Every finding on record at Aperion Care International

Chicago, Illinois · CCN 146001

31 findings across 16 inspections, in the inspector's own words, 13 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 July 17, 2026

6 findings

F812F · No harm, potential for more than minimal, widespread

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices as evidenced by a.) food not properly labeled, b.) food not properly stored, and c.) equipment used for food preparation not properly sanitized. These deficient practices have the potential to affect all 198 residents receiving food prepared in the facility's kitchen. Findings include: On 07/14/2026 at 9:27AM during initial kitchen tour with V3 (Dietary Manager), the following food items were found in the walk-in cooler: 1 opened package of flour tortillas wrapped in clear plastic wrap, no open date, no expiration date or use by date labeled on flour tortillas.1 opened case of cranberry cocktail juice containers- no use by date or expiration date labeled.1 unwrapped cantaloupe inside a box labeled grapes 07/09/2026- no open date or use by date for the cantaloupe labeled. 1 opened package of lettuce and carrot salad mix- no open date or use by date labeled. The following food items were found in the walk-in freezer: 1 box of frozen strawberries observed with frozen ice crystals on the strawberries with a use by date of 03/03/2026 labeled. On 07/14/2026 at 10:04AM the following food items were found in the dry storage area: 1 package of corn meal wrapped in a black plastic bag labeled Corn Meal open date 05/05/2025 use by date 11/05/2025. On 07/14/2026 at 10:05AM, V3 states all opened food items stored in the kitchen should have an open date, use by date, or expiration date labeled on the food items. V3 states all expired food items should not be stored in the facility's kitchen available and intended for resident use. V3 states expired food items are inedible and should be discarded immediately. V3 states if residents consume expired or outdated food items, the residents could acquire a food borne illness and become sick due to bacteria. On 07/14/2026 at 10:06AM, V5 (Dietary Aide), V3 (Dietary Manager), and surveyor located next to the three-compartment sink inside of the kitchen. V5 states the facility uses quaternary solution to sanitize dishes washed in the three-compartment sink. V5 observed washing a pan in the three-compartment sink. V5 observed submerging the pan in the sanitize sink for approximately 16 seconds. V5 states he should have submerged the pan in the sanitize sink for 60 seconds. On 07/14/2026 at approximately 10:35AM, V3 states if the dishware in the facility is not sanitized properly, residents could potentially become sick due to bacteria. Facility census dated 07/14/2026 documents a total of 208 residents reside in the facility. Facility document dated 07/14/2026 titled Diet Roster documents a total of 10 residents are prescribed an NPO/nothing by mouth diet and does not receive food from the kitchen. Facility policy dated 2026, titled, Sinks, Three and Two Compartment documents in part, Purpose: To ensure food safety. Sanitize items in the 3rd sink. Submerge items for at least 60 seconds if using quat, or per the manufacturer's guidelines. Facility policy dated 2026, titled, Storage Labeling & Dating documents in part, Product inventory must be stored, labeled, dated, rotated, and discarded properly according to federal and state guidelines. All stored products will be labeled with the name, appropriate dates and rotated following the First-In, First-Out method. (FIFO). Opened products stored in the dry storage area must be labeled with their received date, open date. Label any food that is not stored in its original container with its common name. Use a standard sticker label or black marker for notations. Items that have exceeded the manufacturer's expiration date or UB/use by date should be discarded.

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

Based on observation, interview, and record review the facility failed to keep call light within reach for one (R89) resident in a sample of 35 residents reviewed.Findings Include:On 07/14/2026 at 11:45 AM, this surveyor observed the R89 sitting on her wheelchair while watching television. R89 appears calm and collected, and free of pain. R89 stated she has a concern about staff not being available when she needs something. R89 stated she needed her water pitcher filled as it was nearly empty. This surveyor observed the call light was out of R89's reach. The call light was placed on top of the bed, and R89 could not reach the call light. This surveyor walked up to the nurse's station to notify the nurse that R89 needed assistance.On 07/16/2026 at 10:24 AM, this surveyor observed R89 sitting in her wheelchair while watching television. This surveyor did not observe the call light was within reach, instead the call light was on top of the mattress. R89 stated she was provided with an extender this to help her in reaching items. R89 attempted to reach for the call light while utilizing her extender, but she was unsuccessful. R89 stated she could not reach the call light, and she cannot bear weight on her lower extremities to grab the call light due to her arthritis. R89 stated she feels discouraged about not being able to utilize the call light for assistance.On 07/16/2026 at 10:28 AM, V29 (Certified Nurse Aide) stated call light should always remain within reach because it will help the residents communicate with staff regarding needs. V29 also stated that if the call light is not within reach it can lead to anything happening such as a fall.On 07/16/2026 at 10:30 AM, V30 (Restorative Nurse/ Certified Nurse Aide) stated she was the one who helped R89 get up from bed this morning and the call light was within reach. V30 stated perhaps it was housekeeping who forgot to give the call light to R89 after cleaning the bed. V89 stated the call light was left on top of the mattress, which was away from R89's reach. R89 stated an extender was provided for her so that she could reach certain items. V30 stated call light must always be within reach the resident can fall, have a hard time breathing, or not being able to make their needs known.On 07/16/2026 at 3:16 PM, V2 (Director of Nursing) stated the call light should be functional and within reach so that the resident needs are met in a timely manner. V2 stated any staff member is allowed to answer the call light, if it is not nursing who answers the call light, the expectation is for that individual to let the nurse, or the aide know of resident requests. V2 stated the nurse should follow up with the resident as soon as he or she becomes V2 stated nurses should be rounding on their residents at least every 2 hours and making sure that their call light is within reach. Policy titled Call Light with review date of 02/02/2018, documents in part, to respond to resident's request and needs in a timely and courteous manner. 1. All residents who can use a call light shall have the nurse call light system available at all and within easy accessibility to the resident at the bedside or other reasonable accessible location.

