours she would mostly stay dry. V15 stated when she sat with R12 on 8/11/22 the facility was short staffed that day and R12 had to wait 1 and 1/2 hours twice that day for staff to come when she said she had to go to the bathroom, and both times she was soaked with urine and had to her diaper and pants changed because the urine had soaked through. V15 stated she had reported this to the Director of Nursing (DON) and to the regional nurse. V15 presented a book with handwritten notes dated day to day that she stated R12's daughter leaves for the caregivers to document what goes on with R12 day to day. V15 stated there were pages missing where the caregivers had written down the times, they had put the call light on and the times that staff had assisted R12 with toileting because it showed the long times R12 went without getting toileted, and the long waits for call lights to be answered when R12 stated she had to go to the bathroom, resulting in R12 being incontinent. R12's Electronic Medical Record (EMR) documents her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's Minimum Data Set (MDS) dated [DATE] documents she is severely cognitively impaired and requires extensive assist with transfers and toileting. The MDS also documents she is always continent of bowel and bladder. R12's Care Plan dated 5/25/22 documents: ADL's (Activities of Daily Living): Requires assistance for Toileting. The interventions for this care plan include Toileting: Two person assist. The care plan did not document R12's incontinence or recent urinary tract infections. R12's Lab Report dated 6/17/22 documents her Urine culture identified the organism, [CONDITION(S)] Pneumonia, causing her urinary tract infection, requiring treatment with antibiotics to treat the infection. R12's Lab Report dated 6/30/22 documents her Urine Culture identified the organism, Proteus Mirabilis, causing her urinary tract infection, requiring treatment with antibiotics to treat the infection. On 8/19/22 at 9:08 AM V2, Director of Nursing (DON) stated the CNAs should cleanse any area on a resident's skin that urine touched when providing incontinent care. The facility's policy, Urinary Incontinence-Clinical Protocol dated April 2018 documents, 4. As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence. The facility's policy, Perineal Care dated February 2018, documents, Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. (1) Separate labia and wash downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about inches. Gently rinse and dry area.) (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction with fresh water and a clean washcloth. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Rinse and dry thoroughly.

Based on observation, interview, and record review, the Facility failed to provide specialized rehabilitation services to prevent a decline in current mobility status in 1 of 1 resident (R187) reviewed for specialized rehabilitation services in the sample of 25. Findings include: On 08/16/22 at 9:24 AM, R187 was sitting in her wheelchair in the living room area. R187 stated, This is my fifth day here after being discharged from the hospital. I am supposed to be here for therapy but have not had any yet. On 8/17/22 at 11:18 AM, R187 was wheeling herself back into her room in her wheelchair. She stated she has not heard back from the facility about therapy and wants to go home. R187 became tearful and stated she could do the same thing she is doing here at home. On 8/17/22 at 11:22 AM, V2, Director of Nursing (DON) stated, (R187) is here because the hospital did not feel it was safe for her to go home. She has Medicaid, and we are trying to get approval from her insurance for therapy. On 8/17/22 at 3:38 PM, V16, Regional Nurse, stated, Medicaid does not pay for therapy, so sometimes we will email our owner and he will let us start therapy out of the kindness of his heart and eat the cost. I will check and see when he was contacted about that. R187's Progress Note dated 8/17/22 at 4:24 PM documents, Resident and her friend came to my office and talked about leaving AMA (against medical advice). Resident is upset because she is not getting therapy, and that is why she came here. (I) explained to resident that it is about her insurance. On 8/18/22 at 7:40 AM, R187 stated, I worked with therapy in the hospital and on the last day they had me walking up and down the hall with a walker on the right side. I came here that afternoon and have not walked since. R187's Minimum Data Set (MDS) dated [DATE] documents R187 is cognitively intact. R187 was admitted to the facility on [DATE] following acute hospitalization . R187's MDS documents activity of walking did not occur over the entire 7-day period. R187's Hospital Physical Therapy Notes dated 8/9/2022 document R187 ambulated 14 feet with the use of a 2 wheeled walker and gait (ambulation) assistance of SBA (stand by assist)/supervision and contact guard assist. Progress was documented to be improving as expected. R187 received a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R187's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R187's Care Plan with start date of 8/11/2022 documents, Resident will participate in rehab and/or nursing goals. On 8/19/2022 at 9:48 AM, there was no documentation received regarding the Facility's attempt to obtain therapy approval for R187. The Facility's Timeliness of Therapy Evaluations Policy dated 2/2009 documents, (Facility's Consultant Therapy Company) documents, (Therapy Company) goal is to complete new evaluations ASAP (as soon as possible) or within 24-48 hours. The outside deadline for compliance is 72 hours, but this should be an uncommon occurrence.

