Every finding on record at Avantara Lincoln Park

Based on observations, interviews and record review, the facility failed to ensure that boxes of food were not stored on the kitchen floor; and failed to ensure that employees' personal items were not stored in food preparation areas. This failure has the potential to affect 213 residents that receive meals prepared in the kitchen.Findings include:During kitchen tour on 8/3/26 at 9:40 am, Surveyor noted a personal radio speaker observed on the table across from the food steamer. At that time, V31 (AM Cook) stated the following, The speaker and all personal items should not be in the food prep areas. This increases the risk of contamination of foods.On 8/3/26 at 9:41 am, Surveyor noted cases of food on the kitchen floor outside of the dry storage room.At that time, V30 (Dietary Manager) stated the following, No food should be stored on the floor because the floor is dirty. For sanitary purposes, we store food off of the floor after deliveries.Facility Dietary Report dated 8/5/26 documents 213 residents that receives meals from the kitchen.Facility policy titled Food Handling and dated 7/7/26 documents, food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Facility policy titled Food Handling and dated 7/7/26, excludes any verbiage regarding personal items in food storage areas.

Based on observations, interviews and record review, the facility failed to ensure that the outside garbage dumpster was closed. This failure has the potential to affect all 217 residents that reside in the facility.Findings include:During facility tour with V30 (Dietary Manager) on 8/3/26 at 10:03 am, outside garbage was observed uncovered (without lid).At that time, V30 stated the following, The garbage should be covered to keep out rodents and to keep the garbage contained.On 8/5/26 at 11:32 am, V2 (DON/ Director of Nursing) stated the following, The outside garbage should be covered at all times for sanitary purposes.On 8/6/26 at 3:20 pm, V1 stated that the facility did not have a policy on the handling of garbage.The Facility Census Report dated 8/3/26 documents 217 active residents.Facility document titled, Director of Housekeeping and dated 12/1/2019 documents the following as part of Director's job duties: ensure the facility is kept clean, sanitary and odor free at all times in compliance with Federal, State and local regulations.

Based on observations, interviews and record review, the facility failed to wear PPE (Personal Protective Equipment) while caring for two residents (R3 and R51) on EBP (Enhanced Barrier Precautions); failed to contain soiled linen while transporting; failed to prevent soiled linen contamination while laundering linen; and failed to prevent respiratory equipment from being stored on the floor uncontained for three residents (R24, R225, and R227). These failures affected five residents (R3, R24, R51, R225 and R227) and have the potential to affect all 217 residents that reside at the facility. Findings include: On 08/04/26 at 10:53am observed V40 (Certified Nursing Assistant/CNA) observed rendering perineal care to R3 with no PPE gown on. V40 observed leaving R3's room with soiled linen and a soiled incontinent brief in hand, not contained in bag. On 08/04/26 at 10:55am V40 (CNA) stated that policy is that staff are supposed to have soiled linen and incontinent briefs in bags but the bags that the facility provides are too small. V40 stated that she is unsure if she was supposed to have on a gown while caring for R3. V40 viewed EBP sign outside R3's door and stated that she should have had a gown on while caring for R3. V40 stated that the gowns are for protection for the staff and the residents. On 08/04/26 at 11:33am surveyor conducted tour of laundry area with V41 (Environmental Service Director). Observed soiled linen coming from the linen chute in untied bags with linen hanging out of bags. Observed V42 (CNA) folding clean linen, dragging clean linen on the floor and tucking clean linen under V42's chin. On 08/04/26 at 11:33am V41 (Environmental Service Director) stated that the soiled linen in the linen chute should be in a closed bag to prevent contamination. V41 stated that V42 (CNA) should not allow the clean linen to touch the floor while she is folding it. V41 stated that the clean linen is now contaminated and has to be rewashed. On 08/04/26 at 11:55am observed residents' clothes on hangers, hanging on the side of a basket, touching the floor. V41 stated that the residents' clothes should not touch the floor and they will have to be rewashed. On 08/04/26 at 3:18pm V3 (Infection Preventionist/IP) stated that PPE is to be worn by staff during resident care if the resident is on EBP and staff are doing direct care to the resident. V3 stated that staff should not come out of the resident's room with soiled linen that is not contained in a bag. V3 stated that staff should bag soiled items to prevent cross contamination. On 08/05/26 at 10:50am observed V45 (CNA) dressing R51 with no PPE on. V45 (CNA) stated that she should have had on a PPE gown while dressing R51, but she was told to hurry up and get R51 dressed and was in a hurry. On 08/05/26 at 1:46pm V2 (Director of Nursing/DON) stated that PPE should be used for any isolation or enhanced barrier room. V2 stated that PPE protects the resident and staff from transfer of infection. R3's care plan dated 07/30/26 documents in part, (R3) requires Enhanced Barrier Precaution related to: (Indwelling urinary) catheter. (R3) will remain on EBP to prevent the transmission or acquisition of MDRO's (multi drug resistant organism) especially during high contact care activities through the next review date. Staff will wear gown and gloves before resident contact especially during high contact activities like dressing, transferring and bathing or any care that involves exposure to a wound or an indwelling device. R51's physician order dated 07/29/26 documents in part, Cleanse enteral tube feeding site with normal saline and apply dry dressing every night shift. Facility's job description titled Laundry Aide dated 12/1/2019 documents in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Laundry Worker plays a critical role in providing general laundry services to all Guests in the facility. The Laundry Worker's main function is to wash, dry, fold and mend clothing while following infection control and safety procedures. Essential Functions: 4. Assure that established infection control and prevention practices and standard precautions are maintained at all times. Facility's job description titled Certified Nursing Assistant dated 05/20/2022 documents in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Certified Nursing Assistant (CNA) plays a critical role in providing superior customer service and nursing care to all Guests. The CNA safeguards the health, safety and welfare of all Guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: 10. Assure that established infection control and prevention practices and standard precautions are maintained at all times. Facility's policy titled Enhanced Barrier Precaution revised 09/16/25 documents in part, Policy: The facility will use Enhanced Barrier Precautions (EBP) to reduce transmission of multi-drug resistant organisms in the nursing homes. EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDROs as well as residents with wounds and/or indwelling medical devices. Procedures:1. EBP will be used for any resident in the facility: Has indwelling medical devices regardless of XDRO colonization status. Devices that are fully embedded in the body, without component that communicate with the outside, such as pacemakers, would not be considered an indication for Enhanced Barrier Precautions. 3. The EBP requires the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of SDRO's to staff hands and clothing. Examples of high contact resident care activities requiring gown and glove use among residents that trigger EBP use include: a. Dressing. C. Transferring. E. Changing linen. F. Changing briefs or assisting with toileting. Facility Census Report documents, in part, that 217 residents reside in the facility. On 8/3/2026 at 11:44 AM, observed in R24's room, R24's oxygen nasal cannula tubing coiled on the floor next to R24's bed, right by the oxygen concentrator machine. R24 was observed sleeping in the bed while wearing nasal cannula. On 8/3/2026 at 11:46 AM, observed in R225's room, R225's oxygen nasal cannula tubing laying on the floor next to R225's bed, coiled on the floor by the oxygen concentrator machine. R225 was observed in the bed laying on the side. R225 said that R225 needs assistance to move around and does not get out of bed without assistance. R225 said that R225's oxygen tubing was in the same place for a while. On 8/3/2026 at 12:07 PM, observed in R227's room, R227's oxygen nasal cannula tubing laying on the floor next to R227's bed, coiled on the floor next to the oxygen concentrator machine. R227 stated that R227 wears oxygen at all times and does not remember staff adjusting nasal cannula tubing position and that R227 does not get out of bed without assistance. On 8/4/2026 at 10:24 AM, observed for the second time in R24's room, R24's oxygen nasal cannula tubing coiled on the floor next to R24's bed, by the oxygen concentrator machine. R24 stated that R24 is unable to ambulate independently and depends on assistance from staff for transfers. On 8/4/026 at 10:32 AM, observed for the second time in R227's room, R227's nasal cannula tubing laying on the floor next to R227's bed, coiled on the floor next to the oxygen concentrator machine. R227 was observed laying in the bed, sleeping, wearing nasal cannula. On 8/4/2026 at 10:37 AM, observed for the second time in R225's room, R225's nasal cannula tubing laying on the floor next to R225's bed, coiled on the floor by the oxygen concentrator machine. R225 was sitting on side of bed, wearing nasal cannula. On 8/4/2026 at 10:38 AM, V24 (Certified Nursing Assistant/CNA) stated that oxygen care and maintenance is nurses responsibility, but the nasal cannula tubing should not be touching the floor. On 8/4/2026 at 10:45 AM, V21 (Registered Nurse/RN) stated that oxygen tubing should not be touching the floor because of infection control issues. On 8/4/2026 at 10:51 AM, V22 (Licensed Practical Nurse/LPN) said that oxygen tubing should not be laying on the floor, because when the tubing is touching the floor, the oxygen tubing could get contaminated. On 8/4/2026 at 10:58 AM, V27 (Assistant of Director of Nursing/ADON/RN) stated that oxygen tubing should get changed once a week and is the nurse's responsibility and proper maintenance is important. V27 said that oxygen tubing should not be touching or be laying on the floor because of risk of causing contamination and infection to residents. V27 also stated that improper maintenance or not changing the tubing could cause mold to form inside of the tubing and could cause infection to resident and could affect the oxygen delivery to the resident. On 8/5/2026 at 10:04 AM, V3 (Infection Preventionist/IP) stated that the long and extended nasal oxygen tubing should not be laying on the floor and should be rolled up in a manner that is not touching the floor, to prevent cross infection and to maintain cleanliness of the nasal tube. On 8/5/2026 at 11:10 AM, V2 (Director of Nursing/DON), stated that oxygen tubing should not be touching the floor to avoid infection spreading and that the long extended nasal cannula tubing should be hanged on the back of the oxygen machine or contained in a way to ensure that the tubing would not be laying on or touching the floor. V2 said that it is important to keep the nasal cannula tubing off the floor to prevent cross contamination and infection spreading. R24's admission Record showed in part that R24's diagnoses include but is not limited to Hypertensive Chronic Kidney Disease, Pneumonia, Type 2 Diabetes Mellitus, Pulmonary Fibrosis, Depression, Anorexia, pain in right and left leg, Hyperkalemia, encounter for palliative care, Insomnia, drug induced subacute dyskinesia, Vitamin D deficiency, Schizophrenia, Hyperlipidemia, Glaucoma, essential primary hypertension, history of falling and Dementia. R24's Minimum Data Sets (MDS), (6/10/2026) in section C for Cognition Patterns showed in part the Brief Interview of Mental Status (BIMS) score of 13 which showed impaired cognition. MDS in section O for Special Treatments, Procedures, and Programs showed in part that R24 is receiving oxygen therapy while a resident and respiratory therapy. MDS section GG showed in part that R24 has upper extremity impairment on one side and impairment of both lower extremities, is dependent on toileting hygiene and shower/bath self, lower body dressing, transfers, needs substantial assistance for personal hygiene and is not ambulatory. R24's Care Plan (CP) (8/1/2026) showed in part focus that R24 is at risk for alteration in respiratory functioning related to Chronic Obstructive Pulmonary Disease (COPD), and Chronic Heart Failure (CHF) and interventions showed in part to administer oxygen and respiratory treatments as ordered. R24's Order Summary Report (8/4/2026) showed in part an Active order (8/2/2026) for change oxygen tubing/bubblers weekly and as needed every night shift every Sunday; Active order (8/2/2026) for Oxygen 2-3L/min via nasal cannula to maintain oxygen saturation level equal or above 92%. R225's admission Record showed in part that R225's diagnoses include but is not limited to Polyneuropathy, herpes viral infection, multiple myeloma, Sarcoidosis of lung, mixed hyperlipidemia, Depression, obstructive sleep apnea, essential hypertension, atherosclerotic heart disease of native coronary artery, chronic diastolic heart failure, lymphedema, chronic obstructive pulmonary disease, unspecified asthma, bilateral primary osteoarthritis of knee, radiculopathy lumbosacral region, Chronic Kidney Disease, morbid obesity, local infection of the skin, Acute kidney failure, cellulitis of left lower limb, personal history of transient ischemic attack (TIA) and cerebral infarction, Memory deficit, dysphagia and abnormalities of gait and mobility. R225's Minimum Data Sets (MDS), (8/4/2026) in section C for Cognition Patterns showed in part the Brief Interview of Mental Status (BIMS) score of 15 which showed intact cognition. MDS section GG for Functional abilities showed in part that R225 needs moderate assistance for toileting, shower/bathe self, lower body dressing and maximal assistance for putting on/taking off shoes. MDS section O for Special Treatments, Procedures and Programs showed in part that on admission and while a resident, R225 has oxygen continuous therapy. R225's Care Plan, (CP) (7/30/2026), showed in part focus that R225 has potential for infection and is on Enhanced Barrier Precautions (EBP). R225's CP showed in part focus that R225 is at risk for alteration in respirator functioning related to COPD, CHF, Asthma. R225's Order Summary Report (8/4/2026) showed in part Active Order, (7/31/2026), Active order for Oxygen via nasal cannula at 2l/min every 1 hour as needed. R227's admission Record showed in part that R227's diagnoses include but is not limited to Benign neoplasm of cerebral meninges, Depression, Essential primary hypertension, Alcoholic cirrhosis of liver without ascites, Tobacco use, Anemia, Persistent atrial fibrillation, Acute and chronic systolic congestive heart failure, Acute and chronic respiratory failure with hypoxia, Acute and chronic respiratory failure with hypercapnia , Chronic obstructive pulmonary disease with acute exacerbation , Unspecified abnormalities of gait and mobility and other lack of coordination. R227's Minimum Data Sets (MDS), (8/3/2026) in section C for Cognition Patterns showed in part the Brief Interview of Mental Status (BIMS) score of 14 which showed intact cognition. MDS in section O for Special Treatments, procedures and programs under respiratory treatments section, read in part that R227 has oxygen therapy while a resident and on admission and has continuous oxygen therapy. MDS section GG for Functional abilities showed in part that R227 needs maximal assistance for toileting hygiene and putting on and taking off shoes, and moderate assistance for shower bathe self. R227's Care Plan, (CP) (7/30/2026), showed in part focus that R227 is on O2 and at risk for alteration in respiratory functioning related to COPD exacerbation, Acute on chronic respiratory failure with hypoxia and Hypercapnia; focus that R227 has potential for infection related to new environment and assistance with care. R227's Order Summary Report (8/4/2026) showed in part Active Order, (7/29/2026), for Oxygen 2-3L/min via nasal cannula to maintain oxygen saturation level equal or above 90% every shift. Facility's Document titled Oxygen Storage , (7/7/2026) reads in part that the facility should store oxygen safely and properly. Facility's Document titled Oxygen Therapy and Administration, (7/7/2026) reads in part that the purpose is to ensure adequate oxygenation to all spontaneously breathing residents and in procedure section document read to date the equipment and that oxygen rounds should be completed weekly by registered nurse (RN) or licensed practical nurse (LPN) and include checking device's proper connection and oxygen setups should be changed every seven days or as needed. Facility's Document titled Infection Prevention and Control, (7/7/2026) reads in part that the facility established policy to identify, control and prevent infections in the facility and that standard precautions should be practiced at all times in all situations and for Enhanced Barrier Precautions, the facility's staff should follow EBP policy and comply with infection control recommendations provided by state health department. Facility's document titled Residents' Rights for People in Long-Term Care Facilities, (11/18) reads in part that long term care residents are guaranteed certain rights , protections and privileges according to state and federal laws and that the facility must provide care in a manner to promote residents quality of life and that the facility must be safe, clean and must provide services to keep resident's physical health at the highest practical levels. Facility's Document titled LPN Floor Nurse, (12/1/2019), reads in part that Licensed Practical Nurse (LPN) should provide superior customer service and nursing care for all residents and provides supervision of staff and safeguards the health, safety and welfare of all residents under the LPN care by following applicable laws, regulations, and established nursing policies and procedures. Some of the essential functions include but are not limited to administering and supervising all treatments prescribed by physicians, ensuring that established infection control and prevention practices and standard precautions are maintained at all times, following established safety precautions when performing tasks and using equipment and supplies, reporting all hazardous conditions, damaged equipment and supply issues to the supervisor. Facility's Document titled RN Floor Nurse, (12/1/2019), reads in part that Registered Nurse (RN) should provide superior customer service and nursing care for all residents and provides supervision of staff and safeguards the health, safety and welfare of all residents under the LPN care by following applicable laws, regulations, and established nursing policies and procedures. Some of the essential functions include but are not limited to administering and supervising all treatments prescribed by physicians, ensuring that established infection control and prevention practices and standard precautions are maintained at all times, following established safety precautions when performing tasks and using equipment and supplies, reporting all hazardous conditions, damaged equipment and supply issues to the supervisor. Facility's Document titled Infection Preventionist, (6/11/2022), reads in part that Infection Preventionist (IP), plays important role in surveillance , of infections and should always maintain an effective infection control program, and includes but is not limited to education of staff, development and implementation, enforcement of infection control policies and procedures. The IP should safeguard the health, safety and welfare of all residents by following applicable laws, regulations, and established nursing policies and procedures. Document read in part that some essential functions include but are not limited to identifying, controlling and preventing infections in the facility, overseeing the proper implementation of the facility's Respiratory protection program, ensuring facility's compliance with federal, state and local infection control standards and monitoring of nursing care and treatments and reporting all hazardous conditions, damaged equipment and supply issues to appropriate staff. Facility's Document titled Director of Nursing, (12/1/2019) reads in part that Director of Nursing (DON) is responsible for the overall operation of the Nursing department and ensures quality of care 24 hours a day. Document read in part that some essential functions include but are not limited to supervising activities of the nursing staff, ensuring that nursing department is in compliance with federal, state and local regulations, ensuring that established infection control and prevention practices and standard precautions are maintained at all times, and following established safety precautions when performing tasks and using equipment and supplies.