F644D · No harm, potential for more than minimal, isolated

Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level II screening was completed for three (R13, R29, and R95) out of 16 residents in the sample of 35. Findings include: R13's face sheet documents R13 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses: UNSPECIFIED SEQUELAE OF CEREBRAL INFARCTION, DYSPHAGIA FOLLOWING OTHER CEREBROVASCULAR DISEASE, TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS; UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY, ESSENTIAL (PRIMARY) HYPERTENSION, ENCOUNTER FOR PALLIATIVE CARE; OPIOID ABUSE, UNCOMPLICATED;NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION, GENERALIZED ANXIETY DISORDER, OCCLUSION AND STENOSIS OF RIGHT CAROTID ARTERY, ACUTE RESPIRATORY FAILURE WITH HYPOXIA and ACQUIRED ABSENCE OF LEFT LEG BELOW KNEE. The following diagnoses were added after R13's original admission date: BIPOLAR DISORDER, UNSPECIFIED was added on 02/13/2025, MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED was added on 06/02/2025. Review of R13's PASRR review date of 02/09/2023 documents the following: PASRR Level I Determination: No Level II Required-No SMI (Serious Mental Illness)/No ID (Intellectual Disabilities)/No RC (Related Conditions). Your Level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IOD (variation of ID) and experience a significant change in treatment needs. On 07/15/2026 at 11:20 AM, V13 (Assistant Administrator) reviewed R13's Level I PASRR as well as R13's current diagnoses listed on R13's face sheet. V13 said the screen is usually completed prior to resident's admission or at the time of resident's admission to the facility. A level II is usually triggered by diagnosis (es). Yes, a level II should have been done. We should have put in a request for that. Preadmission Screening and Annual Resident Review Policy (PASARR) (Review/Revisions: 11-17-17; 11-13-18; 10-27-25) documents, in part: OBJECTIVE PASARR POLICY The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals identified. R29's Face sheet documents that R29 is a [AGE] year-old individual admitted to the facility on [DATE] who has diagnoses not limited to: bipolar disorder. There is no documentation to show that R29 was screened for a Pre-admission Screening and Resident Review (PASRR) level II. R29's PASRR level I screen outcome dated 07/14/2026 documents in part, refer for level II onsite. R95's Face sheet documents that R95 is a [AGE] year-old individual admitted to the facility on [DATE] who has diagnoses not limited to: paranoid schizophrenia. There is no documentation to show that R95 was screened for a PASRR level II. R95's PASRR level I screen outcome dated 07/14/2026 documents in part, refer for level II onsite. Facility document dated 10-27-25 documents in part, the objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals identified.

F697D · No harm, potential for more than minimal, isolated

Based on observation, interview, and record review, the facility failed to a.) ensure medications were ordered from the pharmacy and administered as ordered by the resident's physician and b.) provide pain management in accordance with the resident's preferences. These failures affect one (R133) resident in a total sample of 35 residents reviewed.Findings include: On 07/14/2026 at 12:36PM, surveyor located inside of R133's room with V8 (Licensed Practical Nurse/LPN) and V13 (Assistant Administrator). R133's primary language spoken is Spanish. V13 observed providing Spanish language translation for R133. Through translation provided by V13, R133 verbalizes that she has been experiencing pain in her shoulder and has been receiving Acetaminophen for her pain, but the Acetaminophen medication has not been effective at relieving R133's pain. On 07/14/2026 at 12:40PM, V8 states she will now contact R133's doctor to inquire about getting an order for a stronger pain medication for R133.Review of R133's POS/physician order sheet documents in part the following orders: Pain Assessment every shift for Pain -Start Date 12/30/2025.Acetaminophen Extra Strength Oral Tablet 500 MG (milligrams)- Give 1 tablet by mouth every 4 hours as needed for mild pain 1-3 Start Date 12/29/2025.TraMADol HCL Tablet 50 MG- Give 1 tablet by mouth every 6 hours as needed for moderate and severe pain- Start Date 01/02/2026.Progress note dated 07/14/2026 at 4:42PM written by V8 (Licensed Practical Nurse/LPN) documents in part, Attempted to call NP (Nurse Practitioner) informing her that resident stated that Tylenol doesn't work for her and requesting stronger medication, however, was unsuccessful. Resident stated at this time she has no pain however when she does in her shoulder the (Acetaminophen) is not effective. endorse to oncoming nurse to follow up with np for new orders.On 07/16/2026 at 11:22AM, V33 (Registered Nurse/RN) states she is the nurse responsible for caring for R133 today. V33 states R133 has Acetaminophen medication prescribed as needed for pain and R133 does not have any controlled substance medications prescribed or available in the facility.On 07/16/2026 at 11:25AM, V33 opens the medication cart that stores R133's medications. V33 unlocks the controlled substances lock box inside of the medication cart and surveyor observes that R133's Tramadol medication is not stored or available inside of the medication cart. On 07/16/2026 at 11:27AM, V33 and surveyor located inside of R133's room. V33 states she also speaks Spanish and is observed translating for R133. Through translation provided by V33, R133 verbalizes that she has been experiencing pain in her shoulder and rates her pain at 8/10 on the numbers scale. V33 states R133 verbalized being satisfied with receiving Acetaminophen for pain in the facility.On 07/16/2026 at 11:41AM, V33 observed deploying R133's physician's orders on the computer and is made aware of R133's active Tramadol medication order. V33 states she is not sure why R133 does not have Tramadol medication available in the facility.On 07/16/2026 at 11:42AM, V2 (Director of Nursing/DON) states if R133 has an active order for Tramadol medication, then R133's Tramadol medication order should have been implemented in the facility. V2 then directs V33 to call the pharmacy to inquire about R133's Tramadol medication.On 07/16/2026 at 11:53AM, V32 (Pharmacy Technician) states R133's Tramadol medication prescription was never received from the facility. V32 states since R133's Tramadol prescription was never received, the pharmacy never delivered R133's Tramadol to the facility.Record review of R133's MAR/medication administration record documents that R133's pain was not assessed on the following dates: 01/04/2026 during the 11:00PM-7:00AM shift, 01/05/2026 during the 11:00PM-7:00AM shift, and 01/24/2026 during the 11:00PM-7:00AM shift.R133's pain rating was an 8/10 on 07/09/2026 during the 3:00PM-11:00PM shift. R133's Acetaminophen medication was not administered during this shift. R133's Tramadol was not administered during this shift.Record review of R133's MAR from 01/2026 to 07/2026 documents that R133's Tramadol medication was never administered to R133 for pain in the facility.Facility policy dated 01/31/2018 titled Physician Orders-Entering and Processing documents in part, Fax or call the orders to the appropriate pharmacy as needed. If pharmacy is integrated with EHR/electronic health record, orders will be automatically transmitted with the exception of lengthy orders (over 140 characters, IV orders and narcotics.) These orders will need to be faxed to pharmacy.Facility policy dated 07/06/2018 titled Pain Management Program documents in part, Purpose: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. The pain management program includes the following components: Documentation of pain assessment and monitoring, Medications for the control or relief of anxiety related to pain. Pain assessment protocol will be initiated under any of the following situations: c. Resident receives routine pain medication and/or pain is not controlled.