Based on observation, interview and record review, the Facility failed to provide supervision and implement effective fall prevention measures for 1 of 3 residents (R1) reviewed for incident/accidents in the sample of 5. This failure resulted in R1 sustaining 3 falls within 4 days, and ultimately sustaining a right [CONDITION(S)] requiring hospitalization and surgical repair. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents that R1 is moderately cognitively impaired and requires extensive assist of one staff to transfer, ambulate, and use the toilet. The Facility's Incident/Accident Log documents that R1 experienced falls on 9/21/21, 10/10/21, 11/15/21, 11/21/21, 11/22/21, 11/24/21 and 12/3/21. R1's Care Plan dated 11/16/21 documents, I will not experience any injuries related to falls. It further documents bed alarm in place to bed/chair. It continues to document Start date 11/19/21-non skid tape applied to bathroom floor. It further documents, Start date 11/29/21-(Non skid mat) to patients wheelchair at all times. R1's Care Plan also lists that on 12/6/21, moving to a room near the nurses station was added as an intervention. Other interventions include assist with transfers and ambuation start date 11/16/21, observe for unsafe actions and intervene start date 11/16/21, verbally remind resident not to ambulate without assistance start date 11/16/21, and gripper socks on when out of bed start date 11/24/21. The Facility's Incident Investigation dated 11/15/21 documents that R1 fell in his bathroom and stated that he was going to take a shower. It further documents that a small sensor pad was placed on patient bed to alert staff when patient is getting out of bed and to remind patient to call for help. It further documents, Non skid tape applied to bathroom floor to reduce risk of falls. The Facility's Incident Investigation dated 11/21/21 documents that R1 fell while ambulating in the hallway while bare footed and that gripper socks were applied as an intervention. The Facility's Incident Investigation dated 11/22/21 documents, Patient was attempting to take self to shower. Floor was wet from shower running and his lost his balance, falling to buttocks. It further documents labs were to be drawn and that the nurse practitioner conducted a medication review. It documents, Non skid tape continues in bathroom by toilet and is being placed in shower stall. The Facility's Incident Investigation dated 11/24/21, documents R1 transferred himself to wheelchair with a pillow in the seat, behind his back. It further documents, Patient slid out of wheelchair. It continues, New interventions of (non slid mat) to wheelchair and staff to ensure that no pillows are in wheelchair. R1's Progress Notes dated 11/28/21 at 2:48 PM documents, Resident was found by CNA in another residents' bed, was able to be redirected into his own bed by CNA. The Progress Note does not address whether R1's pad alarm was sounding to alert staff since R1 should have a pad alarm in bed/chair according to the Care Plan. R1's Progress Notes dated 12/3/21 at 4:16 PM, documents, Resident noted to be on floor outside of bathroom door, head leaning on wall with wheelchair behind resident without brakes on. Resident has anti roll back on wheelchair and gripper socks on feet. When interviewing him he stated that he slipped out of wheel chair. Resident able to roll on back. When performing range of motion, resident lifted arms up and screamed in pain and winced. Pillow placed under residents head and covered with a blanket. Staff stayed with resident to maintain body alignment. EMS (Emergency Medical Services) arrived 20 minutes after being called took 3 people to transfer resident to stretcher after neck brace applied. EMS took resident to (local) hospital. The Facility's Incident Investigation dated 12/3/21 documents that R1 was observed up against his bathroom door frame, complained of pain to neck and back and was transferred to the hospital for a fracture of the right femoral (large leg bone) neck. It continues, Safety committee meeting held to review recent fall and ensure that interventions are working. At this time patient is non compliant with self-transfers, taking alarm off, and forgetting to call for help. The Illinois Department of Public Health Final Report dated 12/8/21 documents, Resident Name: (R1). Date of Incident: 12/3/21. Type of Occurrence: Serious Injury. It continues, Nurse called to resident room. Patient was observed on floor in bathroom doorway. It continues to document that R1 complained of neck and back pain, neurological checks were initiated and an ambulance was called. It further documents that R1 was transferred from the local hospital to another hospital for fracture of right femoral (large leg bone) neck. R1's Progress Notes dated 12/9/21 document that R1 was readmitted to the Facility with a diagnosis of a right [CONDITION(S)]. R1's Care Plan start date 12/9/21 documents R1 was readmitted status post surgery due to right [CONDITION(S)]. R1's Progress Notes dated 12/12/21 documents, Resident self transferred several times through out the day. Resident educated on asking for help to avoid falling. The Progress Note does not address whether R1's pad alarm was sounding to alert staff since R1 should have a pad alarm in bed/chair according to the Care Plan. On 12/13/21 at 3:30 PM, R1's previous room's bathroom and R1's current bathroom floors were observed. There were no non-skid strips in either bathroom/shower area. This intervention was supposed to implemented 11/15/21 according to the 11/15/21 Incident Investigation and again according to the 11/22/21 Incident Investigation. On 12/14/21 at 8:30 AM, R1 was observed awake in bed, eating breakfast. On 12/14/21 at 8:50 AM, There were 2 non skid strips observed in R1's bathroom, near the toilet, that had not been there upon observations made on 12/13/21. There were still no non skid strips located in the shower area. At this time, V18, Maintenance, stated, They got put down yesterday. Does that still count? On 12/14/21 at 9:15, V16, Licensed Practical Nurse (LPN), confirmed that R1 had moved rooms and verified the room numbersafter his hospitalization due to a fractured hip. On 12/14/21 at 9:20 AM, R1 was observed by this surveyor and V1, Administrator. R1 was observed standing up, unattended, near the toilet in the restroom which is located in his room. At this time, V1 stated, (R1) do you need the girls (CNAs)? R1 responded, Yes, badly. R1 was barefoot, and R1's non skid socks were located in his bed. V1 called out to V4, Certified Nursing Assistant (CNA), to come and assist R1 onto the toilet. At this time, R1's pad sensor alarm was positioned in R1's bed, under the sheet, and was not sounding. V1 stated, (R1) can unplug it and moves it. I bet someone got him up and reset it. I'll find out who got him up. R1's Care Plan does not address R1 unplugging the pad alarm. On 12/14/21 at 9:25 AM, V3, CNA stated, (R1) was up in his chair wheeling around earlier today but he went back to bed at 6:30 (AM) and has been in bed since. On 12/14/21 at 9:30 AM, V4 looked for R1's non-slip mat in his room, and was unable to locate it stating, I will have to get him one. I am not seeing any. The Facility's Safety and Supervision of Residents policy dated July 2017, documents, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. It further documents, 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: D. Ensuring that the interventions are implemented. 5. Monitoring the effectiveness of interventions shall include the following: A. Ensuring that interventions are implemented correctly and consistently. B. Evaluating the effectiveness of interventions; C. Modifying or replacing interventions as needed; and D. Ensuring the effectiveness of new or revised interventions. On 12/14/21 at 1:30 PM, V17, Regional Clinical Director, stated, I would expect them to follow the policy by ensuring the interventions are implemented, effective and updated.