Based on observation, interview, and record review, the facility failed to ensure medications were stored and secured to prevent unauthorized access by leaving medications unattended at the bedside for two residents (R116 and R140). This failure has the potential to affect 47 residents residing on the fourth floor and all 49 residents residing on the fifth floor. Findings include: On 08/03/26 at 10:56am observed two white round pills on R140's bedside table. R140 stated that the two pills are Acetaminophen and R140 is saving the pills in case he has pain. R140 stated that he asked for the pills from the nurse on the previous night and was saving the pills just in case. On 08/03/26 at 11:04am V4 (Licensed Practical Nurse/LPN) stated that she had no idea what the pills were on R140's table. V4 stated that nurses should not leave medication at the bedside and should watch the residents take their medication to ensure they take it. On 08/05/26 at 1:46pm V2 (Director of Nursing/DON) stated that medications should not be left at the bedside of residents. V2 stated that the nurse should stay with the resident and make sure the resident swallows the medication. V2 stated that other resident could pick up the medication if it is left at a resident's bedside. On 8/3/26 at 10:50 am, during a tour of the fourth-floor unit, Surveyor observed R116 in bed with a medication cup containing five medications on R116's bedside table with no licensed nurse present in the room at the time of the observation, and the medications left unattended. At 10:54 am surveyor observed V16 (Housekeeper) pick the medication cup containing five medications on R116's bedside table, wipe R116's bedside table, place the medication cup containing five medications back don on R116's bedside table and exit R116's room. On 08/3/26 at 11:00 am, Surveyor brought this observation to V15 (Licensed Practical Nurse, LPN) and V15 stated, Oh I should have waited until he took them (referring to medication cup containing five medications on R116's bedside table). Anyone can take them and have an adverse reaction to the medication. On 08/4/26 at 3:05 pm, V2 (Director of Nursing, DON) stated that a nurse should ensure that a resident takes their medication to ensure the medication has been administered. V2 stated that if a nurse leaves medication at the bedside without ensuring the resident has taken the medication, anyone is subject to being able to obtain and take the medication. R116's face sheet shows that R116 has diagnoses which include but not limited to unspecified dementia, Parkinson's disease, depression, stiffness of left shoulder and stiffness of the right shoulder. R116's Brief Interview for Mental Status (BIMS) dated 5/13/26 shows a score of 15 which indicates that R116 is cognitively intact. The facility's policy dated 7/7/26 and titled Medication Storage, Labeling and Disposal documents in part: Policy Statement: It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. Procedure: 3. Medications will be stored safely under appropriate environmental controls. 4. Medications will be secured in locked storage area. Facility Census Report, dated 8/3/26, documents, in part, that 47 residents are residing on the fourth floor and 49 residents are residing on the fifth floor.

