Every finding on record at Aliya of Palos Park

Palos Park, Illinois · CCN 146053

36 findings across 21 inspections, in the inspector's own words, 20 of them at actual harm or above.

Data as of September 30, 2026, released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Inspection of May 11, 2026

1 finding

F550D · No harm, potential for more than minimal, isolated

Based on interview and record review the facility failed to respect a resident's (R1) right by tampering with a camera in the resident's room. This failure affected one resident in a sample of 9. R1 is [AGE] years old with diagnosis not limited to: Metabolic Encephalopathy, Moderate Protein-Calorie Malnutrition, Acute Respiratory Failure With Hypoxia, Adult Failure To Thrive, Chronic Kidney Disease, Retention of Urine, Acute Cystitis Without Hematuria, Syncope and Collapse, Thoracic Aortic Aneurysm, Anemia, Obstructive And Reflux Uropathy, Constipation, Hypothyroidism, Dementia, Insomnia, Parkinson's Disease, Major Depressive Disorder. R1's 4/2/26 BIMS score is 00 (meaning the resident is not cognitively intact). R1's 11/10/25 care plan documents in part: R1's POA (Power of Attorney) prefers to have camera in her brother's room. On 5/8/26 at 12:38 pm R1 was observed. R1 was clean but was not able to be interviewed. On 5/8/26 at 2:00 pm V1 (Administrator) said regarding R1, she was informed on 4/17/26 that a staff member (V12) moved and turned the camera and the employee reported the incident to her. V1 said, V12 was under the impression she needed to give consent to be on the camera. She moved the camera to provide privacy to R1 and thought she needed to give consent herself to be on the camera. She does not work in the facility often, but she works in corporate, she was not aware of the law that was passed in general that a person can't obstruct the camera in residents' room. V1 said, she was not aware she was not supposed to do that, now she is since the incident. V1 said, now as a part of new hire orientation, new staff they sign the form about the law related to the camera and they did in-service with all the staff. V1 said, there is a sign on the residents' door that says there is a live recording in use. On 5/9/26 at 8:27 am V14 (R1's Sister) said on 4/17/26 a corporate wound care nurse of the company, she came and as soon as she saw the camera, she flipped it around to face the wall, this is someone from the corporate and she moved the camera. V14 said, she called V1 right away and after 10 minutes they turned it around to face R1. V14 said, she called V1 and said this is the 3rd time they moved/tampered with the camera, that is a federal violation. V14 said, this is the responsibility of V1 to educate their staff and especially for V12 being from corporate she should know the law. V14 said, the minute V12 walked in the room, she saw the camera, she turned it to face the wall, this is unacceptable from someone who works in corporate. On 5/9/26 at 8:54 am V12 (Corporate Wound Care Director) with V1 (Administrator) present said, she went in to provide care to R1, and she noticed there was a camera there and she turned the camera slightly from the patient to provide privacy to the patient and herself. V12 said, after a couple of minutes one of the nurses on duty came in and she informed V12 that R1's sister is on the phone and is threatening that she will call IDPH due to the camera being moved, so V12 turned the camera back on the resident. V12 said, after providing care she reported this to V1, and she (V1) informed her she should have not moved the camera due to the resident rights. V12 said, she did not follow up with R1's nurse prior to moving the camera if she could move it. V12 said, she was not informed of the law in Illinois, she thought there needs to be 2 party consent, camera was turned away from R1 for 2 minutes. V1 said, she educated V12 she should have not moved the camera. V12 said, she apologized as it was not done as a malicious intent. V1 said, there are cameras in the building so V12 was on camera prior to entering R1's room. On 5/8/2026 at 11:26am during tour of building with V3, Maintenance Director, observed signage outside of R1 and other residents' room that the resident had video surveillance camera in place, informing anyone that entered the room they would be on camera. On 5/9/2026 at 11:52am observed signage at entrance of door of residents that had camera in room stating, monitor in progress. Facility's (4/17/26) in-service for V12 documents in part: Sec. 40. Obstruction of electronic monitoring devices. (a} person or entity is prohibited from knowingly hampering, obstructing, tampering with, or destroying an electronic monitoring device installed In a resident's room without the permission of the resident or the Individual who consented on behalf of the resident in accordance with Section15 of this Act. RESIDENTS' RIGHTS for People in Long-Term Care Facilities documents in part: You have a right to purchase and use an electronic monitoring device after providing notice to the facility using the Electronic Monitoring Notification and Consent.

Inspection of April 9, 2026

2 findings

F686D · No harm, potential for more than minimal, isolated

Based on observations, interviews, and records reviewed the facility failed to follow the menu served to the residents. This failure affected 7 of 7 (R3, R9, R18, R84, R101, R103, and R105) residents receiving pureed diets in a sample of 37 residents. The findings include: On 4/22/25 the Menu listed to be served oven roasted Turkey with Gravy, Sweet Potatoes, Brussel Sprouts, Dinner Roll, Chilled Peaches, and Beverages. On 04/22/25 at 12:00pm the surveyor observing tray service in the kitchen. The surveyor observed the pureed meals served did not receive a bread or roll item on their plate. V9, Cook, said the residents on pureed diet do not have a roll. V10, Dietary Aid, said I can't give them rolls, they puree. On 4/22/25 at 12:03pm V11, Dietary Manager, said we don't do puree bread, we haven't in a long time. V11 said we don't have the bread puree mix. V11 said we have the recipes for the puree bread. Recipe for Pureed Buttered Dinner Roll: ingredients dinner roll, margarine, solids - melted, milk.