Failures identified required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to supervise and implement interventions to prevent falls for 2 of 4 residents (R1, R2) reviewed for supervision to prevent falls in the sample of 13. This failure resulted in R2 falling and sustaining on open nasal fracture and laceration to her forehead. Findings include 1.R2's current Face Sheet documents R2 having the following Diagnoses: [REDACTED]. R2's Minimum Data Set (MDS), with assessment reference date of 9/4/2020, documents R2 has severely impaired cognition. R2's MDS documents R2 requires extensive assistance of 2 plus staff persons for walking in room and corridor, extensive assistance of 2 plus staff persons for location on the unit. The MDS documents she is not steady and only able to stabilize with staff assistance during transitions and walking from seated to standing position. R2's Care Plan, initiated from 2/26 through 8/23/2020, documents she fell 10 times on the following dates: 2/26, 2/14, 2/19, 4/21, 6/12, 6/25, 7/22, 8/4, 8/17 and 8/23/20. R2's Care Plan Problem, initiation date 5/28/20, documents: (R2) has unsteady gait and balance issues when standing. The Care Plan Interventions, with start date 4/22/20, are as follows: assist her to stand, explain what you wish her to do; give step by step instructions; if very unsteady-use two staff assistance when ambulated or w/c (wheelchair). R2's Care Plan Problem, with start date of 10/26/2016, documented (R2) has the potential for falls/injuries related to confusion, wanders, unsteady gait, will slide self to edge of chair/wheelchair, aggressive behaviors, [MEDICAL CONDITION], and use of [MEDICAL CONDITION] meds. Also, she frequently bends over to pick items off the floor. Interventions to address R2's falls are as follows with the following initiating date: Assist her to position correctly/safely when up in chair/wheelchair (7/19/19); Do not leave unattended in the dining room (2/7/20); Encourage to attend activities when out of bed (2/14/20); Refer to therapy (2/19/20); and position pillow to maintain lying in center of the bed (8/4/20). The Facility's Incident Report/Investigation, dated 9/2/20, documented R2 was observed sitting on the floor in the living room. The Investigation documented that R2 ambulates independently throughout the facility and has dementia. The Investigation documented the intervention put into placed to address this fall was wear gripper socks at all times. The Facility's Incident Report/Investigation, dated 9/23/20, documented R2 was found sitting on the floor mat next to her bed. The Report Investigation documented Resident moved closer to the nurse station. The Facility's Incident Report/Investigation, dated 9/30/20, documented at 4:50 AM, R2 was found face down with blood coming from around her face, on the floor in front of her wheelchair. The Report documented that R2 had bleeding coming from her forehead wound and bleeding coming from her nose. R2's Medical records from Local Hospital for the admission due to injuries sustained from incident of 9/30/2020 documents Patient was transported to the E.D. (Emergency Department) and after evaluation/examination she was found to have an open nasal fracture with epistaxis. Laceration was sutured, and right nasal rocket was placed. R2's Hospital Discharge Summary documents Open nasal fx (fracture), [MEDICAL CONDITION] sutured, nasal laceration sutured. On 10/29/2020 at 2:30 PM, V3 (Regional Nurse) stated, I was called by the nurse and she said (R2) had fallen and they had found (R2) in front of wheelchair, blood on floor and had hit face. They said they checked vitals, and (R2's) sats (oxygen saturations levels) were low and they put on oxygen, the sat was around 73%. They called 911 immediately. There were 2 nurses and 2 CNAs on that night, so 4 people in building. The CNAs said (R2) was trying to get out of bed, so they went ahead and got (R2) up, cleaned (R2) up, and put (R2) in a wheelchair. They said within 20 minutes she was on floor. V3 stated when R2 is in bed, she has low bed, and a mat by the bed, but R2 was in chair and mat was against wall, no chair alarm was on when the incident occurred. V3 stated When (R2) sits, she starts to rock to get herself up, so (R2) rocks body then she get up and walks on own. (R2) rocks every time to get up, she then gets her balance then takes off walking. On 10/30/2020, at 2:46 PM, V6, Registered Nurse/RN, stated she was R2's nurse the shift of 9/30/2020, in which the fall incident took place. V6 stated she was getting ready to pass morning medication when she passed by R2's room at approximately 4:50 AM. V6 stated she found R2 face down in front of the wheelchair with blood on the floor. V6 stated she yelled for the other nurse working and that nurse worked on stopping the facial bleeding while she called 911. When questioned if R2 had fallen from bed, V6 stated No, I never thought (R2) fell from bed. I absolutely knew where (R2) fell from, (R2) was face down in front of the wheelchair, (R2) wasn't even by the bed. I did not tell family (R2) fell from the bed. I put in my nurse's notes what happened. it was obvious (R2) fell from the wheelchair. I asked the aides working that night when the last time they were in the room. They told me it was when they started rounds and got (R2) up first at 4:30 AM. On 11/4/2020 at 8:17 PM, V11 (Training Nurse Aide) stated that R2 was trying to get out of bed early in the morning. V11 stated We have been told to go ahead and get them up, so they don't hurt themselves if they are wanting up. We went ahead and got (R2) washed up and put (R2) in her wheelchair. We went on to the next room to help another resident. When we got to about the third room, (V6,RN) came and asked us if we knew where the other nurse was because (R2) had fallen out of her wheelchair.' V11 stated they always put R2 in her in the wheelchair when we get her up. V11 stated R2 constantly rocked herself, back and forth in the chair. V11 stated I even said, I bet (R2) was rocking herself and fell right out of the chair. (R2) always had to rock (R2's) self to get (R2's) balance to get up, and I bet (R2) just fell while rocking herself. It was about 15 minutes before the nurse came and told us (R2) had fallen out of (R2's) chair that we got (R2) up. On 11/4/2020 at 4:29 PM, V10, R2's Physician, Yes, I am aware, (R2) is very unstable on legs and has fallen numerous times and sustained a subdural hematoma from past falls. When asked about R2 being left alone in her room at 4:30 AM, V10 stated I would expect closer observations but more importantly are the key words you used of resident being left alone. Yes, I would agree leaving alone should not have happened that early in the morning with them knowing the history of falls for (R2). 