Every finding on record at Aliya of Palatine

Based on interviews and record review, the facility failed to follow the planned menu and failed to provide and document nutritionally equivalent substitutions when a menu item was unavailable. This failure affected one (R1) of four residents reviewed for dining. Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE] with a medical diagnosis that includes but is not limited to cirrhosis of the liver with ascites, hepatitis, hypertension, and hyponatremia. On the (MDS) Minimal Data Set assessment of 10/23/2025, section C, the BIMS (Brief Interviewed Mental Status) score was 14/15, indicating the resident is cognitively intact. During interview with R1 on 1/5/2026 at 9:15 AM R1 said, last week they (facility) did not have milk for two days, last Thursday and Friday, and someone finally went across the street to the local supermarket and got milk but only got 2% milk. Finally, we got milk on Saturday we were very happy. During interview on 1/5/2026, at 9:35 AM, V3 (Certified Nursing Assistant) on the second floor reported that the facility did not have milk for two days last week (Thursday and Friday), day shift, and the facility was aware of this. During interview on 1/5/2026 at 9:51 AM, V4 (Certified Nursing Assistant) usually works on the 2nd floor, but I am floating to the first floor today. V4 said that last week, on dayshift on Thursday and Friday, the facility did not serve milk because they did not have it. During interview on 1/5/2026 at 2:20 PM, V5 (Certified Nursing Assistant) said, I worked last Thursday (01/012025) PM shift, we did not have milk to serve residents. I was assigned to serve the dining room, and we did not have milk. I don't know when the facility received the milk. I work on the second shift. During interview on 1/5/2026 at 2:25 PM, V6 (Registered Dietitian) said, Food service manager will order the food and supplies, but any menu changes need to be approved by the dietitian, and we use the log to make substitutions, and I usually sign for the substitution and make sure the changes are done properly. I was not aware of any milk shortage, and I did not make any substitutions. If I knew of the shortage, I would have ordered yogurt or cottage cheese to replace the milk so residents would get their proper calcium consumption. During interview on 1/5/2026 at 3:00 PM, V7 (Dietary Manager) said, I placed the milk order, and I did not work Tuesday and Wednesday (12/30/25 and 12/31/25), and I was expecting the delivery, but I did not know that the delivery never came, when I got to the facility on Thursday, 1/1/26, I called, but it was a holiday. The bill was not processed on time for the delivery, and that is why we did not get milk. The milk arrived on Friday afternoon. V7(Dietary manager) confirmed that on 1/1/2026 and 1/2/2026, the facility did not have milk, and someone had to go out to purchase milk for Friday 1//2/2026 until the facility received the delivery. When we don't have an item in the menu, we make substitutions, and we will add the changes to the food log substitution, and the dietitian will review and sign off on the changes. We usually change a protein to another protein, a vegetable to another vegetable, and poultry to another poultry. Milk can be substituted with yogurt and cottage cheese. Surveyors requested the policy for menu changes and the process to order supplies in case they did not receive food items in a timely manner. V7 said, I have only been working for the facility for a month, and I will have the administrator provide that for you. V7 was not able to answer the question on the facility policies. V7 provided the food substitution log and verbalized that all the changes made for January 2026 were in the log. On record review of the food log substitution, it showed no changes were made for the missed milk for the 01/01/2026 and 1/02/2026 menu, and no substitutions were made or approved for the milk noted on the food substitution log. Milk is served at breakfast and dinner, 8 ounces each meal daily. 1/5/2026 12:10 PM during lunch observation, residents also requested milk with their meals per resident's preferences. 1/5/2026 at 3:04 PM V1 (Administrator) said, I do not have a policy on menu changes or substitution and said, I will check on it. V1 said I authorized myself to buy milk at a local supermarket and showed a receipt for six gallons of milk but was not able to see the details of the receipt on V1's phone. The surveyor requested a copy of the receipt, but none were provided for review. V1 said that the facility census is 63 residents, and milk is served for breakfast and dinner. V1 was questioned if the facility bought milk and why the residents did not receive milk for two days. V1 said, I can't answer why. Facility policy titled, On Tray Policies and Procedures Manual (2025 edition), reads in part: Policy: Menus are planned in advance and are followed as written to meet the nutritional needs of the residents. Menus are served as written unless changed due to an unpopular item on the menu, an item could not be procured, or in the event of a special meal. The dietary Manager/Registered dietitian documents the substitution. The dietary Manager, designee, or Registered Dietitian may substitute menu items. The Registered Dietitian should approve the menu substitution/ on the menu substitution form.

Based on interview and record review, the facility failed to follow its policy on conducting background checks for one (V11) of 10 employees reviewed for background checks. This failure has the potential to affect 61 residents currently residing in the facility. Findings include: Per census report, there are 61 residents currently residing in the facility. On 07/16/24 at 2:00pm V3 (Human Resources) completed background screening check for 10 employees. V3 stated, I cannot find the background check reports for V11 (Certified Nursing Assistant). V11 has been working here since 03/18/2024. V11 is missing the Illinois Sex offender and Department of Correction (DOC) sex Offender, DOC Inmate search, DOC wanted fugitive report, National Sex Offender report and Office of Inspector General (OIG) report. On 07/16/2024 at approximately 3:00 pm surveyor was provided with Illinois Sex offender and Department of Correction (DOC) sex Offender, DOC Inmate search, DOC wanted fugitive report, National Sex Offender report and Office of Inspector General (OIG) reports with search dates of 07/16/2024. On 07/17/24 at 10:15 AM V3 stated, I think I (V3) forgot to run V11's background checks. I do not have any other explanation. I am not sure how I let that slide by. I (V3) ran the background checks yesterday and provided them to you. On 07/17/24 at 10:19 AM Administrator (V1) stated, my expectation regarding background checks is that they are all completed prior to start date. On 07/17/24 at 3:41 PM V5 (Former Administrator/Administrator trainer) and (V1) Administrator stated, we do not have a background check policy. We go off the regulations. When asked what regulations they were unsure and said that they would have to check and get back to us. On 07/18/2024 at 8:23 AM (V1) provided the following link: https://www.dhs.state.il.us/page.aspx?item=48125 as what they follow for background check guidelines. This link contains PROFESSIONS, OCCUPATIONS, AND BUSINESS OPERATIONS (225 ILCS 46/) Health Care Worker Background Check Act. Which states in part: (d) On October 1, 2007 or as soon thereafter as is reasonably practical, in the discretion of the Director of Public Health, and thereafter, a health care employer who makes a conditional offer of employment to an applicant for a position as an employee shall initiate a fingerprint-based criminal history record check, requested by the Department of Public Health, on the applicant, if such a background check has not been previously conducted. Initiate means obtaining from a student, applicant, or employee his or her social security number, demographics, a disclosure statement, and an authorization for the Department of Public Health or its designee to request a fingerprint-based criminal history records check; transmitting this information electronically to the Department of Public Health; conducting Internet searches on certain web sites, including without limitation the Illinois Sex Offender Registry, the Department of Corrections' Sex Offender Search Engine, the Department of Corrections' Inmate Search Engine, the Department of Corrections Wanted Fugitives Search Engine, the National Sex Offender Public Registry, and the List of Excluded Individuals and Entities database on the website of the Health and Human Services Office of Inspector General to determine if the applicant has been adjudicated a sex offender, has been a prison inmate, or has committed Medicare or Medicaid fraud, or conducting similar searches as defined by rule; and having the student, applicant, or employee's fingerprints collected and transmitted electronically to the Illinois State Police. Health Care Worker Registry (HCWR) Clearance This clearance must be conducted at the time of hire and annually thereafter to confirm whether new hires or other employees have a criminal background check result reported to the HCWR. It will also confirm whether the person has a disqualifying criminal conviction, if criminal background check results are not reported on the HCWR for employees, they must immediately obtain a fingerprint criminal background check result using a livescan vendor approved by state agency.

Based on observation, interview and record review the facility failed to: 1) follow their policy and procedures for ensuring food is prepared and served under sanitary conditions by not using PPE (personal protective equipment) properly when serving food, 2) Ensure food items were labeled and dated per facility policy, 3) Ensure no expired foods, and 4) Ensure Staff wear hair restraint in kitchen area. This applies to 61 residents that receive oral nutrition and food prepared in the facility kitchen. Findings include: On [DATE] at 10:30 AM surveyor observed two bags of two-pound toasted oats cereal with expiration date [DATE]. On [DATE] 10:40 AM surveyor observed seven loaves of sliced wheat bread dated [DATE] in the storage with two loaves of wheat bread molded and soggy, and one loaf of sliced wheat bread molded on the table by the kitchen. On [DATE] at 11:00 AM surveyor observed two opened half bags of shred lettuce dated [DATE] brown and wilted in the refrigerated. V12 (Dietary Manager) stated, [DATE] is the received dates, there is no sold, consumed, or discarded dated on the bread or lettuce. On [DATE] at 10:45 V19 (Cook) said, expired food needs to be removed and discarded, I did not see the mold on the bread. V12 stated, it is expected that staff will check the date and remove expired food. On [DATE] at 12:00PM surveyor observed V12 serving food from the tray line without wearing gloves touching trays, utensils and clean plates and adjusting eye faces on her face. On [DATE] at 12:30 PM surveyor observed V12 helping place tickets on the trays, and receiving plates and adding bread to trays without wearing gloves and fingers were inside the clean plate with food. V12 touched her eyeglasses and touched the inside of the plates. On [DATE] at 11:30 PM surveyor observed V12 using hair restraints on the top of the head and hair exposed below her shoulders serving lunch to residents. On [DATE] at 12:05 PM surveyor observed V12 serving food on the tray line and removed her gloves and donned clean gloves on without hand hygiene. V12 moved to ticket section and receiving plate with food not wearing gloves and placing tickets on the tray and getting bread to place on the plates. V12 touched eyeglasses and plates without providing hand hygiene during. On [DATE] 02:00 PM V12 stated, I expect staff to wear hair restraints with all the hair inside, proper hand hygiene when changing gloves and wear glove when handling food. V12 said, I did not realize I touched my eyeglasses during food preparation and when I was getting the tickets. Hand hygiene needs to be done when gloves were removed. I expect the food to be dated and the cook to check dates prior to using any food and dispose any food that is expired. Food must be dated when they get to the facility and disposed when it is expired. On [DATE] at 01:00PM V20 (Infection Preventionist) stated, I expect staff to perform hand Hygiene before donning gloves and after removal of gloves and when hands are contaminated. Kitchen staff are expected to wear hair restraints in the kitchen. Hair is expected to be inside of the hair restraints. On [DATE] at 02:00 PM V2 (Director of Nursing) stated, I expect staff to do hand hygiene before donning gloves and after removing gloves, staff must wear hairnets when they are working in the kitchen, and food must be dated and expired food disposed. On [DATE] at 02:09 PM V5 (Former Administrator trainer) stated, I expect staff to wear hair restraints in the kitchen and, all food to be labeled with expiration dates and expired food to be discarded. Facility Policy Titled Labeling and Dating Foods (Date Marking) dated 2020. Which reads in part (but not limited to), 2- Date marking for refrigerated storage food items Unopened cases of refrigerated food items will be dated with the date the item was received into the facility and will be stored using the first in - first out method of rotation. Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in - first out method of rotation. Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date. Facility Policy Titled Food Storage (Dry, Refrigerated, and Frozen) dated 2020. Which reads in part (but not limited to), a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. b. Rotate products so the oldest are used first. Staff shall be instructed to use products with the earliest expiration date before those with a later expiration date. c. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. Facility Policy Titled Proper Hand Washing and Glove Use dated 2020. Which reads in part (but not limited to), 4- Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident. 5. Gloves are to be used whenever direct food contact is required. 6. Hands are washed before donning gloves and after removing gloves. Facility Policy Hair Restraints Dated 2020. Which reads in part (but not limited to), Hair restraints shall be worn by all Dining Services staff when in food production areas, dishwashing areas, or when serving food. Procedure: 1. Staff shall wear hair restraints in all food production, dishwashing, and serving areas.

Based on observation, interview and record review the facility failed to ensure safe and secure storage including proper temperature control of medications. The facility also failed to remove the opened and expired medication in the medication cabinet. These failures have the potential to affect all residents taking medication who reside in the facility. Findings include: On [DATE] at 10:03AM, second floor medication room checked with V8 LPN (License Practical Nurse). Observed medication refrigerator unlocked. V8 said that she did not leave it unlocked. She did not check this morning the refrigerator when she came in to work. The night shift usually checks the refrigerator temperature daily. The following medications found inside the refrigerator: Morphine sulfate oral solution 100mg/5ml, rectal suppositories and (2) Tuberculin (Aplisol) vials. V8 read refrigerator temperature at 32F. V8 does not know what the normal ranges for medication refrigerator temperature is. Review of the daily refrigerator temperature log binder [DATE] incomplete daily monitoring log found inside the binder. No monitoring log for this month of September. Checked medications house stock supplies in the cabinet. Found opened, not dated, and expired Antacid medication (Geri-lanta) 12 fluid ounces expired [DATE]. V8 said she does not know who placed the opened and expired medication inside the cabinet with house stock medications. V8 said expired medication should be returned to pharmacy. She took the medication and placed in the bag labeled return to pharmacy. V8 called V2 DON (Director of Nursing). On [DATE] at 10:25AM, informed V2 DON of above observations. V2 said that nurses should lock the medication refrigerator, monitor, and record the medication refrigerator temperature daily and return the expired medication to the pharmacy. On [DATE] at 12:47PM, first floor medication room checked with V9 RN (Registered Nurse). Observed medication refrigerator unlocked. V9 said that he did not check the medication refrigerator this morning when he came to work. V9 said that the night shift is the one who checks the medication refrigerator. The following medications found inside the refrigerator: (2) morphine sulfate oral solution, (2) lorazepam oral solution, (8) pen insulins, (2) Tuberculin (Aplisol) vials, (6) eye solutions and rectal suppositories. V9 read the temperature inside the refrigerator at 31F. Noted normal refrigerator temperature ranges posted outside the refrigerator is at 36 to 46F. V9 said he cannot find the refrigerator temperature monitoring binder. V9 said the night shift is the one monitoring the daily refrigerator temperature. V9 said the medication refrigerator temperature monitoring binder should be in the medication room. V9 called V2 DON. On [DATE] at 12:59PM, Informed V2 DON of above observations. V2 tried to look for the medication refrigerator temperature monitoring binder but was unable to locate it in the med room. V2 said that the medication refrigerator temperature should be monitored daily, and the binder should be in the medication room. The Refrigerator temperature should be at 36 to 46 F. On [DATE] at 2:44PM, V2 DON presented first floor medication refrigerator temperature daily monitoring binder for 2023. Reviewed monitoring log with V2. Noted missing monitoring log for month of August, June, May, April, Incomplete log for month of July, March, February, and January. V2 said she will give in-services to her nurses regarding completion of daily medication refrigeration temperature monitoring log, securing/locking medication refrigerator and returning expired medication to pharmacy. Facility's policy on Medication Storage Revised date [DATE] indicates: Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes, and needles. Guidelines: 3. General storage procedures: Facility should store Schedule II Controlled Substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment 3.2 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier. 11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. 11.2 Refrigeration: 36F to 46F or 2C to 8C 12. Controlled substance storage: 12.2 After receiving controlled substance and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area and double locked.