F550D · No harm, potential for more than minimal, isolated

Based on observation, interview, and record review, the facility failed to address a resident's and a family's concern about response to call light wait times and failed to allow a resident to have personal refrigerator in at bedside while allowing another resident to have a personal refrigerator at the bedside. This affected two out of three residents (R15, R82) reviewed for resident rights. Findings Include: R15 is an [AGE] year old with the following diagnosis: heart failure, type 2 diabetes, and chronic atrial fibrillation. R82 is an [AGE] year old with the following diagnosis: Alzheimer's disease, dementia, and anorexia. On 04/22/25 at 11:21AM, R15 was interviewed while on the phone with R15's family member (V36). R15 and V36 reported it take 45 minutes or more for staff to answer the call light. R15 and V36 stated they track time on their phones to see how long staff takes to answer the call light. R15 and R36 reported it will take 45 minutes or more to respond to a call light or request about two or three times a week but it happens most on weekends. V36 stated V36 has spoken to V2 (DON) about the concerns but nothing has been addressed. V36 denied being offered an opportunity to fill out a concern form to have the concern addressed. R15 and V36 stated staff told R15 and V36 the facility can no longer accept personal refrigerators in the room due to being cited by IDPH. R15 and V36 reported the refrigerator was removed about a week ago. On 04/24/25 10:31 AM- V2 (DON) stated the facility has recently implemented in the last week that personal refrigerators are unsafe in resident rooms due to keeping food past expiration dates and wandering residents going in the other people's fridge and eating food that is not theirs. V2 reported R15's fridge was removed from the room within the last week due to those reasons. V2 stated R15 is alert and oriented times three but it not mobile to get out of the bed to clean the fridge. V2 reported there was too many other responsibilities the nursing staff have to worry about to have time to clean and check refrigerators all the time. The surveyor asked what was put in place for the residents that want outside food brought in since the refrigerators were taken away, and V2 said, it is still a work in progress. V2 stated the administrator could better answer the questions about the refrigerator. V2 reported V36 has talked to V2 to discuss call light wait time. V2 stated it was not documented on a concern form because the family did not verbalize with exact words that there was a concern with call light wait time. V2 reported the family and V2 were just having a discussion about R15's care and call light response time was mentioned by V36. V2 denied V36 stating how long they wait but reported the family said it was a long time. V2 reported call lights need to be answered as soon as they are put on and gave an average time frame of 5 to 10 minutes on when staff answer call lights. On 04/24/25 at 10:54 AM, V15 (CNA) reported V15 did not care for R15 so V15 was unaware of the refrigerator being taken in V15's room. V15 reported another R82 had a refrigerator placed in the room last week. V15 confirmed staff is responsible to clean the refrigerators and date/label food. V15 stated nurses, CNAs, and the dietary manager check the refrigerator at least a couple times per week. V15 denied any management telling staff that residents were not allowed to have personal refrigerators in their rooms anymore. On 04/24/25 at 11:05 AM, the surveyor observed a personal refrigerator in R82's room. The surveyor then saw V15 in the hall and V15 said, Yes. I told you she had a fridge in her room. On 4/24/25 at 3:57PM, V37 (Director of Customer Experience) stated an in-service was completed on 2/10/25 for call light response time. V37 reported it was discussed the importance of answering the call lights as soon as possible so residents' needs are being taken care of. V37 stated V37 has gotten complaints from residents or family's within the last six months about call light wait time. V37 reported the complaint time is for waits that are more than two or three minutes. V37 could not give an exact time family's reported waiting for a response. On 4/25/25 at 12:15PM V1 stated the facility began removing personal fridges from resident rooms about a week ago due to safety concerns of dementia residents going into fridges and taking items that are not on their diet. V1 reported some residents still have personal fridges in their room because the facility is still getting around to taking them out. V1 reported angel rounds are done daily by staff and anything in the room that should not be there should be removed and reported as soon as possible. V1 stated R82's refrigerator has not been removed yet because the facility has not educated the family yet. There is no documentation of education that was provided to R15 or V36 on the facility's new protocol of not allowing personal refrigerators in the resident rooms. An in-service dated 2/10/25 documents the topic of education as all staff are to ensure that call lights are answered in a timely manner. CNAs and nurses were the staff educated in this in-service. The policy titled, Call Light Response, dated 1/10/24 documents, General: To provide the staff with guidance on responding to residents' requests and needs. Protocol: .6. Answer the patient or resident's call as soon as possible. The policy titled, Personal Food, dated 01/2024 documents, General: To provide guidance regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Responsible Party: Nursing Staff, Social Services, Administration, Housekeeping, Nutritional Services Guideline: .3. Facility staff will assist the resident in accessing and consuming the food, if the resident is not able to do so on his or her own. The Illinois Long-Term Care Residents' Rights for People in Long-Term Care Facilities dated 11/2018 documents, Your rights to dignity and respect- You have a right to make your own choices. Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source .You may be informed, in advance, of changes to the plan of care .You may keep and use your own property. The Contract Between Resident and Facility documents, .C. Resident's Rights and Obligations .4. No food, liquids, or medicines will be brought into the Facility without permission of the Administrator or nurse in charge. Food must be in sealed containers .11. The Resident is free to decorate his/her Room as he/she wishes, provided that the Resident complies with the safety rules of the facility. The Resident may not make any structural or physical changes to his/her Room, unless expressly approved in writing by the Facility.

F558D · No harm, potential for more than minimal, isolated

Based on observation, interview and record review, the facility failed to follow their Call Light Response policy, by not placing the call light within reach. This affected one of three residents (R321) reviewed for accessible call lights. Finding Include: On 4/22/25 at 12:00pm to 12:08PM, R321 heard yelling Someone Please Help me. Observed R321 in his room, up on a Geri chair, on right side of the bed, foot side area. Call Light on bed, in upper head part of the bed, not within reach of R321. R321 was asking to be put back to bed and voiced out that he is looking for his dentures. On 4/22/25 at 12:10PM, confirmed with V4 (CNA/Restorative Aide) that R321's call light is not within R321's reach. V4 moved and placed the call light closer to R321, and within his reach. On 4/25/24 at 9:00AM, V2 (DON) stated that staff should place the call light within resident's reach. If coming from dialysis, the person placing him in the room should make sure that the call light is within the resident's reach, so they can call for assistance. Call light response policy with a revision date of 3/17/25, reads in part: To provide the staff with guidance on responding to residents' requests and needs. Ensure the call light is always within resident's reach. When the patient or resident is in bed or confined to a bed or chair, provide the call light within easy reach of the patient or resident. Answer the patient or resident's call as soon as possible. Listen to the patients/resident request. Do what the resident as of you, if permitted, if you are uncertain whether a request can be fulfilled or cannot fulfill the patient/resident's request, ask for assistance. If assistance is needed when you enter the room, summon help to the room.

F583D · No harm, potential for more than minimal, isolated

Based on observations, interviews, and record reviews, the facility failed to preserve one resident's privacy and dignity and obtain informed consent from the resident and resident's POA (power of attorney) to reside in a semi-private room in which the roommate has constant video monitoring. This failure affected two resident (R71, R77) out of three reviewed for privacy in a sample of 37. Findings include: On 4/22/25 at 10:00 AM, signage was observed on R71 and R77's room doorway noting video monitoring is occurring. On 4/25/25 at 8:30 AM, V1 (administrator) stated that consent is obtained if a roommate is placed in a room with video monitoring. On 4/25/25 at 9:10 AM, V17 (social services) stated that R77's BIMS (brief interview of mental status) is 9 or 10 out of 15. V17 stated that R77 can make her needs known. V17 was questioned regarding reason R77's signature and date do not match from the original document in R77's EMR (electronic medical record) and the copy given to this surveyor. V17 stated that she gave this surveyor the original document of the consent and did not want to ask for the original back so she had the resident sign a new consent form and placed in R77's EMR yesterday. When questioned reason this consent was not uploaded into R77's EMR on 9/23/24, V17 replied that this document does not have to be in the EMR. When questioned reason R71's consent was uploaded into R71's EMR, V17 did not respond. V17 stated that this consent form for R77's roommate having a video monitor in room is not related to healthcare and therefore did not need informed consent from R77's POA (power of attorney for healthcare). V17 stated that she spoke with R77's POA in August 2024 and obtained verbal consent for video monitoring. R77's medical record, dated 7/23/24, V17 noted R77 is up for a quarterly review. R77 has a POA in place. R77 has family involvement. R77 is not able to make her own decisions. Her BIMS score is 9 out of 15, moderate impairment. R77's medical record, dated 8/23/24 at 4:35 PM, V17 noted V17 left voicemail message for R77's POA regarding room change. R77's medical record does not note any documentation by V17 between 8/23/24's note and 1/7/25's note.