2. R1 November 2020 physician's orders [REDACTED]. On 10/29/2020, at 1:38 PM, an alarm was heard coming from R1's room. Staff in hall observed with no urgency to respond to alarm. Staff walked toward R1's room, stopped to talk to resident and staff in another room. V7 (Training Nurse Aide, TNA) then continued on to R1's room. V7 went into bathroom to check on R1. V7 was heard saying, I don't know how to turn it off, several times. V7 came out of bathroom and looked around in room, continuing to say, I don't know how to turn the call light off. V7 came out to hall telling this surveyor she was not sure how to turn off the light. V15, Certified Nurse's Aide/CNA, came down the hall and asked V7 what was wrong. V7 stated, I don't know how to turn off the room light. V15 stated That is (R1's) chair alarm, not the room light. V7 proceeded to go back into the bathroom with R1 and the alarm was turned off. V7 advised R1, V7 would be back, and immediately came back out of the bathroom. This surveyor asked if R1 had gotten on the toilet without help. V7 stated Yes, that's why the alarm was going off. When questioned if R1 was supposed to get on the toilet by R1's self and if R1 should be left alone, V7 stated I honestly don't know. I have only worked here for 4 days, but (R1) does a lot on his own he shouldn't, so he probably shouldn't be left much on his own. V7 stated they had no education on how to check what each resident's needs were to assist them that V7 could find in the room. V7 stated she was assigned to work with V15, but V15 was not with her at the time of this observation. On 10/30/2020, at 1:25 PM, R1 was attempting to go into a resident's room to use the bathroom. V7 redirected R1 to go to his own room to use the bathroom. R1 became upset and started cussing, stating he needed to use the bathroom. V7 again instructed R1 to go to his room and V7 would come help R1. V7 walked away from R1 and went into another resident's room. R1 attempted to roll himself down the hall, upset due to having to go to the bathroom. R1 told V13, Licensed Practical Nurse/LPN, he needed to go to the bathroom. V13 pushed R1 to his room. V13 placed R1 in his room and advised him that V13 would get him help. V13 left R1 alone and R1 proceeded to go into the bathroom on his own. V13 was observed telling staff that were in another room, R1 needed help. V13 saw V14, CNA, in the hall and asked V14 to assist R1 to the bathroom. At 1:27 PM, V14 went to R1's room and saw that R1 was already in the bathroom and went in to assist. At 1:28 PM, V14 was coming out of R1's room and told V7, V14 had already assisted R1 in the bathroom. At the time of this observation, R1 had no floor mat in his room. On 10/30/2020 at 1:51 PM, V14 stated that V14 did not have staff assistance with R1 in the bathroom at 1:27 pm when helping R1. V14 stated R1 had stood up to urinate at the toilet and V14 had assisted R1 by self. V14 stated R1 can roam wherever he wants to go, there are no interventions in place to try and keep R1 in supervised areas. V14 stated that R1 is not on a toilet program or a program to toilet R1 more often. V14 stated that staff take R1 every 2 hours as needed. R1's MDS, dated [DATE], documents R1 has moderately impaired cognition. The MDS documents R1 requires extensive assistance from two staff person for transfers and toilet use. The MDS documents R1 is not steady and needs assistance from to stabilize when moving from a seated to standing position, moving on and off toilet and during surface to surface transfers. R1's Care Plan, from 1/20 through 6/8/20, documents R1 had 11 falls during this period. R1's falls were documented/dated on the Care Plan and are as follows: 1/20/2020 transferring self to toilet unassisted; 2/8/2020 fall from bed; 2/13/2020 fall from bed; 2/19/2020 fall while trying to transfer to bed by self; 2/28/2020 fall from bed; 3/15/2020 found on floor in front of toilet; 3/30/2020 found on floor in bathroom; 4/19/2020 fell from w/c while reaching; 5/21/2020 fell from w/c while leaning forward; 5/22/2020 fell while transferring self to toilet; and 6/8/2020 fell standing up from w/c without locking brakes. The Care Plan Approaches to address these falls were as follows: Give frequent reminder to lock his wheelchair when he wants to stand; Ask him frequently if he needs to go to the bathroom; Encourage him to stay in supervised areas after supper; Keep needed items within his reach; Refer to therapy; Remind him to wait for assistance to go to the bathroom; If noted to bed restless when in bed, get him p and bring to a supervised area; and start restorative toileting program. R1's Care Plan Problem, with initiation date of 1/20/2020, documents (R1) is unable to transfer self safely to the toilet and is incontinent of urine. The Interventions for this Care Plan problem documented Assist of two staff with toileting and Remind him to not transfer without assistance. R1's Facility Incident Report, dated 9/11/20, documented R1 was found in his room on the floor next to the bed with his wheelchair behind him. The Intervention on this Report was to remind him to use his call light. R1's Care Plan, revised on 9/11/20, documented that R1 was re-educated on waiting for assistance and staff were to assist resident to bed after meals. R1's Facility Incident Report, dated 10/9/20 at 7:05 AM, documented he was found on the floor in his bathroom. He was on his left side with his back against the wall. The Report documented he sustained an abrasion to his mid back measuring 4 centimeters by 3 centimeters. The Immediate Action documented on this report was to refer R1 to therapy for transfers and for staff to make this resident a first get up due to him attempting to transfer to toilet. R1's Care Plan, revised on 10/9/20, documented Toileting Program to ensure resident is toileted before and after meals; OT/PT (Occupational/Physical) therapy to eval and treat. R1's Facility Incident Report, dated 10/11/20 at 4:21 PM, documented he was found in his bathroom on the floor near the sink. This report documented Resident to wheelchair alarm when available. R1's Care Plan, revised on 10/11/20 documented W/C alarm will be put into place. R1's Nurse's Note, dated 10/24/20, documented that R1 was found on the floor. The Nurse's Note documented he had removed his personal alarm and tried to transfer self. R1's Care Plan, revised 10/24/20, documented Position alarm box out of my reach, offer to assist me to get into my w/c for super at later time, encourage me to stay in a more supervised area when up in my w/c, therapy screen for possible treatment. B. Based on interview and record review, the facility failed to provide supervision to prevent elopement for one of 4 residents (R5) reviewed for elopement/supervision in the sample of 13. Finding includes: 1. R5's November 2020 Physician order [REDACTED]. R5's Minimum Data Set, MDS, dated [DATE], documents R5 as a [AGE] year-old with severe cognitive impairment. The MDS documents she needs supervision for bed mobility, transfers and walking. Progress notes for the month of September 2020 documented R5 had several falls and incidents. R5's Progress Note, dated 9/9/20 at 4:26 PM, documents, Resident has been up ambulating requesting to go home. Has traveled to facility doors with supervision yet not attempting to open. R5's Progress Note, dated 9/10/20 at 2:53 PM, documented R5 had fallen. The Note documented she missed her chair and landed on her bottom. R5's Progress Note, dated 9/19/20 at 3:50 PM, documented R5 was found in office room sitting on the floor next to chair. R5's Progress Note, dated 9/25/20 at 6:30 AM, written by V21, LPN, documents, DON was doing rounds. When got to this resident's room, resident was not in room. DON let this nurse and other nurse know that resident was not in room and we needed to search rooms and everywhere in the building. Staff split up and half of staff started down c hall and other half started down a - hall. Staff searched every room closet bathroom locked rooms and shower rooms as well as cafe and living room dining room and kitchen. Resident was not found. Half the staff began search outside of facility. All ground around facility was searched. At 6:50 AM, V21 documented Search cont. A couple staff members searched around the block up to one block down. 710am This nurse found resident sitting in front of shed. Staff then ran to get wheelchair and blankets for resident. This nurse stayed with resident and assessed her. No injury noted to legs. Two staff assisted to stand this resident up to sit (R5) in wheel chair. No grimacing noted during transfer. Resident covered with blankets and taken into facility building. R5's Progress note entry on 9/25/2020 at 720 AM by V21, documents, V/S (vital signs) taken 140/70 (blood pressure)-97.1 (temperature) -78 (pulse)-22 (respirations). SPO2 (oxygen saturation levels)-98% on RA (room air). Resident assessed by two nurses when taken to bathroom. Left hip area noted to be swollen with bruise measuring 7.5cm by 4cm. Under right buttock round red area noted. 