Based on observation, interview and record review the facility failed to remove gloves and perform hand hygiene before exiting the isolation room. This deficiency affects one (R43) of one resident in the sample of 19 reviewed for Infection control on isolation precaution. Findings include: On 9/5/23 at 10:40AM, observed V8 LPN (Licensed Practical Nurse) came out from R43's isolation room with gloves on, tried to open the medication room and then she went back to the isolation room. R43 is on isolation set up, droplet contact precaution posted outside the door. R43 has capped tracheostomy and suprapubic catheter. On 9/5/23 at 10:45AM informed V8 LPN of above observation. V8 said that she was putting water in the humidifier oxygen of R43. V8 said she removed the isolation gown but forgot to remove her gloves and wash her hands before she left the isolation room. V8 said that R43 is on isolation precaution. R43 is currently on antibiotic (Bactrim DS) for Urinary Tract Infection. R43 has history of ESBL in wound. On 9/5/23 at 11:00AM, informed V2 DON (Director of Nursing) of above observation. V2 said staff should remove personal protective equipment such as gown, mask, gloves and perform hand hygiene when leaving the isolation room. Facility's policy on Hand Hygiene/Handwashing 1/10/2018 indicates: Definition: Hand Hygiene means cleaning your hands by using either hand washing (washing hands with soap and water), antiseptic hand wash, pr antiseptic hand rub ( i,e alcohol -based hand sanitizer including foam or gel) Guidelines: Example of When to perform hand hygiene (either alcohol-based hand sanitizer or handwashing): *After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient *After glove removal Facility's poster for isolation room indicates: Before leaving the isolation room, please make sure to: 1. Remove gloves 2. Remove Gown 3. Exit room 4. Perform hand hygiene using hand sanitizer. Facility's policy on Infection Precaution Guidelines 5/15/23 indicates: Guidelines: It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility using isolation precaution. Transmission-Based Precaution will be employed for known or suspected infections for which the route of the transmission/prevention is known. The transmission-based categories are the following: *Contact *Droplet Points to remember: *Hand washing (Hand hygiene) is the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact and after contact with resident belongings and equipment. Alcohol based hand rub may be used if hands are not visibly soiled. *All personal protective equipment (disposable, isolation gowns, mask, gloves, etc.) should be used once and discarded in either the trash or used linen receptacle before you leave the room Precaution signs will be utilized to alert staff and visitors to see the nurse for instructions prior to entering room.

Based on observation, interview and record review the facility failed to provide privacy when administering an injection to a resident. This deficiency affects one (R28) of 13 residents in the sample of 19 reviewed for privacy during medication administration. Findings include: On 9/5/23 at 4:24PM, V10 LPN (Licensed Practical Nurse) prepared medication for R28. V10 said that R28's peripheral blood sugar test is 282. V10 said that R28 has sliding scale of Humalog insulin. R28 will receive 6 units. R28 has also scheduled Humalog insulin at 10 units. R29 will receive total dose of 16 units of Humalog insulin. V10 prepared 16 units of insulin. V10 LPN administered the insulin injection subcutaneously to R28's left upper arm. V10 did not close the door or pull the curtain drape in between the room where the roommate is present and looking at V10 giving injection to R28. On 9/5/23 at 4:37PM, Informed V10 LPN of above observation. V10 said she forgot to close the door and to pull the curtain drape. V10 said she should provide privacy when giving injection to resident. On 9/6/23 at 1:01PM, Informed V2 DON (Director of Nursing) of above observation. V2 said the nurse should provide privacy when administering injection to the resident. Facility's policy on Resident Rights 1/14/2019 indicates: Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems, and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Guidelines: Notice of resident rights will be provided upon admission to facility. These rights include the resident's right to: * Privacy and confidentiality. Facility's policy on Medication Administration General indicates: Policy: Medications are administered as prescribed in accordance with good nursing principles and only by persons legally authorized to do so. Personnel authorized to administered medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration).

Based on observation, interview and record review the facility failed to provide foot care and treatment to resident who is totally dependent. The facility also failed to carry out and implement a podiatrist recommendation order. This deficiency affects one (R43) of three residents in the sample of 19 reviewed for foot care. Findings include: On 9/6/23 at 10:10AM observed R43's feet with V2 DON (Director of Nursing) and V12 Nurse Practitioner Wound Care (NPWC). Left foot has dark discoloration scab on great toe. Toenails has dark discoloration, long and thick. The entire foot is dry and scaly. Right foot has dark discoloration thick long toenails. The second toe over [NAME] over great toe. The entire right foot is dry and scaly. V12 NPWC said R43 need to be seen by podiatrist. On 9/6/23 at 10:28AM, review of R43's medical records with V5 Resident Assessment/Care plan Coordinator. R43 was admitted on [DATE] with diagnosis listed in part but not limited to Quadriplegia, Muscle wasting and atrophy. V5 said that R43 is totally dependent with ADLs (Activity with Daily living). R43's Quarterly Minimal Date Assessment (MDS)/Resident assessment dated [DATE] indicated he is totally dependent with ADLs and Transfers. Section G: Functional Status: 1. ADL self-performance coding- 4 Total dependence; 2. ADL support provided- 3 Two+(plus) persons physical assist. No care plan addressing his needs for foot care. On 9/7/23 at 10:30AM, V1 Administrator said they don't have a policy on Podiatrist care and referral. On 9/7/23 at 11:02AM, V1 Administrator presented copy of Podiatrist notes dated 6/9/23 which indicated: This [AGE] year-old male present with calluses, toenails that are difficult to cut and skin is dry and flaky. Orthopedic Exam: Contracted digit feet bilateral, arthritis feet bilateral. Difficulty in walking, muscle weakness. Treatment: Manual debridement by use of nail clippers to debride all fungal nails to decrease pain and risk as required by medical necessity. Podiatric professional is needed to avoid possible infection. Xerosis treatment: Feet bilateral- Full exam performed. Removed skin flakes. Applied Aquaphor ointment to bilateral lower legs and feet. Recommended the use of skin protectant daily (Aquaphor or Vitamin A and D ointment) or coconut oil to bilateral lower legs and feet. Patient to see again in 2 months. R43's podiatrist notes reviewed with V1. Informed that podiatrist recommendation was not carried out and implemented by the facility. On 9/7/23 at 11:30AM, V2 DON said that after the podiatrist treated the resident, he will talk to the floor nurse about his treatment plan. The floor nurse should carry out and implement treatment ordered. Facility's policy on Foot Care indicates: Purposes: To provide comfort and prevent infection of the feet.

Based on observation, interview and record review the facility failed to monitor and record fluid intake of resident who is on push fluids as ordered due to dehydration. This deficiency affects one (R63) of three residents in the sample of 19 reviewed for ensuring proper Hydration. Findings include: On 9/5/23 at 9:03AM, observed R63 in the dining room in recliner chair. V8 LPN (Licensed Practical Nurse) said R63 is totally dependent with ADLs (Activity with daily living) and transfers. On 9/6/23 at 10:28AM, review of R63's medical records with V5 Resident Assessment/Care plan Coordinator. R63 was admitted on [DATE] with diagnosis listed in part but not limited to Traumatic hemorrhage of Cerebrum with loss of consciousness, and Dysphagia. Physician order sheet (POS) indicates he is on pureed texture, honey consistency diet. Push fluids every shift ordered on 9/1/23. No documentation found for monitoring of fluid intake. V8 said there is no documentation in R63's chart of monitoring and recording of his fluid intake. V8 said for residents with orders of push fluid, the nurses and CNAs should monitor and record the fluid intake. R63's Nurse Practitioner Cardiologist consultation dated 9/1/23 indicated: Plan: 5. AKI (Acute Kidney Injury): Recent creatinine level elevated-1.8, BUN (Blood Urea Nitrogen) elevated-42 possibly due to dehydration. Recommending push fluids. Avoid nephrotoxins. We will monitor BMP (Basic Metabolic Profile). Requested for policy on Push Fluids. On 9/6/23 at 2:00PM, R63's blood test (BMP) dated 9/6/23 results indicated: Creatinine elevated -2.0, BUN elevated- 42. Nurse Practitioner notified by staff with new orders: fluid every shift, Sodium Chloride Intravenous solution 0.45% (Sodium Chloride) use 50ml intravenously every shift for dehydration order to give 1000ml 50ml/hr. On 9/7/23 at 9:30AM, V2 DON (Director of Nursing) said they don't have a policy on Push Fluids. V2 said the nurses and CNAs should monitor and record R63's fluid intake. Facility is unable to provide policy.

Based on observation, interview and record review the facility failed to obtain physician's order for oxygen and tracheotomy care management for a resident who has tracheostomy capped and using oxygen via nasal cannula. The facility failed to ensure that there is water in the humidifier bottle. This deficiency affects one (R43) of one resident in the sample of 19 reviewed for Respiratory care. Findings include: On 9/5/23 at 10:38AM, R43 observed lying in bed with oxygen at 3.5 LPM (Liters per minute) via NC (Nasal Cannula) connected to oxygen concentrator with V8 LPN (Licensed Practical Nurse). Noted emptied and dried humidifier bottle. Oxygen tubing is not dated. V8 said that she forgot to check this morning when she made her rounds. V8 said there should be water in the humidified bottle to prevent nasal dryness. No manual resuscitator at bedside. R43 has capped tracheostomy. On 9/6/23 at 10:58AM, review of R43's medical records with V5 Resident Assessment/Care Plan Coordinator. R43 was readmitted on [DATE] with diagnosis listed in part but not limited to Acute Respiratory Failure, Quadriplegia, Paralysis of Vocal Cords, and larynx. No order of oxygen via nasal cannula and tracheostomy care management on the POS (Physician Order Sheet). V5 said there should be an order of oxygen in his POS and tracheostomy care management. The oxygen tubing should be dated and changed weekly. The nurse should check the level of water in the humidity bottle. On 9/6/23 at 1:01PM Informed V2 DON (Director of Nursing) of above concerns. V2 said tracheostomy care should be performed every shift. There should be an order for oxygen usage and tracheostomy care management. The nurse should check the water level in the humidifier. The oxygen tubing and humidifier bottle should be changed weekly and dated. Facility's policy on Oxygen Concentrator indicates: Purpose: To provide oxygen for therapeutic use by utilizing a concentrator that converts ambient air to a higher concentration of level of oxygen. It is commonly used to provide oxygen therapy. Oxygen concentrators are the least expensive, more convenient, and safe options to compressed oxygen in metal tanks. Equipment needed: 3) Humidifier device 4) Nasal Cannula Procedure: 1) Verify and understand the physician's order. 2) Know the flow rate and duration of use. 8) If prescribed, attach the humidifier bottle to the oxygen outlet connection, and ensure there is water in the bottle Daily Maintenance: 1) Check the water level in the humidity bottle. Change the bottle as needed or every 7 days. Facility's policy on Tracheostomy Care indicates: Policy: Tracheostomy care should be performed once per shift or as often as required to maintain patency of the airway and minimize the risk of infection. Tracheostomy tube cuffs will be continuously deflated unless otherwise ordered by the physician. When the tracheostomy tube is fenestrated, the inner cannula is to be in place during suctioning or manually ventilating. Depending upon the physician's order/feeding policy, the inner cannula should be in during feeding and for thirty minutes afterwards. A replacement tracheostomy tube is to be always kept at bedside, clearly visible.

Based on observation, interview, and record review the facility failed to ensure residents did not smoke/vape in the facility. This failure applied to one (R2) of one resident reviewed for supervision. The findings include: On 4/8/23 at 8:05 AM, there was a strong smell of marijuana on the first floor upon exiting the elevator. At 1:25 PM, V6 Nurse showed this surveyor R2's vape pen stored in the medication cart. The pen was a nicotine pen and did not smell of marijuana. On 4/8/23 at 8:58 AM, V2 Director of Nursing (DON) stated we keep taking away a vape pen from a resident identified as R2. R2's nicotine vape pen smelled like marijuana, so we keep it in the nurse's cart. V2 was notified by this surveyor that the second floor smelled of marijuana at 8:05 AM today. V2 stated R2 probably has another vape pen. R3 and R7 smoke cigarettes and go outside to smoke. Smoking hours are 7-8 or 8-8. At 9:56 AM, R4 stated, It already started this morning. I smell marijuana on the first floor. R4 stated that R2 smokes in her room and sprays air freshener or opens her window. I know the smell of it. I was around it at home and used to smoke it to help with a chronic medical condition. At 10:13 AM, R5 stated there's a marijuana smell in the hall. It happens when there's no Administrator or anyone in the building. I think it comes through the air vent outside our room. R2 is doing it (mentioned her by name). She has shown it to me before. She smokes joints and smokes it out of a vape. I know the smell of pot. My son smokes it. She does not go out at smoking times. It's highly dangerous. We have oxygen on this floor, and she smokes it in her room. I told the Administrator about the concerns of marijuana smoking in the building. She said she'll look into it. Some other residents are afraid to say anything about the pot smoking bothering them. They're afraid of her (R2). At 10:21 AM, R6 stated I have trouble breathing. I use that machine at night. Just talking to R2 you can smell it (marijuana) on her breath. I can smell it in the hallway. It's offensive. It aggravates my breathing. She smokes it almost every day. V1 Administrator and V2 DON talked to her about it. R2 is the only pot smoker here. She does not go outside to smoke her pot. She should go outside to do it. At 10:36 AM, R3 stated there's only two people who go out to smoke here, me and another guy (R7). At 10:55 AM, V4 Certified Nursing Assistant (CNA) stated I smell marijuana when I work here. I usually work on the weekends, and I smelled it this morning. At 1:15 PM, V3 Certified Nursing Assistant stated R3 and R7 are the only two residents who go outside to smoke. At 1:20 PM, R7 stated he and R3 are the only two resident who go outside to smoke. R7 stated R2 has a vape and you can't smell it, so she doesn't go outside. At 1:25 PM, V6 nurse stated R2's vape pen is kept in the medication cart. R2 has not taken it all day. At 2:00 PM, V1 Administrator and V2 Director of Nursing were unable to explain why R2 never goes outside to smoke. The facility's 3/13/23 Resident Council Meeting Minutes showed a resident stated they could smell someone smoking marijuana and the smell upsets her. A 4/7/23 grievance by R4 reporting R2 had a weed smell like. R2 denied the allegation. The grievance was not substantiated. There was no evidence other residents were interviewed for the investigation. The facility's 10/24/22 Smoking Safety Policy showed a Smoking Safety Assessment will be completed to determine the level of assistance and supervision needed during smoking, the ability to carry and store smoking materials, and if a smoking apron is indicated. The plan of care shall reflect the results of this assessment. This assessment will be completed upon admission, quarterly and with significant change. If a resident chooses to smoke electronic cigarettes (e-cigarettes, vapes, vaporizers, vape pens etc.,) they must smoke them in designated smoking areas outside. A Smoking Safety Assessment will be completed to ensure that the resident is capable of safe storage, charging and use of the electronic cigarette or vaping device. Individuals who are non-compliant, potentially dangerous, exercise poor judgement, and show a lack of concern for the welfare of others will be counseled accordingly. The facility maintains the right to limit and restrict access to smoking products, matches, and lighters for persons deemed unsafe. Smoking privileges will be revoked if there is a pattern of persistent, hazardous behavior. No resident may smoke near/around oxygen. The following behaviors and/or conditions will jeopardize and/or cause revocation of the person's independent privileges: Smoking in any non-designated area, such as resident rooms .Consequences of non-compliance: Residents will be instructed, educated and counseled about their inappropriate behavior. Safe, appropriate behavior will be stressed. Documentation will be entered into the record accordingly. Further incidents of non-compliance may result in loss of independent privileges which means smoking materials will be turned over to a designated staff member., held in a secure location and the resident will only be allowed to smoke when supervised by a responsible individual (i.e , staff member, family, friend) and at the discretion of the organization. Behavior determined to be potentially harmful may jeopardize the person's ability to remain in the health care facility. The facility may exercise its right to involuntarily discharge such individuals. The facility recognizes the potential harm that may result from careless, hazardous smoking and has implemented this policy to maintain a safe living environment. Violation of this policy will be taken seriously, and appropriate action will be forthcoming.