F656D · No harm, potential for more than minimal, isolated

Based on interviews and records reviewed the facility failed to include intervention prevent or reduce the risk of skin breakdown. for one of three (R1) residents reviewed for plan of care interventions for skin breakdown, failed to follow their policy to complete a comprehensive skin assessment on one resident (R1) with skin impairments on readmission from the hospital to identify the size and appearance of the wounds or dressings present. This failure affected 1 of 4 residents in a sample of 37 residents reviewed for pressure ulcers. The findings include: 1.R1's diagnosis includes but are not limited to diabetes, Dementia, Anemia, End Stage Renal Disease, Sacral Pressure Ulcer, Dependence on Renal Dialysis. R1 was admitted to Hospice services on 3/15/25. On 4/24/25 V8 presented the surveyor a care plan labeled original dated 2/3/25 for R1 risk for alteration in skin integrity due to risk factors associated with decreased mobility, poor oral intake, history of pressure ulcers, and advanced age. A second care plan labeled updated for R1 identifies heel protectors and low air loss mattress in place dated 4/24/25. On 04/23/25 10:32 AM R1 in bed, on her back, surveyor knocked on door R1 is not verbally or physically responding to the surveyor. On 04/23/25 at 10:33 AM R1 observed in bed, on an air mattress. V8, Wound Nurse, present. V8 wearing protective boots with toes exposed and support to upper calf region. R1 did not verbally respond or move as V8 was touching R1's legs. On 4/23/25 at 3:29PM V8, Wound Nurse, said the wounds on R1's legs were already there when she returned from the hospital on 3/6/25 in the evening. The surveyor asked how the facility ensures prevention interventions are in place for residents at risk for developing skin impairments. V8 replied I check them and make sure everyone with pressure ulcers has interventions in place. V8 said R1 is not able to move. V8 said I don't know how R1 was laying in the facility bed on readmission because she was not here. V8 said R1 was already considered a high risk for skin. V8 said a score of 0-12 is a high risk on the Braden assessment. The surveyor asked for documentation to show interventions she mentioned, like heel protectors were in place for R1. V8 said I have never had to document the interventions, like heel protectors, were used, or frequency of use. The facility Skin Care Prevention policy dated 1/2025 states all residents will receive appropriate care to decrease the risk of skin breakdown. The facility Care Plan dated 1/2023, in part, states purpose to provide the staff with guidance on completion of comprehensive person centered care baseline care planning. Person centered care means that the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. The facility presented a second policy, Comprehensive Care Plan dated 3/17/25 states the care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental, and psychosocial needs. The comprehensive care plan should drive the care and services provided for the resident and allow for the highest practicable physical, mental, and psychosocial well-being. R1's diagnosis includes but are not limited to diabetes, Dementia, Anemia, End Stage Renal Disease, Sacral Pressure Ulcer, Dependence on Renal Dialysis. R1 was admitted to Hospice services on 3/15/25. On 04/23/25 10:32 AM R1 in bed, on her back, surveyor knocked on door R1 is not verbally or physically responding to the surveyor. On 04/23/25 at 10:33 AM R1observed in bed, on an air mattress. V8, Wound Nurse, present. V8 uncovered R1's legs and showed the right, outer, lower leg with rectangle white dressing. V8 showed left leg with white dressing to back of lower leg/calf region. V8 wearing protective boots with toes exposed and support to upper calf region. R1 did not verbally respond or move as V8 was touching R1's legs. On 04/23/25 at 10:36 AM V13,LPN, said she didn't have pain signs or symptoms for me. V13 said some people say R1 speaks but she only moans for means to communicate. On 4/23/25 at 2:16PM V12, LPN, said when I readmitted R1, I did my skin assessment. V12 said I saw two scars on each leg. One on her right outer legs and one on her left leg. V12 said there were no open areas. V12 said I would have documented any open or impaired areas, R1 had scars. On 4/23/25 at 3:29PM V8, Wound Nurse, said the wounds on R1's legs were already there when she returned from the hospital on 3/6/25 in the evening. The surveyor asked how the facility ensures prevention interventions are in place for residents at risk for developing skin impairments. V8 replied I check them and make sure everyone with pressure ulcers has interventions in place. V8 said I was made aware R1 had pressure ulcers on her legs when I assessed her on 3/7/25. V8 said R1 was readmitted on [DATE] in the evening and V8 said she did not see R1 on 3/6/25. V8 said when I saw the pressure ulcers I saw scars that are open. V8 said there are no skin pictures from 3/6/25 for R1. V8 said R1 had scabs, which are necrotic, the areas on R1's legs are pressure ulcers. V8 said R1 is not able to move. V8 said I am not sure how R1 would have been laying in the bed while in the hospital. V8 said I don't know how R1 was laying in the facility bed on readmission because she was not here. V8 said R1 was already considered a high risk for skin impairment because she had been seen by the wound doctor for a sacral wound. V8 said a score of 0-12 is a high risk on the Braden assessment. V8 said I believe the admitting nurse did a skin assessment on 3/6/25. The surveyor asked for documentation to show interventions she mentioned, like heel protectors were in place for R1. V8 said I have never had to document the interventions, like heel protectors, were used, or frequency of use. On 4/24/25 at 2:07PM V24, Wound Doctor, said a scab is a thick dry area of the skin. V24 said a scar is different than a scab. V24 said a scar is healed tissue not a dry skin area. V24 said I would think a nurse should know the difference between a scab and a scar. V24 said a pressure ulcer can have a scab in it, but a scab is not the same as a pressure ulcer. V24 said a pressure ulcer can develop in a number of hours. V24 said devlopin a necrotic wound in 15 hours is not impossible. V24 said R1 has pressure ulcers on the left and right lower legs. V24 said I only saw R1 once and debrided one leg because of moderate drainage. Review of R1's Treatment Administration Record (TAR) there is no treatment dated 3/6/25 for R1's legs. Progress notes dated 3/6/25 at 5:17PM documents R1's bilateral lower extremities with some healing scars that mirror each other. They are to the lower lateral and front ankle area of both extremities. Bilateral heels are intact. R1's Admission Evaluation dated 3/6/25 identifies healing scars on right and left outer ankles. Large deep open area to the sacrum. Other states healing scar to lateral left and right lower legs. On 4/24/25 V8 presented the surveyor a care plan labeled original dated 2/3/25 for R1 risk for alteration in skin integrity due to risk factors associated with decreased mobility, poor oral intake, history of pressure ulcers, and advanced age. A second care plan labeled updated for R1 identifies heel protectors and low air loss mattress in place dated 4/24/25. R1's hospital record dated 2/28/25 states lower left leg. 3/11/25 pressure injury right lower leg. The facility Skin Care Prevention policy dated 1/2025 states all residents will receive appropriate care to decrease the risk of skin breakdown. The facility Skin Management policy dated 1/2025 states an evaluation of the pressure ulcer/injury if no dressing is present. An evaluation of the status of the dressing, if present.