6cm by 6cm. Area to right forearm circular bruise measuring at 3cm by 3 cm. No pain or disc (discomfort) noted. On 11/9/2020 V17, Previous employed CNA, stated she was working night/morning of R5's elopement, V17 stated: I told them (R5) is a huge fall risk I told them (R5) needed an alarm on so we knew when (R5) was standing up. When we are trying to get people up, we can't always keep an eye on everyone. I was just trying to keep (R5) safe. (R5) has [MEDICAL CONDITION], walked all over the place and was a fall risk. When I started, the old owner had an alarm on (R5), the new company took it off (R5). The wander guard only goes off if going out the door, we needed a different alarm. (R5) was there on my last bed check at 2:30 a.m., not sure when I left. V19 (former Director of Nursing) came in for me and she took over. The door alarm went off a little after 3:00 a.m., but we have this guy who is a smoker and they said it was him probably going out to smoke, so we turned off the alarm. I went outside and looked down the ramp but didn't see him or (R5). They said it wasn't that door that alarmed, it was the front door. I'm just not sure when (R5) left, not sure if that was the time or not. They started calling me around 6 a.m. in the morning, I was sleeping, I called them back and they asked when the last time was I saw (R5). On 11/12/20 at 12:40 PM, V19, Former Director of Nursing, stated she came in early because V17 need to go home on 9/25/2020 around 4:30 AM. V19 stated she started on bed rounds and remembers had a couple messes to clean up prior to getting to R5's room. V19 stated around 6:00 AM, she and V15 (CNA) went into R5's room and R5 was not in the room. V19 stated, We did a check of the entire building and could not find R5. (V1/Administrator) had also came in at 0600 and I reported (R5) missing. We did another sweep of whole facility including closets and bathrooms. When we couldn't find (R5). We called (V3, Regional nurse) to advise and we then went outside to start looking and found (R5), 2 blocks away. On 11/12/2020 at 11:43 AM, V21stated she found R5 about 1.5 to 2 blocks from the facility on 9/25/2020. V21 stated she filled out a report and should also be in progress notes. V21 stated We think (R5) walked down the road. I found (R5) sitting on (R5's) buttocks. V21 stated that R5 did not have injuries. V21 stated she was not sure why the wander guard had not gone off or if it did somehow and got missed. V21 stated she was not sure how long R5 was missing but she found R5 around 7 a.m. that morning. Facility Policy titled Door Alarm Policy undated, documents 1. All exit doors are alarmed/code locked and remain on 24 hours per day. 2. All facility exit doors are secured with an alarm that chimes when the doors are open. The alarm sound continuously until manually shut off. The purpose of the continuous alarm is to alert staff that an exit door has been open. Staff responding to the alarm should check on the reason for the alarm to be sounding. A thorough observation should be done to look for a wandering resident. 3. To assure the safety of the residents, after a thorough observation is completed, all residents should be accounted for. 4. No alarm should be silenced until a thorough observation is completed. Facility Policy titled: Safety and Supervision of Residents documents Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility - wide priorities. Facility-oriented approach to safety: 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting processes; QAPI reviews of safety and incident/accident data, and a facility-wide commitment to safety at all levels of the organization. Individualized, Resident-centered approach to safety. 4. Implementing Interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff. b. assigning responsibility for carrying out interventions. c. providing training, as necessary. d. ensuring interventions are implemented.

Based on observation, interview, and record review, the facility failed to prevent the formation of pressure ulcers, timely treat new pressure ulcers, and turn and reposition residents to prevent skin breakdown for 2 of 3 residents (R9 and R3) reviewed for pressure ulcers in the sample of 11. This failure resulted in R3 developing three facility acquired stage 2 pressure ulcers. Findings include: 1. R3's Minimum Data Set ((MDS) dated [DATE], documents R3 requires extensive assistance by two staff members for bed mobility, and total assistance of two staff members for transfers. R3's MDS documents she had no pressure ulcers but was at risk for developing pressure ulcers. R3's Care Plan dated 11/27/1, documents (R3's) skin will remain intact through the next review period of 05/29/19. R3's Care Plan Approaches, dated 11/27/18, documented staff were to apply moisture barrier/ointment to skin after incontinent care, daily inspection of skin surfaces during daily care, and report findings of redness or opened areas to nurse, and Turn and reposition with care, as needed and as requested. Approach , dated 1/20/17, documented Report any signs of skin breakdown to nurse (sore, tender, red, or broken areas) who will assess area and inform MD for treatment. On 05/02/19, at 1:35 PM, V12 and V6, Certified Nursing Assistants (CNAs) propelled R3 into her room and told her they were going to lay her down. V12 and V6 used a mechanical lift and transferred R3 from her geriatric chair to her bed to perform incontinent care. R3 had an opened dime sized pressure ulcer to her left outer buttock. R3 also had two dime sized pressure ulcers where her right thigh meets her buttock, one an intact blister and one was opened. V12 and V6 stated the nurse told them to put cream on it. On 05/03/19 at 7:55 AM and 8:15 AM, R3 was sitting in her geriatric chair near her room. At 8:30 AM, R3 was sitting in her geriatric chair in the dining room. She remained in the dining room from 9:00 AM through 9:30 AM. From 9:30 AM until 10:00 AM, V12, Certified Nurse's Aide, fed R3 her breakfast. During this time, staff did not reposition R3. At 10:30 AM, R3 continued sitting in the dining area in her geriatric chair. On 05/03/19 at 10:15 AM, V3 Licensed Practical Nurse (LPN), stated She (R3) only has an open area to her left foot, and she receives [MEDICATION NAME] to her foot. R3's Physician order [REDACTED]. R3's POR does not document any treatment for [REDACTED]. R3's Treatment Administration History, dated 04/01/19 through 04/30/19, documents skin checks were performed on Friday (MONTH) 5th, 12th 19th and 26th. On 05/02/19 at 2:30 PM, V2, Director of Nursing (DON), stated They sign off on the Treatment sheet, and they document what they saw in the progress