Based on observation, interview and record review, the facility failed to contain and date respiratory equipment (nebulizer masks, continuous positive airway pressure (CPAP) mask and nasal cannula) per facility's policy. This failure affected seven resident (R3, R7, R8, R24, R61, R100 and R229) reviewed for oxygen equipment, in a total sample size of 72 residents. Findings include: R3's admission Record documents medical diagnoses which include but are not limited to dementia, chronic kidney disease, type 2 diabetes, essential hypertension, schizoaffective disorder. R61's admission Record documents medical diagnoses which include but are not limited to chronic diastolic heart failure, atrial fibrillation, acute respiratory failure with hypoxia, asthma. On 08/03/26 at 11:42am observed R61's humidifier bottle with no date. On 08/03/26 at 11:44am V39 (Registered Nurse/RN) stated that R61's humidifier bottle does not have a date on it, but it should have a date on it. On 08/03/26 at 11:49am, observed nebulizer face mask on top of R3's dresser, not dated or contained in a bag. On 08/03/26 at 11:56am V39 (Registered Nurse/RN) stated that R3's nebulizer face mask is not contained in a bag. V39 stated that R3's face mask should be contained in a bag to minimize the risk of infection. V39 stated that R3's nebulizer face mask does not have a date on it and is only good for a week. On 08/05/26 at 1:46pm V2 (Director of Nursing/DON) stated that nebulizer face mask and humidifier bottles are changed weekly. V2 stated that nebulizer face mask and humidifier bottles should be dated and changed weekly and prn (as needed). On 8/3/2026 at 11:44 AM, observed in R24's room, R24's oxygen nasal cannula tubing not being labeled or dated. Observed R24's continuous positive airway pressure (CPAP) mask laying on top of R24's dresser, not contained. R24 was observed to be sleeping and wearing nasal cannula. On 8/4/2026 at 10:38 AM, V24 (Certified Nursing Assistant/CNA) stated that oxygen care and maintenance is nurses' responsibility, but the nasal cannula tubing should be labeled with a date changed. On 8/4/2026 at 10:45 AM, V21 (Registered Nurse/RN) stated that oxygen tubing should be changed every Sunday night and as needed, and the tubing should be labeled and dated. V21 said that CPAP mask when not in use should be contained in a plastic bag and should not be laying on top of dresser. V21 said that containment of oxygen tubing and CPAP mask is important because of infection control. On 8/4/2026 at 10:51 AM, V22 (Licensed Practical Nurse/LPN) said that oxygen tubing and water bubblers should be labeled and dated. V22 said that CPAP mask should be not touching any surfaces and should be contained in a plastic bag when not in use. On 8/4/2026 at 10:58 AM, V27 (Assistant of Director of Nursing/ADON/RN) stated that oxygen tubing should get changed once a week and is the nurse's responsibility and proper maintenance is important. V27 said that the oxygen tubing and canister should both be labeled and dated every 7 days and that CPAP mask should be stored contained inside of plastic bag. V27 said that oxygen tubing or CPAP masks should not be laying on the top of the dresser uncontained. V27 said that if tubing is not contained properly or changed every week, mold can form, and cause issues for resident by effecting delivery of oxygen to the resident or causing infection. V27 said that Nasal cannula should be labeled with a piece of tape and dated with a black marker. V27 stated that the marked date should be clearly visible and readable for everyone. On 8/5/2026 at 10:04 AM, V3 (Infection Preventionist/IP) stated that the oxygen tubing and masks should be stored in plastic bags, and that tubing should be labeled and dated every week. V3 said that CPAP masks should be stored in plastic bag and dated, and mask should be changed with the tubing. V3 stated that the staff should label tubing with piece of tape, and it should be labeled close to the machine. V3 said that date should be marked with sharpie and should be visible and readable, and bubblers and canisters should be dated and marked visibly and legibly. On 8/5/2026 at 11:10 AM, V2 (Director of Nursing/DON), stated that oxygen tubing should be changed weekly, should be labeled and dated. V2 said that when oxygen tubing or mask is not in use, the equipment should be contained in the plastic bag. V2 said that labeling of oxygen equipment should be done with marker and labeled with the date the oxygen equipment was changed. V2 said that the marked date should be readable, and the tubing and bubblers should be labeled separately. V2 said that if the nasal cannula tubing is not labeled or date is not readable, the staff should change the tubing with new one. R24's admission Record showed in part that R24's diagnoses include but is not limited to Hypertensive chronic kidney disease, Pneumonia, Type 2 diabetes mellitus, Pulmonary fibrosis, Depression, Anorexia, Pain in right and left leg, Hyperkalemia, Encounter for palliative care, Insomnia, Drug induced subacute dyskinesia, Vitamin D deficiency, Schizophrenia, Hyperlipidemia, Glaucoma, Essential primary hypertension, History of falling and Dementia. R24's Minimum Data Sets (MDS), (6/10/2026) in section C for Cognition Patterns showed in part the Brief Interview of Mental Status (BIMS) score of 13 which showed impaired cognition. MDS in section O for Special Treatments, Procedures, and Programs showed in part that R24 is receiving oxygen therapy while a resident and respiratory therapy. MDS section GG showed in part that R24 has upper extremity impairment on one side and impairment of both lower extremities, is dependent on toileting hygiene and shower/bath self, lower body dressing, transfers, needs substantial assistance for personal hygiene and is not ambulatory. R24's Care Plan (CP) (8/1/2026) showed in part focus that R24 is at risk for alteration in respiratory functioning related to Chronic Obstructive Pulmonary Disease (COPD), and Chronic Heart Failure (CHF) and interventions showed in part to administer oxygen and respiratory treatments as ordered. R24's Order Summary Report (8/4/2026) showed in part an Active order (8/2/2026) for change oxygen tubing/bubblers weekly and as needed every night shift every Sunday; Active order (8/2/2026) for Oxygen 2-3L/min via nasal cannula to maintain oxygen saturation level equal or above 92%. Facility's Document titled Oxygen Storage , (7/7/2026) reads in part that the facility should store oxygen safely and properly. Facility's Document titled Oxygen Therapy and Administration, (7/7/2026) read in part that the purpose is to ensure adequate oxygenation to all spontaneously breathing residents and in procedure section document read to date the equipment and that oxygen rounds should be completed weekly by registered nurse (RN) or licensed practical nurse (LPN) and include checking device's proper connection and oxygen setups should be changed every seven days or as needed. Facility's Document titled Infection Prevention and Control, (7/7/2026) reads in part that the facility established policy to identify, control and prevent infections in the facility and that standard precautions should be practiced at all times in all situations and for Enhanced Barrier Precautions, the facility's staff should follow EBP policy and comply with infection control recommendations provided by state health department. In section 23 of the policy, document read that resident's personal items should be labeled. Facility's document titled Residents' Rights for People in Long-Term Care Facilities, (11/18) reads in part that long term care residents are guaranteed certain rights, protections and privileges according to state and federal laws and that the facility must provide care in a manner to promote residents quality of life and that the facility must be safe, clean and must provide services to keep resident's physical health at the highest practical levels. Facility's Document titled LPN Floor Nurse, (12/1/2019), reads in part that Licensed Practical Nurse (LPN) should provide superior customer service and nursing care for all residents and provides supervision of staff and safeguards the health, safety and welfare of all residents under the LPN care by following applicable laws, regulations, and established nursing policies and procedures. Some of the essential functions include but are not limited to administering and supervising all treatments prescribed by physicians, ensuring that established infection control and prevention practices and standard precautions are maintained at all times, following established safety precautions when performing tasks and using equipment and supplies, reporting all hazardous conditions, damaged equipment and supply issues to the supervisor. Facility's Document titled RN Floor Nurse, (12/1/2019), reads in part that Registered Nurse (RN) should provide superior customer service and nursing care for all residents and provides supervision of staff and safeguards the health, safety and welfare of all residents under the LPN care by following applicable laws, regulations, and established nursing policies and procedures. Some of the essential functions include but are not limited to administering and supervising all treatments prescribed by physicians, ensuring that established infection control and prevention practices and standard precautions are maintained at all times, following established safety precautions when performing tasks and using equipment and supplies, reporting all hazardous conditions, damaged equipment and supply issues to the supervisor. Facility's Document titled Infection Preventionist, (6/11/2022), reads in part that Infection Preventionist (IP), plays important role in surveillance, of infections and should always maintain an effective infection control program, and includes but is not limited to education of staff, development and implementation, enforcement of infection control policies and procedures. The IP should safeguard the health, safety and welfare of all residents by following applicable laws, regulations, and established nursing policies and procedures. Document read in part that some essential functions include but are not limited to identifying, controlling and preventing infections in the facility, overseeing the proper implementation of the facility's Respiratory protection program, ensuring facility's compliance with federal, state and local infection control standards and monitoring of nursing care and treatments and reporting all hazardous conditions, damaged equipment and supply issues to appropriate staff. Facility's Document titled Director of Nursing, (12/1/2019) reads in part that Director of Nursing (DON) is responsible for the overall operation of the Nursing department and ensures quality of care 24 hours a day. Document read in part that some essential functions include but are not limited to supervising activities of the nursing staff, ensuring that nursing department is in compliance with federal, state and local regulations, ensuring that established infection control and prevention practices and standard precautions are maintained at all times, and following established safety precautions when performing tasks and using equipment and supplies. R7's admission Record documents diagnoses which include, but are not limited to, gout, depression, anemia, hypothyroidism, anxiety disorder, autistic disorder, epilepsy, insomnia, obstructive sleep apnea, hypertension, and asthma. R7's Minimum Data Set (MDS) Section C, dated 7/11/26, shows cognitive skills for daily decision-making score of 3. R7 is severely cognitively impaired. On 8/3/26 at 12:04 p.m., the surveyor observed R7 seated in bed. The resident's Continuous Positive Airway pressure (CPAP) mask was not contained and was lying on the nightstand. R229's admission Record documents diagnoses which include, but are not limited to, hemiplegia and hemiparesis, syncope, aphasia, pulmonary hypertension, chronic obstructive pulmonary disease, respiratory failure, chronic kidney disease, hypertension, and cerebral infarction. R229's MDS Section C, dated 8/5/26, shows a Brief Interview for Mental Status (BIMS) score of 13. R229 is cognitively intact. On 8/3/26 at 11:35 a.m., the surveyor observed R229 lying in bed, awake and alert. R229 was receiving 4 liters of oxygen via nasal cannula. The tubing was undated, and the writing on the humidifier bottle was unreadable. R229 stated that the oxygen had been started three days prior upon admission. On 8/3/26 at 11:43 a.m., the surveyor observed R229's room alongside V22 Licensed Practical Nurse (LPN). V22 stated that the oxygen tubing was not labeled and that the writing on the humidifier bottle was unreadable. V22 stated that both should have been labeled with the date when oxygen was initiated. V22 added that oxygen tubing and humidifier bottles are typically changed weekly on Sunday nights and as needed. V22 stated that this practice is for infection control. On 8/4/26 at 11:00 a.m., V27 Assistant Director of Nursing (ADON) stated that oxygen tubing and humidifier bottles should be labeled and changed once a week, usually by the Sunday night nurse. V27 stated that when not in use, oxygen tubing and CPAP masks should be contained in a plastic bag. V27 stated that dating equipment alerts staff when to change it, adding that failure to change equipment weekly makes it prone to infection, mold, and clogs, which can obstruct oxygen flow and cause harm to residents. V27 stated that labels must be legible and placed in visible areas. On 8/5/26 at 10:04 a.m., V3 Infection Preventionist (IP) stated that CPAP masks should be cleaned and contained in a plastic bag after each use. V3 stated that nasal cannulas should be labeled with a piece of tape near the concentrator and that humidifier bottles should also be labeled clearly and legibly. V3 stated that oxygen tubing and humidifier bottles must be changed weekly every Sunday and as needed to prevent cross-infection and maintain cleanliness. On 8/5/26 at 11:11 a.m., V2 Director of Nursing (DON) stated that oxygen tubing and humidifiers should be labeled separately with the date of placement, and CPAP masks should be contained in a plastic bag when not in use. V2 stated that both tubing and humidifiers must be changed weekly and as needed; if no date is visible, staff should immediately replace and label the equipment to prevent cross-contamination and support infection control. R7's care plan dated 7/1/26 in part; R7 is at risk for alteration in respiratory functioning related to Obstructive Sleep Apnea. Intervention: CPAP as ordered. R229's Physician order dated 8/4/26 in part; Oxygen at 2-4 liters per minute via nasal Cannula. Notify MD for oxygen saturation below 92%. R229's Care plan dated 8/5/26 in part: R229 is at risk for alteration in respiratory functioning related to Small Airway disease and Chronic Hypoxic Respiratory Failure. Intervention: administer oxygen, other medications and respiratory treatment as ordered. The facility's policy with a revision date of 07/07/2026 titled Oxygen therapy and administration in part; Procedure: use a humidifier for all patients requiring nasal cannula. Date all equipment. Oxygen setups should be changed every seven days and as needed if heavy soiling is present. R100's admission record documents diagnoses which include but are not limited to COPD (Chronic Obstructive Pulmonary Disease), Hypertension, Cerebral Infarction, Cardiovascular Disease and Dependence on supplemental oxygen. R100's Minimal Data Set (MDS) dated (7/23/26) document in part, Section C. Brief Interview of Mental Status (BIMS) score is blank. R100 is severely impaired with decisions regarding task of daily living. On 8/3/26 at 11:10 am, R100's nasal cannula tubing was observed lying over the oxygen machine contained and not dated. On 8/5/26 at 9:51 am, V19 LPN (License Practical Nurse) stated that the oxygen tubing should be changed once a week. It should be dated with the date it was changed and contained to prevent cross contamination and prevent things from getting in the nose. On 8/6/26 at 12:24 pm, V2 DON (Director of Nursing) stated that oxygen tubing changes are weekly every Sunday night, and it should be dated when changed. If the oxygen tubing is not in use, the nasal cannula should be inside of a plastic bag with the date that it was changed. R8 face sheet shows that R8 has diagnoses which include but not limited to chronic obstructive pulmonary disease, dependence on supplemental oxygen, sleep apnea, chronic respiratory failure with hypoxia, and shortness of breath. R8 Brief Interview for Mental Status (BIMS) dated 5/13/26 shows a score of 15 which indicates that R8 is cognitively intact. R8 Physician Order Sheet (POS) shows active order dated 08/03/26 shows that R8 has orders for Oxygen 3 L/min (liters/minute) via nasal cannula to maintain Oxygen Saturation level equal or above 92%. On 08/03/26 at 10:40 am, R8 was observed in bed awake and alert. R8 stated that he does not recall the last time R8's nebulizer mask was used or changed by the facility. On 08/03/26 at 11:00 am, this observation was brought to V14 (Licensed Practical Nurse, LPN) and V14 stated that nebulizer mask should be contained when not in use to keep the nebulizer mask clean and prevent infection. On 08/04/25 at 3:00 pm, V2 (Director of Nursing DON) stated that nebulizer mask is scheduled to be changed on the night shift every Sunday at the facility to prevent the residents from an infection. V2 explained if the nebulizer mask is not changed timely, it can increase the risk of a resident getting an infection. R8's Physician Order Sheet (POS) shows that R8 has orders for ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/ 3ml (milligrams/milliliters) 3 ml inhale orally via nebulizer every 4 hours as needed for SOB (shortness of breath)/ wheezing hold when HR (heart rate) is greater than 100. The facility's policy dated 07/08/26 and titled Respiratory Therapy Equipment Use documents, in part: Policy Statement: It is the facility's policy to ensure that oxygen and nebulizer equipment use is compliant with the acceptable standards of practice. Procedure: 2. Once opened, this equipment will be dated and discarded after 7 days of use, whether used continuously or on a prn (as needed) basis. The facility policy dated 7/7/26 and titled Oxygen Therapy and Administration documents in part: Oxygen therapy shall be administered to patients as indicated and upon a physician's order. Purpose: to assure adequate oxygenation to all spontaneously breathing and ventilator dependent patients . Noted: Oxygen rounds will be completed by RCP (Respiratory Care Practitioner) for the vent unit. Rounds will be completed by RN (Registered Nurse)/ LPN (Licensed Practical Nurse) for all other floors. C. Oxygen setups should be changed every seven days and as needed if heavy soiled is present.