F686D · No harm, potential for more than minimal, isolated

Based on observation, interviews and records the facility failed to follow their policy to complete a comprehensive skin assessment on one resident with skin impairments on readmission from the hospital to identify the size and appearance of the wounds or dressings present, failed to ensue effective interventions were in place, and failed to ensure low air loss mattress was used per manufactures recommendations. This affected two of four residents (R1, R325) reviewed for pressures sore preventions and effective interventions. The findings include: 1. R1's diagnosis includes but are not limited to diabetes, Dementia, Anemia, End Stage Renal Disease, Sacral Pressure Ulcer, Dependence on Renal Dialysis. R1 was admitted to Hospice services on 3/15/25. On 4/24/25 V8 presented the surveyor a care plan labeled original dated 2/3/25 for R1 risk for alteration in skin integrity due to risk factors associated with decreased mobility, poor oral intake, history of pressure ulcers, and advanced age. A second care plan labeled updated for R1 identifies heel protectors and low air loss mattress in place dated 4/24/25. 04/23/25 10:32 AM R1 in bed, on her back, surveyor knocked on door R1 is not verbally or physically responding to the surveyor. On 04/23/25 at 10:33 AM R1 observed in bed, on an air mattress. V8, Wound Nurse, present. R1 wearing protective boots with toes exposed and support to upper calf region. R1 did not verbally respond or move as V8 was touching R1's legs. On 4/23/25 at 3:29PM V8, Wound Nurse, said the wounds on R1's legs were already there when she returned from the hospital on 3/6/25 in the evening. The surveyor asked how the facility ensures prevention interventions are in place for residents at risk for developing skin impairments. V8 replied I check them and make sure everyone with pressure ulcers has interventions in place. V8 said R1 is not able to move. V8 said I don't know how R1 was laying in the facility bed on readmission because she was not here. V8 said R1 was already considered a high risk for skin. V8 said a score of 0-12 is a high risk on the Braden assessment. The surveyor asked for documentation to show interventions she mentioned, like heel protectors were in place for R1. V8 said I have never had to document the interventions, like heel protectors, were used, or frequency of use. The facility Skin Care Prevention policy dated 1/2025 states all residents will receive appropriate care to decrease the risk of skin breakdown. The facility Care Plan dated 1/2023, in part, states purpose to provide the staff with guidance on completion of comprehensive person centered care baseline care planning. Person centered care means that the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. The facility presented a second policy, Comprehensive Care Plan dated 3/17/25 states the care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental, and psychosocial needs. The comprehensive care plan should drive the care and services provided for the resident and allow for the highest practicable physical, mental, and psychosocial well-being. R1's diagnosis includes but are not limited to diabetes, Dementia, Anemia, End Stage Renal Disease, Sacral Pressure Ulcer, Dependence on Renal Dialysis. R1 was admitted to Hospice services on 3/15/25. On04/23/25 10:32 AM R1 in bed, on her back, surveyor knocked on door R1 is not verbally or physically responding to the surveyor. On 04/23/25 at 10:33 AM R1observed in bed, on an air mattress. V8, Wound Nurse, present. V8 uncovered R1's legs and showed the right, outer, lower leg with rectangle white dressing. V8 showed left leg with white dressing to back of lower leg/calf region. V8 wearing protective boots with toes exposed and support to upper calf region. R1 did not verbally respond or move as V8 was touching R1's legs. On 04/23/25 at 10:36 AM V13, LPN, said she didn't have pain signs or symptoms for me. V13 said some people say R1 speaks but she only moans for means to communicate. On 4/23/25 at 2:16PM V12, LPN, said when I readmitted R1, I did my skin assessment. V12 said I saw two scars on each leg. One on her right outer legs and one on her left leg. V12 said there were no open areas. V12 said I would have documented any open or impaired areas, R1 had scars. On 4/23/25 at 3:29PM V8, Wound Nurse, said the wounds on R1's legs were already there when she returned from the hospital on 3/6/25 in the evening. The surveyor asked how the facility ensures prevention interventions are in place for residents at risk for developing skin impairments. V8 replied I check them and make sure everyone with pressure ulcers has interventions in place. V8 said I was made aware R1 had pressure ulcers on her legs when I assessed her on 3/7/25. V8 said R1 was readmitted on [DATE] in the evening and V8 said she did not see R1 on 3/6/25. V8 said when I saw the pressure ulcers I saw scars that are open. V8 said there are no skin pictures from 3/6/25 for R1. V8 said R1 had scabs, which are necrotic, the areas on R1's legs are pressure ulcers. V8 said R1 is not able to move. V8 said I am not sure how R1 would have been laying in the bed while in the hospital. V8 said I don't know how R1 was laying in the facility bed on readmission because she was not here. V8 said R1 was already considered a high risk for skin impairment because she had been seen by the wound doctor for a sacral wound. V8 said a score of 0-12 is a high risk on the Braden assessment. V8 said I believe the admitting nurse did a skin assessment on 3/6/25. The surveyor asked for documentation to show interventions she mentioned, like heel protectors were in place for R1. V8 said I have never had to document the interventions, like heel protectors, were used, or frequency of use. On 4/24/25 at 2:07PM V24, Wound Doctor, said a scab is a thick dry area of the skin. V24 said a scar is different than a scab. V24 said a scar is healed tissue not a dry skin area. V24 said I would think a nurse should know the difference between a scab and a scar. V24 said a pressure ulcer can have a scab in it, but a scab is not the same as a pressure ulcer. V24 said a pressure ulcer can develop in a number of hours. V24 said devlopin a necrotic wound in 15 hours is not impossible. V24 said R1 has pressure ulcers on the left and right lower legs. V24 said I only saw R1 once and debrided one leg because of moderate drainage. Review of R1's Treatment Administration Record (TAR) there is no treatment dated 3/6/25 for R1's legs. Progress notes dated 3/6/25 at 5:17PM documents R1's bilateral lower extremities with some healing scars that mirror each other. They are to the lower lateral and front ankle area of both extremities. Bilateral heels are intact. R1's Admission Evaluation dated 3/6/25 identifies healing scars on right and left outer ankles. Large deep open area to the sacrum. Other states healing scar to lateral left and right lower legs. On 4/24/25 V8 presented the surveyor a care plan labeled original dated 2/3/25 for R1 risk for alteration in skin integrity due to risk factors associated with decreased mobility, poor oral intake, history of pressure ulcers, and advanced age. A second care plan labeled updated for R1 identifies heel protectors and low air loss mattress in place dated 4/24/25. R1's hospital record dated 2/28/25 states lower left leg. 3/11/25 pressure injury right lower leg. The facility Skin Care Prevention policy dated 1/2025 states all residents will receive appropriate care to decrease the risk of skin breakdown. The facility Skin Management policy dated 1/2025 states an evaluation of the pressure ulcer/injury if no dressing is present. An evaluation of the status of the dressing, if present. 41156 2. R325 admitted in the facility on 4/15/25. On 4/22/25 at 1030AM, observed R325 in bed, asleep and on Low air loss Mattress. Weight setting is on 220, Alternate. Weight record reviewed and R325 weighed 134.6 lbs (pounds) on 4/16/25. Braden Scale for Predicting Pressure Sore dated 4/16/25 R325 scored 12, High Risk. R325 has care plan for potential and is at risk for alteration in skin integrity due to risk factors associated with Alzheimer's, Dementia, immobility, and nutrition. Pressure ulcer to the sacrum. On 4/24/25 at 9:35AM, V8 (Wound nurse) stated that We set the low air loss mattress closest to the weight of the resident. R325 is admitted with stage 3 in coccyx. We placed her on low air loss mattress upon admission due to the stage 3 pressure sore. We do in services; and have nurses and CNA checks the low air loss mattress machine to make sure that it is in the right setting and to make sure it is closer to their current weight. Mattress Use Policy with a review date of 1/2024 reads in part: To provide a statement on the types of mattresses that are standard in the facility. The standard for all mattresses on the beds will be pressure reducing. At the discretion of the Wound Care Team, Nurse, DON or ADON the resident may be changed to a pressure relieving mattress. Information regarding the mattresses is based on the manufacture's literature. Proactive medical products Operational Manual, reads in part: Intended use: pump and mattress is intended to reduce the incidence of pressure ulcers while optimizing patient as prescribed by a physician. Pressure set up: users can adjust the pressure level of the air mattress to a desired firmness by themselves or according to the suggestions from a health care professional.

F690D · No harm, potential for more than minimal, isolated

Based on observations, interviews, and record reviews, the facility failed to obtain and document a diagnosis in the physician orders for an indwelling catheter for one resident (R70) out of three reviewed for indwelling catheters in a sample of 37. Findings include: On 4/22/25 at 10:00 AM, R70 was observed to have an indwelling catheter. On 4/25/25 at 8:30 AM, V2 DON (director of nursing) stated that a diagnosis should be documented on the physician order to indicate reason why an indwelling catheter is in place. R70's POS (physician order sheet), dated 3/24/25, notes Indwelling Catheter: _18_Fr,_10cc balloon size for a Diagnosis of _---_. There is no documentation in R70's current POS provided to this surveyor noting reason for indwelling catheter. This facility's physician orders policy, reviewed 3/17/25, notes the elements of an order includes, but not limited to, orders specify the diagnosis or indication for.