Based on interview and record review, the facility failed to ensure a resident was treated with dignity after requesting to be changed prior to outside appointment. This affected 1 of 3 residents (R2) reviewed for dignity. This failure resulted in R2 arriving soiled at the outside medical appointment being soiled with feces, having to be changed by outside office staff, wearing a gown because the clothes were soiled, and having feelings of embarrassment, humiliation, and powerlessness. Findings include: On 3-15-23 at 10:00 AM, R2 told surveyor about concerns of R2 asking V7 Certified Nursing Assistant (CNA) to be changed (due to bowel movement) prior to her transport to outside appointment. R2 stated the CNA refused to change her at that time because CNA said she had other residents to attend to. R2 stated she went to her outside appointment soiled with bowel movement. The office had to clean R2 up and changed R2 into a hospital gown because R2's clothes were soiled. R2 returned to the facility in a gown. R2 was noted in gown by 2nd shift nurse. V7 had already left for the day. R2 stated she felt humiliated, embarrassed, and helpless. R2 told Human Resources (HR) about this incident on Sunday. HR told R2 that she will speak to V7. R2 stated HR did not get back to R2 regarding this incident. R2 stated she would like to share this info with new Administrator and new Director of Nursing (DON). On 3-15-23 11:29 AM, V1 (Administrator-previous) stated R2 is alert, oriented times 3-4, and able to make her needs known. R2 has history of confabulation and making up stories. V1 stated HR told V1 R2 asked to be changed and transportation was there and R2 did not want to miss transportation to her appointment so R2 went to appointment dirty because she did not want to miss her ride. V1 stated she did not talk to R2 directly. V1 told HR to make sure R2 will be changed prior to all outside appointments. The facility would not send a resident out to appointment dirty or soiled. V1 stated neglect is intentionally holding back care when requested. On 3-15-23 at 1:05 PM, V12 (Administrator-new) said neglect is willfully refusing to provide care to resident who needs it. V12 stated the facility would change the resident prior to outside appointment and ensure the resident is presentable outside the facility. On 3-15-23 at 10:35 AM, V7 (CNA) stated around 9:05 AM, V7 stated she was with another resident and R2 asked V7 for another brief change. V7 stated yes but said she will finish with the resident and R2 will be next. V7 stated R2 was agreeable. V7 stated she saw R2's ride in the parking lot and said she cannot change R2 because she needs to go with transportation. V7 stated R2 will take more than 20 minutes for a change. R2 was agreeable to going to her appointment at that time. On 3-15-23 at 10:46 AM, V8 Registered Nurse (RN) stated she was aware R2 had an outside appointment. V8 stated she saw R2 wearing a hospital gown over her shirt and pants when she returned from the outside appointment. V8 asked R2 how the visit went and R2 requested a pain pill. V8 stated R2 is dependent for care and R2 can ask for help. V8 stated R2 would know when she needs to be changed. V8 stated it can take some time for R2 to be changed. R2 requires mechanical lift and two staff. V8 stated it can take almost 30 minutes or longer to change R2 depending on the situation. V8 stated if a resident asks to be changed, V8 would change resident because she is alert enough to know she needs to be changed. V8 stated neglect is something you can do but not do, like a CNA not changing a resident when needed. Abuse Prevention and Reporting- Illinois Policy reviewed 4-14-22 documents: Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident proper, and exploitation. Definitions: Neglect is defined as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on interview and record review, the facility failed to ensure a resident was treated with dignity after requesting to be changed prior to outside appointment. This affected 1 of 3 residents (R2) reviewed for dignity. This failure resulted in R2 arriving soiled at the outside medical appointment being soiled with feces, having to be changed by outside office staff, wearing a gown because the clothes were soiled, and having feelings of embarrassment, humiliation, and powerlessness. Findings include: On 3-15-23 at 10:00 AM, R2 told surveyor about concerns of R2 asking V7 Certified Nursing Assistant (CNA) to be changed (due to bowel movement) prior to her transport to outside appointment. R2 stated the CNA refused to change her at that time because CNA said she had other residents to attend to. R2 stated she went to her outside appointment soiled with bowel movement. The office had to clean R2 up and changed R2 into a hospital gown because R2's clothes were soiled. R2 returned to the facility in a gown. R2 was noted in gown by 2nd shift nurse. V7 had already left for the day. R2 stated she felt humiliated, embarrassed, and helpless. R2 told Human Resources (HR) about this incident on Sunday. HR told R2 that she will speak to V7. R2 stated HR did not get back to R2 regarding this incident. R2 stated she would like to share this info with new Administrator and new Director of Nursing (DON). On 3-15-23 11:29 AM, V1 (Administrator-previous) stated R2 is alert, oriented times 3-4, and able to make her needs known. R2 has history of confabulation and making up stories. V1 stated HR told V1 R2 asked to be changed and transportation was there and R2 did not want to miss transportation to her appointment so R2 went to appointment dirty because she did not want to miss her ride. V1 stated she did not talk to R2 directly. V1 told HR to make sure R2 will be changed prior to all outside appointments. The facility would not send a resident out to appointment dirty or soiled. V1 stated neglect is intentionally holding back care when requested. On 3-15-23 at 1:05 PM, V12 (Administrator-new) said neglect is willfully refusing to provide care to resident who needs it. V12 stated the facility would change the resident prior to outside appointment and ensure the resident is presentable outside the facility. On 3-15-23 at 10:35 AM, V7 (CNA) stated around 9:05 AM, V7 stated she was with another resident and R2 asked V7 for another brief change. V7 stated yes but said she will finish with the resident and R2 will be next. V7 stated R2 was agreeable. V7 stated she saw R2's ride in the parking lot and said she cannot change R2 because she needs to go with transportation. V7 stated R2 will take more than 20 minutes for a change. R2 was agreeable to going to her appointment at that time. On 3-15-23 at 10:46 AM, V8 Registered Nurse (RN) stated she was aware R2 had an outside appointment. V8 stated she saw R2 wearing a hospital gown over her shirt and pants when she returned from the outside appointment. V8 asked R2 how the visit went and R2 requested a pain pill. V8 stated R2 is dependent for care and R2 can ask for help. V8 stated R2 would know when she needs to be changed. V8 stated it can take some time for R2 to be changed. R2 requires mechanical lift and two staff. V8 stated it can take almost 30 minutes or longer to change R2 depending on the situation. V8 stated if a resident asks to be changed, V8 would change resident because she is alert enough to know she needs to be changed. V8 stated neglect is something you can do but not do, like a CNA not changing a resident when needed. Abuse Prevention and Reporting- Illinois Policy reviewed 4-14-22 documents: Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident proper, and exploitation. Definitions: Neglect is defined as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on interview and record review, the facility neglected to change a resident who requested to be changed and was changed prior to an outside appointment. This affected 1of 3 residents (R2) reviewed for neglect. This failure resulted in R2 arriving at the outside medical appointment being soiled with an old bowel movement. R2 reflected on being embarrassed, humiliated and powerless. Findings include: On 3-15-23 at 10:00 AM, R2 told surveyor about concerns of R2 asking V7 Certified Nursing Assistant (CNA) to be changed (due to bowel movement) prior to her transport to outside appointment. R2 stated the CNA refused to change her at that time because CNA said she had other residents to attend to. R2 stated she went to her outside appointment soiled with bowel movement. The office had to clean R2 up and changed R2 into a hospital gown because R2's clothes were soiled. R2 returned to the facility in a gown. R2 was noted in gown by 2nd shift nurse. V7 had already left for the day. R2 stated she felt humiliated, embarrassed, and helpless. R2 told Human Resources (HR) about this incident on Sunday. HR told R2 that she will speak to V7. R2 stated HR did not get back to R2 regarding this incident. R2 stated she would like to share this info with new Administrator and new Director of Nursing (DON). On 3-15-23 11:29 AM, V1 (Administrator-previous) stated R2 is alert, oriented times 3-4, and able to make her needs known. R2 has history of confabulation and making up stories. V1 stated HR told V1 R2 asked to be changed and transportation was there and R2 did not want to miss transportation to her appointment so R2 went to appointment dirty because she did not want to miss her ride. V1 stated she did not talk to R2 directly. V1 told HR to make sure R2 will be changed prior to all outside appointments. The facility would not send a resident out to appointment dirty or soiled. V1 stated neglect is intentionally holding back care when requested. On 3-15-23 at 1:05 PM, V12 (Administrator-new) said neglect is willfully refusing to provide care to resident who needs it. V12 stated the facility would change the resident prior to outside appointment and ensure the resident is presentable outside the facility. On 3-15-23 at 10:35 AM, V7 (CNA) stated around 9:05 AM, V7 stated she was with another resident and R2 asked V7 for another brief change. V7 stated yes but said she will finish with the resident and R2 will be next. V7 stated R2 was agreeable. V7 stated she saw R2's ride in the parking lot and said she cannot change R2 because she needs to go with transportation. V7 stated R2 will take more than 20 minutes for a change. R2 was agreeable to going to her appointment at that time. On 3-15-23 at 10:46 AM, V8 Registered Nurse (RN) stated she was aware R2 had an outside appointment. V8 stated she saw R2 wearing a hospital gown over her shirt and pants when she returned from the outside appointment. V8 asked R2 how the visit went and R2 requested a pain pill. V8 stated R2 is dependent for care and R2 can ask for help. V8 stated R2 would know when she needs to be changed. V8 stated it can take some time for R2 to be changed. R2 requires mechanical lift and two staff. V8 stated it can take almost 30 minutes or longer to change R2 depending on the situation. V8 stated if a resident asks to be changed, V8 would change resident because she is alert enough to know she needs to be changed. V8 stated neglect is something you can do but not do, like a CNA not changing a resident when needed. Abuse Prevention and Reporting- Illinois Policy reviewed 4-14-22 documents: Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident proper, and exploitation. Definitions: Neglect is defined as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on interview and record review, the facility neglected to change a resident who requested to be changed and was changed prior to an outside appointment. This affected 1of 3 residents (R2) reviewed for neglect. This failure resulted in R2 arriving at the outside medical appointment being soiled with an old bowel movement. R2 reflected on being embarrassed, humiliated and powerless. Findings include: On 3-15-23 at 10:00 AM, R2 told surveyor about concerns of R2 asking V7 Certified Nursing Assistant (CNA) to be changed (due to bowel movement) prior to her transport to outside appointment. R2 stated the CNA refused to change her at that time because CNA said she had other residents to attend to. R2 stated she went to her outside appointment soiled with bowel movement. The office had to clean R2 up and changed R2 into a hospital gown because R2's clothes were soiled. R2 returned to the facility in a gown. R2 was noted in gown by 2nd shift nurse. V7 had already left for the day. R2 stated she felt humiliated, embarrassed, and helpless. R2 told Human Resources (HR) about this incident on Sunday. HR told R2 that she will speak to V7. R2 stated HR did not get back to R2 regarding this incident. R2 stated she would like to share this info with new Administrator and new Director of Nursing (DON). On 3-15-23 11:29 AM, V1 (Administrator-previous) stated R2 is alert, oriented times 3-4, and able to make her needs known. R2 has history of confabulation and making up stories. V1 stated HR told V1 R2 asked to be changed and transportation was there and R2 did not want to miss transportation to her appointment so R2 went to appointment dirty because she did not want to miss her ride. V1 stated she did not talk to R2 directly. V1 told HR to make sure R2 will be changed prior to all outside appointments. The facility would not send a resident out to appointment dirty or soiled. V1 stated neglect is intentionally holding back care when requested. On 3-15-23 at 1:05 PM, V12 (Administrator-new) said neglect is willfully refusing to provide care to resident who needs it. V12 stated the facility would change the resident prior to outside appointment and ensure the resident is presentable outside the facility. On 3-15-23 at 10:35 AM, V7 (CNA) stated around 9:05 AM, V7 stated she was with another resident and R2 asked V7 for another brief change. V7 stated yes but said she will finish with the resident and R2 will be next. V7 stated R2 was agreeable. V7 stated she saw R2's ride in the parking lot and said she cannot change R2 because she needs to go with transportation. V7 stated R2 will take more than 20 minutes for a change. R2 was agreeable to going to her appointment at that time. On 3-15-23 at 10:46 AM, V8 Registered Nurse (RN) stated she was aware R2 had an outside appointment. V8 stated she saw R2 wearing a hospital gown over her shirt and pants when she returned from the outside appointment. V8 asked R2 how the visit went and R2 requested a pain pill. V8 stated R2 is dependent for care and R2 can ask for help. V8 stated R2 would know when she needs to be changed. V8 stated it can take some time for R2 to be changed. R2 requires mechanical lift and two staff. V8 stated it can take almost 30 minutes or longer to change R2 depending on the situation. V8 stated if a resident asks to be changed, V8 would change resident because she is alert enough to know she needs to be changed. V8 stated neglect is something you can do but not do, like a CNA not changing a resident when needed. Abuse Prevention and Reporting- Illinois Policy reviewed 4-14-22 documents: Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident proper, and exploitation. Definitions: Neglect is defined as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interview and record review the facility failed to implement its policy on Abuse Prevention by failure to assess residents for abuse/neglect screening upon admission. The facility failed to care plan residents who are identified as risk for abuse /neglect. The facility also failed to formulate abuse care plan for resident who has an abuse allegation incident. This failure affects all five (R2, R3, R4, R5 and R6) residents reviewed for Abuse Prevention Program. Findings include: R2 was admitted to the facility on [DATE] with diagnosis listed in part but not limited to cerebral palsy, functional quadriplegia, morbid obesity, depression, anxiety disorder. Surveyor notes no admission abuse/neglect screening assessment done upon admission. On 2/28/23 at 10:27am, R2 was observed propelling herself in her wheelchair. R2 is alert, oriented, and able to express herself to staff. R2 stated she was admitted last year December 2022. R2 stated that R3 has been sexually harassing her since December. R2 stated R3 has been expressing his inappropriate sexual comments to her like give him some head, come to him and jack him off, work his $20 dollar and he could give extra. R2 reported it to V3 Resident Services Director (RSD) and V1 Administrator. R2 stated that she still sees him on the unit, but he (R3) is not allowed to talk to her or come near her. R2 stated that she feels safe in the facility. R2's abuse/neglect screening assessment completed on 2/8/23 by V3 RSD indicated low risk. R2 reported that R3 was making sexual inappropriate comments toward her. Upon interview, she stated she is not afraid of R3 and that she feels safe here and I just want him to stop saying that stuff because it's gross. V3 RSD did not formulate Abuse prevention care plan after completing abuse/neglect screening done. R2's inappropriate sexual abuse allegation reported to IDPH dated 2/8/23 indicates: R2 informed V1 that she feels uncomfortable with comments that R3 makes to her. R2 stated that on 2/7/23 around 9pm she was sitting in the TV room with two other male residents, and they were talking and joking with each other, when R3 told her Give me some head. R2 stated that she feels uncomfortable, and she wants him to stop saying any inappropriate comments. R2 stated no staff was around when the incident happened. Conclusion: The verbal comment cannot be substantiated. R3 thought they all were joking around at that moment and no intention to harm or make R2 feel uncomfortable, it's a misunderstanding. R2 is not afraid of R3 and feels safe in the facility. R2 and R3 will continue to receive psychiatric services. Immediate actions for the residents involved: R2 will continue to monitor resident and be seen and followed by the psychiatrist and psychologist. R3 was seen by the psychiatrist with medication changes and educated regarding unnecessary inappropriate comments. R3 verbalized understanding and importance of it. R3's care plan was not updated after the abuse allegation investigation. On 3/1/23 at 11:23am, V3 Resident Services Director stated that she does the abuse/neglect screening assessment upon admission, annually and if there is an abuse or allegation. She stated she only care plans for abuse prevention those who are moderate risk and high risk. She does not care plan those who triggered for low risk of abuse. V3 stated she does not know if they have a policy or procedure guidelines for completing abuse/neglect screening assessment. Surveyor informed V3 of the concern identified with R1 that no abuse screening assessment was done upon admission and no abuse prevention care plan was initiated after R2 made inappropriate sexual remarks allegation against R3. V3 stated she thought she did it, she might have forgotten it. On 3/1/23 at 11:46am, V1 Administrator said that Abuse and neglect screening assessment is done upon admission, annual and as needed if there is an abuse incident or allegation. V1 said that any mark yes will trigger risk and should be care plan for abuse prevention. V1 said that they don't have specific policy for abuse/neglect screening. It is incorporated in their Abuse prevention policy. R3 was admitted on [DATE] with admitting diagnosis listed in part but not limited to cerebral infarction, dementia with behavioral disturbance, nicotine dependence, bipolar schizoaffective disorder, psychotic disorder, mix anxiety disorder, drug induced subacute dyskinesia. R3's admission abuse/neglect screening done on 6/4/22 indicated moderate risk. Surveyor notes no abuse/neglect prevention care plan formulated and no abuse screening done after R3 had the allegation of inappropriate sexual remarks by R2 on 2/8/23. On 3/2/23 at 11:30am, review of R3's medical record with V1 Administrator. V1 stated the abuse and neglect screening assessment is done upon admission, annually and as needed if there is an abuse incident or allegation. V1 stated that any mark yes will trigger risk and should be care planned for abuse prevention. R4 was admitted on [DATE] with diagnosis listed in part but not limited to bipolar schizoaffective disorder, borderline intellectual functioning, and epilepsy. R4's abuse/neglect admission screening done on 12/5/22 indicated at moderate risk. Surveyor notes no abuse/neglect care plan prevention formulated. On 3/2/23 at 11:30am, review of R4's medical record with V1 Administrator. V1 stated the abuse and neglect screening assessment is done upon admission, annual and as needed if there is an abuse incident or allegation. V1 stated that any mark yes will trigger risk and should be care planned for abuse prevention. R5 was admitted on [DATE] with diagnosis listed in part but limited to cerebral infarction, hemiplegia and hemiparesis, bipolar schizoaffective disorder, major depression, and mental disorder. R5's abuse/neglect admission screening done on 12/7/18 indicated moderate risk. Surveyor notes no abuse/neglect prevention care plan formulated. R5 had a resident-to-resident altercation with R6 on 10/3/22. R5's abuse/neglect assessment done on 10/17/22 after resident-to-resident altercation investigation indicated moderate risk. Surveyor notes no care plan formulated for abuse prevention. On 3/2/23 at 11:30am, review of R5's medical record with V1 Administrator. V1stated that abuse and neglect screening assessment is done upon admission, annually and as needed if there is an abuse incident or allegation. V1 stated that any mark yes will trigger risk and should be care plan for abuse prevention. R6 was admitted on [DATE] with diagnosis listed in part but not limited to degeneration of nervous system due to alcohol, alcohol dependence, schizoaffective disorder, psychosis, and dementia with behavioral disturbance. R6's abuse/neglect admission screening done on 8/20/22 indicated: at high risk. Surveyor notes no abuse prevention care plan formulated. R6 had a resident-to-resident altercation with R5 reported to IDPH on 10/3/22 which indicated: V7 CNA reported R6 with increased agitation pushed the overbed table and hit R5. V7 stated residents where immediately separated and a call for help was made. R6 was interviewed by V1, R6 was upset because he wanted R5's chips. When R5 refused to give the chips to R6, R6 pushed the overhead table. R6 did not mean to intentionally hurt R5. R6 was upset. R5 was interviewed by V1 regarding the incident, R6 was trying to get his chips and he did not allow him to have it and R6 pushed the overbed table to him. Upon conclusion of the investigation, the incident of physical contact cannot be substantiated. R5 was not injured during the incident. The allegation was unfounded. R5 does not exhibit emotional distress. Completed report on 10/10/22, indicates no abuse screening done. Abuse/neglect screening assessment done on 10/23/22 after the two incidents of R6's resident to resident altercation indicated moderate risk. Still no care plan formulated for abuse/neglect preventions. On 3/2/23 at 11:30am, review R6's medical record with V1 Administrator. V1 stated that abuse and neglect screening assessment is done upon admission, annually and as needed if there is an abuse incident or allegation. V1 stated that any mark yes will trigger risk and should be care plan for abuse prevention. Facility's policy on Abuse Prevention and Reporting- Illinois indicates: Guidelines: The resident has the right to be from abuse, neglect, misappropriation of resident property and exploitation. Establishing a resident sensitive environment: Resident assessment: As part of resident social history evaluation and MDS assessment, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriate of resident property or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis.