notes. R3's Resident Progress Note, dated 04/05/19, documents a 1 x (by) 1-centimeter (cm) blister like area noted to her right knee. R3's Resident Progress Note does not document any open area or blisters to her buttocks. R3's Resident Progress Note dated 04/11/19, documents discontinue treatment to right knee. R3's Resident Progress Note dated 04/12/19, documents weekly skin check completed, no new areas. The Resident Progress Note does not document open areas or blisters to R3's buttocks. R3's Resident Progress Note dated 04/26/19, documents R3 continued with hospice care and had no signs of pain or discomfort, skin warm and dry. R3's Resident Progress Note for this date does not document any open areas or blisters to R3's buttocks. On 05/03/19 at 11:45 AM, V16, Attending Physician, stated Yes, they told me about the open areas a couple weeks ago. I didn't give any orders, hospice usually have standing orders, but if she needed more specialized care they could call me back. On 05/03/19 at 11:55 AM, V17, Hospice Case Manager/Registered Nurse, stated, So I just heard about it today. I took a look at it and it measures 1cm x 0.5 cm left buttock. Her right thigh blister measures 2cm x 1.5 cm. Her right thigh open area measures 2cm x 1.5 cm. I notified our doctor today as we just heard about it today. A facility pressure ulcer policy was requested twice from V2, Director of Nurses, and V1, Administrator. No policy was provided. 2. R9 was admitted to the facility 5/31/17. R9's MDS dated [DATE], documents a Brief Interview of Mental status as 99-unable to complete. The MDS further documents R9 requires 2 staff extensive assistance for Activities of Daily Living (ADL's). On 5/1/2019 from 9:45 AM through 10:45 AM, R9 was in the main dining room in activities. At 11:05 AM R9 was sitting in the small dining room at the table. R9's crotch area was visibly wet at this time. At 1:05 PM, V6 (CNA) and V5 (CNA) pushed R9 into her room. V6 (CNA) and V5 (CNA) both stated, I did not see her pants wet. V6 (CNA) and V5 (CNA) transferred R9 from wheelchair to bed, and the seat of R9's pants was visibly soaked with urine and the cushion in R9's chair was visibly wet. V6 and V5 stated, I have no idea when's she has been out of this chair. V6 (CNA) and V5 (CNA) stated they did not get R9 up this morning. On 5/1/2019 at 1:20 PM, V4 CNA stated that she got R9 up around 7:00-7:30 AM this date. On 5/1/2019 at 2:45 PM,V10 (R9's daughter) stated, V10 stated My mother (R9) has had pressure ulcers and urinary tract infections in the past. V10 stated the staff do not turn R9 every two hours like they are supposed to. On 5/2/2019, V2 Director of Nursing (DON) stated she expects staff to reposition residents every 2 hours to prevent pressure ulcers.

Based on observation, interview and record review the facility failed to implement progressive interventions and provide safety interventions to prevent falls for 2 of 5 residents (R15, R241) reviewed for falls in the sample of 22. This failure resulted in R15 falling and sustaining a nasal fracture and head contusion. Findings include: 1. R15's (YEAR) (MONTH) Physician order [REDACTED]. R15's Minimum Data Set (MDS) documents a Brief Interview of Mental Status score of 2, indicating she has severe cognitive impairment. R15's Incident Report dated 12/18/2017 at 12:15 AM, documents, Resident was found sitting on floor leaning against the dresser, personal alarm sounding. No visible injuries. Resident able to move all extremities. Within normal limits for resident. Assisted resident to standing position and resident able to ambulate with no complaints of pain. The Report documented Intervention as Resident will be kept in common area for 1:1 care. Very anxious about something to do with grandpa. grandma. There was no intervention documented related to the prevention of further falls. R15's Progress Notes dated 12/18/2017 at 12:20 AM, documents Resident was found by certified nursing assistant (CNA) with personal alarm sounding leaning against the dresser sitting on the floor. Resident was agitated and crying out and screaming. Resident will be kept in common area for 1:1 care. R15's Progress Notes dated 12/18/2017 at 3:30 AM. Resident was still at nurses' station, writer was at medicine cart, resident stood up, Nursing alarm sounding and started to fall to right side. This nurse stopped resident from falling hard but resident did bump head on floor. Resident has no open area but temple is bruising with small hematoma. Assisted resident to room, cold compress applied, resident unable to participate with neuro-checks at this time, weak and unable to understand request. R15's Incident Report dated 12/18/2017 at 4:08 AM, documents, Resident was sitting in wheelchair at nurse's station, stood up, alarm sounding. Started to fall to right side. Writer fell with resident but resident still bumped head on floor, right temple area. Cold compress applied. Neurochecks started. Intervention: Resident is in recliner with ice to right temple area. No complaint of pain or discomfort. There was no intervention documented related to the prevention of further falls. R15's Incident Report dated 01/30/2018 at 7:45 AM, documents, Resident in café in wheelchair personal alarm in place. Alarm sounding and Certified Nursing Assistant (CNA) saw resident starting to fall out of wheelchair and eased resident to floor. Resident to floor. Resident has bruise to left check. Medical Doctor also notified via fax. There was no intervention documented related to the prevention of further falls. R15's Progress Notes dated 01/30/2018 at 11:34 AM, documents, Resident in cafe in wheelchair personal alarm in place. Alarm sounding. R15's Incident Report dated 02/08/2018 at 9:13 AM, documents, Stood up in wheelchair and on lap protector, lost balance and fell to floor in hallway. Head injury noted. Was sitting in high back wheelchair after breakfast; with lap protector in place and chair alarm on. Resident stood up in chair and fell forward pulling lap protector off during fall. Resident witnessed by Social Service Director (SSD) to fall prone to floor in hallway. Resident has laceration to upper area of nose 1 inch in length. Bleeding noted to left eye and nose. Resident alert and responds to staff, (911 called). Head and neck immobilized by First responders and resident voiced no complaints of pain. Power of Attorney (POS) called and is going to Local Hospital at this time. Event Report for 02/08/2018 documents Lap buddy removed from chair. There was no intervention documented related to the prevention of further falls. R15's Progress Notes dated 02/08/2018 at 12:16 AM, documents in part, Resident personal alarm sounding, writer went to room, resident sitting on the floor by window on mat. Resident taken to bathroom, noticed abrasion to left side of back and abrasion and bruising to lower back, old skin tear to left elbow. There was no intervention documented related to the prevention of further falls. R15's Progress Notes dated 02/09/2018 at 1:33 AM, documents, Resident continues on Incident Follow Up related to fall with nasal fracture and head contusion. Purple discolorations/swelling to eyelids/nose and forehead. R15's Progress Notes dated 02/09/2018 at 1:55 PM, documents, resident moaning and crying. R15's Progress Notes dated 02/09/2018 at 1:50 PM, Incident Follow Up with Nasal fracture and head contusion. R15's Progress Notes dated 02/10/2108 at 2:20 AM, documents, fall with head injury. Purple bruising remains, right eye and