Based on observations, interviews and record reviews, the facility failed to maintain the activities of daily living (ADL) care of grooming, personal hygiene and incontinence care for four residents (R17, R51, R78 and R140). This failure affects four residents (R17, R51, R78 and R140) reviewed for ADL care in a total sample size of 72.Findings include:R17's admission Record documents medical diagnoses which include but are not limited to chronic kidney disease, chronic obstructive pulmonary disease, type 2 diabetes, essential hypertension, major depressive disorder.R17's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R17's cognition is intact.R17's MDS dated [DATE] section GG for Functional Abilities dated 07/02/26 documents in part, Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving. 2. Substantial/maximal assistance. Helper does More Than Half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.R51's admission Record documents medical diagnoses which include but are not limited to cerebral infarction, anxiety disorder, depression, essential hypertension, heart failure.R51's MDS section C for Cognitive Patterns dated 07/02/26 BIMS score of 13, indicating R51's cognition is intact.R51's MDS section GG for Functional Abilities dated07/02/26 documents in part, Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving. 2 Substantial /maximal assistance. Helper does More Than Half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.R51's care plan dated 07/27/26 documents in part, (R51) is diagnosed of but not limited to sequela cerebral infarction. (R51) needs staff assistance to complete ADL (Activities of Daily Living) task r/t (related to) cognitive impairment, confusion, left sided weakness, poor balance, immobility and decrease activity endurance. Transfer: (R51) requires mechanical lift with 2 or more total assistance with transfers.R78's admission Record documents medical diagnoses which include but are not limited to hemiplegia dn hemiparesis following cerebral infarction affecting left dominant side, hypertensive heart disease with heart failure, depression, aphasia.R78's MDS dated [DATE] has a Staff Assessment for Mental score of 1. Memory Problem.R140's admission Record documents medical diagnoses which include but are not limited to chronic obstructive pulmonary disease, depression, anxiety disorder, essential hypertension, heart failure.R140's MDS dated [DATE] has a BIMS score of 14, indicating R140's cognition is intact.R140's MDS section GG for Functional Abilities dated 05/06/26 documents in part, Toileting hygiene: The ability to maintain perineal hygiene. 1. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.On 08/03/26 at 10:56am R140 observed lying in bed soaked with urine with dry brown urine stain on R140's top sheet and bed pad. R140 stated that he had not been cleaned since the previous night. R140 stated that the staff periodically check on him and it is usual for staff to come to clean him close to lunch time.On 08/03/26 at 11:04am V4 (Licensed Practical Nurse/LPN) stated that R140 is lying in a bed with a dry ring of urine that appears to have been there for a while. V4 stated that R140 refuses care sometimes and if R4 refuses care then it should be documented in R140's chart.R140's progress note dated 08/03/26 documented by V4 (LPN) documents in part, Resident noted this am to be wet with what appears to be urine (also noted to have dried on resident as well). Resident is also preferred to be wet do to his preference at that given time. Resident is educated on the importance of keeping his skin dry to prevent break down. He then allowed CNA to clean him up at this time.On 08/05/26 at 11:07am V4 (LPN) stated that on 0803/26 when R140 was observed wet, R140 did not refuse care. V4 stated that R140 sometimes refuses care but did not refuse care at the time that R140 was found soiled and R140 has not refused care in over a week.On 08/03/26 at 11:37am R51 observed with full unkept facial hair. R51 stated that he would like to be shaved. R51 stated that he does not like his beard.On 08/04/26 ay 10:04am R17 observed with full unkept facial hair. R17 stated that he would like to be shaved. R17 stated that he thought that staff should come around and ask if he wants to be shaved.On 08/04/26 at 10:25am V4 (LPN) stated that R17 is not shaved. V4 stated that she does not know if R17 asked to be shaved. V4 stated that the facility had a beautician that came to cut the resident's hair and shave the residents. V4 stated that the beautician has not been to the facility in a couple of months. V4 stated that the staff should shave the residents since the beautician has not been to the facility.On 08/05/26 at 11:38am surveyor entered R78's room with V4 (LPN). R78's mouth examined with V4 (LPN) and R78 observed with fuzzy yellowish colored tartar on teeth and gumline. V4 (LPN) stated that R78's teeth does not appear to have been brushed but should have been brushed by now. V4 stated that an order is not needed for staff to brush resident's teeth and mouth care is part of daily hygiene.On 08/05/26 at 11:52am V7 (CNA) stated that she had not done mouth care on R78. V7 stated that R78's mouth care should have been done in the morning by the night shift.R78's MDS section GG for Functional Abilities dated 06/09/26 documents in part, Oral hygiene: The ability to use suitable items to clean teeth. 5. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.Facility's policy titled General Care revised 07/07/26 documents in part, Policy Statement: It is the facility's policy to provide care for every resident to meet their need. Procedures: 1. Upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs. Physical needs would include, but are not limited to ADL, wound care, medical needs. 2. The facility will assist the resident to meet these needs.Facility's job description titled Certified Nursing Assistant updated 05/20/2022 documents in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Certified Nursing Assistant (CNA) plays a critical role in providing superior customer service and nursing care to all Guests. Essential Functions: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Provides quality nursing care to Guests in an environment that promotes their rights, dignity and freedom of choice. 2. Provides individualized attention, which encourages each Guest's ability t maintain or attain the highest practical physical, mental and psychosocial well-being.

Based on observation, interview and record review, the facility failed to ensure residents' (R6, R15) indwelling catheter drainage bags were covered and failed to give residents (R43, R51) the opportunity to out of bed. These failures affected four residents (R6, R15, R43 and R51) reviewed for dignity in the sample of 72 residents. Findings include: R43's medical diagnoses include but are not limited to hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, essential hypertension, type 2 diabetes, depression. R43's Minimum Data Set (MDS) section C for Cognitive Patterns dated 06/22/26 has a Brief Interview for Mental Status score of 5, indicating R43's cognition is severely impaired. R43's MDS section GG for Functional Abilities dated 06/22/26 documents in part, E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (wheelchair), 2. Substantial/maximal assistance – Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. On 08/03/26 at 12:32pm surveyor observed R43 lying in bed with a hospital gown on. On 08/03/26 at 12:32pm R43 stated that she would like to get out of bed sometimes. R43 stated that the facility does not get her out of bed. R43 stated that she is stuck in bed everyday all day. R43's care plan dated 06/29/26 documents in part, (R43) has extensive care needs and requires the support/services of the LTC (Long Term Care) setting. The stay is presently identified as Long-Term. Resident's care need will be provided during stay at the facility through next review date. The facility will provide care to enable the resident to function at their most practical level and support (R43's) adjustment towards residence is a homelike environment. R43's care plan dated 06/29/26 documents in part, (R43) has residual left sided weakness related to stroke. (R43) will remain free of complications or discomfort related to left sided weakness related to stroke through next review. Assist R43 with ADL's (Activities of Daily Living/mobility as needed. R51's medical diagnoses include but are not limited to cerebral infarction, anxiety disorder, depression, essential hypertension, heart failure. R51's MDS section C for Cognitive Patterns dated 07/02/26 BIMS score of 13, indicating R51's cognition is intact. R51's MDS section GG for Functional Abilities dated07/02/26 documents in part, E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (wheelchair), 1. Dependent: Helper does All of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. R51's care plan dated 07/27/26 documents in part, (R51) is diagnosed of but not limited to sequela cerebral infarction. (R51) needs staff assistance to complete ADL (Activities of Daily Living) task r/t (related to) cognitive impairment, confusion, left sided weakness, poor balance, immobility and decrease activity endurance. Transfer: (R51) requires mechanical lift with 2 or more total assistance with transfers. On 08/03/26 at 11:37am R51 observed lying in bed in a hospital gown. R51 stated that he would like to get out of bed. R51 stated that he has only been offered to get out of bed once since R51 has been in the facility. On 08/05/26 at 10:27am V44 (Restorative Director) provided surveyor with a 5th floor Get Up List. Facility's 5th floor Get Up List has a total of 10 residents listed for Get Up with 6 of the 10 residents scheduled for Monday, Wednesday, Friday schedule for Get Up. On 08/05/26 at 10:27am V44 (Restorative Director) stated that all residents should be able to get up and staff should be offering them to get up daily. R44 stated that the 5th floor Get Up list is a list of residents that get up that require mechanical lift transfer assistance. V44 stated that she is unaware if R43 gets up or not. V44 stated that it is not the responsibility of the restorative department to get the residents up out of bed, it is the responsibility of the CNA's (Certified Nursing Assistants) to get the residents up as part of the resident's daily routine. V44 stated that there is not a reason why R51 cannot get out of bed. On 08/05/26 at 10:45am surveyor observed two staff members placing R43 in wheelchair via mechanical lift. On 08/05/26 at 10:50am observed Certified Nursing Assistant (CNA) observed putting R51 on clothes. V45 (CNA) stated that she was just told to hurry up and get R51 dressed and up to the chair. On 8/05/26 at 11:00am R43 stated that staff just came in her room and told her that they were getting her out of the bed. R43 stated that the facility thinks that it is a game and that they are fooling the surveyors by getting R43 up to the chair. R43 stated that it felt good to get out of the bed to the chair. On 08/05/26 at 11:10am R201 (R43's roommate) stated that it is not normal for the staff to get up R43. R201 stated that staff had just rushed in to get R43 out of the bed because surveyors were in the building. On 08/05/26 at 1:46pm V2 (Director of Nursing/DON) stated that she is not sure why the residents are not getting out of the bed. V2 stated that residents that want to get out of the bed should be getting out of the bed. V2 stated that she has in-serviced the staff multiple times about getting residents up and out of bed. V2 stated that the Get Up list has residents that require mechanical lift transfers. Facility's policy titled General Care revised 07/07/26 documents in part, Policy Statement: It is the facility's policy to provide care for every resident to meet their need. Procedures: 1. Upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs. Physical needs would include, but are not limited to ADL, wound care, medical needs. 2. The facility will assist the resident to meet these needs. Facility's job description titled Certified Nursing Assistant updated 05/20/2022 documents in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Certified Nursing Assistant (CNA) plays a critical role in providing superior customer service and nursing care to all Guests. Essential Functions: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Provides quality nursing care to Guests in an environment that promotes their rights, dignity and freedom of choice. 2. Provides individualized attention, which encourages each Guest's ability t maintain or attain the highest practical physical, mental and psychosocial well-being. On 08/03/26 at 10:53 am, R6 was observed in bed with indwelling catheter bag hanging on the bottom of R6's bed, visible to the doorway and not covered in a privacy bag. R6 stated that R6 has been at the facility for several weeks and has never had a privacy bag for R6's indwelling catheter. On 08/03/25 at 11:09 am, this observation was brought to V15 (Licensed Practical Nurse, LPN) and V15 stated, I don't know if we have anymore. It should be in a bag for HIPPA (Health Insurance Portability and Accountability Act) privacy. On 08/04/26 at 3:10 pm, V2 (Director of Nursing, DON) stated that residents with indwelling catheters should have an indwelling catheter privacy bag for the indwelling catheter to maintain the resident's privacy and dignity. V2 explained that the facility does have indwelling catheter privacy bags and that she would obtain one for R15. R6's face sheet shows that R6 has a diagnosis which includes but not limited to bladder disorder, gross hematuria, other retention of urine, and acute kidney failure. R6 Brief Interview for Mental Status (BIMS) dated 7/9/26 shows a score of 12 which indicates that R6 has some cognitive impairments. R6's physician order sheet (POS) shows active orders dated 7/29/26 shows that R6 has orders for indwelling catheter 18Fr (French) 10cc (cubic centimeter) balloon size Dx (diagnosis) Obstructive Uropathy. The facility policy dated 7/8/26 and titled Dignity documents in part: Privacy and Dignity: Policy statement: It is the facility policy to ensure that resident's privacy and dignity is respected by the staff at all times.: Procedures: 4. Urine bags will be covered with the use of privacy bags. The facility's undated policy and titled Resident Rights for People in Long-Term Care Facilities documents, in part: Your right to dignity and respect: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. R15's admission record includes but is not limited to dementia, urinary infection, urinary retention, hypertension, altered mental status, and anemia. R15's Minimal Data Set (MDS) dated (6/26/26) document in part, Section C. Brief Interview of Mental Status (BIMS) score is 3, which indicates that R15 is severely impaired. Section H. Appliances: A. Indwelling catheter. Yes. On 8/3/26 at 10:22 am, R15's Indwelling catheter was observed hanging from the bed frame on the right side of the bed on the floor not in a privacy bag. On 8/5/26 at 9:46 am, V18 CNA (Certified Nursing Assistant) stated that the Indwelling catheter should be in a privacy bag for the privacy of the resident and not on the floor because of contamination. On 8/5/26 at 12:24 pm, V2 DON (Director of Nursing) stated that all Indwelling catheters should be below the bladder and should not be touching the floor in a privacy bag. It should be in a privacy bag to provide privacy and dignity for the residents. R15's Order Summary Report active orders as of 8/4/26, documents in part, Indwelling Catheter FR (French)#16 10cc (cubic centimeter) balloon, Reason for use: Acute urinary retention. R15 care plan (6/30/26) documents in part, Focus: R15 has Indwelling Catheter r/t acute urinary retention. Resident was trialed off the indwelling catheter in the hospital but unable to void.