F740D · No harm, potential for more than minimal, isolated

Based on observation, interview and record review the facility failed to a.) ensure food items were discarded by the best by dates, b.) failed to perform hand hygiene during preparation of mechanical soft and pureed food and c.) failed to wear a beard guard while in the kitchen area. This failure has the potential to affect all residents that receive nutritional intake from the kitchen. Findings Include: On 06/03/25 at 09:21 AM V17 (Food Handler) was observed moping the kitchen floor with no beard guard in place. On 06/03/25 at 09:25 AM Surveyor conducted a brief kitchen observation with V5 (Dietary Supervisor). Upon entering the dry storage room four 5-pound Creamy Peanut Butter jars were observed on a shelf with a best by date of 04/27/24. V5 said I am going to throw them away because someone opened this and it's saying best by. It should not be used because it has best by and it can cause food borne illnesses and the residents getting sick, that we don't want. On 06/03/25 at 09:42 AM Surveyor entered the walk-in cooler. A bag of spinach was observed on a shelf with a prep date of 05/05/24 and a use by date of 05/12/25. On 06/03/25 at 09:47 AM Surveyor entered the walk-in freezer. Two boxes of strawberry shakes with 74 four-ounce cartons with a best by date of 11/01/24, One box of chocolate shakes with 74 four-ounce cartons with a best by date of 10/06/24, Two boxes of strawberry shakes with 74 four-ounce cartons with a best by date of 06/15/23, One box of strawberry shakes with 74 four-ounce cartons with a best by date of 06/01/23, One box of vanilla shakes with 74 four-ounce cartons with a best by date of 01/13/23 and One box of vanilla shakes with 74 four-ounce cartons with a best by date of 12/08/22 was observed on a shelf in the freezer. V5 (Dietary Supervisor) instructed V17 (Food Handler) to discard the boxes of shakes. On 06/04/25 at 10:59 AM V18 (Cook) removed then donned a pair of gloves to puree the buttered peas without performing hand hygiene. V18 put 5 scoops of buttered beans in the food blender then added an additional 2 scoops. V18 put the pureed buttered beans in 3 small pans on a cart, covered them with plastic wrap then proceeded to the steam tables placing one pan on each steam table. V18 retrieved and placed a pan of turkey meat on the cart and returned to the food blender. On 06/04/25 at 11:05 AM V18 (Cook) removed the gloves and donned another pair of gloves without performing hand hygiene. V18 put the turkey meat into a food blender and prepared the mechanical soft meat. V18 places the turkey meat into 3 pans on the cart, poured gravy over the meat, covered the meat with plastic wrap then proceeded to the steam tables placing one pan on each steam table. On 06/04/25 at 11:16 AM V18 (Cook) removed the gloves, retrieved the blender, blade and top. V18 placed the blender on the table then donned a pair of gloves without performing hand hygiene. On 06/04/25 at 11:18 AM V18 (Cook) put turkey, gravy and broth in the blender to puree the turkey. On 06/04/25 at 11:24 AM surveyor asked V18 (Cook) should hand hygiene be done after removing gloves. V18 stated every time I change gloves I am supposed to wash my hands. There is a potential for cross contamination. On 06/05/25 at 09:54 AM V5 (Dietary Supervisor) stated when in the kitchen staff are to wear the hair nets and beard guards to protect from hair dropping into the food. After we left the kitchen, I did in-service V18 (Cook) again about when she did change her gloves but did not wash her hands. Our policy says to wash your hands after removing your gloves. There is a potential for cross contamination. Diet Roster - By Diet dated 06/04/25 indicate 40 residents receiving Dental soft (Mechanical soft) diets,16 residents receiving a pureed diet and 8 NPO (Nothing by Mouth) residents. Facility census of 193 was obtained from the Resident List Report dated 06/03/25. Policy: Titled Food Storage (Dry, Refrigerated, and Frozen) dated 2020 document in part: Guideline: Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. c. Discard food that has passes the expiration date. Titled Hair Restraints dated 2020 document in part: Guideline: 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. 2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing area. Titled Hand Washing undated document in part: Staff should wash their hands before handling food (even between tasks). Purpose: Food safety. Procedure: 1. Wash hands to remove contamination after entering the kitchen, during food preparation, before donning gloves for working with food, and after engaging in other activities that contaminate the hands.