Based on observation, interview and record review the facility failed to follow its policy for fall prevention program by failing to implement fall prevention interventions for residents who are high risk for falls and have a history of falls. The facility failed to update resident's fall care plan after each fall occurrence based on root cause analysis. The facility failed to accurately complete fall assessment of resident. This deficiency affects all eight (R1, R3, R4, R5, R6, R7, R8 and R9) residents reviewed for Fall prevention program. Findings include: R1 was initially admitted on [DATE] and recently readmitted on [DATE] with diagnosis listed in part but not limited to fracture of neck of right femur, encounter for orthopedic after care, history of falling, difficulty walking, gait and mobility abnormality, unsteadiness on feet, displaced intertrochanteric fracture of femur, lack of coordination, abnormal posture, displaced fracture of surgical neck of right humerus, and polyarthritis. R1's care plan indicated she is at moderate risk for falls r/t (related to) poor safety awareness from progression of disease process. R1's care plan was not updated after fall incident occurred on 1/19/23. R1's fall incident dated 1/19/23 indicated: at approximately 3:30pm, heard a loud noise in the dining room. R1 was found sitting on her right side on the dining room floor. V12 CNA witnessed R1 getting up from chair and loss her balance and fell landed her buttocks on the floor, assessment done. R1 unable to give description of what happened. R1 observed grimacing and complaining of pain in right hip area. Tylenol given orally. Nurse Practitioner and family notified. R1 was sent out to hospital for evaluation. Fall IDT notes dated 2/1/23 indicated: Intervention: Educated R1 on self-transferring asking for and waiting for assistance demonstrated call light, therapy to evaluate for gait and balance. Care plan was not updated. R1's Fall incident reported to IDPH dated 1/19/23 indicated: R1 was in the dining room when CNA witnessed R1 getting up, losing her balance when trying to sit back on the chair and falling on her buttocks. R1 was sent to hospital for evaluation. R1 was hospitalized due to right hip fracture. Report summary: Resident slipped from chair while trying to transfer self. R1 returned to the facility. PT/OT (Physical Therapy/Occupational Therapy) to evaluate and treat for gait belt and balance. Intervention and care plan updated. Frequent check for pain and medication given as needed. Competed report dated 1/26/23. Care plan was not updated. Fall admission assessment after fall incident dated 1/19/23 indicated not at risk for fall. R1's hospital record dated 1/19/23 indicated: history and physical: chief complaint: status post (s/p) fall. A [AGE] year-old female who came to the hospital from the LTC facility where she resides s/p fall, reported from chair. She has dementia and poor historian. X-ray of right femur. Impression: Intertrochanteric fracture of the right hip. Right hip fracture intermedullary nailing done on 1/20/23. On 2/28/23 at 2:02pm, V1 Administrator stated that she overlooks the nursing services in the facility in absence of the DON (Director of Nursing). V1 stated that each fall incident is investigated/reviewed by Fall IDT to determine new fall interventions to prevent future falls. The resident's fall care plan is updated by MDS/Care plan coordinator, since she does not have a care plan coordinator, the fall care plan is updated by V2 Corporate nurse. Surveyor informed V1 that R1's fall care plan was not updated. V1 stated that R1's fall care plan should be updated for new care plan interventions after each fall incident to prevent future falls. It also should be updated in a timely manner. Surveyor informed V1 of fall assessment done inaccurately after fall incident on 1/19/23. R1's fall assessment indicated not at risk for falls. V1 stated that the fall assessment score will increase after each fall making R1 at high risk for falls. V1 stated that they have not updated the list of residents on the Falling Leaf Program. On 3/2/23 at 12:49pm, V11 RN stated that she took care of R1 when she had the fall incident on 1/19/23. It happened around 3pm, the beginning of the shift. V11 did not witness the fall. V12 CNA witnessed the fall. V12 stated that R1 was sitting on the couch and got up took a few steps and lost her balance and fell on her right side. R1 ambulates with 1-2 assist with wheelchair following her for safety. V12 stated that she placed R1 on the couch because she was restless, agitated, and uncomfortable in the wheelchair. On 3/2/23 at 1:30pm, V1 Administrator stated that V12 CNA is no longer in the facility. Surveyor attempted to call V12 but no response. R3 was admitted on [DATE] with diagnosis listed in part but not limited to cerebral infarction, repeated falls, difficulty walking, abnormal posture, lack of coordination, bilateral age-related nuclear cataract, multiple sites arthritis, and generalized osteoarthritis. R3's care plan indicated that he is at high risk for falls related to recent admission, impaired mobility and balance, and history of repeated falls. R3's new fall care plan interventions after each fall occurrence was not updated. R3's Fall incident reports indicated: 1. unwitnessed fall dated 7/4/22 indicated: observed R3 sitting on the floor. R3 stated I was transferring to the wheelchair, and I slid down to the ground. Fall IDT note dated 7/5/22 indicated: Intervention: reminded staff to anticipate R3's needs (toileting/transfer). Reminded R3 to ask for assistance during transfer. Referred to Nurse Practitioner (NP) for evaluation. Continue ongoing physical therapy as ordered. 2. Witnessed fall dated 7/19/22 indicated: CNA saw resident transferring from chair to bed, as she was approaching R3 accidentally tripped. R3 denied falling. Fall IDT note dated 7/21/22 indicated: Intervention: Anticipate needs. Refer to NP for further evaluation and management. Continue ongoing physical therapy as ordered. 3. Unwitnessed fall dated 8/3/22 indicated: at around 10:05pm, heard a loud thud and found R3 on the floor leaning by the wall beside the bathroom door. The resident wasn't wearing a helmet. He fell as he was going back to his bed from using the bathroom and he didn't ask for help or pulled the call light. R3 went to the bathroom without using his wheelchair and when he was about to go back to his bed, he fell and hit his head on the door. Fall IDT note dated 8/4/22 indicated: Intervention neuro check initiated. R3 reminded to use wheelchair, protective helmet, and call light for assistance. R3 sent to hospital for CT (Computed Tomography) scan of the head as ordered. Review of R3's medical record with V1 Administrator. Administrator was informed that R3's new fall care plan interventions after each fall occurrences were not updated in the care plan. On 3/2/23 at 11:46am, V1 stated that fall care plans should be updated with new care plan interventions after each fall incident to prevent future falls. On 2/28/23 at 10:50am, V6 RN was observed whispering to V9 CNA in the dining room. V9 was then observed going into R4's room. Surveyor followed V9 and observed R4 sleeping in bed which was pushed against the wall. Surveyor notes the bed was not in lowest position. The surveyor notes a mattress standing on the right side of the bed with wooden dresser pushed against the standing mattress to prevent R4 from getting out of bed. V9 stated that they had been doing it because R4 becomes agitated and combative. V9 stated that everyone is aware of it. On 2/28/23 at 10:52am, V6 RN was called and showed the above observation. V6 stated that they had been doing it because R4 is attempting to get out from bed and agitated. V6 stated that the family is aware of it. On 2/28/23 at 10:55am, V10 Nurse Practitioner was called and showed above observation. V10 stated that she is taking care of R4. V10 said that she has observed it before, she knows that is not acceptable, but it has been going on. On 2/28/23 at 11:00am, V1 Administrator showed above observation. V1 stated that she is not aware of it, and it is not acceptable. The mattress is used as a floor mat for fall prevention not as a restraint to place against the open side of R4's bed with wooden dresser blocking the mattress. On 2/28/23 at 11:05am, V7 CNA stated that she is the CNA assigned to R4 and she placed the mattress pad in the standing position blocking the opening of the right side of the bed and pushed the wooden dresser against the mattress to prevent R4 from getting out of bed. R4 was admitted on [DATE] with diagnosis listed in part but not limited to history of falling, aftercare following surgery on the nervous system, epilepsy. R4's care plan indicated that she is at high risk for falls related to confusion, unaware of safety needs and history of falls. R4's fall admission assessment done on 11/19/22 indicated at risk for falls. R4's new fall care plan interventions after each fall occurrences were not updated. Surveyor notes no documentation in care plan that family agreed to restrain R4 by pushing her bed against the bed and placed mattress with wooden dresser to block the bed preventing her from getting out of bed. R4's fall incidents reports: 1. Unwitnessed fall dated 2/5/23 indicated: Observed R4 on the floor away from her bed and in front of the room cabinets lying on the floor. She is trying to put on her pants on. R4 unable to give description of what happened. No documentation of floor mat was used and bed in lowest position. Fall IDT note dated 2/9/23 indicated: Interventions: Re-educated on using call light and waiting for assistance, therapy to evaluate resident. Frequent rounding to be conducted to ensure resident safety. R4's care plan was not updated. No fall assessment was done after fall on 2/5/22. 2. Unwitnessed fall dated 1/2/23 indicated: Noted R4 slowly sliding down from her bed and sat on the floor. R4 unable to give description of what happened. No documentation of floor mat was used and bed in lowest position. Fall IDT note dated 1/4/23 indicated: Intervention: Dilantin and thyroid levels, psych evaluation, medical reconciliation. Care plan was not updated. 3. Unwitnessed fall dated 12/22/22 indicated: Found R4 lying on her back on the floor. R4 unable to give details of what happened. No documentation of floor mat was used and bed in lowest position. R4 was sent to the hospital for evaluation. Fall IDT note dated 12/22/22 indicated: Intervention: R4 returned to the facility no injury showed from hospital visit. Post fall monitoring and neuro check ongoing. Cervical collar in place. R4 is up in wheelchair in the dining room with staff supervision. R4's care plan was not updated. No fall assessment done after fall incident on 12/22/22. 4. Unwitnessed fall dated 12/1/22 indicated: CNA found kneeling beside her bed. Bed in the lowest position. Call light within reach. R4 unable to give description of what happened. R4 was sent to the hospital for evaluation. Fall IDT note dated 12/2/22 indicated. Intervention: Sent to hospital as ordered. Post fall monitoring and neuro check done as ordered. Floor mat as ordered. Anticipate R4's needs and frequent monitoring at night. Care plan was not updated. Fall assessment done after fall incident on 12/1/22 indicated not at risk for falls. 5. V1 cannot find the fall incident report dated 11/16/22. Progress noted indicated: R4 observed lying on the floor on supine position. Neck collar in placed. No apparent injury. R4 was sent to the hospital for evaluation due to coumadin usage. Fall IDT note dated 11/17/22 indicated: Intervention: R4 was sent to hospital for evaluation. Care plan was not updated. During review of R4's medical record with V1 Administrator. Surveyor informed V1 that R4's new fall care plan interventions after each fall occurrence were not updated in the care plan and no fall assessment was done after fall incident on 2/5/22 and 12/22/22. Fall assessment inaccurately done after fall incident on 12/1/22 indicated not at risk for falls. V1 unable to locate documentation of R4's fall incident dated 11/16/22. On 3/2/23 at 11:46am, V1 Administrator stated that fall care plan should be updated for new care plan interventions after each fall incident to prevent future falls. V1 stated that fall assessments are done after each fall occurrence. The fall assessment score will increase after each fall making R4 at high risk for falls. V1 said that they don't use restraint in the facility. R5 was readmitted on [DATE] with diagnosis listed in part but not limited to cerebral infarction, unsteadiness on feet, gait and mobility abnormality, abnormal posture, history of falling, osteoporosis, osteoarthritis, cataract. R5's care plan indicated that he has potential for minor/major fall due to a history of falls, poor safety awareness, noncompliance to plan of care, psychotropic drug use, balance problems, episodes of dizziness, physical impairment secondary to history of stroke, and osteoarthritis. R5's fall admission assessment dated [DATE] indicated at risk of falls. R5's fall incidents reports: 1. Unwitnessed fall dated 2/21/23 indicated: at 3am, Observed R5 sitting on the floor. R5 stated I was trying to use pee and I slip. Fall IDT note dated 2/22/23 indicated: Intervention: Re-educated on use of call light with return demonstration. Therapy working on gait and balance will do frequent rounding and over frequent use of bathroom. Care plan was not updated. Fall assessment done after fall 2/22/23 indicated not at risk for fall. 2. Unwitnessed fall dated 2/17/23 indicated: R5 woke up tried to pee tipped over and fell on his both knees and fell on his right-side trying to get up. R5 stated: I want to pee, I tipped over and fell on my knees. Fall IDT note dated 2/22/23 indicated: The root cause analysis of the report is inconsistent with what was written in incident report. Intervention: Educated on call light and asking got assistance. Therapy will evaluate for gait and balance. Care plan was not updated. Fall assessment done after fall on 2/17/23 indicated not at risk for fall. 3. Unwitnessed fall dated 1/9/23 indicated: Observed R5 sitting on the floor. R5 stated that he was transferring from the wheelchair to the toilet and slipped to the floor. Fall IDT note dated 1/10/23 indicated: Intervention: Re-educated on importance of asking assistance and use call light for transfers to prevent fall and injury. Referred to therapy for evaluation and management. Staff to anticipate resident's needs such as toileting and to do frequent rounding. Care plan was not updated. 4. Unwitnessed fall dated 11/2/22 indicated: Observed R5 sitting on the floor between the bed and his motorized chair. R5 stated that during transfer to his wheelchair he slid down to the floor. Fall IDT note dated 11/3/22 indicated: Intervention: Re-educated the resident the importance of safety and ask for assistance during transfer. Care plan was not updated. 5. Unwitnessed fall dated 11/2/22 indicated: Observed R5 sitting on the floor. R5 stated that he was getting up and he tip over from bed. Fall IDT note dated 11/3/22 indicated: on monitoring. Care plan was not updated. 6. Unwitnessed fall dated 10/11/22 indicated: Observed R5 lying supine on the floor in his room. R5 stated he was getting up to use the urinary and lost his balance then he slid down to the floor. Fall IDT noted dated 10/11/22 indicated: Intervention: Re-educated to ask for assistance for toilet needs and during transfer. Call light placed within reach, bed in the lowest position. Post fall monitoring in progress. Therapy made aware. Care plan was not updated. 7. Unwitnessed fall dated 10/10/22 indicated: R5 observed on the floor. R5 said he slid off the bed trying to get out of bed. Fall IDT note dated 10/11/22 indicated: Intervention: Explained that he needed assistance during transfer/ help when getting up. R5 was sent to the hospital for evaluation. R5 was admitted with Rhabdomyolysis. Care plan was not updated. 8. Witnessed fall dated 10/9/22 indicated: Nurse witnessed R5 slid off from his bed when he was trying to transfer from bed to his wheelchair. Nurse couldn't catch him and was on the floor on is left side. R5 unable to give description. Fall IDT note dated 10/10/22 indicated: Intervention: Re-educated him regarding safety precaution and to call for assistance during transfer. Therapist made aware. Care plan was not updated. 9. Unwitnessed fall dated 10/2/22 indicated: Observed R5 sitting on the floor by the side of his bed. R5 stated I was knelling to pee and slid off. Fall IDT note dated 10/3/22 indicated: Intervention: Re-educated to ask for assistance for toilet use. Referral to OT to screen. Call light placed within reach. Care plan was not updated. Review of R5's medical record with V1 Administrator. V1 was informed that R5's new fall care plan interventions after each fall occurrences were not updated in care plan. Fall assessment inaccurately done after fall incident on 2/21/23 and 2/17/23 indicated not at risk for falls. On 3/2/23 at 11:46am, V 1 Administrator stated that fall care plans should be updated with new care plan interventions after each fall incident to prevent future falls. V1 stated that fall assessments are done after each fall occurrences. The fall assessment score will increase after each fall making R5 at high risk for falls. R6 was admitted on [DATE] with diagnosis listed in part but not limited to degeneration of nervous system due to alcohol, gait and mobility abnormality, lack of coordination, and dementia with behavioral disturbance. R6's care plan indicated that he is at high risk for falls related to deconditioning from recent hospitalization and impaired safety awareness secondary to alcoholic encephalopathy. R6's fall admission assessment dated [DATE] was inconsistent with his care plan which indicated he is not at risk for fall. R6's fall incident reports dated: 1. Witnessed fall dated 2/27/23 indicated R6 was walking down the hallway with his dinner tray. The tray was going to fall and he tried to catch it and he fell on the floor on his right side. Fall IDT note dated 2/27/23 indicated: Intervention: Anticipate resident needs- to pick up tray from the room. Care plan was not updated. 2. Unwitnessed fall dated 1/5/23 indicated: Heard fall noise by the hallway, found R6 on the floor. R6 stated that he was walking at the hallway, and he lost his balance but was able to hold by the chair while going down to the floor with left knee first. Complained soreness on left knee that hit the floor. Fall IDT note dated 1/5/23 indicated: Intervention: Continue to monitor. Referred to therapy for PT evaluation. Care plan was not updated. Fall assessment not done after fall incident. Review of R6's medical record with V1 Administrator. V1 informed that R6's new fall care plan interventions after each fall occurrences were not updated in care plan. R6's fall assessment was not done after fall incident on 1/5/23/23. On 2/28/23 at 10:07am, V4 RN presented list of residents on fall prevention program as requested. V4 stated that it was not updated. V4 stated that R7 had a fall last week. R7 was observed lying in bed with her sweater covering her face. R7's bed was pushed against the wall; her wheelchair was on the left side of her bed. R7's call light was not within reach; it was not clipped to her bed/pillow. V4 took the call light string from the floor and placed it within R7's reach. R7 was admitted on [DATE] with diagnosis listed in part but not limited to generalized osteoarthritis, multiple sclerosis, unsteadiness on feet, lack of coordination, seizures. Care plan indicated she is at risk for fall related to multiple sclerosis, muscle weakness and side effects of psychotropic medication use. Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance. R7's fall admission assessment dated [DATE] was inconsistent with his care plan indicated he is not at risk for fall. R7's fall incident reports indicated: 1. Witnessed fall dated 2/21/23 indicated: R7 forgot to lock her wheelchair and when she sits down, the chair moved. R7 stated that she was trying to help her roommate to go to the toilet and she forgot to lock her wheelchair as she sat down, her wheelchair moved and fell on her butt. Fall IDT noted dated 2/22/23 indicated: Intervention: Instructed and educated on safety and fall precaution such as making sure to lock wheelchair when in stationary position. Care plan was not updated. Fall assessment done after fall incident on 2/25/23 indicated not at risk for falls. 2. Witnessed fall dated 9/30/22 indicated: During med pass, R7 stood from her wheelchair to turn on the light and when she sat down, she missed the wheelchair and slipped. She hit the floor with her buttocks. R7 stated I'm okay, I just slipped. I did not know why I missed the chair. Fall IDT note dated 10/3/22 indicated: Intervention and care plan updated: Re-educated regarding safety and to ask for help. Care plan was not updated. Fall assessment after fall incident on 9/30/22 not done. Review of R7's medical record with V1 Administrator. V1 informed that R7's new fall care plan interventions after each fall occurrence were not updated in the care plan. R7's fall assessment inaccurately done after fall incident on 2/25/23 indicated not at risk for falls. R7's fall assessment was not done after fall incident on 9/30/22. Surveyor informed V1 that R7's call light was not within reach. On 2/28/23 at 10:14am, rounds made to R8's room with V4 RN. V4 stated that R8 is in the dining room, she walks with walker with assistance. R8 wheelchair observed at bedside no Dycem (non-slip material underneath the wheelchair cushion). R8 was admitted on [DATE] with diagnosis listed in part but not limited to pathological fracture, rheumatoid arthritis, spondylosis lumbar region, fibromyalgia, lack of coordination, dementia with mood disturbance. R8's care plan indicated she at moderate risk for falls related to chronic pain, arthritis and COPD. Intervention: Dycem to wheelchair. Fall admission assessment done on 4/5/21 indicated at risk for falls. R8's fall incident report dated Unwitnessed fall dated 11/3/22 indicated: R8 found sitting on the floor. R8 stated I slid off my bed when I tried to reach for my mask and hit my arm on the garbage can. Fall IDT note dated 11/3/22 indicated: Intervention: Apply ice pack on the left upper arm and continue to monitor. Care plan was not updated. Fall assessment done after fall incident on 11/3/22 indicated not at risk for falls. Review R8's medical record with V1 Administrator. V1 informed that R8's new fall care plan interventions after each fall occurrences were not updated in care plan. Fall assessment inaccurately done after fall incident on 11/3/22 indicated not at risk for falls. Informed V1 that Dycem was not in placed in R8's wheelchair. On 2/28/23 at 10:16am, rounds made to R9's room with V4 RN. R9 observed in semi-fowler's position in bed. R9's call light is not within reach. V4 took the call light string hanging by the wall and placed it to R9's within reach. R9 said he just fall last week. R9 was admitted on [DATE] with diagnosis listed in part but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, rhabdomyolysis, difficulty walking, history of falling, and dementia. R9's care plan indicated that he is at high risk for falls related to history of falls and weakness post stroke. Intervention: Be sure the resident call light is within reach and encourage the resident to use it for assistance as needed. R9's fall admission assessment done on 6/2/22 indicated not at risk for falls. R9's fall incidents report indicated: one witnessed fall dated 2/11/23. The report states R9 was standing on the side of his bed and trying to reach his walker, he slowly slipped and fell on his buttocks. R9 stated I slipped and fell . Fall IDT note dated 2/11/23 indicated: Intervention: Educated resident on call light with return demonstration educated on asking for and waiting for assistance therapy to eval for gait and balance. R9's care plan was not updated. R9's fall assessment done after fall incident dated 2/11/23 indicated not at risk for falls. 2. Unwitnessed fall dated 10/21/22 indicated: R9 was seen on the floor inside his room. R9 stated I was grabbing my pants to get dressed, I slipped from bed and fell on my buttocks. Fall IDT note dated 10/21/22 indicated: Intervention: Educated regarding safety awareness and ask for assistance. Referred to therapy. Care plan was not updated. Fall assessment done after fall incident on 10/21/22 indicated not at risk for falls. Review of R9's medical record with V1 Administrator. Surveyor informed V1 that R9's new fall care plan interventions after each fall occurrence were not updated in R9's care plan. R9's fall assessment inaccurately done after fall incident on 2/11/23 and 10/21/22 indicated not at risk for falls. Surveyor informed V1 that R9's call light was observed not within reach when made during rounds. On 3/2/23 at 11:46am, V1 stated that fall care plans should be updated with new care plan interventions after each fall incident to prevent future falls. V1 stated that fall assessments are done after each fall occurrence. The fall assessment score will increase after each fall making R9 at high risk for falls. Fall care plan intervention should be implemented. Facility's Fall prevention Program indicates: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Standards: *A fall risk assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. *Safety interventions will be implemented for each resident identified at risk. *Accident/incident reports involving falls will be reviewed by the interdisciplinary team to ensure appropriate care and services were provided and determine possible safety interventions. *The Director of Nursing or Designee is responsible for monitoring the fall prevention program, including further staff education programs, purchase of additional equipment or other appropriate environmental alterations. In addition, DON is responsible for informing the Administrator of program analysis. Facility's policy on Falling leaf program indicates: Guidelines: This facility has instituted a Falling Leaf Program as one intervention of the fall reduction process. With this program, the facility Interdisciplinary Team targets a select of residents who are at risk for falls.