F692D · No harm, potential for more than minimal, isolated

Based on observations, interviews, and record reviews, the facility failed to document accurate meal intakes. This affected two of three residents (R12 and R51) reviewed for nutrition in a sample of 37. Findings include: On 4/24/25 at 1:00PM, R12 and R51 were observed in the dining room eating lunch. R12 consumed 25% of meal. R51 consumed 25% of meal. On 4/24/25 at 9:37 AM, V35 RD (registered dietitian) stated that R12 has been losing weight. V35 stated that recently R12's oral intake has decreased. V35 stated that R12 was started on weekly weights to monitor. V35 stated that last week R12 was started on a medication to stimulate R12's appetite and nutrition monitoring currently being followed weekly by the the interdisciplinary team. V35 stated that yesterday V35 saw R51 and observed that R51 was not eating much. V35 stated that yesterday R51 was placed on weekly nutrition monitoring by the interdisciplinary team. V35 stated that staff should be monitoring and documenting the amount eaten at each meal. On 4/24/25 at 1:00 PM, V22 CNA (certified nurse aide) stated that the CNAs are expected to chart amount eaten for each resident after each meal. On 4/24/25 at 1:05 PM, V23 CNA stated that the CNAs are expected to chart amount eaten for each resident after each meal. V23 stated that CNAs are responsible for picking up all meal trays. V23 stated that if resident doesn't eat or eats very little, she will let the nurse know so the nurse will follow up with resident. V23 stated that if she observes a resident not eating, she will assist with feeding resident, encourage resident to eat, and/or offer an alternative meal choice. On 4/24/25 at 3:15 PM, V34 RN (registered nurse) stated that the CNAs are responsible for documenting the amount eaten for each resident for each meal served. V34 stated that V34 will notify the resident's physician after two consecutive meals not eaten or very little eaten. V34 stated that V34 monitors residents' weights monthly and reviews for any weight changes. On 4/25/25 at 8:56 AM, V31 (attending physician) stated that the nurse can let him know if a resident is not eating. V31 stated that if he is working in his office and the nurse calls to inform him a resident lost 5 pounds, his response is what do you want me to do. V31 stated that at the time of his face-to-face visits he looks at the big picture, reviews laboratory testing and weights. V31 stated that he was aware of R51's weight loss. V31 stated that in July 2022, R51 weighed 68 pounds. V31 stated that at the time of his face-to-face visits he looks at the big picture and R51 has gained weight. On 4/25/25 at V2 DON (director of nursing) stated that she is unable to provide amount of each meal eaten for the past three months for R12 and R51. R12: R12's medical record notes the following weights: 10/3/24, R12 weighed 181 pounds. 12/4/24, R12 weighed 173 pounds There is no documented weight for January 2025. 2/5/25, R12 weighed 166.4 pounds. 3/5/25, R12 weighed 164.2 pounds. 4/8/25, R12 weighed 149.2 pounds. 4/24/25, R12 weighed 146.6 pounds. R12's POC (point of care) charting, dated 4/24/25, notes R12 consumed 76-100% of lunch meal. R12's amount eaten documentation for the past 30 days, 89 opportunities, 71 meal opportunities were documented. On 4/17/25, V35 noted weight warning: weight 147 pounds, body mass index 26. R12 with -7.5% change [ 11.7% , 19.4 ] and -10.0% change [ 17.9% , 32.0 ]. Significant weight loss x 3 and x 6 months noted; R12's weight overall going down and continues to trend down despite interventions with nutrition supplement and wound healing supplement. Mirtazapine started on 4/15 to stimulate appetite and prevent further weight loss. On 3/26/25, V35 RD (registered dietitian) noted weight warning: weight 154 pounds, body mass index 27.3. R12 with -5.0% change [ 6.2% , 10.2 ] and -10.0% change [ 14.9% , 27.0 ]. R12 is receiving nutrition supplement three times a day. Intake 0-75% varied oral intakes noted. R12 was last seen by V35 on 7/8/24. R51: R51's medical record notes the following weights: 10/3/24, R51 weighed 93 pounds. 11/4/24, R51 weighed 88 pounds. 12/4/24, R51 weighed 81 pounds. 1/2/25, R51 weighed 80 pounds. 4/16/25, R51 weighed 80 pounds. R51's amount eaten documentation for the past 30 days, 89 opportunities, 66 meal opportunities were documented. This facility's weight management policy, reviewed 02/2025, notes weekly weights will be done with a significant change of condition or food intake decline that has persisted for more than one week.

F712D · No harm, potential for more than minimal, isolated

Based on interviews and record reviews, the facility failed to follow their physician services policy and ensure the attending physician conducted face-to-face visits within the first 30 days of admission/re-admission and/or at least once every 60 days. This affected two of three (R12, R51) residents reviewed for care managed by a physician in a sample of 37. Findings include: On 4/25/25 at 8:56 AM, V31 (attending physician) stated that he is present in this facility several times a week. V31 stated that he focuses more on the residents on 2 South nursing unit because this is the acute unit. V31 stated that V31 documents his face-to-face visits with residents in each resident's electronic medical record. R12: R12's medical record notes R12 was admitted to this facility on 5/4/23. R12's medical record notes V33 (attending physician) had face-to-face visit with R12 on 5/24/23. There are no other documented face-to-face visits found in R12's medical record. R12's medical record notes R12 was hospitalized [DATE] - 10/15/24 and 3/7/25 - 3/12/25. R51: R51's medical record notes R51 was admitted to this facility on 7/8/2022. R51's medical record notes V31 face-to-face visits with R51 on 2/24/25, 3/27/24, and 6/15/22. There are no other documented face to face visits found in R51's medical record. This facility's physician services policy, reviewed 1/2025, notes the physician must see the resident at a minimum of every 30 days for a Medicare resident and every 60 days for all other residents. When the physician visits a resident, a progress note will be placed in the medical record. The physician is responsible for reviewing the treatment plan.

F745D · No harm, potential for more than minimal, isolated

Based on interview and record review, the facility failed to assist a resident with a degenerative eye disease in obtaining transportation to an outside retinal specialist appointment. This affected one of one (R27) residents review for transportation in a total sample of 37. Findings Include: R27 is an [AGE] year old with the following diagnosis: macular degeneration. On 4/22/25 at 10:22AM, R27 stated R27 had an appointment for an eye appointment the first week of April but had to cancel it because the cost of transportation was $270. R27 denied being offered to see the in-house eye doctor. R27 reported R27 would be willing to see the in-house eye doctor because R27 wants to preserve R27's vision for as long as possible. On 4/24/25 at 12:15PM,V18 (Health Information Management Director/Appointment Scheduler/Transportation) stated V18 had an appointment on 4/8. V18 reported R27 is now a private pay patient so R27 needs to now pay for transportation to outside appointment. V18 stated social services called a family member to about R27 refusing to paying for transportation. V18 reported the cost of the transportation was over $200 for round trip. V18 stated V18 called one company for a med car, but R27 refused to pay. V18 reported V18 explained to her about this before the appointment about one week before. V18 reported the appointment was a different doctor R27 wanted to go to in Chicago and was so expensive for this reason. V18 stated Elite and Trace were contracted with the facility for transportation at the time of this appointment. V18 stated V18 only contacted Trace for a medicar. She had an option for family to take her or for an in-house eye doctor to see her but V18 did not offer that to R27. V18 denied documenting any education R27 was provided about being responsible to pay for transportation and denied documenting any other alternative transportation for R27. On 4/24/25 at 12:32PM, V17 (Memory Care Coordinator) stated V17 recalled there was an appointment scheduled for R27 was supposed to go to but didn't because it was an out of pocket expense. V17 didn't know if the appointment was rescheduled. V17 stated R27 does have visual impairment but was unaware of what the diagnosis are. V17 reported V17 didn't offer R27 to see any other specialists after R27 declined to pay for the most recent appointment. When asked why it was that option wasn't offered to R27, V17 said, I just didn't offer it. V17 denied looking into any alternative transportation methods for R27 to get to the appointment. On 4/25/25 at 12:15PM, V1 (Administrator) stated R27 is private pay and the facility does not need to provide any alternate transportation if a resident refuses to pay. The Ophthalmologist Patient Encounter notes dated 1/14/25 documents R27 has puckering of the right macula. Care plan should see a retinal specialist on 4/14/25 for posterior segment encounter. The Physician Order Sheet documents an order for R27 to see a retinal specialist per the recommendations from the ophthalmologist. This order was placed on 1/17/25. There are no notes documenting when education was provided to R27 about R27 being responsible for the transportation to the appointment. There is also no documentation that R27 was offered any alternative solutions for transportation to the retinal specialist appointment. The Care Plan dated 11/28/24 documents R27 has impaired vision as evidenced by macular degeneration and receives routine eye drops. An intervention includes arrange for consult as needed for ophthalmologist and optometrist. The policy titled, Appointments and Transportation, dated 2/9/23 documents, General: When a resident has an appointment outside of the facility, the staff will make the transportation arrangements, unless the responsible party chooses to make the arrangements themselves. Procedure: 4. If the family is not making transportation arrangements, the Unit Clerk, HIM (Health Information Manager), or designee will call the transportation company (Medicare, ambulance, etc.) to set up date and time of pick up. The pickup time should be at least one our prior to the appointment. 5. If the family will not be accompanying the resident, the Unit Clerk, HIM Director, or designee will inform the DON to determine if an escort is needed for the resident .9. If the resident is unable to keep the appointment, it is the Unit Clerk, HIM Director, or designee's responsibility to cancel the appointment and reschedule it at the earliest time.