Based on observations, interviews and record review the facility failed to ensure the one resident at risk for skin breakdown (R152) had a properly set LALM (Low Air Low Mattress). This failure has affected one (R152) of three residents (R9, R16, R152) reviewed for skin integrity in a total sample of 72.Findings include:R152's admission Record documents R152 is an [AGE] year old with diagnoses including but not limited to: polyneuropathy, spinal stenosis, unspecified severe protein-calorie malnutrition and disorder of bone.R152's BIMS (Brief Interview of Mental Status) dated 5/4/26 documents a score of 15, which indicates cognitively intact.On 8/5/26 at 10:38 am, Surveyor and V47 (Wound Care Coordinator) entered R152's room to inspect her (R152's) LALM (Low air low mattress).At that time, the dial on R152's LALM motor was set at 300 Lbs. (pounds), and the Low Air pressure light was illuminated on the mattress meter. On 8/5/26 at 10:39 am, R152 stated the following, Sometimes the air is too low on my mattress, and I can feel the springs in it. I don't know how long the low-pressure light has been on.On 8/5/26 at 10:40 am, V47 stated the following, The mattress setting should be at the patient's weight. If it's not set at the patient's weight, it could impair the pressure mechanism. I will need to call maintenance now because it (LALM) has low pressure.On 8/5/26 at 11:32 am, V2 (DON/ Director of Nursing) stated the following, The purpose of a low air loss mattress is for maintenance and prevention of skin breakdown for patients with limited mobility and alterations in skin integrity. The mattress setting is based on the patient's weight. If the patient's weight is 156, a weight setting of 300 is too high. If the setting is too high or too low, the effectiveness of the air mattress could be altered. It could potentially result in skin breakdown. Wound care manages the settings of the air mattresses.R152's Care Plan dated 4/16/25 documents the following: R152 has actual impairment to skin integrity and potential development of skin impairment related to Braden scale score of 10; Implement Low air loss mattress to prevent skin breakdown.R152's Section M/Skin Conditions assessment dated [DATE] documents, R152 is at risk for developing pressure injuries. R152's Braden Scale assessment dated [DATE] documents: a problem with friction and shear; and high risk for skin breakdown.R152's last recorded weight on 7/6/26 was 156.5 Lbs. (pounds).Facility policy dated 7/30/26 documents, the facility will adhere to guidelines governing the use of Low Air Loss systems in accordance with the NPIAP (National Pressure Injury Advisory Panel) standards and manufacturer's specifications to prevent and treat pressure wounds, manage skin moisture and help regulate body temperature; enter resident's weight accordingly if the Low Air Loss Mattress has a weight specification button.

Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were two medication errors out of 27 medication opportunities, resulting in 7.41% percent medication error rate. This failure affected two residents (R45 and R191) in the sample of 72 residents reviewed for medication administration.Findings include: On 08/4/26 at 9:14 am, V5 (Licensed Practical Nurse, LPN) was observed at the 6th floor south medication cart preparing 9:00 am, medications for R191. Surveyor did not observe V5 prepare and administer folic acid 1 mg (milligram). Upon this surveyor reconciling of R191's medications as to what medications were ordered for administration and what medications were observed as administered and documented by V5 the following medication errors were identified: 1. Medication Omission: No folic acid 1 mg (milligrams) tablet by mouth one time a day for supplement was not administered during this observation. R191's Medication Administration Audit Report (MAAR) documents that at 9:15 am folic acid 1 mg (milligrams) tablet by mouth one time a day for supplement was administered. R191'S POS (Physician Order Sheet) dated 08/5/26, documents folic acid 1 mg (milligrams) tablet by mouth one time a day for supplement was. R191's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R191 is cognitively intact. R191's face sheet shows that R45 has diagnosis which include but are not limited to iron deficiency, nutritional anemia, hyperlipidemia, atherosclerosis of native arteries of extremities with rest pain, and moderate protein-calorie malnutrition. On 08/05/26 at 10:55 am, V2 (Director of Nursing, DON) was interviewed regarding Iron 27 mg medication and stated that Iron 27 mg medication is different from Ferrous sulfate 325 mg medication and should not be substituted without a physicians order. V2 also explained if a nurse does not administer what is ordered by the physician the nurse is not following the physicians orders and an interaction with residents can occur. On 08/4/26 at 9:16 am, V5 (Licensed Practical Nurse, LPN) was observed at the 6th floor south medication cart preparing 9:00 am, medications for R45. Surveyor observed V5 prepare and administer Iron 27 mg (milligrams) for R45. Upon this surveyor reconciling of R45's medications as to what medications were ordered for administration and what medications were observed as administered and documented by V5 the following medication errors were identified: 1. Medication Administration: Iron 27 mg one tablet by mouth. R45's Medication Administration Audit Report (MAAR) documents that ferrous sulfate tablet 325 (65 fe (iron)) mg give 1 tablet by mouth two times a day for supplementation. R45'S POS (Physician Order Sheet) dated 08/5/26, documents Ferrous Sulfate Tablet 325 (65 Fe) mg give 1 tablet by mouth two times a day for supplementation. R45's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R45 is cognitively intact. R45's face sheet shows that R45 has diagnosis which include but are not limited to anemia, and vitamin D deficiency. On 08/05/26 at 10:55 am, V2 (Director of Nursing, DON) was interviewed regarding Iron 27 mg medication and stated that Iron 27 mg medication is different from Ferrous sulfate 325 mg medication and should not be substituted without a physicians order. V2 also explained if a nurse does not administer what is ordered by the physician the nurse is not following the physicians orders and an interaction with residents can occur. The facility's document dated 07/7/2026 and titled Medication Pass documents, in part: Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. The facility's document dated 12/01/2019 and titled LPN Floor Nurse documents, in part: Summary/Objectives in keeping with our organization's goal of improving the lives of the guest we serve, the Licensed Practical Nurse (L.P.N.) plays a critical role in providing superior customer service and nursing care to all guests. The L.P.N. provides supervision of staff and will safely guard the health, safety, and welfare of all guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: 5. Administer medications within the scope of practice of the L.P.N.

Based on observation, interview, and record review the facility failed to maintain a safe environment (hazardous chemicals at the bedside) for one resident (R19). This failure has the potential to affect all 47 residents residing on the fourth floor unit at the facility.Findings include: On 8/3/26 at 10:47 am, R19 was observed sitting in a wheelchair next to her bed with a green plastic bottle labeled liquid laundry detergent that was half filled at R19's bedside. R19 stated that the liquid laundry detergent belonged to R19 but was not able to tell surveyor how she obtained it. On 08/3/26 at 10:55 am, Surveyor brought this observation to V15 (Licensed Practical Nurse, LPN) and V15 stated, She (R19) is not supposed to have this. I don't know how she got this. Someone can drink it and get poisoned. On 08/4/26 at 3:07 pm, V2 (Director of Nursing, DON) stated that chemicals such as detergent are a hazard if left at the residents' bedside. V2 explained that a resident can be poisoned if they ingest detergent. The facility's policy dated 7/7/26 and titled Hazard documents, in part: Policy Statement: It is the facility's policy to ensure the safety of each resident in the building and remove hazardous items and correct situations to prevent accidents. Procedures: 1. Ensure that residents have no access to medications, sharps, and chemicals that would be hazardous to them. R19's Face Sheet shows that R19 has diagnosis which include but not limited to schizoaffective disorder. R19's Brief Interview for Mental Status (BIMS) dated 6/30/26 shows a score of 13 which indicates that R19 is cognitively intact. Facility Census Report dated 8/3/26 documents, in part, that 47 residents currently reside on the fourth floor in the facility.