left. Sterile adhesive strips to bridge of nose intact with some swelling and bruising. R15's Incident Report dated 04/27/2018 at 9:45 PM, documents, CNA called nurse to resident's room. Resident noted on her left side next to bed on mat. Bed alarm clip and box still intact. Resident restless and refused vital signs. Skin assessment done with no injuries. There was no intervention documented related to the prevention of further falls. R15's Progress Notes dated 04/27/2018 documents, CNA called nurse to resident's room. Resident noted on her left side next to bed on mat. Bed alarm and clip and box intact. No injuries noted. On 10/09/2018 at 4:01 PM V2, Director of Nursing (DON) stated, The interventions for the falls are listed at the bottom of the Incident reports. There was no intervention documented related to the prevention of further falls for R15 after each fall. On 10/10/2018 at 3:40 PM, V20, Physician of R15 stated, (R15) has [DIAGNOSES REDACTED]and dementia and because of that she constantly has to be redirected and have supervision. The only change I could see related to her falls is to move (R15) closer to the nurses' station for closer supervision. Which the facility eventually was able to do. 2. The MDS, dated [DATE] documents R241 is moderately impaired with cognition, is independent with transfers, is ambulatory and has no limitation in range of motion. The EHR, (electronic health record) documents R241 has diagnoses, in part, as Alzheimer's Dementia, and Convulsions. R241's Care Plan, dated as edited 10/01/2018, documents : has impaired decision making skills and is at risk for falls due to the use of [MEDICAL CONDITION] medications and uses a cane. On 10/03/2018 at 12:12 PM, R241 was in bed. There were no side rails on the bed. A fall mat was on the floor. On 10/09/2018 at 8:24 AM and 9:46 AM, R242 was in bed on his back on an alternating air loss pressure relieving mattress. There were no side rails on the bed. A fall mat was on the floor. The Progress Note, dated 10/08/2018 at 5:35 PM, documents, in part, Rolled out of bed onto mats on floor. Bed in low position with air mattress in place, The Event Report, dated 10/08/2018 at 5:35 PM, documents, in part, Resident rolled out of bed onto his left side of his body with no injuries noted per nurse. Stated he had no pain occurring after this fall at this time. The intervention documented after the fall is , More bed pads and long length cushion placed to right side of resident along right back side while left side bed was pushed up against the wall for better safety measures noted. On 10/09/2018 at 4:00 PM, V2, DON reported R241 got the alternating air loss mattress on 10/08/18, and they do not have the manufacturer's guidelines for its use because the mattress belongs to the facility. V2 reported R241's new mattress was not assessed for safety to prevent falls. The facility's policy and procedure, dated 12/2016 and entitled, Fall Procedure and Policy documents, in part, Nursing is required to perform fall assessments on residents and placed on a prevention program if indicated upon admission and quarterly. Complete fall report with appropriate interventions in Matrix under the event section.

Based on observation, interview and record review, the Facility failed to prevent the formation of pressure ulcers, provide repositioning and provide prescribed treatment for 2 of 5 residents (R2, R8) reviewed for pressure ulcers in the sample of 13. This failure resulted in R2 developing 3 facility acquired Stage II pressure ulcers. Findings include: 1. R2's current face sheet documents R2 was admitted on [DATE] with [DIAGNOSES REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has severe cognitive impairment, requires extensive assist of 2 staff members for bed mobility and transfer, and is totally is dependant on staff for incontinent care. R2's Braden Scale For Prediction of Pressure Score Risk, dated 10/17/16, documents R2 is at high risk. R2's Care Plan, dated 10/19/16, documents, in part, Problem: Resident is at risk for pressure ulcers R/T (related to) impaired mobility- res (resident) not ambulatory at this time due to recent [MEDICAL CONDITION]. Resident has no pressure areas at this time. Approach: Turn and reposition every 2 hours and prn (as needed). On 11/15/2016 at 9:45 AM, E12 and E13, Certified Nurses Aides (CNAs) performed pericare for R2. At this time, R2's left buttock was slightly red and his right buttock was red. Both buttocks and coccyx were intact with no open areas. E12 and E13 transferred R2 into his wheel chair. R2 remained in his wheelchair without the benefit of repositioning from 9:45 AM until 2:00 PM based on 15 minute or less observation intervals performed by 2 surveyors. On 11/15/16 at 1:55 PM, E11, CNA stated, (R2) usually stays up in his wheelchair all day once he is up. On 11/15/16 at 2:00 PM, E12 and E13 laid R2 down. R2 was wet with urine. R2 had 2 red open circular Stage 2 areas approximately 0.5 x 0.5 centimeters (cm) on his left buttocks. On 11/15/2016 at 2:15 PM, E4 Registered Nurse (RN)/ Wound Treatment Nurse, inspected R2's buttocks. E4 noted 3 open areas at this time. E4 stated, (R2) did not have open areas yesterday. I did a skin check on him. On 11/15/2016 at 3:30 PM, E2, Director of Nurses (DON), stated, Staff should turn, reposition and offload (R2) every 2 hours at least. R2's Nurses Note, dated 11/15/16 at 2:45 PM, documents, Notified hospice, re (in reference to) 3 stage II open areas to left buttocks/coccyx = top Left buttock 0.5 L (length) X 0.3 W (wide). mid + 0.7 L x 0.2 cm W and lower 0.5 cm L X 0.2 cm W. The facility's undated Pressure Ulcer, Care and Prevention of policy and procedure documents, in part, 6. Turn the resident every two hours and position with pads or pillows to protect bony prominence's. 8. Whenever possible, teach the resident to change his position at regular interval and shift his weight in wheelchair. 2. The Facility Wound Report, dated 11/7/16, documents R8 has a facility acquired Stage 3 pressure ulcer on the coccyx. R8's Braden Scale for Prediction of Pressure Sore Risk, dated 10/31/16, documents R8 is at a moderate risk for the development of pressure sore. R8' Electronic Physician order [REDACTED]. Apply santyl and calcium alginate dressing, cover with island dressing, change daily and (prn) as needed. R8's Weekly Wound Progress Note, dated 11/9/16, documents, Continue to treat coccyx with santyl and calcium alginate. Wound 1.0 cm by 0.3 cm by 0.4 cm with minimal serosanguinous drainage. Red area to buttock resolved. No other open areas, redness or blisters noted over bony prominences. On 11/15/16 at 9:41 AM, E4 provided treatment to R8's stage 3 pressure ulcer on the coccyx. E14, CNA, assisted E4. R8 was in bed. E7 and E11, both CNAs, had just finished providing incontinent care to R8. R8 did not have any dressing covering her coccyx pressure ulcer nor any loose dressing was found anywhere in the bed clothes. E4 washed her hands and donned gloves. E4 cleansed the pressure ulcer with wound cleanser and applied santyl and calcium alginate and covered with an island dressing. On 11/15/16 at 9:49 AM, E7 and E11 both stated they cleaned up R8 before breakfast that morning and there was no dressing covering the wound then. They stated E4 was not in the facility at the time so she was not informed about it. On 11/16/16 at 4:00 PM, E2 stated she expects the staff to notify the nurse immediately when wound dressings come off or get soiled so the nurse can put a new dressing on.