F880F · No harm, potential for more than minimal, widespread

Based on observations, interviews and review of records the facility failed to maintain clean equipment used in the clean laundry areas and failed to ensure policies, procedures and standards were reviewed at least annually as required. These failures have the potential to affect all residents residing in the facility. Findings include: On 06/03/2025 at 12:02 PM with V24 (Laundry Tech) in laundry room at the clean clothing section. A black colored fan was used on top of the folding table blowing air directly on clothes. According to V24 those clothes are clean and will be folded. V24 turned off the fan, checked back and front grills and blades that was seen full of grayish colored materials. V24 said, It is full of dirty lint. When asked when was the last time fan was cleaned? V24 replied, I am not sure when was this fan was cleaned. V24 stated that laundry room is divided into 2 sections. The section where washing machines was located is not clean area. And area where folding table is the clean area. The clean area that fan was blowing and circulating air from the fan focuses on the clean area. V24 then went out the laundry room and went to another room where clean linens are stored. Inside the room was another fan with grayish lint on the grills and blade. V24 said, This is also dirty, we need to take it out. Both fans when grayish material was touch can easily detach and move through circulation inside the room. On 06/04/2025 at 11:24 AM, V4 (Infection Preventionist/Registered Nurse/Nurse Manager) during review of all infection control policies, procedures and standards currently use by facility on infection control and prevention programs. The following policies and procedures were identified as last date of review more than a year: - Personal Protective Equipment (PPE) - Determining PPE needs dated 10/30/2017 - Infection Surveillance policy and procedure dated 2/14/2018 - Antibiotic/Antimicrobial Stewardship Program dated 1/7/2019 - Infection Precaution Guidelines dated 5/15/2023 - Infection control - Interim Covid 19 policy last revised on 7/24/2023 - C Diff policy dated 03/01/2023 - Infection Precaution Guideline dated 05/15/2023 - Activities - Infection Precautions dated 01/10/2018 - Linen Handling - Laundry Department policy and procedure dated 01/11/2018 - Influenza and Pneumococcal Immunizations policy dated 04/21/2022 V4 stated that she is aware that infection control needs to be current due to often changes in practices. On 06/05/2025 at 09:45 AM, V3 (Director of Nursing) stated that currently V2 (Assistant Administrator) managing laundry department and housekeeping department because there is no housekeeping director. At 10:58 AM, V1 (Administrator) and V2 confirmed that facility is in the process of hiring housekeeping director. V1 stated that fans in the laundry area need to be clean when using to avoid contamination of clean laundry. Linen Handling - Laundry Department policy and procedure dated 01/11/2018 purpose is to ensure the proper handling, storage, processing, and transport of all linens and laundry in accordance with accepted national standards to produce hygienically clean laundry and prevent the spread of infection to the extent as possible. The Laundry Department shall design so that there is a flow of functions that prevent contamination of clean linen. In using fans in laundry processing areas, prevent cross-contamination of clean linens.