Based on interview and record review, the facility failed to ensure that residents were kept free from involuntary seclusion when staff tethered a bedsheet from the resident's room door handle to a hallway handrail, physically trapping the resident inside the room. This deficient practice affected one of four residents (R1) reviewed for abuse. A reasonable person reviewing these actions would conclude that tying a door shut with a bedsheet is a punitive, non-therapeutic mechanism used to involuntarily confine a resident.A reasonably prudent caregiver would recognize that blocking an exit in this manner completely strips the resident of their freedom of movement, creates an immediate fire and entrapment hazard, and serves strictly as a measure of staff convenience to manage the resident's whereabouts.Findings include: R1's medical record (face sheet) documents R1 is an [AGE] year-old female with diagnoses including but not limited to: Polyneuropathy, unspecified, Bipolar disorder, current episode manic without psychotic features, severe, Unspecified protein- calorie malnutrition and Violent behavior. R1's MDS (Minimum Data Set of 3.6.2026) documents a BIMS (Brief Interview for Mental Status) as 8 denoting R1 is moderately cognitively impaired.On 5.14.2025 at 9:49 PM, R1 said, I don't recall them locking me in my room.On 5.15.2026 at 6:05 PM via telephone, V17 (NP-Nurse Practitioner) said, I was notified by nursing that (R1) was aggressive and violent towards staff and roommate. I was informed that resident was in her room alone. I didn't feel comfortable that R1 was in her room alone. I was concerned that R1 was not being monitored in her manic state, that something could happen to her, R1 could have fallen or hung herself. I was crucified by email for writing detained in my note. They (facility) wanted me to change my note, to say resident was monitored. They had a script they wanted me to follow. I didn't feel comfortable doing that. They harassed me so much that I added an addendum to my original note. On 5.16.2026 at 1:10 PM and 5.19.2026 at 3:26 PM via telephone, V8 (CNA-Certified Nursing Assistant) said, around 5:00 AM, I heard R1 saying lady, lady. I went to investigate, R1 said she was okay, R4 you could tell she looked agitated. Approximately 30-40 minutes later, R4 came out of the room. R4 said she (R1) woke me up. She had her hand in my face. I told R4 to have a seat at the nurse's station. It was crazy. Okay, so at this point, V10 comes out of restroom. I let her know what's going on. V10 told R1, you can't do that. R1 said something like who's house is that. R1 comes all the way to the med cart, saying stuff to her (V10), putting her hand in V10's face like she (R1) was going to hit V10. At this point I saw R1 grab the pill crusher. V10 grabbed R1's hands. Now R1 is fighting. I grabbed R1's wheelchair and sat her down in her wheelchair. R1 bit V10 before I was able to get R1 in the wheelchair. V10 was holding R1's hands to prevent her from hitting people, R1 was kicking at me. V10 pushed R1 in her room. At this point R1 is still trying to fight, still aggressive. V10 stated I called V9 (ADON-Assistant Director of Nursing). I (V10) told V9 that R1 was very aggressive at the moment, fighting with V10; V10 put R1 in R1's room. V9 asked me to speak with V10, I let V10 know. R1 ended up tied in her room so she wouldn't get out. The sheet was on the door, I'm guessing tied to the handrail in the hallway. I stood outside the door to monitor. R1 did end up calming down and lying down when R1 realized she couldn't get out of the room. I know it wasn't appropriate (to tie sheet to door handle and secure to hallway handrail). It's part of abuse, it's seclusion. On 5.16.2026 at 2:07 PM, V9 (ADON-Assistant Director of Nursing) said, the first call I received from V10 was at 5:59 AM on 5.2.2026. V10 told me, I got bit by R4, she bit me on the arm. V10 said R1 was bothering R4 I asked her what she (V10) did. V10 said, I removed R4 from the room and put her at the nurse's station. I tried to talk to R1, she came to my med cart, she grabbed the pill crusher and tried to hit me with it. I blocked her from hitting and that's when she bit my arm. V10 told me she brought R1 back to her room. We hung up so that V10 could go and check on R1. I called a third time, around 7:00 AM. V10 said, R1 is calm now. Earlier when she was having behavior, I put a towel or a sheet on the door, I tied the door. I told her to immediately remove it. That's abuse, involuntary seclusion. On 5.19.2026 at 12:34 PM, V11(CNA) said, well, I was standing at the nurse's station at approximately 7:10 AM looking to see who would be working with me that day. V15 (CNA) was coming down the hallway. He asked me, what's going on with R1's room. We both saw the sheet tied to the door and handrail, the door was completely closed. I heard her call help. I undid the sheet. I went into R1's room, she was alone in the room. When I was going to untie the door, the nurse (V10) said, you don't know what's going on, don't let her out. I said this is our morning shift. I'm unlocking the door. When we went in, R1 was standing by the door. R1 seemed upset, anxious. R1said, I had to fight for my life. Where were you at? I told R1 to calm down. The door shouldn't have been tied. I think it's abuse. I would panic if I were secluded in a room like that. On 5.19.2026 at 2:14 PM, V2 (DON-Director of Nursing) said, V10 said, In the moment I was flustered, I didn't want her (R1) to come out of the room again. I didn't want anyone to get hurt. V10 acknowledged what she did. She was suspended pending outcome of the investigation. She finally resigned. That's involuntary seclusion. That's a form of abuse. How would you feel? I would feel bad. I would be confused why I am being kept in the room. I would feel bad. When I spoke to administration no report had been sent in. It should have been reported. On 5.19.2026 at 3:02 PM, V14 (CNA-Certified Nursing Assistant) said, I did see the sheet tied to R1's room door handle and handrail. The door was closed, R1 was alone in her room. V10 should not have done that, I don't feel it was safe for R1. I would feel upset if someone did that to me. On 5.2.2026 at 5:30 AM, R1's Progress Note documents, in part: Resident was physically aggressive toward her roommate and staff. (R1) attempted to hurt her roommate. Roommate was immediately separated from (R1). (R1) came out to the nurse's station toward the nurse and grabbed the pill crusher machine to hit the nurse. The nurse tried to remove the machine from (R1). (R1) then bit the nurse in the Rt.(right) arm.On 5.2.2026 at 7:37 AM, R1's (Telehealth) Progress Note documents, in part: Notified by nursing this morning that patient has been extremely violent and aggressive towards staff and her roommate. Patient is currently detained in her room alone. Patient has been biting staff physically, assaulted her roommate and grabbed the pill crusher machine to attempt to throw at the nursing staff. Review of R1's care plan and physician orders revealed no clinical rationale, behavior management protocol, or orders permitting the restriction of the resident's exit.In-service sign in sheet dated 5.4.2026 documents a 1:1 was given over the phone to V10. The topics were Abuse Policy (Prevention, Identification & Reporting). Crisis Management, documentation and thorough communication/communication of events to MD/medical doctor, family, Nurse Practitioner. Abuse and Retaliation Policy (Reviewed/Revised 1.29.2026) documents, in part: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows federal guidelines dedicated to prevention of abuse and timely and thorough investigation of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Types of Abuse and Examples 4. Involuntary Seclusion: Isolation of a resident against his/her will (involuntary, imposed seclusion). This is different from placing the resident in a room for emergency reason to protect resident form himself or protect other residents in emergency situations. Examples: statements to threaten or secluding, isolating or locking a resident in their room or a room or area by themselves.

Based on interview and record review, the facility failed to follow their abuse policy by failing to ensure that one of four residents (R1) was protected by failing to immediately report an allegation of involuntary seclusion to the State Survey Agency within the required two-hour timeframe for one of four (R1) residents reviewed for abuse in the sample of four.Findings include:On 5.14.2026 at 7:21 PM and 5.15.2026 at 9:17 PM, V1 (Administrator) said I only have one reportable incident for the past three months. I just sent that one in yesterday. I did not send an incident report to IDPH (Illinois Department of Public Health) for R1. I should have; it was a missed opportunity. There was a moment when V10 (LPN-Licensed Practical Nurse) called V9 (ADON-Assistant Director of Nursing). V10 told V9 that V10 had placed a bedsheet on R1's door handle and tied it to the hallway handrail. V9 told V10 to immediately remove the sheet.On 5.16.2026 at 2:07 PM, V9 (ADON-Assistant Director of Nursing) said, the first call I received from V10 was at 5:59 AM on 5.2.2026. V10 told me, I got bit by R4, she bit me on the arm. V10 said R1 was bothering R4 I asked her what she (V10) did. V10 said, I removed R4 from the room and put her at the nurse's station. I tried to talk to R1, she came to my med cart, she grabbed the pill crusher and tried to hit me with it. I blocked her from hitting and that's when she bit my arm. V10 told me she brought R1 back to her room. We hung up so that V10 could go and check on R1. I called a third time, around 7:00 AM. V10 said, R1 is calm now. Earlier when she was having behavior, I put a towel or a sheet on the door, I tied the door. I told her to immediately remove it. That's abuse, involuntary seclusion. It should have been reported to IDPH.Abuse and Retaliation Policy (Reviewed/Revised 1.29.2026) documents, in part: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows federal guidelines dedicated to prevention of abuse and timely and thorough investigation of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. VII. Reporting/Response. All allegations and/or suspicions of abuse and retaliation must be reported to the Administrator immediately. All allegations of abuse and retaliation must be reported to IDPH immediately not exceeding 2 hours after the initial allegation is received.

Based on observation, interview and record review, the facility failed to ensure that residents are free from physical abuse for one of four residents (R2) reviewed for abuse in the sample of four.Findings include:Facility's final incident report documents, in part: on 5.13.2026, Administrator notified by V5 (LPN-Licensed Practical Nurse) that she responded to a commotion on the fourth floor. Staff observed (R3) standing at the bedside of his roommate, R2), holding (R2's) grabber with both hands gesturing back and forth in front of (R2). Residents immediately separated. (R3) on 1:1 supervision. V6 (Physician) notified and orders to be sent to hospital for further evaluation.R2's medical record (Face sheet) documents R2 is a[AGE] year-old male with diagnoses including but not limited to: Other Reduced Mobility, COPD, Dysphagia, Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 3, and Chronic Respiratory Failure. R2's MDS (Minimum Data Set of 3.6.2026) documents a BIMS (Brief Interview for Mental Status) of 13 denoting R2 is cognitively intact.R3's medical record (Face sheet) documents R3 is a 73- year -old male, with diagnoses including but not limited to: Encephalopathy, Delusional Disorders, Chronic Kidney Disease, Dementia, Psychotic Disorder, and Anxiety Disorder. R3's MDS (Minimum Data Set of 5.22.2026) documents a BIMS (Brief Interview for Mental Status) of 9 denoting R3 is moderately cognitively impaired.On 5.15.26, Administrator (V1) interviewed resident R3 and re-interviewed R3 on 5.19.26. R3 stated that his roommate is very old and he would never intentionally hurt an old man. He stated that his roommate was banging his reacher against the table and he didn't like the noise, so he went to his roommate and attempted to take the reacher from him.On 5.15.26, Administrator (V1) interviewed resident R2 and re-interviewed R2 on 5.19.26. R2 stated that his roommate had come over, they were struggling with the reacher, as his roommate was trying to take it away from him. R2 stated his roommate hit him. R2 was asked to explain what hit him meant. R2 kept motioning the motion of going back and forth with the reacher. R2 was shown an example of striking with the reacher and he stated no.On 5.14.2026 at 7:21 PM, V1 (Administrator) said, I only have one reportable incident for the past three months. I just sent that one in yesterday. R2 and R3 are roommates and have never had any issues. R2 has a behavior of banging things (remote, grabber/reacher tool). Apparently R2 was banging his grabber, R3 got up and tried to take it away from R2. The nurse heard a commotion, went to their room and saw R2 and R3 involved in a tug of war of sorts. Both residents were holding onto the grabber and pushing/pulling back and forth. R2 had a small reddish circle like area on his hand. R3 was petitioned out to (hospital) for psych eval and has not returned.On 5.14.2026 at 9:35 PM, R2 was observed awake, alert in bed. Head of bed was elevated approximately 30 degrees. Gauze wrap dressing to left palm appeared clean/dry/intact. Elevated side rails x2. Call light within reach. Surveyor asked R2 what happened to R2's hand, and R2, without hesitation, clearly said in English, my roommate hit me. He's gone now; he's at a mental hospital.On 5.15.2026 at 5:09 PM via telephone, V5 (LPN-Licensed Practical Nurse) said, it happened on 5.13. 2026. I was doing my med pass. Around 11:00 AM, I heard a commotion coming from R2 and R3's room. I walked in, R2 was lying in bed, R3 was at the bedside. Both were holding on to R2's grabber, like playing tug of war. I tried to redirect R3, but he wasn't being compliant. When V7 came into the room, she said to R3, let go and escorted I R3 out of the room. R2 had an abrasion to his left palm. R3 was petitioned to the hospital for psychiatric evaluation and treatment.5.15.2026 at 7:17 PM, V7 (CNA-Certified Nursing Assistant) said, on that day I was in another room doing patient care. I heard R2 hollering and then V5 (LPN-Licensed Practical Nurse) going into R2's and R3's room and hollering don't do that, get off him. I stopped what I was doing and ran into their room, V5 was by the doorway still hollering at R3 to get off him (R2). When I got there, R3 was standing over (R2). Both R2 and R3 were holding onto the grabber, almost like tug of war, going back and forth. R3 was pushing towards R2 and R2 was pushing towards R3. To me it looked like R3 was trying to push it towards R2's neck. As I got into the room I said to R3, what are you doing? You need to stop. R3 stopped and went over to his bed and laid down. That's when three staff (Housekeeper, CNA and Nurse) came into the room. R2 was hollering, because his hand was hurt. R2 said, he hit me, he hit me. I did see his hand (R2) was bleeding between thumb and index fingers. I think R3 just got annoyed and angry with R2 and just wanted him to stop.On 5.21.2026 at 12:20 PM, R3 was observed awake, alert sitting in wheelchair at bedside, eating lunch and watching TV. R3 agreed to speak with surveyor. R3 said, R2 has a stick that R2 uses to beat on the counter when R2 wants the nurse. He was banging on the counter, he was annoying me, I tried to get the stick away from him. That's all there is to it. I'm getting tired of talking about it.On 5.13.2026 R2's Skin/Wound evaluation documents, in part: left hand (palm), new abrasion. Length: 2 centimeters, width: 1.5 centimeters, depth: 0.1 centimeters. Initial treatment applied after cleansing with saline. Will refer to wound specialist.Abuse and Retaliation Policy (Reviewed/Revised 1.29.2026) documents, in part: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows federal guidelines dedicated to prevention of abuse and timely and thorough investigation of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Types of Abuse and Examples 1. Physical: Physical abuse includes but is not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling.