Based on interview and record review, the Facility failed to provide progressive interventions to prevent falls for 1 of 4 residents (R2) reviewed for falls in the sample of 13. This failure resulted in R2 sustaining lacerations, a subarachnoid hemorrhage, and a hip fracture. Findings include: R2's current face sheet documents R2 was admitted on [DATE] with [DIAGNOSES REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documents R2 had severe cognitive impairment, ambulation did not occur, and needed extensive assist of 1 staff member for mobility in a wheelchair. R2's MDS, dated [DATE], documents R2 has severe cognitive impairment and requires limited assist of 1 for ambulation. R2's Care Plan, dated 12/20/15, documents resident exited facility requiring assist of 2 staff members to return him into facility. The Care Plan also documents resident was combative caused staff and resident to fall. The Care Plan documents R2 was sent to emergency room and admitted with a hip fracture. R2's Fall Risk Evaluations, dated 3/2/16, 6/6/16, 7/22/16, and 10/17/16 document R2 is considered high risk. The facility Occurrence Report for R2, dated 5/12/16 at 11:15 AM, documents, in part, Resident very agitated earlier in day and unable to redirect. Lorazepam administered, calmed. Resident placed in activities when fall occurred. Sent to ER (emergency room ) for lacerations. To prevent further occurrence place in front of activities. (fall occurred when activity staff had back towards resident). The facility follow up report, dated 5/12/16 and untimed, documents, in part, Returned to facility at 8:52 PM with subarachnoid hemorrhage, laceration to forehead skin tear to left elbow and Left hand. Family has been visiting and sits with him daily. Remains with agitation, 15 minutes checks continue. One on One as needed and provided (family and staff). The facility Occurrence Report for R2, dated 5/18/16 at 2:00 PM, documents, in part, Nurse Statement of other Contributing Factors: Resident found on floor in own bathroom head to toe assessment performed- 911 called. The Report continues, New Intervention check alarm is in place on bed and wheelchair. Do not leave alone in bathroom. R2 ' s Nurses Note, dated 05/18/2016 at 02:04 PM, (Recorded as Late Entry on 05/18/2016 10:04 PM) documents, Resident fell in bathroom in own room. Reopened laceration above left eye. Skin tear measuring 4 cm (centimeter) x 4 cm to left forearm. 1 cm x 1 cm skin tear to top of left hand. Neurological assessment completed. 911 contacted. POA (Power of Attorney) contacted. Resident sent to Hospital for evaluation & treatment. R2's Safety event, dated 6/6/16 at 6:06 AM, documents, Resident found on floor in dining room laying on back. Chair alarm sounding at the time. Full body assessment completed. Resident states ' no pain ' range of motion good in all extremities. Skin tear to forearm measuring 1 cm X 1 cm, cleansed with normal saline and steri-strips applied. Resident assisted to sitting position and then standing position. Able to take 3 steps without difficulty and sit in wheelchair. Alarm on and patent. 15 minute checks initiated. R2's Nurses Note, dated 6/6/16 at 1:51 PM, documents, in part, Resident complains of pain in right hip. ambulance here at 1 PM and took to emergency room . R2's Nurses Note, dated 6/6/16 at 8:29 PM, documents, Resident admitted to hospital with [DIAGNOSES REDACTED]. R2's Nurses Note, dated 7/3/16 at 4:59 PM, documents, in part, Found on floor in cafe. laceration to left forehead. Call to 911. R2's Nurses Note, dated 7/3/16 at 9:50 PM, documents, in part, Resident returned to facility at 9 PM with sutures to forehead. Preventive Measure Continue with monitoring/ use of personal alarm. R2's Safety event, dated 9/28/16 at 8:29 PM, documents, Resident slide out of w/c (wheelchair) in DR (dining room) at table and landed on R (right) knee as noted per staff. New Intervention Hospice contacted - tried another chair repositioned medicate when restless/ discuss with hospice to obtain different type of w/c cushion. R2's Safety event, dated 10/14/16 at 9:54 PM, documents, in part, Staff pushing resident in w/c out of dining room when resident leaned forward and slid off w/c seat onto floor lying on his right side. New Intervention Discuss with hospice of adjusting wheelchair. On 11/17/16 at 8:50 AM, E2 Director of Nurses (DON), stated, The 1/5/16 fall was nonwitnessed and we implemented a (lap top cushion), 15 minute checks and personal alarms. The 5/12/16 fall we implemented personal alarms, place where he would be seen at all times during activity, family involvement and a medication review. The 5/18/16 fall new intervention was to check alarms to make sure they are working, do not leave alone in bath and frequent 15 minute checks. E2 stated The alarm was sounding when found. The 6/6/16 fall happened at 5:30 AM, chair alarm was sounding he was in dining room. The night staff put him in dining room to redirect him with snack and drink with chair alarm on. He tried to stand up and fell . This resulted in a fractured right hip. E2 further stated, When (R2) came back, the interventions started all over again alarms, frequent checks and turn and reposition. The fall 9/28/16 at 8:35 AM, he was in the dining room because he was playing a puzzle and having a snack. The alarm was sounding when found. The new intervention was to get a different wheelchair cushion, medicate when restless and staff to do frequent checks to make sure he is safe. On 11/21/16 at 2:55 PM, E2 stated, I think the fall on 10/14/16, he was in a high back wheelchair and the girls couldn't reach him. On 11/21/16 at 2:55 PM, E3, MDS/Care Plan Coordinator, stated, I know we have tried a lot of different things with (R2) it ' s just not documented anywhere. (R2) is just so quick ,before you know it he is up and on the floor. On 11/22/16 at 10:55, Z2, Medical Director, stated, There are many reasons for (R2) falling. The most significant is his mental status. He is unable to process information. Despite our attempt, it is a struggle to keep him safe. That is why he needs to be at the Nurses Station so he can be watched. The facility ' s undated Fall Protocol policy and procedure documents, in part, Preventive measures will then be implemented for those residents assessed as moderate to high risk. These measures will be documented on the Plan of Care and/ or nurses notes. The Protocol continues, 8. Care Plans will be updated as appropriate within 3 days of a fall occurrence.