F558E · No harm, potential for more than minimal, pattern

Based on observations, interviews, and record reviews, the facility failed to follow their policies and (a) assist residents outside in the patio per their preference; (b) ensure call lights were within reach; and (c) ensure call light was answered in a timely manner. These failures affected 5 (R24, R173, R143, R163 & R13) residents out of a total sample of 36 residents with an additional 4 residents (R61, R57, R105, and R183) verbalizing frustration during the resident council meeting. Finding Include: R24 has diagnosis not limited to Paraplegia, Disorders of Bone Density and Structure, Left Ankle and Foot, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Atrial Fibrillation, Cerebrovascular Disease, Acute Osteomyelitis, Left Ankle and Foot, Multiple Sclerosis, Schizophrenia, Type 2 Diabetes Mellitus, Malignant Neoplasm of Colon, Essential (Primary) Hypertension, Chronic Obstructive Pulmonary Disease and Asthma. R24's Care Plan document in part: Focus: I am at risk for falls. 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 all requests for assistance. Focus: I have alteration in urinary elimination r/t (related/to) diagnosis of BPH (Benign Prostatic Hyperplasia). Interventions: Ensure call light is within reach and answer promptly. On 06/03/25 at 10:59 AM R24 was observed in a reclining wheelchair at the foot of the bed with bilateral hand splints in place. Surveyor asked R24 how he calls for assistance. R24 stated it is supposed to be a call light, but it is not always where I can reach it. I do not know where my call light is. R24's call light was observed located on top of the overhead light at the head of R24's bed out of R24's reach. R173 has diagnosis not limited To Type 2 Diabetes Mellitus, Unsteadiness on Feet, Cognitive Communication Deficit, Depression, Secondary Hypertension, Limitation of Activities due to Disability, Generalized Anxiety Disorder, Pressure Ulcer of Sacral Region, Stage 4 and Lower Abdominal Pain. R173's Care Plan document in part: Focus: I am incontinence of bowel/bladder. Interventions: Encourage resident to call for assistance when feeling urge to void or have BM (bowel movement). On 06/03/25 at 11:06 AM V16 (Certified Nurse Assistant) was observed in R173's room making the bed. V16 then exited R173's room. R173 was observed sitting in a wheelchair at the bedside. R173's call light was observed wrapped around the left upper side rail positioned behind R173 out of reach. When R173 was asked the location of her call light R173 responded, for the most part I have a thing around me. I don't know where it is at right now, it is probably put away. On 06/03/25 at 11:15 AM the surveyor entered R173's room with V16 (Certified Nurse Assistant). Surveyor asked V16 (Certified Nurse Assistant) the location of R173's call light. V16 responded, it should be attached to R173. That is the main thing that I forgot to do. R173 knows how to use the call light. V16 unwrapped the call light from around the bed side rail and attached it to R173. On 06/03/25 at 11:17 AM the surveyor entered R24's room with V16 (Certified Nurse Assistant). Surveyor asked V16 (Certified Nurse Assistant) the location of R24's call light. V16 responded, R24 has a tap call light. V16 removed the call light tap pad from the top of the over bed light and clamped it to R24's shorts. V16 stated the purpose of having the call light in reach is so the resident can call if they need something, emergency or need something turned off. If the call light is not within reach, they will probably wind up falling. On 06/05/25 at 09:01 AM V3 (Director of Nursing) stated the call light should be placed within reach of the resident, for the resident safety in case, they need something or for an emergency. If the call light is not in reach, potentially the resident can be placed in a situation that is unsafe for them. Policy: Titled Call light revised 02/02/18 document in part: Purpose: To respond to residents' request and needs in a timely and courteous manner. Guidelines: 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. On 6/03/2025 at 11:35 AM, R143 and R163 requested to go outside from V29 (Activity Aide). V29 stated only CNAs (Certified Nurse Aides) can assist the residents when it is not a scheduled activity or on the calendar. V29 stated there was a scheduled patio social the next day at 2:00 PM and V29 can only take them out during that time. V29 instructed R143 and R163 to ask their assigned CNA instead. After V29 left, R163 stated [R163] wanted to get fresh air and sit out near the front entrance. Staff informed R163 that it was possible if staff take R163 and monitor R163 outside. On 6/03/2025 at 11:39 AM, R143 stated [R143] has been trying to go out since yesterday. R143 stated [R143] was up in the wheelchair yesterday by 2:00 PM and ready to go outside but staff would not assist R143. R143 waited until 6:00 PM but CNA put R143 back in bed instead of helping R143 go out to the patio. R143 stated has been wanting to go outside for weeks but staff are not assisting R143. R143 has asked the CNAs but they're too busy and have too many things to do. R143 has asked activity staff but they said they can't take residents out unless its on the activity calendar. During a follow-up interview with R163 on 06/04/2025 at 9:55 AM, R163 stated staff did not assist R163 to go outside yesterday. R163 stated staff didn't bring [R163] clothes and R163 did not want to go outside in a gown. During a follow-up interview with R143 on 06/04/2025 at 9:57 AM, R143 stated it started raining around the time R143 was to go outside. V30 (CNA) brought R143 back to the room and went to go chart. After the rain stopped, staff refused to assist R143 outside. R143 stated the evening shift refused and made excuses that they had to pass out dinner and do other things. R143 stated there's not enough staff to help residents go outside and monitor them. R143 stated hasn't been outside since January and wants to enjoy the upcoming nice weather. On 6/04/2025 at 10:31 AM, V30 stated if a resident wants to get up and go outside, someone should be able to do it. V30 stated attempting to take R143 outside yesterday but it rained. V30 was going to attempt again once the rain stopped but got busy and couldn't do it. On 6/04/2025 at 10:39 AM, V31 (Activities Director) stated it's the activities department that helps the residents go outside when they want to. V31 stated residents at any time can let the activities department know if they want to go outside and they will arrange it. V31 stated the activity aide (V29) should not have declined to take R143 and R163 outside. V31 stated the appropriate response would have been to assist them outside or arrange for a time later in the day to assist them outside. On 6/05/2025 at 9:14 AM, V3 (Director of Nursing) stated it is all the staff's responsibility including the nurse, CNA, or activity aide to assist residents who want to go outside and enjoy some fresh air. Facility's 8/23/2017 Resident Rights policy documents in part residents' rights to exercise their rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. R13 is an [AGE] year-old, non-ambulatory female who was admitted to the facility on [DATE] with diagnoses that includes but not limited to dementia, schizophrenia, heart failure, and chronic kidney disease. R13's Minimum Data Set (MDS) dated [DATE] shows R13 is extensive to total assistance with activities of daily living and is severely impaired with cognition. R13's care plan addressed needing assistance with grooming, hygiene, and bathing. On 6/3/25 at 11:52 AM, R13 was lying in bed alert and awake but confused. R13 was noted wearing just an incontinence pad, with no clothes on. R13 had food stain around her chin, hair disheveled, and leaning on the side of the bed. Surveyor pressed R13's call light but no staff was answering until surveyor asked V14 (Certified Nursing Assistant) for help at 12:08 PM. On 6/4/25 at 2:17 PM, resident council meeting was held. R61, R57, R105, and R183 were in attendance. All stated call lights are sometimes not answered in a timely manner. All stated that facility lacks staffing to accommodate the needs of the residents. R57 and R61 stated that the facility does not accommodate their preferences to go outside to get fresh air when the weather is nice. On 6/5/25 at 9:40 AM, V3 (Director of Nursing) stated that it is the facility's policy for the call lights to be answered as soon as possible in less than five minutes. V3 stated that answering call lights more than ten minutes is delayed. V3 stated that it is important for the staff to answer the call light promptly because the resident could be compromised. They could have incident or needing transfer assistance to prevent incident. The facility's Call Light policy dated 2/2/18 documents in part: To respond to residents' requests and needs in a timely and courteous manner. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered.