Based on interviews and records reviewed the facility failed to complete an accurate fall risk assessment to identify a newly admitted resident (R2), with a history of falls, unsteady gait, and Dementia with confusion was at high risk for falls and provide 1 person assistance for safe transfers and ambulation. This failure affected 1 of 3 residents reviewed for falls.R2's diagnoses include but are not limited to Polyneuropathy, Peripheral Vascular Disease, Hypertension, Dementia, Osteomyelitis of the Left Ankle and Foot, and Cellulitis of the Left Lower Limb. According to admission assessment R2, [AGE] year-olds, was admitted to the facility on [DATE] at approximately 2:21PM. According to Incident Report dated 2/25/25 at approximately 3:10AM R2 fell in the hallway. R2 was transferred on 3/25/25 to the hospital for evaluation and did not return to the facility. R2's medication includes a daily blood thinner, Xarelto.On 3/28/26 at 12:34PM V11, CNA (certified nursing assistant), listed as assigned to R2 on 3/25/26 at 3:00AM said I don't remember R2. V11 said I work on all floors. V11 said contact guard assist (CGA) means I would assist the person with transfer or walking to the next location by placing my hand on them. V11 said I would use a gait belt.On 3/27/26 at 1:30PM V16, Fall Coordinator, said to be a fall risk, we need to know of any previous falls, if a family tells us there is a history of falls, then the resident is at risk. We have an assessment for fall risk. Interventions used will depend on the person and situation, we can use floor mats or alarms.On 3/28/26 at 11:55AM V8, Restorative Aide, said CNAs are issued a gait belt at the time of hire and everyone is trained on use of gait belts. V8 said we have extra gait belts at the nurses' stations for the staff to use. V8 said for new admissions, we wait for therapy to assess them before we give them a walker. V8 said Restorative aids do not assess new admissions for transfers, that would come from therapy.On 3/28/26 at 9:52am V12, RN (registered nurse), said I was given report from the day shift on that day (3/24/26). V12 said I was told R2 was alert and oriented times 2-3 and he used a walker. V12 said I can't recall when I first saw R2 on that shift. V12 said I had assisted R2 with toileting about an hour before the fall. V12 said I was in the hall and saw R2 walking alone to the bathroom and I went in to help him. V12 said I helped him because he was still new at the time. V12 said R2 had a steady gait up until the fall. V12 said R2's room was about halfway down the hall from the nurses' station. V12 said when the fall occurred, R2 had come out of his room and was walking towards the nurses' station with a walker, he was in a gown and had non-skid socks on. V12 said I was walking towards him, and he was asking about breakfast, I offered to help him with returning to his room. V12 said he went to turn around, lifted his walker, I was near him and tried to catch him, but he then fell onto his buttock and backwards hitting his head. V12 said R2 was on blood thinners, he hit his head, so I sent him to the hospital. V12 said when they gave me report at the start of the shift, they told me he was a fall risk. V12 said interventions for residents at risk includes monitor them, keep the bed low, all needed items are near the bedside, call light is in reach, and we do frequent rounds. V12 said I can't remember who the CNAs were that shift. V12 said after the fall, we left R2 on the floor for paramedics to pick him up. V12 said when I went to make the phone calls, someone stayed with R2, but I can't remember which CNA. V12 said R2 was a new admission, and he did not use the call light either time I assisted him, that shift. V12 said R2 was getting up a lot during the shift, it was a new environment for him, and he had some confusion.On 3/28/26 at 11:44am V7, CNA, said I was on the opposite side of the hall doing rounds and saw R2 walking to nurses' station. V7 said R2 was coming to the nurse where she was with her cart. V7 said I saw the nurse with R2 and my back was turned to both of them. V7 said R2 had a walker and was dressed in street clothes. V7 said R2 had gotten himself up, he had been in his bed. V7 said I think he heard the noise in the hall of us doing rounds and it prompted him to see what was going on. V7 said when I heard the noise, I saw he had fallen, then I went to help. V7 said R2 was on the floor. V7 said V11, CNA, (the other CNA assigned to the floor) was not in the area during the time of the fall.On 3/28/26 at 1:03PM V13, R2's wife, said my husband fell several times prior to his admission to the facility. V13 said R2 fell off the toilet at home trying to get up. V13 said R2's last fall was just before he was hospitalized on [DATE], I think his last fall was in January 2026. V13 said while R2 was in the hospital he had a chair and bed alarm. V13 said we have a full time care giver for R2 and he told a group of staff at the desk R2 was at risk for falls and had alarms in the hospital. V13 said the staff said we can't do that until he gets assessed the next day. V13 said R2 does not have a good sense of where he is, he is elderly, has dementia, and was weak from the IV therapy he was undergoing. V13 said the facility placed him in a room far from the nurses' station, about 4 rooms away from the desk. V13 said no one ever called me from the facility for a history or to ask any questions about him during the admission. V13 said I think they were going off of what R2 said to them.On 3/27/26 2:29 V10, Director of Nursing, said I expect the Fall Risk Assessment for a new admission to be completed within 4 hours of admission to have a baseline for the plan of care. V10 said I did not meet R2. R2 had just been admitted . V10 said after the fall, I spoke to the nurse, V12 (RN), about it. V10 said I was told around 2:00am R2 was observed ambulating to the bathroom, he was steady with a walker, and the nurse assisted him. V10 said later, R2 was observed in the hallway with a walker, steady gait, anti-skid socks, and he was looking for breakfast. V10 said when the nurse saw him she was redirecting him. He was lifting his walker while turning. V10 said it was a witnessed fall, he then fell to the floor. V10 said R2 landed on his buttock and hit his head, then we sent him out 911. V10 said V12 saw R2 hit his head on the floor; he sustained an abrasion and reported back pain. V10 said based on R2's fall risk assessment he was at low risk for falls. V10 reviewed R2's admission skin assessment and said he was noted to have wounds on the left ankle and had an amputated toe (healed). V10 said R2 went to the hospital, and he did not return. V10 said I didn't speak to his family regarding R2.On 3/28/26 at 12:28pm V10 said contact guard assist (CGA) for ambulation means staff is touching the person, uses a gait belt, and walks with the person.On 3/28/26 at 1:33pm V10 said when gathering information on admission it comes from nurse-to-nurse verbal communication from the hospital. V10 said the hospital will report what equipment is needed, IVs used, or any restrictions. The admitting nurse looks at assessments, medical records sent from the hospital and note any appointments. V10 said for questions, if the patient can answer they use that, but the answers need to correlate with the medical record. V10 said social services will do cognition assessments. V10 said the nurse is expected to review the medical record, if the family is here, we can discuss care with them. V10 said after, we may place a courtesy call to let the family know the have arrived to the facility. V10 said some residents can be responsible for themselves. V10 was asked if a resident fell in January and is admitted to the facility in February, are they a fall risk? V10 replied hypothetically, in that situation yeah then they are a fall risk. V10 said if the family is present with the resident and making a request, such as siderails or alarms, then we should look at the request. V10 said we would not tell the person that they will have to wait until the next day, we should not say that. V10 said no one reported to me that the care giver was present and requesting an alarm for R2 on the day of admission. V10 reviewed R2's fall risk assessment with the surveyor. V10 said the fall assessment was accurate based on the history that R2 had a fall in the past. V10 said I don't know where the walker R2 was using when he fell came from, it was not from us. On 3/27/26 at 3:02PM V9, Administrator, said we used the hospital paperwork to determine R2's ambulation status on admission. V9 said therapy had not seen R2, yet. V9 said therapy was going to see R2 the next day (3/25/26), but he went to the hospital. V9 presented hospital records with Therapy Notes highlighted and said this it what was used to determine ambulatory status. Hospital Physical Therapy Note dated 2/23/26 documents Standing balance: contact guard and with double UE (upper extremity) support. Transfers: gait belt, 2 wheeled walker, sit to stand and stand to sit: minimal assist. Ambulation/Gait: gait belt and 2 wheeled walker. Assistance level: contact guard/touching/steading assist and with verbal cues. Description: decreased cadence. pace, decreased step length left/right, unsteady, heavy reliance on BUE and narrow base support. Education: fall prevention, safety role of PT, gait training, use of assistive device and transfer technique. Impairments that require further therapy intervention: activity tolerance, balance, cognition, strength and safety awareness. The admitting assessment completed by V17, RN, for R2 dated 2/24/26 includes Mental status: Confused and forgetful at times. Call Light Evaluation: alert and oriented x3 is selected; comments: alert and oriented x 1-2, very forgetful and confused at times. Functional mobility states R2 requires partial/moderate assist with transfers and walking assessment was was not attempted due to medical conditions or safety concerns. Braden Scale: Activity: Walks occasionally. Mobility: Ability to change and control body position: slightly limited. Friction and Shear: Potential problem: moves feebly or requires minimum assistance. Unsuccessful attempts to contact V17 for interview on 3/28/26 at 9:45AM and 2:43PM. There is a discrepancy noted on R2's Incident Report and Change in Condition Form which both note the occurrence at 3:10AM. R2's Post Fall Investigation documents the incident occurred at 4:10AM. Post Fall Investigation fall risk assessment: Is resident at risk for falls? No. Does the resident have any history of falls? No. Were fall interventions in place prior to incident? N/A Root Cause Analysis: Resident is alert/oriented x1 baseline. admitted within 24 hours. Based on the investigation nurse observed resident lifted his walker in an attempt to turn and lost balance in the process and fell on buttocks and then hit head. R2 Resident Inventory dated 2/24/26 does not identify a walker. R2 nurse to nurse report includes diagnosis Dementia, mental status: X1, Confusion, Forgetful. Behaviors: pulls IV at times. Mobility [NAME] +1 Assist.