Based on observation, interview and record review the facility failed to implement its policy in monitoring resident receiving psychotropic medications for medication side effects (Abnormal Involuntary Movement Scale/AIMS) . This deficiency affects all 4 (R21, R30, R35 and R39) residents in a sample of 18 reviewed for psychotropic medication usage. Findings include: R21 was admitted on [DATE] with diagnoses listed in part not limited to Dementia/Alzheimer's, Psychosis, Communication deficit, Gait abnormality, Multiple site arthritis, Atrial fibrillation, Heart failure. R21's physician order sheet indicates: Haldol Solution give 0.5mg topically in gel form apply to upper back twice daily and Lorazepam intensol concentrate 2mg/ml give 0.5mg by mouth every 4 hours as needed for anxiety. R30 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses listed in part not limited to Alzheimer's disease, Fibromyalgia, Restlessness, and agitation. R30's physician order sheet indicates: Seroquel tablet 25mg 1 tab by mouth one time a day, Seroquel 50mg 1 tab by mouth one time a day, Escitalopram oxalate 10mg 1 tab by mouth one time a day and Trazadone HCL 100mg 1 tab by mouth at bedtime. R35 was admitted on [DATE] with diagnoses listed in part not limited to Dementia, Psychotic disorder, Anxiety disorder, Major depression, Insomnia, Parkinson's disease, Lack of coordination, Gait abnormality and posture. R35's physician order sheet indicates: Clozaril 25mg 1 tab by mouth in the morning, Clozaril 75mg 1 tab by mouth in the evening and Sertraline HCL 50mg 1 tab by mouth one time a day. R39 is admitted on [DATE] with diagnosis listed in part not limited to Alzheimer's disease late onset, Psychosis, Major depressive disorder, Other specified mental disorder due to known physiological condition, Gait abnormality. R30's physician order sheet indicates: Olanzapine 2.5mg 1 tab by mouth one time a day. On 12/6/22 at 9:39 AM, V7 Registered Nurse (RN) stated that R21, R30, R35 and R39 are on psychotropic medications. All residents were observed in the dining room. On 12/7/22 at 2:30 PM V1 Administrator and V12 Nurse Consultant informed that R21, R35 and R39's last AIMS assessment was completed 4/2/22 and R30 does not have an admission AIMS assessment. All residents are on psychotropic medications. On 12/8/22 at 9:45 AM surveyor reviewed AIMS assessment records the following residents with V4 MDS/Care plan coordinator: R35, R21, R39 and R30. R35, R21 and R39's last AIMs assessment was competed on 4/2/22. No AIMS assessment was done on R30. V4 stated that V2 Director of Nursing/DON is responsible for completing the AIMS assessments for residents on psychotropic medications upon admission and quarterly. V4 stated that the former Director of Nursing (DON) did the last AIMS assessments 4/2/22. V4 stated the facility did not have DON for a while and V2 was hired last August 2022. V2 DON is not available for interview per V1 Administrator. Facility's policy on Psychotropic Medication indicates: Monitoring: Resident on anti-psychotic drug therapy will be monitored for tardive dyskinesia side effects every 6 months through the use of the AIMS scale. Facility's policy on AIMS Side Effect Monitoring indicates: Purpose: Abnormal involuntary movement scale (AIMS) records the occurrence of tardive dyskinesia (TD-a neurological disorder characterized by involuntary movements of face and jaw) of residents receiving psychotropic medications. To assess the presence of movement and non-movement side effects and to follow severity of TD over time. Guidelines: *The examination will be performed either at the time of resident's admission or when medications are initially prescribed. In addition, for residents taking psychotropic medication, AIMS examination procedures will be repeated at intervals of no less than every six (6) months. *Assessment results will be conveyed to attending psychiatrist and NP when abnormal findings or increasing in severity and side effects in noted. *The assessment will include direct observation, strict adherence to the test guidelines and medical record review.