F758D · No harm, potential for more than minimal, isolated

Based on interviews and records reviewed the facility failed to follow their policy and complete quarterly psychotropic assessments and assess for or attempt a Gradual Dose Reduction for one resident on an antidepressant. This failure affected one of one (R47) resident in a sample of 37 reviewed for psychotropic medication. The findings include: R1 admitted to the facility on [DATE] with hospitalization and readmissions to the facility since. R1's diagnosis include but are not limited to Multiple Sclerosis and Depression. On 4/24/25 at 12:17PM V3, Assistant Director of Nursing, said she monitors the psychotropic program. V3 said Gradual Drug Reductions (GDR) are attempted or addressed quarterly or if something is going on. V3 said in the electronic charting system there is a Psychotropic Medication Assessment Form for residents on psychotropics, including antidepressants. V3 said the assessment should be assessed quarterly. At 1:23PM V3 said I didn't see one (Psychotropic Assessment) for R47, she should have one. V3 said target behaviors are monitored and documented on the residents' Medication Administration Record (MAR). R47's Order Summary Report December 2024 thru April 2025 identifies R47 receiving Duloxetine 20mg. R47's April 2025 MAR does not include target behaviors for depression. During the survey no progress notes were presented stating a GDR was attempted or that it is not appropriate for R47. R47's care plan includes use of Duloxetine used for Depression. Interventions do not include psychotropic quarterly assessment for GDR or documentation of why GDR is not appropriate. Facility Psychotropic Medication Program policy dated 1/2024 states the purpose is to promote the safe and effective use of psychotropics medications. To ensure the lowest dose of medication is used, for the shortest time frame. Upon admission and Quarterly each resident will have psychotropic medications reviewed utilizing the Psychotropic Medication Assessment Form. This form will identify the time period the resident has been taking the medication, the diagnosis for the medication, behaviors associated with the need for the medication, and non-pharmalogical interventions. Behaviors associated with medications .non-pharmalogical interventions.

F760D · No harm, potential for more than minimal, isolated

Based on observation, interview, and record review, the facility failed to give prednisolone acetate ophthalmic suspension 1% (steroid eye drop) and Midodrine 5mg tablet (medication that increases blood pressure) as prescribed. This affected two of six resident (R320, R27) reviewed for medication administration in a total sample of 37. Findings Include: R329 is a [AGE] year old with the following diagnosis: hematuria. On 4/23/25 at 8:37AM, V25 (Nurse) took R320's blood pressure and it was 83/39 (low). On 4/23/25 at 9AM, V25 administered all morning medication except Midodrine 5mg tablet. V25 stated medication should be stocked in the pyxis by pharmacy or ordered by the nurse when the medication is low within three to four pills left. V25 reported pharmacy will deliver the medication automatically when it is due to be delivered. V25 called the pharmacy at 9:05AM to ordered the missing medication. V25 stated the medications can be delivered an hour before or an hour after the scheduled time. V25 reported if the medication is given after 10AM and it is scheduled at 9AM then it is late. On 4/23/25 as the surveyor was exiting the room from the medication pass at 11:52AM, V2 (DON) approached the surveyor and stated R320 received the Midodrine that was delivered by pharmacy. The surveyor then walked back over to 2North and verified with V25 that the Midodrine 5mg table was given. V25 showed the surveyor the pharmacy delivery slip and stated the medication was given at 10:59AM. V25 reported taking another blood pressure before the medication was given and the blood pressure was 101/59. A Nursing note dated 04/23/25 at 8:29AM documents the nurse observed the midodrine 5 mg was missing from the cycle med roll. Upon checking the pyxis, the medication was still unavailable at this time. The nurse called the pharmacy and will be delivered in a couple hours. The physician was notified of the missing dose. A Nursing noted dated 4/23/25 at 11:24AM documents the pharmacy delivered the midodrine for R320. The nurse called the physician and was given the ordered to give the medication. Medication was administered upon rechecking the medication. The Physician Order Sheet documents R320 has an ordered for Midodrine (medication to increase blood pressure) 5mg 1 tablet by mouth two times a day ordered on 4/7/25. The Medication Administration Record dated 04/2025 documents the 9AM dose was not given at the scheduled time but an additional dose was ordered 9AM and administered. R27 is an [AGE] year old with the following diagnosis: macular degeneration. On 4/22/25 at 10:22AM, R27 reported R27 gets eye drops four times a day to relieve pressure in R27's eyes because R27 has macular degeneration. R27 stated R27 did not receive the scheduled 9AM yet and was feeling increased pressure in the eyes. On 4/22/25 at 10:46AM, the surveyor asked V32 (Nurse) if R27 has received the 9AM dose of eye drops this morning and V32 denied administering the eye drops. V32 reported the eye drops were not given because R27 was in the dining room eating breakfast and medications cannot be administered in the dining room. V32 stated medications can be given an hour before or up to an hour after the scheduled. V32 reported R27 left the dining room around 10 or 10:30AM. V32 stated the eye drops still have not been given yet because V32 has been passing other resident medications. V32 stated since the next dose is due at 12PM, V32 will skip the 9AM dose and administer the 12Pm dose around 11AM. V32 reported R27 gets this medication to bring down the swelling in R27's eyes. The Physician Order Sheet documents prednisolone acetate ophthalmic suspension 1% eye drops are ordered 1 drop in each eye four times a day. That ordered was placed on 12/9/24. The Medication Administration Record (MAR) dated 04/2025 documents the eye drops are ordered to be given at 9AM, 12PM, 5PM, and 9PM. On 4/22/25, the MAR documents the eye drops were not given at the 9AM dose. The Care Plan dated 11/28/24 documents R27 has impaired vision as evidenced by macular degeneration and receives routine eye drops. The policy titled, Medication Administration, dated 01/2024 documents, General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: .6. Check medication administration record prior to administering medication for the right medication, dose, route, patient/resident and time .26. If medication is ordered, but not present, check to see if it was misplaced then call the pharmacy to obtain the medication. If available, obtain it from the contingency or convenience box.