F644E · No harm, potential for more than minimal, pattern

Based on record review and interviews the facility failed to incorporate the recommendations for pre-admission screening and resident review (PASARR) Level II for 2 residents (R48 and R130) that were required to have Level 2 screening. Facility also failed to coordinate and provide full information for proper assessment of PASARR Level I as required to 4 residents (R61, R10, R48, R106) for a total of 6 residents reviewed for PASARR assessments in a sample of 36. Findings include: R61 is 8 years old, initially admitted in the facility on 11/28/2015. Facility submitted PASARR Level 1 dated 06/03/2025 the day it was requested. Under Mental Health Diagnosis it documents no mental health diagnosis is known or suspected. Although facility's face sheet for R61 documents adjustment disorder with anxiety and major depressive disorder. Under Mental Health Medications documents no medication. Although R61 has an order for Doxepin 25 MG tricyclic antidepressant scheduled at bedtime. R10 is [AGE] years old, initially admitted in the facility on 12/30/2021. Facility submitted PASARR Level 1 dated 06/03/2025 the day it was requested. Under Mental Health Diagnosis it documents no mental health diagnosis is known or suspected. Although facility's face sheet for R10 documents schizoaffective disorder bipolar type and major depression. R10 documents adjustment Under Mental Health Medications documents no medication. Although R10 has an order for antidepressant medication aripiprazole Oral Tablet 15 MG to take daily for depression. R130 is [AGE] years old, initially admitted in the facility on 05/06/2022. R130's diagnosis includes bipolar disorder. Facility submitted PASARR Level I dated 05/09/2024 documents that R130 PASARR Level 2 must be conducted. That evaluation will occur as an onsite face-to-face evaluation. On 06/04/2025 at 01:52 PM, V6 (Social Service Director) stated that PASARR screening or assessment need to be done before admitting residents in the facility. V6 stated that the purpose of PASARR screening is to make sure that resident admitted fit skilled facility setting. Or that the facility can provide the needs necessary for individuals that will be admitted . V6 said, You don't want to put them in the wrong setting. V6 stated that residents that were just screened for PASARR Level I does not have all necessary medical diagnosis that should have been included to accurately screen residents. These can affect the screening when Level II may be needed but due to lack of medical diagnosis screening results does not require Level II. V6 said, Yes, not including this diagnosis can affect accuracy of PASARR assessment. V6 stated that he will coordinate with nursing department to correct these mistakes. On 06/05/2025 at 09:45 AM, V3 (Director of Nursing) stated that she was made aware by V6 about lack of medical diagnosis that should have been included in PASARR assessments. V3 was made aware about PASARR importance. PASARR forms signed by V28 (admission Director) documents that by submitting the forms, facility staff attest that all information contained herein and that taking responsibility for the completeness and accuracy of information reported throughout this submission. I (V28) attest that I am a health care professional working in a clinical capacity for this provider. I understand that approved submitters include clinical professionals such as nurses, LPNs, social workers (with a BS degree or higher), physicians, or home health agency clinical staff. Social service staff are not required to be licensed to submit information. I understand that administrative staff are not permitted to submit clinical information to clinical division that process PASARR. PASARR forms of R10, R61 and R106 does not provide accurate medical diagnosis and psychotropic medications. Preadmission Screening and Annual Resident Review (PASARR) policy dated 11/17/17 provides that screening all potential admissions should be done on an individual basis as part of preadmission process. The facility needs to participate in the Preadmission Screening and Annual Resident Review (PASARR) screening process (Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Based upon the Level I screen, the facility will not admit an individual with a mental disorder or intellectual disability until Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen. If a provisional admission to the facility is approved via the Level II screen process, the facility will coordinate with the State PASARR representative related to the individual needs of the resident as indicated. The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals identified. R48 was admitted to the facility on [DATE] with diagnosis not limited to Rheumatoid Arthritis, Insomnia, Abnormal Weight Loss, Major Depressive Disorder, Single Episode, Arthritis, Schizophrenia, Type 2 Diabetes Mellitus, Acquired Hemolytic Anemia, Drug Induced Subacute Dyskinesia, Chronic Kidney Disease, Adult Failure to Thrive, Anemia, Hyperlipidemia, Pressure Ulcer of Sacral Region, Stage 4, Essential (Primary) Hypertension, Dementia and Anxiety. The facility provided a document titled PASARR Level I Form (Preadmission Screening and Resident Review) dated 06/04/25 document in part: Reason for screening: This nursing facility resident has never had a PASARR Level I screen. Ascend Outcome: Level I Outcome: Refer for Level II Onsite. Rationale: A PASARR Level II evaluation must be conducted. What are the primary medical conditions requiring nursing facility care? Dementia, Major Depression. R106 was admitted to the facility on [DATE] with diagnosis not limited to Morbid (Severe) Obesity, Type 2 Diabetes Mellitus, Major Depressive Disorder, Recurrent, Schizophrenia, Bipolar Disorder, Essential (Primary) Hypertension and Acute Bronchitis. The facility provided a document titled PASARR Level I Form (Preadmission Screening and Resident Review) dated 06/03/25 documenting in part: Reason for screening: This nursing facility resident has never had a PASARR Level I screen. Mental Health Medications: No Medication. Ascend Outcome: Level I outcome: No Level II Required. Rationale: The Level I screen indicates that a PASARR disability is not present because of the following reason: There is no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral health condition. R106's PASARR Level I Form lacks information for the diagnosis of Schizophrenia, Major Depressive Disorder and Bipolar Disorder. The PASARR Level I Form also lacks R106's mental health medication consisting of Geodon Capsule 80 MG (milligrams) at bedtime. R106's PASRR Level I Form lacks information for the diagnosis of Schizophrenia, Major Depressive Disorder and Bipolar Disorder. The PASARR Level I Form also lacks R106's mental health medication consisting of Geodon Capsule 80 MG at bedtime.