Based on observation, interview and record review the facility failed to ensure that call lights were in reach and easily accessible for 3 of 6 residents reviewed for accommodation of needs in a sample of 18. Findings include: On 12/6/2022 at 10:40 AM R3 was observed in the bed, alert, and oriented times three with her legs out the bed and bilateral feet wrapped in bandages, stating I'm waiting for someone to help me, R3's call light was observed behind the bedside table out of reach. On 12/6/2022 at 11:00 AM V10 (Nurse) stated R3's call light should be in reach and placed the call light in her hand. R3's Admission Record indicates that R3 has a diagnosis of repeated falls. A care plan dated 7/16/2022 with a revision on 9/29/2022 focus of high risk for falls related to impaired mobility, and an intervention to keep call light within resident's reach. On 12/6/2022 at 10:45 AM R37 was heard yelling into the hallway for help, R37 observed in high back chair asking to go back to bed. R37's call light was observed on the floor behind the bedside table. On 12/6/2022 at 11:05 AM V10 state R37 yells out all the time and is a fall risk, indicated by the picture of the leaf at the head of the bed on the wall and sign stating the call light should be within reach and placed the call light in R37's hand. R37's Order Summary Report dated 12/7/2022 indicated R37 has an age-related physical disability, presence of left artificial hip, Osteoarthritis, and abnormal posture. A care plan dated revision on 4/25/2022 for frequent falls. On 12/6/2022 at 10:55 AM R55 was observed in the bedroom by the door asking for help to put on a clean shirt. R55's call light was observed attached to her bed out of reach, R55 state I can't wheel myself to the bed to pull the light. On 12/6/2022 at 11:10 AM V10 stated I'll get help for R55 and wheeled R55 in reach of the call light. R55's Order Summary Report dated 12/7/2022 indicates R55 has an history of falls. A care plan dated 9/7/2022 with a focus of requiring extensive assistance to dress and an intervention to be sure to keep the call light within resident's reach. Facility Policy: Call light effective 11/28/2012, revision on 2/2/2018 Purpose: To respond to resident's requests and needs in a timely and courteous manner. Guidelines: Resident call light will be answered in timely manner. 1. All residents that can use a call light shall always have the nurse call light system available and within easy accessibility to the resident at the bedside or other reasonable accessible location.

Based on observation, interview, and record review, the facility failed to maintain personal hygiene for one of six residents (R262) observed for activities of daily living (ADLs) in the sample of 18 residents. Finding Include: On 12/6/2022 at 10:45 AM, surveyor observed R262 sitting in 2nd floor dining room with V19 - CNA (Certified Nurse's Aide) assigned to R262. R262's shirt, mouth and chin were stained with food particles from breakfast food that morning. V19 stated R262's shirt should have been changed and his mouth/chin cleaned after breakfast. On 12/6/2022 at 11:00 AM, surveyor observed R262 with V7 RN (Registered Nurse) assigned to R262. R262 was still wearing the shirt with stained food particles and his mouth and chin not cleaned. V7 stated that V19 should have taken R262 to his room, cleaned him up and put a clean shirt on him. On 12/7/2022 at 2:30 PM, V12 (Nurse Consultant) stated that V7 should have cleaned R262 up and put on a clean shirt. R262 is a [AGE] year-old admitted on [DATE] with a diagnoses of Dementia, Psychotic disturbance, Mood disturbance, Anxiety, altered mental status, other abnormalities of gait and mobility. R262's care plan indicated that R262 has an ADL self-care performance deficit related to altered mental status. Facility Policy: Activities of Daily Living (ADLS) Grooming: Maintaining Personal Hygiene.

Based on observation, interview and record review the facility failed to provide privacy to residents when providing care/procedure/medication. This deficiency affects two (R11 and R30) of three residents in the sample of 18 reviewed for privacy. Findings include: On 12/6/22 at 9:35 AM, V6 Hospice RN observed performing assessment and vital signs on R30 in the dining room with 18 residents, one CNA and one housekeeping staff. On 12/6/22 at 9:45 AM V6 Hospice Nurse stated that she is from a hospice service and has been coming for one month to see R30. She stated that she always assesses and takes vitals of R30 in the dining room. She stated she assess the residents where they are sitting and this is how she was taught during her orientation. When surveyor asked her if she should provide privacy when assessing residents and taking vital signs, she said, I guess so. On 12/6/22 at 10:08 AM, surveyor informed V5 RN Supervisor of observation made with V6 Hospice Nurse to R30. She stated she should do the assessment and vital signs in the resident's room to provide privacy. It should not be done in the dining room where there are residents present. Surveyor requested policy on Resident's Privacy from V5. On 12/6/22 at 1:21 PM, V10 RN administered oral medication to R11. V10 did not close the curtain to provide privacy from R11's two roommates (R13 and R163). R163 wheeled himself into the room. At 1:27 PM, V10 administered Nebulizer treatment to R11 without closing R11's curtain to provide privacy from his roommates (R13, R14 and R163). On 12/7/22 at 11:03 AM, Follow up request for facility's policy on privacy as requested yesterday. V12 Nurse consultant stated that they don't have a policy on Resident's Privacy.

Based on interview and record review, the facility failed to follow their wound care protocol, failed to provide wound care certified staff, failed to ensure that a wound did not increase in size and decline, failed to ensure that physicians were notified regarding change in wound status on 4/26/21, and failed to stage a wound correctly in order for the dietician to follow the nutritional protocol after a wound is detected. These failures resulted in one (R214) out of two residents reviewed. R214 affected by developing a coccyx pressure ulcer and required transfer to a local hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 05/25/21 at 1:35 PM, R214's wound rounds and progress notes were reviewed. The initial assessment was done on 3/11/21 at 4:44 PM. Identified by V2 DON (Director of Nursing). Type: Pressure. Classification: [CONDITION(S)]. Source: Facility Acquired. Date Identified: 3/11/21. Performed by: V2 DON Director of Nursing. Clinical stage: Stage 1. Tissue type: Non-blanchable [CONDITION(S)] 100%. Exudate: None. Size (cm) centimeters: 2.00 x 2.00 x 0.00 (LxWxD). Area: 4.00 centimeters squared. Current plan and comments: V2 DON documented-Duoderm every 3 days and daily as needed. Progress notes indicate: there is no documentation of V13 Family Member being notified on 3/11/21 of R214's wound development. The 3/17/21 at 10:49 AM progress note by V20 MDS Coordinator indicates: R214 continues to refuse on repositioning. R214 continues to ask for prn (as needed) pain medications due to chronic pain. POA (Power of Attorney) aware. The 3/21/21 at 11:34 AM progress note by V20 MDS Coordinator indicates: R214 takes scheduled pain medications and PRN (as needed) to control pain. She prioritizes her pain more than anything at this time. The 3/25/21 at 1:45 PM wound assessment by V2 DON indicates: clinical stage 1. Tissue type: Non-blanchable [CONDITION(S)] 100%. Exudate: None. Size (cm) centimeters: 2.00 x 2.00 x 0.00 (LxWxD). Area: 4.00 centimeters squared. Current plan and comments: Cleanse site with wound cleanser. Pat dry with gauze. Apply [MEDICATION(S)] and calcium alginate and foam dressing cut to size of the wound, then apply transparent dressing. May use bordered foam dressing instead of the cut foam dressing and transparent dressing. Change every 3 days and daily as needed until healed. The 4/8/21 at 1:39 PM wound assessment by V2 DON states: clinical stage: 1. Size (cm) centimeters: 8.00 x 2.00 x 0.00 (LxWxD). Area: 16.00 centimeters squared. Tissue type: Non-blanchable [CONDITION(S)] 100%. Exudate: None. Current plan and comments: Same wound treatment. The 4 /15/21 at 2:38 PM wound assessment by V2 DON states: clinical stage: 1. Tissue type: Non-blanchable [CONDITION(S)]-100%. Exudate: none. Size (cm) centimeters- 6.00 x 6.00 x 0.00 (LxWxD). Area: 36.00 centimeters squared. Current plan and comments: Same wound treatment. The 4/16/21 at 1:05 PM progress note by V2( DON) indicates: R214 refused to be repositioned on her side. She also refuses incontinent product change. Coccyx wound is bigger in size. Resident may also refuse wound care. Will need order for protein supplement, wound evaluation and labs. Left message for POA (Power of Attorney). Awaiting for call back. V19 Physician also aware. The 4/20/20 at 2:02 PM progress note by V2 (DON) indicates: Spoke with R214's V13 (Family)regarding wound care/referral. V13 was aware that R214 would refuse to be turned on her side or have wound care/dressing done. R214 verbalized that she does not want the wound care evaluation at the NCH (wound care facility). V19 Physician are aware. Appointment on hold for wound evaluation as resident is refusing at this time. The 4/20/20 at 11:18 AM progress note by V20 MDS Coordinator indicates: R214 verbalized the staff reposition her more than it should and it takes time for the pain to go away when staff moves her. R214 claims that her [MEDICATION(S)] is not working for her and that V19 Physician was made aware. The 4/22/21 wound assessment by V2 (DON) indicates: clinical stage: 1. Tissue type: Non-blanchable [CONDITION(S)]-100%. Exudate: none. Size (cm) centimeters- 6.00 x 6.00 x 0.00 (LxWxD). Area: 36.00 centimeters squared. Current plan and comments: Cleanse site with wound cleanser. Pat dry with gauze. Apply skin prep to surrounding skin. Apply Santyl to the wound base and then calcium alginate cut to the size of the wound and cover with bordered dressing for dry dressing. Change dressing daily and as needed until healed. The 4/22/21 at 4:03 PM progress note by V2 (DON) indicates: Tele visit with wound care physician for wound evaluation. New order obtained for treatment. R214 agreed to outpatient wound clinic evaluation. Awaiting for insurance pre authorization to be approved in order to schedule for outpatient wound evaluation. Nurse practitioner was aware. Notified and updated POA (Power of Attorney). The 4/26/21 at 6:04 AM progress note by V22 (LPN) indicates: R214's wound has worsened despite applying treatment. Tunneling noted, along with brown leakage and foul odor. R214 complains of pain during dressing changes, administered [MEDICATION(S)] and [MEDICATION(S)]. R214 states, I want to go to hospital. Notified V2 (DON). The 4/26/21 at 2:31 PM progress note by V2 (DON) indicates: Called wound center to set up appointment. Preauthorization is already clear. R214 has agreed to go to wound clinic for her wound to be evaluated. The 4/27/21 at 4:24 PM, progress note by V2 (DON) indicates: Spoke with V13 (Family) regarding R214's wound and overall condition. The 4/27/21 at 4:25 PM progress note by V1 (Administrator) indicates: Spoke with V13 (Family) regarding R214's recent refusals to eat, gave general update. R214'S Wound rounds were reviewed. The last assessment was on 4/27/21 at 4:58 PM which indicates: Wound to coccyx site, date identified: 3/11/21, type: pressure, classification: ulceration, source: facility acquired, tissue type: slough white and fibrinous 80%, exudate: moderate amount; purulent, length: 6.80, width: 6.80, depth: 0, area: 46.24 cm squared. Clinical stage: Unstageable. Performed by V2 (DON). Current plan and comments state: Wound measurement is bigger in size. Old dressing with odor. Moderate amount of serous drainage noted. Notified wound MD about wound condition. Notified V19 (Physician) with order to send resident out to a local hospital On review of R214's care plan it indicates: I have a pressure injury on my coccyx 3/11/21. Wound is not healing well. R214 prefers not to turn side to side and has stated she values her comfort over her health 4/16/21. Interventions: Assess/record changes in skin status weekly and as needed, avoid shearing, use lift sheet for reposition, educate resident/family/caregivers of causative factors and measures to prevent skin injury, encourage good nutrition and hydration in order to promote healthier skin, encourage turn and reposition and explain the importance of turning side to side 4/16/21. Keep skin clean and dry. Lab work [MEDICATION(S)] level 4/16/21. Minimize pressure over boney prominences. Monitor skin injury to coccyx area, healing status, any signs and symptoms of infection and inform wound nurse and medical doctor of any significant changes 3/11/21. Registered dietician to re-evaluate needs for healing process of the wound 3/11/21. Registered dietician and medical doctor to review medications and follow recommendations accordingly 4/16/21. Report pertinent changes in skin status to physician. Skin assessment every day and wound nurse to check wound every week 3/11/21. R214 needs pressure relieving/reducing mattress to protect the skin while in bed. Treatment as ordered. Measure all open areas as needed and record. Monitor signs, symptoms of infection during dressing change. Notify medical doctor of non-healing wounds, or of wound deterioration. Observe for pain during treatment. Pain management as ordered. Notify medical doctor as needed. At 12:30 PM, reviewed R214'a physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order date: 6/8/20. March of 2021- [MEDICATION(S)] 2mg (milligrams) give 1 tablet by mouth every 4 hours as needed for chronic pain. 4/21/21 [MEDICATION(S)] 4mg (milligrams) give 1 tablet by mouth every 6 hours as needed for chronic pain for 14 days. [MEDICATION(S)] 200mg (milligrams) give 2 tablets by mouth every 6 hours as needed for shoulder pain. Multiple Vitamins-Minerals tablet give 1 tablet by mouth one time a day for supplement. Order date: 6/8/20. R214's MAR (Medication Administration Record) indicates an increase in her pain with use of [MEDICATION(S)] and [MEDICATION(S)] during March and April of 2021. On 5/26/21 at 1:20 PM, V13 (Family) was interviewed regarding R214. V13 stated, The staff did tell me that R214 had another bedsore. I asked V2 (DON) why it was taking so long to heal. They did not tell me R214 was refusing treatments or dressing changes. I did not speak with V2 about R214 not eating. I spoke with V2 (DON) on April 27th around 6pm. She said they were sending R214 to the hospital, I did not speak with V1 (Administrator). I was not updated on her condition. I spoke with R214 and she was asking to go to the hospital, but they didn't send her until the next day. On 5/25/21 at 1:37 PM, V1 Administrator was inquired if he contacted R214's family regarding her condition. V1 stated, Yes I did on April 27th. I called her daughter. I called the number we have on file. On 5/26/21 at 2:11 PM, V2 (Director of Nursing) inquired of R214's wound care treatment. Inquired if V2 (DON) was wound care certified? V2 (DON) stated, I am not. Inquired if any nursing staff providing wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] ? V2 (DON) stated, No. Inquired when R214 developed the wound and the staging of a wound. V2 (DON) stated, R214's wound developed on March 11th of this year to my knowledge. I know how to stage a wound. The 3/25/21 assessment there is some skin opening, the wound should be a stage 2. I do the assessment on an iphone and I take pictures of the wound. I can't change the stage on there, but I could have put the correct stage of the wound in the comments. Inquired if R214's POA Power of Attorney was notified of the wound development. V2 (DON) stated, V13 Family was notified and it was documented what the plan and interventions in the progress notes. V13 was well aware of the wound. Inquired when the wound care physician was consulted regarding R214's wound. V2 (DON) stated, We were trying to get R214 to the wound clinic but had some issues with the insurance. V19 Physician, the primary was aware of the status of the wound and the appointment. V19 was giving the orders for the wound. The wound care physician said they were not allowed to come in the building so they did a telehealth visit. The telehealth visit was on April 22nd. Inquired what nutritional interventions were ordered for R214 regarding the development of the wound. V2 (DON) stated, There was a house supplement and multivitamins ordered. R214 was requesting more and more pain medications. She was on [MEDICATION(S)]. On 5/26/21 at 2:30 PM, R214's wound treatment administration record and nutrition notes were reviewed. R214's nutrition progress note by V23 (Dietitian) indicates: 3/23/21: R214 refusing to be weighed. Noted with stage 1 coccyx wound. Multivitamin/[MEDICATION(S)]. House stock 2.0 90 ml (mililiters) three times a day. Continue current POC (plan of care). No Recommendations. 4/26/21 nutrition progress not by V23 Dietitian which indicates: R214 last seen by V23 4/8. Skin stage 1 coccyx wound stable per 4/22 skin report. Continue current POC (plan of care). No Recommendations. V2 (DON) Director of Nursing did not stage the wound correctly resulting in V23 (Dietitian) not following the nutritional protocol after a wound is detected. The nutritional notes reflect R214 wound as stage 1 status on every assessment versus the worsening condition. On 05/27/21 at 08:32 AM, V19 Physician was interviewed regarding R214's wound care. V19 inquired when she was notified R214's wound worsened. V19 stated, The initial orders were from me. The middle of April the wound care specialists were giving some input. The wound started to get worse toward the end of April. She was not eating or drinking much; she started declining. It would have been V2 (DON) or the floor nurse who notified me. V19 inquired why there were no wound care certified staff providing care to R214's wound? V19 Physician stated, We utilized the facility staff on site. They are capable of following the wound care orders. I don't know why we don't have wound certified staff, it would have been good. V19 inquired why R214 was not sent to the hospital with increasing pain and change in her wound condition. V19 Physician stated, The condition had to be significant enough, she was stable at the time. We managed with pain medication changes. We had to adjust her meds, we tapered them then had to increase them. She was being cared for her [CONDITION(S)] (Chronic Obstructive Pulmonary Disease) and discussed hospice care with her POA (Power of Attorney) but she was not receptive. She was declining slowly. On 05/27/21 at 12:32 PM, V24 (Regional Dietitian) interviewed regarding R214's nutritional assessments related to the wound stage. V24 was inquired what would have been implemented if she was aware of R214's wound progressively worsening. V24 stated V23 Dietitian is on vacation and she will conduct the interview. V24 stated, We do read the wound assessments, what V23 wrote in her assessment is what she saw at the time. A stage one wound is like a diaper rash. We typically do a protein module to provide more protein for wound healing. V2 (DON) should have sent a new referral when she downgraded the wound to un-stageable. We have an on-call dietician she could have sent it to. The information on the 4/26/21 assessment was not accurate from the wound assessment which stated it was a stage 1. The revised 6/8/18 Skin Condition Assessment & Monitoring Pressure and Non-Pressure Policy states: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Wound Assessment/Measurement: 2. When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record. Physician and responsible party notification will be documented in the clinical record. These changes include but are not limited to: a. new onset of purulent drainage, b. new onset of odor, d. increased pain related to wound, e. significant increase in wound measurements. The revised 1/15/18 Pressure Ulcer Prevention Policy states: Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 12. encourage resident to maintain proper nutrition and hydration, providing supplements as ordered and necessary assistance at mealtime as needed.