Inspection of July 5, 2024

1 finding

F689G · Actual harm, isolated

Based on interview and record review the facility failed to implement effective fall intervention to prevent a resident from falling which resulted in resident walking by herself, falling, and sustaining a left hip fracture. This failure affected 1 resident (R2) of 3 residents reviewed for falls in a total sample of 15. Findings include: On 7-3-24 at 11:12 AM, V2 (Director of Nursing) said R2 is primarily Spanish speaking and R2 can make simple needs known. V2 said R2 has poor safety awareness due to dementia, impulsive behaviors, and gets up by herself without asking for assistance. V2 said R2 will become aggressive during redirection which could lead to falls. V2 said R2 has unsteady gait and requires 1-person assistance and assistive walking device. V2 said R2 is a fall risk. V2 said CNA cleaned, dressed, and brought R2 to common area. V2 said high fall risk residents were grouped in common area and supervised. V2 said CNA left the group to give ADL care. On 7-3-24 at 8:50 AM, V20 (Certified Nurse Aide) said R2 is alert and able to make her need known in simple terms since R2 is primarily Spanish speaking. V20 said R2 has periods of confusion, can be impulsive, and constantly tries to get up by herself. V20 said when staff redirect R2, R2 becomes combative. V20 said R2 tries to get up out of her bed and wheelchair. V20 said R2 attempts to walk to other rooms without her wheelchair and walker. R2 is a high fall risk due to unsteady gait, confusion, and impulsive behavior. V20 said all staff is aware of fall risk thus R2 is placed in common area for supervision and staff takes turn to supervise fall risk group. V20 said high risk for fall residents are kept in a group and supervised by 1 or 2 staff. V20 said she was giving R2 care when nurse discovered R2 on the floor. V20 said she cleaned and dressed R2 less than 30 minutes prior to the fall. V20 said she was supervising R2 in the common area during the night shift. V20 said she had to leave the group and give patient care for the next shift. V20 said she told the nurse she was going to do CNA rounds and nurse said OK. V20 said nurse was at nurses' station and went to pass medications. V20 said she heard R2 boom from a fall. V20 said she came out of the room and nurse was standing over R2. On 7-2-24 at 2:10 PM, V21 (Registered Nurse) said R2 is alert, oriented x 1-3, and with occasional confusion and stubbornness. V21 said R2 has no safety awareness due to confusion and impulsive behaviors. V21 said R2 is a high fall risk due to unsteadiness on her feet, confusion, and poor safety awareness. V21 said R2 requires 1 person assistance with transfers. V21 said she does hourly rounding when R2 is in her room. V21 said most of the high fall risk residents are kept in common area under staff supervision. V21 said R2 does not use the call light and R2 will get up by herself. On 7-3-24 at 10:32 AM, V19 (Licensed Practical Nurse) said R2 is alert, oriented x1-2, and able to make simple needs known. V19 said R2 has occasional confusion and R2 has no safety awareness. V19 said R2 is a fall risk and believes she can do things independently but can't. V19 said R2 will try to stand up and walk, take herself to the bathroom, and gets up without telling any staff. V19 said R2 requires assistance due to fall risk and history of falls. V19 said she was ambulating around the nurses' station, V19 redirected, and R2 became aggressive. V19 said she just finished passing medications and noted R2 ambulating by herself. V19 said CNA cleaned and dressed resident prior to incident. V19 said R2 was unattended at that time. V19 said R2 requires 1:1 because she tries to do things by herself. V19 said she was passing medications and CNA did not mention R2 was placed in common area or CNA was leaving R2 unattended. R2's Admission Evaluation dated 5-23-24 documents: 1h. 19 (A score of 10 or higher indicates a High Fall Risk). Fall Risk Evaluation dated 5-24-24 documents: Score: 26 (Scoring a 10 or higher makes resident high risk for falls). State Reportable dated 5-24-24 documents: Incident Description: Resident was observed ambulating the hall, when nurse on duty attempted to redirect to seating area, she became resistant/ combative, NOD then allowed resident to ambulate and followed close behind as to not agitate resident further. While walking behind her, (R2) stumbled, falling to the floor and NOD was not able to break her fall. Upon assessment, (R2) left leg appeared to be shortened. Resident sent to ER for eval and was admitted with L hip fx. NOD made MD aware, received orders to send resident to ER for eval. EMS called; ETA of 30-60 minutes was given. Responsible party notified and agreeable with plan of care. NOD called ER and was made aware that resident was being admitted with dx of left hip fx. Investigation is ongoing. State Reportable (Final) documents: Summary of Investigation: (R2) had been awake and trying to ambulate since 1 am, when she was placed in common area for monitoring. At 0540, (R2) was observed ambulating and the nurse attempted to redirect her to the seating area, but (R2) became resistant and combative, so nurse allowed her to walk, but followed close behind her to not to agitate her to walk but followed close behind her not to agitate her further. As the resident continued to ambulate, she stumbled, falling to the floor, and the nurse was not able to break her fall. Hospital Record dated 5-24-24 documents: Admission Diagnosis: (not limited to:) Closed left hip fracture, Displaced fracture of left femoral neck. Inpatient Problem List: Displaced fracture of left femoral neck, Closed left hip fracture. Principal Problem: Closed left hip fracture. Left hip fracture traumatic on pathological secondary to osteoporosis. Chief Complaint: witnessed fall. History of Present Illness: (R2) is an 81 y.o. female history of dementia, essential hypertension, generalized anxiety disorder, presented to hospital due to weakness falls at the nursing home resulted in left hip fracture she was admitted for surgical intervention per Ortho on consult. Progress note dated 5-24-24 documents: Resident was noted ambulating the unit. This writer came upon resident and was attempting to assist her to a chair. Resident became resistant/combative. This writer allowed resident to walk while walking behind her. Resident stumbled and fell to the floor; this writer was unable to break her fall. Resident landed into the CNA cart and ended up on her left side on the floor. Resident immediately grabbed her left leg and shouted in pain. Left leg appears shortened. This writer reached out to daughter and made her aware of situation. Orders received to send to Hospital for eval. All parties aware. Fall Prevention and Management Policy dated 1-23 documents: General: This facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for fall, plan for preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Inspection of May 17, 2024

2 findings

F689G · Actual harm, isolated

Based on interview and record review, the facility failed to supervise one resident while sitting in the dining room unattended who was identified as a high fall risk and has a diagnosis of Dementia, syncope, and a history of falls. This failure resulted in R401 having an unwitnessed fall from her wheelchair sustaining a left hip fracture. The facility also failed to utilize a leg rest during a transport for a wheelchair bound resident. This failure resulted in R61 having a fall from the wheelchair sustaining a right forehead hematoma. These failures affected two of three residents reviewed for falls in a total sample of 26. Findings Include: R401 was diagnosed with Dementia, Syncope and Collapse. Minimal data set Section GG (functional abilities and goals) dated 3/31/24 documents: R401 required partial/moderate assistance for sit to stand (the ability to come to a standing position from sitting in a chair. Helper lifts, holds or support trunk or limbs but provides less than half the effort). Comprehensive restorative assessment dated [DATE] documents: History of falls in the past 1-6 months, S/P Fall and/or Fracture in past 6 months. Fall Risk Scoring: Add up the numbers of the responses above twenty-two. Fall risk scoring: ten or above: high fall risk. On 5/14/24 at 1:01PM, V4 (restorative nurse) said R401 had an unwitnessed fall. V22 (CNA) saw R401 on the floor. No staff was in the dining room when R401 fell . Staff should have been in the dining room monitoring R401. On 5/15/ 24 at 12:51PM, V22 (cna) said she saw R401 on the floor after a resident mentioned R401 had fallen. V22 said R401 used a rollator walker to assist with ambulation. V22 said she saw R401's walker unlocked after the fall. V22 said at the time of R401's fall no staff was in the dining room. Staff was moving residents from the dining room to the television room. V22 said no staff was monitoring R401 when R401 fell . Nursing note dated 03/31/24 documents: V47 (nurse) was called to the dining room by a CNA at 1:15pm stating resident fell on the floor and was laying on her left side. Fall was unwitnessed. R401 observed laying on the floor on her left side. When asked what occurred R401 stated in broken English, stood up, lost balance. R401 complained and was rubbing area of left hip/leg stating it hurts. R401 was assisted onto her rollator walker with staff assist. POA was called to try to translate R401's pain and what occurred. R401 with Dementia diagnosis. M.D called and order was obtained to send to emergency room (ER) for evaluation. POA (power of attorney) requested call 911. 911 called, Paramedics arrived and transferred R401 to a stretcher and departed facility at 1:50 PM to Hospital per POA request for evaluation. Care Plan Initiated on 03/28/2024 documents: R401 is at high or increased risk for falls, R401 is at risk for injury from falls related to diagnosis of Dementia, Syncope, decreased physical mobility, generalized weakness, and history of falls. R401 is positive for recent and frequent falls at home. Hospital record dated 03/31/24 documents: Patient (R401) presented to emergency department via emergency medical service after fall out of wheelchair. R401 complained of left hip pain. Positive external rotation and shortening. X-ray dated 03/31/24 documents: Left Femur (hip) Findings: Comminuted intertrochanteric fracture of the proximal LEFT femur with displacement of the lesser trochanter fragment and medial angulation of the distal femur shaft. Fall prevention and management policy dated 1/2024 documents: The facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all fall is not possible, the facility will identify and evaluate those resident at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. R61 was diagnosed with Dementia, Alzheimer's disease and Anxiety. Minimal data set section GG (functional abilities and goals) dated 01/05/24 documents: manual wheelchair. R61 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident complete activity. Assistance may be provided throughout the activity or intermittently. R61's care plan dated 3/12/24 documents: actual fall. Slid to front of wheelchair and slid out of chair. Intervention: staff to encourage R61 to sit back in wheelchair, assist to reposition as indicated. On 5/14/24 at 1:01PM, V4 (restorative nurse) said, R61 was being transported in her wheelchair without leg rests. R61 was holding her feet up off the ground. R61 dropped her feet at some point. R61 had on anti-skid foot wear. R61's foot gripped on the floor leading to a fall forward out of the wheelchair. Residents who use wheelchairs for mobility should not be pushed without leg rests. Leg rests were available at the time of R61's fall. On 5/14/23 at 3:37PM, V13 (cna) said, R61 was in a wheelchair. R61 asked him to push her to the dining room. V13 said, R61 did not have any leg/foot rest on her wheelchair. R61 usually self-propel. V13 said he pushed R61 and her right foot got stuck on the floor. V13 said R61 fell forward onto the floor landing on the right side of her body. V13 said at the time of the incident, R61 reported she hurt her right side and her back. R61 laid on the floor until the emergency medical technicians arrived. Nursing note dated 03/19/24 documents: around 0745 CNA observed assisting resident (R61) to the dining room. Nurse observed resident (R61) leaning forward in the wheelchair and fell to the floor. R61 left in position, during assessment, R61 was observed with a small lump to the right side of her forehead. R61 complained on right arm pain. R61 was observed with swelling to right lower leg without shortening of extremity. 911 called. Fall event dated 03/19/24 predisposing physiological factors documents: gait imbalance, impaired memory, decrease vision or hearing; predisposing situation factors: using wheelchair and leaning. V13's witness statement dated: 03/19/24 documents: during breakfast resident (R61) asked CNA (V13) if he can push her to the dining room. While pushing R61 her foot got stuck to the floor causing R61 to fall forward. In-service dated 03/19/24 topic of education: propelling residents without foot rest. Please report to nursing when residents ask for assistance propelling. Resident may need to be evaluated for the need of leg rest. R61's kardex dated 3/19/24 documents: safety: staff education to only propel wheelchairs with footrest on them. Facility reportable incident dated 3/20/24 documents: Patient name: R61, describe incident/accident: while being assisted to dining area resident fell forward from the wheelchair. She (R61) complained of pain to her right arm and leg. Hospital record dated 3/19/24 documents: She (R61) leaned forward and fell out of her wheelchair. R61 has hematoma to right forehead. Fall prevention and management policy dated 1/2024 documents: The facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all fall is not possible, the facility will identify and evaluate those resident at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible.