F645E · No harm, potential for more than minimal, pattern

Based on record review and interviews the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program as required to 4 out of 5 residents (R61, R10, R48, R106) reviewed for resident assessments in a sample of 36. Findings include: R61 is 8 years old, initially admitted in the facility on 11/28/2015. R61's diagnosis includes adjustment disorder with anxiety, major depressive disorder. Facility submitted PASARR Level 1 dated 06/03/2025 the day it was requested. R61 has an order for Doxepin 25 MG (milligrams) scheduled at bedtime. R10 is [AGE] years old, initially admitted in the facility on 12/30/2021. R10's diagnosis includes schizoaffective disorder bipolar type and major depression. Facility submitted PASARR Level 1 dated 06/03/2025 the day it was requested. R10 has an order for antidepressant medication aripiprazole Oral Tablet 15 MG take 1 tablet daily for depression. On 06/04/2025 at 01:52 PM, V6 (Social Service Director) stated that PASARR screening or assessment need to be done before admitting residents in the facility. V6 stated that the purpose of PASARR screening is to make sure that resident admitted is fit to skilled facility setting. Or that the facility can provide the needs necessary for individuals that will be admitted . V6 said, You don't want to put them in the wrong setting. Preadmission Screening and Annual Resident Review (PASARR) policy dated 11/17/17 provides that screening all potential admissions should be done on an individual basis as part of preadmission process. The facility needs to participate in the Preadmission Screening and Annual Resident Review (PASARR) screening process (Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Annually and with any significant change of status, the facility will complete the PASARR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly. The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals identified. R48 was admitted to the facility on [DATE] with diagnosis not limited to Rheumatoid Arthritis, Insomnia, Abnormal Weight Loss, Major Depressive Disorder, Single Episode, Arthritis, Schizophrenia, Type 2 Diabetes Mellitus, Acquired Hemolytic Anemia, Drug Induced Subacute Dyskinesia, Chronic Kidney Disease, Adult Failure to Thrive, Anemia, Hyperlipidemia, Pressure Ulcer of Sacral Region, Stage 4, Essential (Primary) Hypertension, Dementia and Anxiety. The facility provided a document titled PASARR Level I Form (Preadmission Screening and Resident Review) dated 06/04/25 document in part: Reason for screening: This nursing facility resident has never had a PASARR Level I screen. Ascend Outcome: Level I Outcome: Refer for Level II Onsite. Rationale: A PASARR Level II evaluation must be conducted. What are the primary medical conditions requiring nursing facility care? Dementia, Major Depression. R106 was admitted to the facility on [DATE] with diagnosis not limited to Morbid (Severe) Obesity, Type 2 Diabetes Mellitus, Major Depressive Disorder, Recurrent, Schizophrenia, Bipolar Disorder, Essential (Primary) Hypertension and Acute Bronchitis. The facility provided a document titled PASARR Level I Form (Preadmission Screening and Resident Review) dated 06/03/25 documenting in part: Reason for screening: This nursing facility resident has never had a PASARR Level I screen. Mental Health Medications: No Medication. Ascend Outcome: Level I outcome: No Level II Required. Rationale: The Level I screen indicates that a PASARR disability is not present because of the following reason: There is no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral health condition. R106's PASARR Level I Form lacks information for the diagnosis of Schizophrenia, Major Depressive Disorder and Bipolar Disorder. The PASARR Level I Form also lacks R106's mental health medication consisting of Geodon Capsule 80 MG at bedtime.

F578D · No harm, potential for more than minimal, isolated

Based on interviews and record reviews, the facility failed to follow their policies and manifest residents' (R60, R143, R163) advanced directive choices consistently in their electronic medical records (EMR) for 3 out of a total sample of 36 residents. Findings include: R60's IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form dated [DATE] documents in part No CPR (Cardiopulmonary Resuscitation): Do Not Attempt Resuscitation (DNAR) and Comfort-Focused Treatment: Primary goal is maximizing comfort through symptom management. Allow natural death. R60's POSLT documents in part no intubation or mechanical ventilation. R60's Care Plan Report documents in part I am a full code. Attempt resuscitation, CPR, including intubation and mechanical ventilation (initiated [DATE]). Facility did not update this care plan focus after R60 developed POLST form. R143's [DATE] POLST form and R163's [DATE] POLST form documents in part orders for cardiac arrest is Yes CPR. Orders for when R60 is not in cardiac arrest is Comfort-Focused Treatment: Primary goal is maximizing comfort through symptom management. Allow natural death. Use medication by any route as needed. Use oxygen, suctioning and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Transfer to hospital only if comfort cannot be achieved in current setting. R143 and R163's Order Summary Report documents in part Full Code. No orders specifying comfort measures for when not in cardiac arrest. On [DATE] at 10:07 AM, surveyor asked V25 (Nurse) for R143 and R163's code status. V25 checked the electronic medical records (EMR) and the physician orders for both residents on the computer. V25 stated R143 and R163 are full code. V25 stated physician orders did not specify any other wishes. On [DATE] at 9:45 AM, V26 (Agency Nurse) stated it was [V26's] first day working at the facility and taking care of R143 and R163. Surveyor asked how V26 would review residents' code statuses such as R143 and R163. V26 stated information is listed in their EMRs near their profile picture. V26 showed surveyor that both residents were full code. V26 stated no other instructions under comment section. On [DATE] at 10:13 AM, surveyor followed-up with R143 and R163. R143 and R163 did not want a machine keeping them alive or breathing for them. Both stated they want the facility staff to try but wanted to die naturally. On [DATE] at 1:40 PM, V6 (Social Service Director) stated staff will review residents' advanced directives with the residents or their representatives. Social service will ensure that the residents understand their options. Once the residents or their representatives make their wishes known, they will have the resident or their representative fill out the POLST form and the social service department will update their care plan. The nurses will then communicate with the doctor or nurse practitioner. Once the provider gives the order, the nurse will put the order in the EMR. Surveyor reviewed R60's care plan with V6. V6 stated the care plan should reflect R60's POLST orders. Reviewed R143 and R163's POLSTs and physician orders with V6. V6 stated R143 and R163's choice of comfort-focused treatment should be noted in the comment section of the advanced directive in the EMR. On [DATE] at 9:14 AM, V3 (Director of Nursing) stated staff are to update residents' care plans as needed. V3 stated staff are to refer to the residents' POLST forms and follow the residents' wishes. V3 stated residents' wishes should be clearly communicated with staff and partnering EMS. Facility's [DATE] Resident Rights policy documents in part residents' rights to choose treatment and participate in decisions and care planning. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. Facility's Advance Directives policy (last revised [DATE]) documents in part: Purpose: To ensure that all residents and/or resident representatives are informed concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. A written physician's order is required in response to the resident's Advanced Directive(s). Physician's orders shall be specific and address each Advanced Directive(s). Advanced Directive(s) shall be included in the resident's plan of care, and will be reviewed during the care plan meeting with the resident and/or the resident's legal representative when present. Facility's Comprehensive Care Plan policy (last revised [DATE]) documents in part: Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Guideline: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving.