Based on observation, interview, and record review, the facility failed to follow their fall prevention program by failing to monitor residents at high risk for falls and with a history of multiple falls; failed to implement safety interventions for each resident identified at-risk for falls; failed to inform/instruct nursing staff of residents at-risk for falls to prevent serious injury; and failed to develop individualized plans of care and interventions to mitigate falls for residents assessed to be at risk for falls and with a history of falls. These failures affected five of five residents (R1, R2, R3, R4, and R5) reviewed for falls with injuries and resulted in (R1) having a fall , with injury, which resulted in a left [MEDICAL CONDITION]; (R2) having 14 falls while in the facility; (R3) having a fall that resulted in a left femur fracture; (R4) having a fall that resulted in a shoulder fracture; and (R5) having seven falls while in the facility. Findings include: 1. R1 was an [AGE] year old resident with [DIAGNOSES REDACTED]. Facility fall incident report dated [DATE] written by V2 (Director of Nurses), stated in part (but not limited to): Date of occurrence: [DATE]. Time of occurrence 12:00 PM. Resident name: (R1). Diagnosis: [REDACTED]. hospitalization Diagnosis: [REDACTED]. R1 lost his balance, causing him to fall on his left side. V7 (CNA) witnessed the fall, and attempted to prevent the fall, however was unable to reach him in time. R1 was sent to hospital on [DATE] where a left [MEDICAL CONDITION] was confirmed. Facility records show R1 fell a total of 7 times: Fall 1 on [DATE], R1 had un-witnessed/un-supervised fall and was found on bathroom floor in an unoccupied room. Fall 2 on [DATE], R1 had a witnessed fall and sustained an injury in the dining room ,due to falling on his face and then sent to the hospital ER for treatment of [REDACTED]. Fall 3 on [DATE], R1 had un-witnessed/un-supervised fall in the dining room and was sent to the hospital ER for a CT scan to the head to ensure there was no bleeding in his brain. Fall 4 on [DATE], R1 had a witnessed fall in the dining room ,while he was walking without assistance, and fell backwards on his buttocks. Fall 5 on [DATE], R1 had an un-witnessed/un-supervised fall in the dining room and was found on the floor by a housekeeper. Fall 6 on [DATE], R1 had an un-witnessed/un-supervised fall in a vacant bedroom and was found lying on his side. R1 was sent to the hospital ER for further evaluation. Fall7 on [DATE], R1 had a witnessed fall in the dining room. R1 stood up from his wheelchair and fell to the ground, sent to the hospital ER and diagnosed with [REDACTED]. Nursing progress notes written on [DATE] at 11:52 PM by V12 (RN) stated, Called to room by CNA on duty at 10:15 PM . Noted resident without pulse, respirations, or blood pressure. No spontaneous movements were present, no response to verbal or tactile stimuli. Resident DNR (Do Not Resuscitate). Death was pronounced by writer and second RN at 10:15 PM. On [DATE] at 10:45 AM, Surveyor entered the second floor of the facility and spoke to V3 (Registered Nurse/RN) and was asked about R1's fall incident. V3 stated, Yes I know about that. (R1) had a fall but he was on hospice already and he was sent out to the hospital, came back, and I heard he died . I wasn't the nurse that was on duty when he fell . Surveyor asked what type of floor R1 was on, V3 stated, This is a dementia floor and he was oin his wheelchair, sitting right outside his room. Surveyor asked how many residents were considered high risk for falls. V3 stated, Most everyone here is high risk for falls. Surveyor asked what fall preventative measures were implemented for R1 and for other residents on the dementia floor. V3 stated, We try to watch them closely, we keep their call lights within reach, and we use fall mats. Tour of the dementia floor where R1 resided showed no floor mats placed with residents who were still in their beds . Call lightswere observed not within reach of residents. V3 (Registered Nurse/RN) accompanied surveyor to check resident rooms and observed almost every call light that was left on the floor or behind the bed and not within reach of residents. V3 stated, I don't know why these call lights aren't within reach of these residents but I will let all the CNAs know. Surveyor asked if she was able to see any fall mats placed beside the beds of any of the residents that were still in bed, V3 stated, We used to use them , there should be mats on the residents that are in bed, especially if they have a history of falling out of bed. Surveyor asked what other fall preventative measures the facility used for the residents at risk for falls, V3 stated, I know we just try to monitor everyone frequently but we don't use any kind of bed alarms or chair alarms but I will relay your concerns with management. Surveyor asked V3 if she knew of the facility fall protocols, V3 stated, I'm not sure. Surveyor asked when she received any in-service training on the facility fall protocols, V3 stated, I don't remember. On [DATE] at 11:00 AM, surveyor observed V4 (Certified Nursing Assistant/CNA) in the dining area and was asked if she worked the day R1 fell and inquired as to duties today. V4 stated, No I wasn't there. Right now we're getting everyone ready for lunch, so we put some of them in the dining room, because they have to be watched. Surveyor asked what she meant, V4 stated, Well they're confused so we watch them, and we toilet them. Surveyor asked whether she knew or was told by of the nurses which residents were at risk for falls, V4 stated, No, but they all are confused up here. Surveyor asked V4 if she was in-serviced or given instructions on how to keep the confused residents from falling, V4 stated, I don't know, we just watch them a lot. On [DATE] at 11:10: AM, surveyor asked V6 (CNA) if he was working the day of R1's fall, V6 stated, I was working, but I was on break when it happened. Surveyor asked if he knew R1. V6 stated, Yes, he was kind of confused. He would try to get up a lot. Asked on the day of R1's fall, whether he was assigned to watch the dining room, V6 stated, We take turns and I just went on my break, but I think it was (V7-CNA) who was there when R1 fell . Surveyor asked whether he let anyone know he was leaving the floor to go on break, V6 stated, No, it's on the schedule. Surveyor asked if he was instructed by the nurses or anyone in the facility about fall prevention, V6 stated, I think he had a fall mat by his bed and a chair alarm for his wheelchair but I'm not sure what else we do. A review of R1's care plan show no fall mats, chair alarms or any other safety devices used. On [DATE] at 11:20 AM, surveyor asked V5 (CNA) about R1's fall incident. V5 stated, When (R1) fell I was on my break. I told my coworker V6 and V7 about 11:00 AM and they said okay because someone has to be with R1 all the time. He was in his wheelchair, with his wheelchair against the wall ,over there (pointing to the location in the dining room area). As soon as I came back from break, R1 was already put back in bed after he fell . We always watch him but we can't restrain him, we just give him something to do like magazines. Most of the time he just sits out here in the dining room. Surveyor asked what R1's fall precautions were when he was in bed, V5 stated, He didn't fall out of bed, he fell from his wheelchair and it happened when I was on break. V5 was here in the dining room and they said he stood up and the CNA couldn't catch him because she went to get something for another resident. Surveyor asked what fall prevention interventions were in place to keep R1 from falling, V5 stated, He didn't have any. We were just supposed to watch him closely. Surveyor asked if he recalled who the nurse on duty was at the time of R1's fall, V5 stated, It was a new nurse I know that, I think it was (V8). On [DATE] at 1:25 PM, V8 (RN) stated, I was at the nursing station preparing my medications for the 12:00 PM med-pass. I didn't see R1 fall because my cart was at the nursing station at the time and there's a wall that blocks part of the dining room so I couldn't see where R1 was sitting. Surveyor asked what she could recall about R1 and his behaviors, if any. V8 stated, I didn't really know (R1) or that he was even a fall risk. I just started about a month ago in [DATE] when this incident happened. After (R1) fell we left him on the floor in the dining room, so we did not move him at first. We had the CNA's put him on a lift and placed him back in his room on his bed and applied ice on him. I gave him pain medications and I know he was on hospice and that he usually was in his room. (R1) is alert and oriented times 2 to 3 that's about what I know. When asked how many nurses were working on the floor when R1 fell on [DATE], V8 stated, I was the only one on duty on the dementia unit and it was my first day out of general orientation working by myself . I didn't know the residents well. Surveyor asked if she knew, or if anyone of the nurses informed her that R1 was at high risk for falls, V8 stated, No, no one ever told me that. Surveyor asked whether she received any formal in-service training from the facility on fall prevention. V8 stated she received no formal fall prevention in servicing. Surveyor asked whether she knew what fall prevention protocols were in place to keep R1 and any of the other residents on the dementia floor safe, V8 stated, No. I was not given anything. Surveyor asked again whether during her orientation, whether any staff may have told her of any of the residents who were high risk for falls on the floor she served, V8 stated, No sir, I was not told anything specific about R1 or any of the other residents on the floor R1 was on. I just know they are all pretty confused. On [DATE] at 1:30 PM, V7 (CNA) stated, I was in the dining room helping residents and (R1) was in the dining room sitting in his wheelchair He wasn't my resident, it was V5's (CNA) and he was on break and so was V6, the other CNA. Surveyor asked how many residents there usually were that were in the dining room during lunch time, V7 stated, Sometimes 13 or 14, maybe more. When asked what happened on [DATE] when R1 fell , V7 stated, We put all the residents in the dining room around 11:00 AM to get them ready for lunch and I was the only one in the dining room because like I said, V5 and V6 both went on break . I had to watch everyone. So I went to get some tea or hot water for another resident . when I turned around, R1 stood up and he fell down and I couldn't catch him. Surveyor asked whether she knew if R1 fell before this incident, V7 stated, Yes, he fell in his room I think and he fell out in the dining room too before. Surveyor asked why R1 was unattended based on fall history, V7 stated, He's not my resident and I was just watching everybody. Surveyor asked if she knew what to do with R1 to keep him from falling, V7 stated, We are supposed to watch him and check on him, keep him calm, and keep the call light by him. Surveyor asked if there was a call light by R1, V7 stated, No, there isn't one near him outside his room. Surveyor asked what in-service training she received to keep residents like R1 from falling, V7 stated, We are just supposed to keep close watch on all of them, keep them calm like give them newspaper or something to do. Surveyor asked if R1 was provided any of these things, V7 stated, No. On [DATE] at 12:10 PM, V2 (DON-Director of Nurses) stated, I just started [DATE]th as the DON here, but I've been a DON elsewhere. Surveyor asked V2 to describe the nursing staff scheduling. V2 stated, Nurses make the assignments for the CNAs. There's group 1, 2, and 3, which is how they schedule breaks. This was already in place when I got here. V8 was the nurse on duty when R1 fell on [DATE]. She was new and a PRN (as needed) nurse. Surveyor asked V2 if she was on the floor when R1 fell . V2 stated, No, I wasn't. I didn't observe it. I did the investigation though and reported it. Surveyor asked if she was aware of any fall risk interventions the facility utilized for high fall-risk residents including R1. V2 stated, Well I know that we have the pharmacy review medications, we tried to monitor R1 closely and see if he needed to have 1:1 supervision. Surveyor asked if R1 required 1:1 supervision, V2 stated, I'm not sure, but I know he had a history of [REDACTED]. We use side rails and increased toileting. We don't use any bed alarms or chair alarms, but I'll have to check what else we do. Surveyor asked V2 whether there were any other fall prevention strategies she learned as the head of the nursing department but could not offer any further fall prevention strategies. Surveyor provided V2 examples such as wedge cushions, pommel cushions or any other assistive devices that could have protected R1 or any fall-risk residents she had, V2 stated, I don't think we used any of those on R1 or anybody here. Surveyor provided another example such as a pressure-activated wheelchair cushion alarm that could have been used on R1 to alert staff once he got up from his chair, V2 stated, Like I said, we don't use alarms here. Surveyor asked if she knew what interventions were in place to prevent R1 from falling, V2 stated, I don't know. Surveyor asked if she did the R1's fall investigation, V2 stated, I did. Surveyor asked if she looked at the wheelchair R1 fell from and checked to see if it was locked or if it was in proper working order during her investigation, V2 stated, No, I interviewed staff and we assessed the resident. Surveyor asked what interventions were implemented to keep R1 from falling, V2 stated, I just know they're supposed to watch him closely. Interview with V11 (Medical Director) on [DATE] at 12:55 PM stated, I am the medical director and yes I was the attending physician for (R1). I saw him every month on follow up sometimes via tele-health. I was made aware of his falls and his high-risk for falls. I know that the nurses did daily meetings pertaining to his falls. He was declining and he had no ability for safety awareness. I was informed of the big fall in the dining room as he was sent out to the hospital based on my order. He was already declining and certainly this fall didn't help,but again, people fall and there is not much you can do as this population with dementia, you are going to expect multiple falls. Short of tying someone down which I'm not suggesting, (R1) would continue to fall and people with progressive dementia will fall. Surveyor asked whether they talked about staffing levels that may impact falls, V11 stated, I thought you're only asking me about R1 Surveyor asked V11 if she was the medical director and oversaw all the residents, V11 stated, Well, I'm unaware of who was watching (R1) at the time of the incident and I am not involved in staffing so I can't comment on that. We have monthly QA (Quality Assurance) meetings and yes I am involved in them. We meet about the first week of the month. I physically attend them and yes we do discuss falls. I'm certain V1 (Administrator) can provide you with minutes. I know we bring up the falls each month but I can't tell you if we do any changes to any interventions, that would be up to the facility. 2. R2 is a [AGE] year old resident with [DIAGNOSES REDACTED]. Facility records show R2 fell a total of 14 times during his stay at the facility. His most recent falls occurred on [DATE], [DATE], [DATE], [DATE] and [DATE]. R2's care plan last updated [DATE] states in part (but not limited to): R2 has history of multiple falls with no minor/major fall-related injuries related to history of falls, impaired balance, [MEDICAL CONDITION] drug use, cognitive and physical impairment secondary to dementia, anxiety, [MEDICAL CONDITION], limited range of motion of lower extremities.R2 was noted on the floor witnessed from his recliner chair (specialty) with no injury noted during this review. Goal: I will not sustain serious injury through the review date. Interventions: Anticipate and meet the resident's needs; be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Bed height to be placed where the floor mat is; Floor mats in place when resting in bed; Pommel cushion to the (specialty) recliner chair to minimize falling incident; PT/OT to evaluate current trunk control to determine which assistive device is most appropriate. Staff reminded to place resident in the center of the bed. Nursing notes on [DATE] showed: Fall Description: Resident had a witnessed fall [DATE], 5:45 PM. Location of fall: Dining Room. Resident was sitting on his (specialty) recliner chair in the dining room. NOD (Nurse on duty) was in nurse's station charting and noted resident sliding down from his (specialty) recliner chair. NOD (nurse on duty) ran to dining room and yelled for CNA to help residen,t but was not able to reach resident in time to prevent fall. Resident fell to the floor on left lateral position. Nurses notes on [DATE] showed: Resident had an un-witnessed fall [DATE], 4:30 AM. Location of Fall: Resident's bedroom, at bedside, on padded floor mat. CNA began rounds, heard resident yelling, called to resident's room, resident found crawling on floor mat. On [DATE] at 11:15 AM, R2 was observed in the center of bedroom and was placed in a recliner that appeared to be elevated waist-high. R2 appeared agitated and was moaning and talking unintelligibly. There were no call lights within his reach . R2's left leg was dangling out of the reclining chair and he appeared precariously placed in the recliner. Surveyor called over V3 (RN) and asked about R2. V3 stated, That is (R2) we put him in the (specialty) recliner chair because he is a fall risk and he's fallen several times. Surveyor asked how R2 could ask for help since there was no call light within R2's reach, V3 stated, He doesn't use the call light, he's confused so we try to check on him a lot. Surveyor asked what kind of fall interventions she knew of they used for R2, V3 stated, I think we use a fall mat on him when he's in bed. Surveyor asked V3 if she saw any in the room, V3 stated, I don't see any. Surveyor asked whether they might store the mats when not in use anywhere, V3 stated, It would be folded up by his bed if we used it. Surveyor asked if there were any other safety devices used for R2 when in his reclining chair or if she saw any on him now, V3 stated, There isn't any that I see, but I don't know what else they use. I just know they check on him frequently. Surveyor asked whether R2 should be placed in the center of the room like he is now, V3 stated, No, he shouldn't be here like this. 3. R3 is a [AGE] year old resident with [DIAGNOSES REDACTED]. R3's care plan most recent update [DATE] states in part (but not limited to): I have a history of falls related to cognitive impairment: poor safety awareness, unsteady gait and balance and constant wandering in the hallway. I have no safety awareness and would accidentally bump into things when I am walking around that may cause skin issues. (R3) was recently hospitalized and undergone a surgery to her right femur fracture. She is currently using a wheelchair with restrictions to walk. Goal: The resident's fall risk will be reduced by the review date. Interventions: I will not have complications from my restrictions of walking; anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Bed height to be placed where my feet are flat on the floor. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing; The resident needs to be evaluated for, and supplied such as wheelchair and walker. Re-evaluate and as needed for continued appropriateness and to ensure least restrictive device or restraint; follow facility fall protocol. Nurses notes showed: Resident had a witnessed fall [DATE] 5:10 AM Location of Fall: Dining room/common area. Resident had a witnessed fall by CNA. CNA states resident hit head on corner of table. Resident was walking and fell . On [DATE], 3:54 PM, MDS Progress Note. Late Entry: Narrative: resident unable to tell if she had pain during the look back period. Resident was send out to the ER due to fracture in the femur during this assessment, continues to require moderate to extensive assistance due to poor safety awareness and confusion. Resident needed verbal cuing during her Activities of Daily Living. Resident had fall which she obtained injury and she was sent out to the hospital. Facility incident report dated [DATE] states in part (but not limited to): Resident: (R3) Diagnosis: [REDACTED]. Description of occurrence: Nurse noticed a slight limp while resident was ambulating in the hallway. Resident had a fall 3 days prior without notable change in range of motion. Injuries: Incomplete non-displaced fracture involving the right subcapital femur. On [DATE] at 12:20 PM R3 was seated in the dining room area eating lunch. She appeared very confused and agitated and was pushing her food around on her plate and was repeating Come here, come here to no one in particular. There were 14 other residents seated in the dining area with lunch trays placed in front of each resident. Surveyor asked V3 how many residents were usually in the dining room at this time having their meal, V3 stated, This is about the usual. We have these 14 or so residents and we have some seated outside their rooms and there's about three others in that small area in front of the nursing station. Surveyor asked about R3, V3 stated, Yes she's a fall risk. She had a fracture recently but that's all I know. Surveyor asked if there were any type of devices used on R3 as she sat on the edge of her wheelchair. V3 stated, I'm not sure what else we'd use on her. Surveyor asked V3 whether she's ever been instructed to use a wedge cushion or pommel cushion to keep R3 from sliding down, V3 stated, I've never seen that on anyone here but I will let management know your concerns. 4. R4 is a [AGE] year old resident with [DIAGNOSES REDACTED]. R4's most recent care plan dated [DATE] shows in part (but not limited to): I have a history of falls related to muscle weakness, unsteady gait, impaired balance, [MEDICAL CONDITION], history of falls, [MEDICAL CONDITION] drug use, incontinence, poor safety awareness. Goal: I will not have any unavoidable falls through the next review date. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to request for assistance. Bed height to be placed where my feet are flat on the floor. Ensure that the resident is wearing appropriate footwear describe correct when ambulating or mobilizing in wheelchair. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Facility incident dated [DATE] report stated, Resident had an un-witnessed fall [DATE] 11:15 PM Location of fall: resident's room at her bedside. Heard the loud voice help, went to her room and found lying by her bedside. Helped resident sit on the bed and assessed range of motion, obtained vital signs. Administered pain medication for pain. Nurses note written by V3 (RN) stated, Observed resident with guarded movement of the right arm, pain with movement ,[DATE], palpable pulses, no discoloration or bruising at right arm noted. DON and POA made aware of the resident's current condition. Facility incident report completed by V1 (Administrator) states in part (but not limited to): Resident: (R4) Nurse noted a complaint of pain and inability to raise arm. No pain noted since fall on [DATE]. Injuries: Superior dislocation of humeral head. 5. R5 is a 61 resident with [DIAGNOSES REDACTED]. Facility fall occurrence records show R5 fell 7 times ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]). Facility fall occurrence records showed: Resident had an un-witnessed fall [DATE] 4:40 PM Location of fall: Dining room. Resident was walking when he turned around and trying to sit on the chair and missed it. He sat on the floor. Resident had a witnessed fall [DATE], 5:20 PM Location of fall: common area, dining room. Resident ambulating shuffling both feet, making a turn, aiming to sit on chair and missed, hit back on wall then slide to floor. Resident had an un-witnessed fall [DATE], 5:15 PM Location of fall: Outside of resident's room, near dining room, in the hallway. CNA stated that resident had fell /tripped, and was lying on their side when they fell . Resident ambulated and stood up without assistance. No pain or apparent physical injuries noted. R5's care plan states in part (but not limited to): I have potential for minor/major fall-related injuries related to unsteady gait and poor safety awareness. R5 like to walk around the hallway. He has a wander guard to alert staff if (R5) is near the elevator when he wanders around. Goal: I will be free from minor/major fall-related injuries through the next review date. Interventions: Anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Bed height to be placed where my feet are flat on the floor; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; Ensure that The resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, personal items within reach. Facility policy dated [DATE] titled Fall Prevention Program states in part (but not limited to): Purpose: to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The fall prevention program includes the following components: Methods to identify risk factors, residents at risk, assessment time frames, immediate change in interventions that were successful; communication with direct care staff members. Care plan incorporates: Identification of all risk/issue, addresses each fall, interventions are clanged with each fall as appropriate, preventative measures. Standards: A fall risk assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident; Safety interventions will be implemented for each resident identified at risk; the admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Fall/safety interventions may include but are not limited to: Direct care staff will be oriented and trained in the Fall Prevention Program; the time of admission and in accordance with the plan of care the resident will be oriented to use the nurse call device. The nurse call device will be placed within the resident's reach at all times. Resident will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned. Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet. Nursing personnel will be informed of residents who are at risk of falling.