F776G · Actual harm, isolated

Based on interview and record review, the facility failed to have a system to track requests for diagnostics services to ensure timely x-ray services are provided to residents. This failure resulted in R5 being transported to the hospital after waiting over 30 hours for x-ray service and being diagnosed with multiple rib fractures for one of one reviewed for diagnostic services in a total sample of 26. Findings include: R5 was admitted to the facility on [DATE] with a diagnosis of syncope, unsteadiness on feet, orthostatic hypotension, restless leg syndrome, unspecified dementia and anxiety disorder. R5's Minimum Data Set, dated dated dated [DATE] documents brief interview for mental status is 12/15 which indicates cognitively intact. On 5/14/24 at 3:10 PM, R5 who was alert and oriented to self, place and time at time of interview said he was in his room, was putting on a jacket when he lost his balance and fell backwards hitting his left side on the heating/air conditioning wall unit and windowsill. The next day he was having pain and told staff. R5 said he was having pain in his left side 9/10. R5 pain was worse with movement and it hurt when breathing in. R5 facility reportable dated 4/6/24 documents: R5 informed nurse on duty that he fell two days ago, but did not report it, but now has pain in his left arm and left side. R5 was noted with a scrape to left side of his back. Nurse on duty notified doctor and received order for chest x-ray. Power of attorney made request for resident to go to emergency room . R5 returned on 4/8/24 with multiple rib fractures. R5's progress notes dated 4/6/24 at 12:32PM documents: Resident informed writer that he fell 2 days ago while putting on his shirt. Resident states that he didn't think it was a big deal, so he didn't tell anyone but now he is experiencing pain from his left shoulder to his abdomen. Upon assessment writer noted a scrape to left side of back. MD made aware. MD ordered chest x-ray. R5's progress notes dated 4/7/24 at 11:57AM documents: Resident alert verbally responsive. Breathing even unlabored. Denies pain and discomfort at this time. Resident and daughter inquired about estimated time of arrival of X-ray service. Writer placed call to x-ray company, informed that technician is en route. Resident and family made aware of estimated time of arrival status. Will continue plan of care. R5's progress notes dated 4/7/24 at 21:00PM documents: Per report AM nurse contacted x-ray company with estimated time of arrival and the company claimed they were en route. Resident's family concerned with timeliness of x-ray technician. Writer called x-ray services again and was unable to reach anyone. Per family's request resident sent out to local hospital. On 5/14/24 at 3:46PM, V12 (Nurse) was assigned to R5 on day he reported fall. V12 said she called the doctor who ordered an x-ray. X-ray called in and requisition completed. X-ray usually comes within 24 hours. They said they would be there the next day. V12 said she put in report but was not assigned to R5 after that day. On 5/15/24 at 12:03pm, V2(DON), said x-rays should be completed within 24 hours. If x-ray is not completed the doctor should be notified and any further orders followed. On 5/15/24 at 1257PM, V26 (Xray tech) said they received an x-ray order for R5 on 4/6/24 at 2:44PM and staff said the x-ray was to be done on 4/7/24. V26 said there was no other documentation from the facility that they called for follow up about x-ray. Technician arrived at 9:40PM on 4/7/24 but resident was already at the hospital. On 5/16/24 at 10:15AM , V32 (MD) I would expect an x-ray to be completed within 24 hours or be notified if not completed within 24 hours. I would not necessarily send the resident to hospital for pain because it's not an emergency and rib fractures are hard to see on x-rays. There really isn't much treatment. There can be pain with movement or breathing but I would not prescribe narcotics for pain. The x-ray is more of a legality, to show that fracture occurred at that time. On 5/17/24 at 10:12AM, V2(DON) said they track diagnostics services by when staff enter the order into electronic medical record under orders. Staff communicate through report when waiting for an x-ray to be conducted. Requested physician order and communication for R5's x-ray and no documentation received. R5's physician order sheets for April did not document any order for a chest xray. R5's hospital record dated 4/7/24 documents R5 arrived in emergency room at 21:54. At 22:36 Pain score of 8. Under history: R5 with mild dementia present to emergency room for evaluation of left sided back and shoulder pain. Patient states that approximately 2 days ago, he was reaching for his jacket in the middle of the night, when he slipped and fell off the bed possibly striking a shelf near his bed. Patient was able to get himself up, and nursing noticed the injuries and recommended a chest x-ray that is yet to be done. Patient states that he has been noticing increasing pain with movement on the left side and standing and finally called 911 and was brought to the emergency room . Patient denies any headache, neck pain, low back pain, chest pain, shortness of breath, cough, fevers or chills, bowel or bladder changes. Patient feels some fullness along the left upper quadrant extending from his injury in the left lower thoracic area. Patient is unaware of the pain medicine they have been given at the nursing home but states it has been only mildly helping him. Under Xray results documents: Acute left lateral seventh and eighth rib fractures. X-ray services facility in-service packet undated documents under ordering procedure: All non stat orders are performed same day, unless requested to be done another day. If the results cannot be provided same day as the procedure, you will receive them early the next day.

Inspection of January 30, 2024

2 findings

F678J · Immediate jeopardy, isolated

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