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

Based on interview and record review, the facility failed to follow their policy and develop a comprehensive care plan for a resident (R60) with an indwelling urinary catheter for 1 out of a total sample of 36 residents. Findings include: On 6/03/2025 at 10:55 AM, R60 stated indwelling urinary catheter is new and has had it for a few weeks now. R60's Order Summary Report documents in part urinary catheter insertion to promote wound healing (dated 5/15/2025). R60's Care Plan Report does not contain a focus, goal, or interventions pertaining to urinary catheter use. On 6/05/2025 at 9:14 AM, V3 (Director of Nursing) stated staff are to update residents' care plans as needed. Urinary catheters should be included in the care plan when inserted. Facility's Comprehensive Care Plan policy (last revised 11/17/2017) documents in part: Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Guideline: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving.

F677D · No harm, potential for more than minimal, isolated

2 findings

F686G · Actual harm, isolated

Based on interview and record review, the facility failed to implement appropriate interventions to prevent skin breakdown for 1 of 3 residents (R1) reviewed for pressure ulcers in a total sample of 8. This failure resulted in R1 developing a stage 4 pressure ulcer within 3 months of being admitted to the facility. Findings Include: The Face Sheet documents that R1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R1 required maximum assist from staff with all activities of daily living. The Skin assessment dated [DATE] documents that R1 had no skin breakdown on admission and the resident was placed on a pressure reducing mattress as a preventative measure. The Nurse's Notes dated 5/15/16 documents that R1 was noted with maceration, or skin irritation related to moisture, on the left and right buttocks. The MD was notified, new orders were received and on 5/17/16 R1 was placed on a pressure re-distributing mattress. The Nurse's Notes dated 6/9/16 documents that the maceration to the left and right buttocks had deteriorated and was being measured as one sacral wound. The MD Wound Notes dated 7/12/16 documents that the wound had deteriorated and was classified as a stage 4 pressure ulcer and on 7/27/16 R1 was transferred to the local hospital for evaluation and treatment. The hospital records dated 7/27/16 documents that R1 was admitted with a stage 4 pressure ulcer to the sacrum with part of the bone exposed. The pressure ulcer had a foul odor on admission and R1 was started on antibiotic therapy. R1 also had a stage 2 pressure ulcer to the right and left ear. R1's pressure ulcer care plan documents that the resident was on a pressure re-distributing mattress, the resident should be assisted with turning and repositioning every 2 hours and more often as needed, and the plan of care should be re-evaluated if there is no improvement noted in 3-4 weeks. On 2/22/18 at 12:45pm V4 stated The resident had no skin issues on admission. R1 was [MEDICAL CONDITION] and was very high risk for skin breakdown. R1 had a pressure re-distributing mattress and heel protectors in place. It started as moisture associated skin damage from incontinence and later developed into a pressure ulcer. On 3/2/18 at 10:45am V8 (Nurse Practitioner) stated The resident had a [MEDICAL CONDITIONS] feeding tube in place, and R1 constantly moved around in bed. The resident could not be calmed down. It started as maceration and went on to a stage 4 pressure ulcer. R1 had no control over the movements; it was due to the [MEDICAL CONDITION]. I had R1 on the maximum dose of [MEDICATION NAME], an anti-anxiety medication, and it just did not work. The staff tried to turn and reposition R1 but the resident would flail around and end up in another position. The wound deteriorated very quickly. It just got worse and worse so I had the resident sent out to the hospital. On 3/2/18 at 11:15am V4 stated All of our mattresses are pressure reducing mattresses for residents at high risk for skin breakdown. Residents with Stage 3, 4 or unstageable wounds are given a low air loss mattress. Pressure re-distributing mattresses have some of the same functions as a low air loss mattress, it redistributes the pressure. Low air loss mattresses are used for prevention and treatment of [REDACTED]. The Manufacturer's Recommendations for the low air loss mattresses used by the facility documents that the mattress is used to prevent and treat pressure ulcers. The facility could not provide Manufacturer's Recommendations to document the use for pressure re-distributing mattresses, the mattress being used by the resident.

F689G · Actual harm, isolated

Based on interview and record review the facility failed to follow their Fall Prevention Program and failed to ensure that fall interventions were securely in place prior to leaving the room for 1 resident (R2) reviewed for falls in a total sample of 8. This failure resulted in the R2 falling out of bed and being hospitalized with a laceration to the forehead. Findings Include: The Fall Risk assessment dated [DATE] documents that R2 was at risk for falls due to confusion, recent falls and the resident being legally blind. The care plan was updated and appropriate interventions were put into place. The Nurses Notes dated 1/30/18 documents that R2 was found on the floor by staff in between the resident's bed and dresser. R2 was observed with a laceration to the mid forehead and moderate bleeding. The Incident Report documents that R2 was in bed prepared to be transferred to the chair by staff prior to the fall. When staff returned to the room to transfer, R2 was observed on the floor with a laceration on the forehead. R2 was sent to the hospital for evaluation and treatment. The hospital records dated 1/30/18 documents that R2 presented with a laceration to the forehead where adhesive was used to close the wound. On 2/27/18 at 12:55pm V2 (DON) stated The CNA informed me that it was time for the resident to get up out of bed. The CNA went in and got the resident dressed. The CNA left the room and upon returning, R2 was observed on the floor. At the time of the fall the resident had bed bolsters in place. My investigation concluded that the CNA had loosened the bed bolsters while getting the resident dressed. The CNA did not re-tighten the bolsters before leaving the room. The resident did not move much so had the bolsters been securely in place, the resident probably would not have fallen. The CNA is no longer employed at the facility. On 2/27/18 at 1:35pm V2 stated The resident was to be transferred by a Hoyer lift. The CNA did not bring the equipment in the room prior to providing care for the resident. The CNA left the room to get the equipment and my investigation concluded that this was done without securing the bolsters. The CNA also should have had the equipment needed for the resident prior to entering the room. The CNA had been educated on this before the incident occurred. The facility's Fall Prevention Program documents that It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. Staff should use and implement professional standards of practice.

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