Based on observation, interview, and record review, the facility failed to provide dining assistance to one (R1) resident who has a history of confusion and assessed to require extensive assistance in eating and drinking, along with a one person physical assistance to accomplish this task. This failure resulted in R1 sustaining a hot water burn with permanent scarring. Findings include: R1 is an [AGE] year old resident with [DIAGNOSES REDACTED]. V2 (Director of Nurses) was asked the type of floor R1 resided on and stated, It's our dementia floor and everyone there is confused except for one male resident who did not want to move floors. Facility incident report dated 7/6/2020 titled Burn shows: During dinner resident requested hot tea. Tea was served as requested by CNA (Certified Nurses Aide). Resident accidentally dropped the tea over her left leg. Cold compress were applied immediately. Skin was pink in color. No other skin abnormalities were noted. Half hour later when resident was taken shower. CNA noted an intact blister on left leg, no pain complaints observed. Nurse Practitioner called and made aware, Director of Nurses and Power of attorney were notified as well. Resident unable to give description. The same incident report for R1 lists: Mental status: 1. Disoriented, but within normal limits for this resident. 2. Oriented to person. Predisposing Physiological factors listed: 1. Confused. 2. Impaired Memory. 3. Fragile Skin. Predisposing Situation factors listed: 1. Combative with care. 11/12/20 at 10:20 AM, R1 was observed seated in a geriatric chair outside her room. R1 appeared confused and was only able to respond to her name when called. Surveyor asked about an incident that occurred with R1, V3 (Licensed Practical Nurse) stated, Yes, I know what you mean. It's when she got burned from hot water on her leg. Surveyor asked to see R1's burn wound, V3 wheeled R1 back inside her room and showed the wound to the surveyor. V3 stated, During dining we passed coffee for dinner around 6 or 7 o'clock. (R1) dropped the coffee or was it tea, on herself and we checked it and put cold compress and I called the doctor, V2 (director of nurses) and POA (power of attorney). The next day it was pink but later on when she got a shower it was red and it was a blister. Surveyor asked to describe the burn wound, V3 stated, It's dark and measures about 2 to 3 centimeters and it looks like it caused a scar. Asked who was assigned to be with R1 while assisting in her feeding, V3 stated, She (R1) eats on her own, she doesn't need help. 11/13/20 at 12:27 PM, V4 (Certified Nursing Assistant) stated, I was the CNA that gave R1 her hot tea , but I didn't see her spilling it on herself. I just heard her scream out and I immediately went to her and saw her pants wet with the hot water. I recall the nurse (V3) drying her pants with towels. Surveyor asked if she saw the nurse bringing R1 into her room, V4 stated I think when dinner was over she was put her back in her room but I didn't see the nurse take her clothes off to check her leg right away. I think that when she got a shower is when they discovered the hot water burned her leg because it was a blister I was told. Asked if R1 was able to feed herself, V4 stated, She's confused but I think she can eat on her own but she wasn't my resident when this happened. I just happen to be standing near her when she wanted tea so I gave it to her. No one was near her when she spilled the tea because like I said, she yelled out and so I ran to her when this happened. R1's initial MDS (Minimum Data Set) dated 4/6/20 and two consecutive MDS assessments dated 7/7/20 and 9/17/20 all show R1 requiring extensive assistance in eating and drinking along with a 1-person physical assistance to accomplish this task. R1's care plans dated 3/24/20 states in part (but not limited to): 1. Problem: I have impaired cognitive function or impaired thought processes related to Dementia. Interventions: Eating: extensive assistance; one person physical assist. Cue, reorient, and supervise as needed. 2. Problem: I am unable to consume regular consistency diet and require mechanically altered foods. Interventions: Position for eating and drinking safely. 3. Problem: I use [MEDICAL CONDITION] medications: [REDACTED]. Interventions: Monitor/document/report as needed any adverse reactions of [MEDICAL CONDITION] medications: [REDACTED]. 11/12/20 at 12:15 PM observed that a CNA (Certified Nursing Assistant) was seated next to R1 feeding her. Surveyor asked for the dietary manager to take the temperatures of the coffee and hot water for tea. V2 stated, The dietary manager is off today but I've asked the administrator to come up to do it. V1 (Administrator) stated, I used to be in dietary so I know how to temp food. V1 took the temperature of the coffee which read 116 degrees Fahrenheit and hot water for tea read 130 degrees Fahrenheit. According to the U.S. Consumer Product Safety Commission, Publication #5098 states in part (but not limited to): The majority of injuries and deaths involving tap water scalds are to the elderly and children under the age of five. Most adults will suffer third-[MEDICAL CONDITION] exposed to 150 degree water for two seconds.[MEDICAL CONDITION] also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns. 11/12/20 at 2:15 PM, V2 (Director of Nurses) stated to surveyor, I know you're looking in to the burn that happened with (R1). I know at the time I didn't think it was a significant burn but I wanted to show you the treatment orders for her. Surveyor asked if she conducted the wound treatment, V2 stated, Yes I did the treatment for [REDACTED]. It started out as pink and then a blister which was reddened. Treatment orders V2 presented showed treatment orders starting 3 days later on 7/9/20 for [MEDICATION NAME] ointment 500 units/grams. Apply to left upper thigh topically every night shift for open blister apply [MEDICATION NAME] ointment then dressing and cover with dressing until healed. Another treatment order initiated 16 days later on 7/22/20 show Silver [MEDICATION NAME] Cream 1% apply to left thigh topically every evening and night shift for burn for 7 days. Interview with V6 (Nurse Practitioner) on 11/13/20 at 11:35 AM stated, I am the NP overseeing (R1) and yes I'm pretty familiar with her. I'd say she is cognitively impaired and I recall being informed of the incident where she got burned from hot tea I believe what was told to me. Surveyor asked if staff informed him about R1's behavior as causing the burn to her thigh, V6 stated, I don't think I was informed of any behavior .if R1 had a behavior of combativeness, I would not be serving her hot beverages placed in front of her without adequate supervision. Surveyor asked if he saw R1's burn injury, V6 stated, I recall it was healed and appeared like there was a darkened area on her leg. I last saw it in August but as mentioned it has healed. Surveyor asked if a 3rd-degree burn could cause permanent scarring, V6 stated, Yes it can.

Based on record review and interview the facility failed to provide adequate supervision by leaving a resident a risk for falls unattended in a bathroom. This failure applies to one of three residents (R1) reviewed for fall in a sample seven. As a result, R1 had an unwitnessed fall and sustained a laceration to the head and hematoma to the right hip. Findings include: Surveyor observation of R1 on 8/20/14 revealed the injury. There was a large hematoma to the right hip area which spread to the front of the abdomen. R1 had one staple to the back of the head. E2 ( Director of Nursing ) observed the resident at this time with a full body check. E2 found no other bruising on R1s body. R1 was unable to answer questions. R1 is an [AGE] year old resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of documents note R1 is alert but non verbal. R1 uses a wheelchair and can walk with a walker. R1 was assessed with [REDACTED]. R1's current care plan documented R1 is a risk for fall and had 6 falls since May of 2014. R1's hospital records show upon return to the facility on [DATE] , R1 sustained a small laceration to the back of the head, a hematoma on the left side of the abdomen and a closed fracture to the nasal bones. On 8/23/14 9:55AM E5 (Certified Nurse Aid/CNA) stated by phone the following: On 8/8/13 at 8PM, I took R1 to the bathroom. I put her on the toilet. I walked across the hall for a diaper. When I came back R1 was on the floor. I notified staff for assistance. I was only gone for a few seconds. I was not supposed to leave R1 unattended. E2 ( Director of Nursing ) told us never to leave a fall risk resident unattended during care. On 8/23/14 10:18AM E2 ( Director of Nursing ) stated R1 has been assessed for good sitting balance and is able to ambulate with staff assistance. R1 had 4 falls from her bed since May of 2014. The interventions seemed to work. The 8/8/14 fall was the first in the bathroom. I re- in-serviced staff on not leaving fall risk residents alone during care in their room /bathroom or shower room. On 8/23/14 11:20AM E6 ( nurse ) stated staff are not supposed to leave residents in the toilet room unattended if they are on fall precautions. On 8/23/14 11:25PM E8 (certified nurse aid ) stated residents who are at risk for falls are not to be left unattended at all during toileting. On 8/23/14 11:30AM E3 ( nurse) stated residents at high risk for falls are not to be left alone in the toilet room. On 8/23/14 11:40AM E8 (certified nurse aid) stated staff are not supposed to leave residents alone at all if they are high risk for falls.