Based on interview and record review, the facility failed to ensure that fall interventions were in place for one resident (R1) who was a high risk for falls. These failures resulted in R1 sustaining a fall which required R1 to go the local hospital due to sustaining an intracranial subdural hematoma. Findings include:R1's medical diagnoses include but are not limited to history of falling, type 2 diabetes mellitus, essential hypertension, obstructive sleep apnea, seizures, chronic kidney disease.R1's Minimum Data Set (MDS) dated [DATE] has R1's Cognitive Skills for Daily Decision Making scored at 3 Severely Impaired. R1's initial Reportable Incident to the state agency dated [DATE] documents in part, Resident was last seen by CNA (Certified Nursing Assistant) asleep approximately 2:30am. On [DATE] approximately 3:00am while nurse is at the nurse's station heard and responded to a thud sound: observed resident in a supine position on the hallway floor. Obtained update from hospital CT (Computed Tomography) of head resulted acute chronic subdural hematoma, scalp hematoma. There is also acute hemorrhage throughout the cerebral cisterns. Review of R1's records shows that R1 had four falls at the facility dated [DATE], [DATE], [DATE] and [DATE]. R1's progress note dated [DATE] at 10:30am documents in part, Situation: s/p (status post) fall.Patient s/p fall. Noted to have a lump on right dorsal head of the patient. Patient c/o (complain of) headache, denies n/v (nausea/vomiting) denies blurry vision. NP (Nurse Practitioner) informed that 911 was called and patient already left the facility. R1's progress note dated [DATE] at 21:39pm documents in part, admitted to hospital for subdural hematoma per RN (Registered Nurse). On [DATE] at 2:19pm V2 (Director of Nursing/DON) stated that R1 had fallen multiple times at the facility. V2 stated that R1 was very forgetful and confused. V2 stated that R1's 3rd fall was unwitnessed and R1 was sent to the hospital for evaluation. V2 stated that she spoke to R1's son before R1 returned to the facility after the 3rd fall and promised to place R1 close to the nurse's station and place a bed alarm on R1. V2 stated that she interviewed the 3pm to 11pm CNA (Certified Nursing Assistant) and was told that R1 was anxious throughout the shift and that she had been going in and out of R1's room all day.On [DATE] at 3:33pm V32 (Certified Nursing Assistant/CNA) stated that R1 is normally sleep when V32 starts her shift at 11pm. V32 stated that on [DATE] at 11pm, R1 was still awake. V32 stated that she had received report from the outgoing CNA that R1 was anxious and combative. V32 stated that R1 was refusing to lay down, so she placed R1 at the nurse's station to be monitored. V32 stated that when R1 appeared to be sleepy, she placed R1 in the bed. V32 stated that approximately 30 minutes after placing R1 to bed, she (V32) heard a loud boom. V32 stated that she rushed to the boom and found R1 laying in the hallway on the floor.On [DATE] at 9:18am V33 (Registered Nurse/RN) stated that R1 had been refusing to go to bed during his shift. V33 stated that around 2am R1 appeared to be sleepy so the CNA placed R1 in bed. V33 stated that around 3am he heard a loud thud and got up to see where the noise came from. V33 stated that he found R1 laying on the floor in the hallway. V33 stated he tried to stimulate R1 but R1's speech had become unclear. V33 stated that R1's speech before the fall was clear. V33 stated that R1 was a huge fall risk because she kept trying to get out of bed and self-ambulate. V33 stated that he did not inform R1's doctor that R1 was restless and did not want to go to bed.On [DATE] at 9:50am V32 (CNA) stated that R1's bed alarm was on, but the bed alarm had a faint sound. V32 stated that R1's bed alarm needed a new battery and only maintenance could change the battery. V32 stated that the CNA before her had reported that she already informed everyone that R1's bed alarm was low and needed a battery. V32 stated that R1's bed alarm was on at the time of R1's fall, but it was too low for anyone to hear it.R1's care plan revision date [DATE] documents in part, R1 is a high risk for falls related to pain weakness and MUTL (multiple) MED (medical) condition. R1 will be free of minor or major injury RT (related to) an undetected incident of fall.Update upon return: Room closer to nurses' station, bed alarm, bed position in lowest position.R1's care plan revision date [DATE] documents in part, R1 is at risk for altered thought process related to chronic left SDH (subdural hematoma) . R1 will be free from any injury r/t (related to) accidents through the next review date. R1's needs will be anticipated. Call MD (medical doctor) for any changes in cognitive functioning and/or any changes in behavior.R1's Final Reportable Incident to state agency dated [DATE] documents in part, Final Investigation/Conclusion: Based on staff interview. On [DATE] approximately 10:30pm CNA noted resident wanting to get up verbalized that she does not want to miss her appointment and want to go home. CNA suggested to go to the washroom, resident responded no, diaper dry. CNA gotten resident up in wheelchair and situated by the nurses' station with bedside table in front of resident.Approximately 2:30am observed resident sleepy, instructed the CNA to take resident to her room and assist to bed. Resident was taken to her room, checked and diaper changed. 3:01am CNA observed resident sound asleep, bed in lowest position call light within reach: CNA stepped out of room to do her routine rounds. Approximately 3:10am both nurses at the nurse's station heard and responded to a thud sound: observed resident in a supine position on hallway floor in front of 212 just slightly across her room. Resident unable to relay what happened. [DATE] resident remains in the hospital at this time. R1's hospital records dated [DATE] documents in part, Chief complaint: Fall. Visit Diagnoses: Acute on chronic intracranial subdural hematoma, Intracranial hemorrhage, Brain herniation, Unresponsive, Fall. R1's hospital records dated [DATE] documents in part, Physical Exam: Constitutional: Patient is unresponsive with a Glasgow Coma Scale of 3. Respiratory Patient is intubated. General: She is in acute distress. R1's CT scan dated [DATE] documents in part, Findings and Impression: Large acute on chronic subdural hematoma along the right lateral convexity measures 1.8cm (centimeter) in thisness. Significant mass effect on the right cerebral hemisphere resulting in 9 mm (millimeter) of leftward midline shift and mild right uncal herniation. There is also considerable amount of acute hemorrhage throughout the cerebral cisterns. R1's hospital records dated [DATE] documents in part, Hospital Course: The patient is an [AGE] year old female with a history of hypertension with hypertensive heart disease with chronic HFpEF (Heart Failure with preserved ejection fraction), type II diet diabetes with nephropathy/CKD (chronic kidney disease) stage IV, history of TIA, asthma, dementia, and multiple recent presentations with falls with resultant subdural hematoma who again present after presumably mechanical fall when found unresponsive, and was note to have a large right acute on chronic subdural hematoma with cerebral edema and midline shift with uncal herniation. 1. Unwitnessed fall with acute on chronic right subdural hematoma with associated cerebral edema, midline shift, and right uncal herniation. The patient was initially admitted to the SICU (Surgical Intensive Care Unit) when CT head showed the above. Neurosurgery was consulted who advised nonoperative management due to overall poor prognosis of the injury. She was initially intubated for airway protection, and did require intermittent pressor support. Unfortunately, she did not improve, and palliative care was consulted. Family ultimately elected to proceed with palliative extubations and transition to comfort measures only. She is treated with a morphine drip for air hunger and/or pain. An order was placed to consult inpatient hospice, who reached out to the family, but inpatient hospice was not established prior to the patient expiring. The patient expired on [DATE] at 11:34pm. Facility's job description titled RN Floor Nurse dated [DATE] documents in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Registered Nurse plays a critical role in providing superior customer service and nursing care to all Guests and guests. The RN provides supervision of staff and will safeguard the health, safety and welfare of all Guests under their care by following applicable laws, regulation, and established nursing policies and procedures. Essential Functions: 9. Responsible for all nursing care of assigned Guest while on duty. Must notify appropriate persons if there is any significant change in a Guest's condition or any transfer to hospital. 10. Ensure that Guest care plans are being followed and assess each Guest's status in accord with their care plan. Facility's undated job description titled Certified Nursing Assistant documents in part, Job Summary: The primary purpose of your job position is to provide residents of this facility in you nursing unit with nursing and personal care under the supervision of a Charge Nurse, and to safeguard the health, safety , and welfare of all resident of the facility, in accordance with the facility's established policies and procedures and applicable laws and regulation, and the directions your supervisors, who include the Administrator, Director of Nursing, Assistant Director of Nursing, House Supervisor, Charge Nurse, Rehabilitation Director, and other members of the facility's management to whom such persons report, in order to assure that the highest degree of quality care is maintained at all times. Main Duties: P. Detect and report situations that have a high probability of causing accidents or injuries to residents and/or staff. U. Report all equipment malfunctions and breakdowns to the charge nurse as soon as possible and keep his/her informed of supply needs and equipment needing replacement. Facility's policy titled Fall Prevention Program Guidelines revised date [DATE] documents in part, Policy Statement: Fall prevention program guidelines shall be implemented to promote safety of all residents in the facility. This program shall include measures to determine the individual needs of each resident by assessing the risks for fall and the implementation of evidence-based prevention interventions. Procedure. 2. Safety interventions shall be initiated and implemented for each resident identified at risk for fall. 3. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. 7. An individualized evidence-based plan of care shall be created to reflect fall prevention interventions which could be but not limited to h. Residents shall be observed to ensure the resident is safely positioned in bed or chair. Provide care as assigned in accordance with the plan of care. k. May utilize personal alarms when appropriate such as bed alarms, chair alarms and motion sensor alarm and floor mat alarms.p. Ensure equipment is properly functioning and maintained. If malfunctioning, equipment must be removed immediately and reported to maintenance department for repair or replacement.

Based on interview, and record review, the facility failed to administer covid 19 vaccine to one resident (R5) that consented for the covid 19 vaccine. The facility also failed to document the administration or declination of covid 19 vaccine for the same resident. This failure affected one resident (R5) in a sample of four residents reviewed for covid 19 vaccine administration. R5 admitted to facility on 11/17/2025 with diagnosis that documents in part; Cerebral infarction, hyperlipidemia, essential hypertension, chronic atrial fibrillation, insomnia, protein calorie malnutrition, covid 19 (12/1/25).On 12/29/25 at 3:15pm, V2 (Director of Nursing) stated that she expects the infection control nurse to obtain consents for resident vaccinations and schedule a vaccine clinic to ensure that vaccinations are administered and recorded in the immunization tab in chart.On 12/30/25 at 1:05 pm, V19 (family member of R5) stated that he did give consent for R5 to receive the covid 19 vaccine on 11/18/2025 and that he wanted R5 to have the covid vaccine administered.On 12/30/25 at 09:45 am, V30 (Infection Control Nurse/LPN) stated the covid outbreak started 11/23/25 which was a Sunday and we started testing based on contact tracing with guidance from Chicago Department of Public Health (CDPH), it was one case on 2nd floor and one case on the 5th floor. By 11/26/25 we had so many cases around 18 that CDPH stated to begin unit base testing. One of our staff aides tested positive who worked directly with R5 on 11/28/25, this was discovered thru contact tracing. V30 stated the purpose of consents and declination forms is to ensure that residents and staff are educated on benefits and risk of vaccines. I feel it is important for residents and staff to sign the consent and declination forms and also receive their vaccine if they consent to be vaccinated. Currently we have two residents that are on isolation for covid 19 in the facility.Review of facility contact tracing log for residents displays that R5 tested positive for Covid 19 on 12/1/25 and is no longer a resident in the facility.Review of facility policy titled Infection prevention control with revision date of 6/30/25 documents in part: Policy statement; the facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for the identified infection.;29.) The facility shall comply with infection control recommendations provided by the IDPH or certified local health department, including, but not limited to, testing plans, infection control assessments, training or other measures designed to reduce infection rates and disease outbreaks.

Based on interviews and record reviews, the facility [A] failed to provide adequate supervision for 1 cognitive impaired resident (R1) who is a high fall risk with a history of falls, and [B] failed to follow their fall prevention policy to ensure fall interventions were put into place for each fall, and failed to implement the interventions that were in place, for one [R1] of two residents reviewed for falls. Findings Include:R1's clinical record indicates the following in part: R1 with medical diagnoses of hydrocephalus, repeated falls, type II diabetes, dementia, history of falling, and essential hypertension. Minimum data set [MDS] Brief Interview Mental Status Score Indicates R1 is cognitively impaired. R1's Clinical Electronic Record indicates:R1 sustained 11 falls on: 3/31/25, 4/10/25, 5/12/25, 5/16/25, 5/30/25, 6/28/25, 7/15/25, 7/17/25, 8/4/25, 8/15/25, and 8/27/25.R1's Care plan in part:3/14/25, R1 is a high fall risk related to dementia.Interventions:Keep all needed items like water pitcher, tissue box, urinal within reach [3/14/25],Provide a safe environment, and a working and reachable call light [3/14/25]Engage R1 in activities that interest him during the day [5/12/25]R1 to assisted in putting on appropriate footwear when out of bed in the morning [5/12/25]Family will provide well-fitting nonskid shoes [6/28/25]Bed alarm [7/17/25][Missing fall interventions for 3/31/25, 4/10/25, 5/16/25, 5/30/25, 8/4/25, 8/15/25, and 8/27/25]8/28/25 R1 has osteoarthritis of bilateral hips and chronic pain due to cervicalgia. Interventions: Educate care givers on safety measures that need to be taken in order to reduce risk of falls.R1's Progress notes in part:8/15/25 Nurse Note at 11:30 PM:R1 is awake. He got out of his bed sitting on the floor.V5 [Registered Nurse]8/21/2025 9:30 PM Behavior Note Behavior: CNA [Certified Nurse Assistant] staff observed R1 slowly lowering self to the floor. Resident able to stand up by himself, no assistance. R1 given a chair to sit on. Non-Pharmacological Interventions: Redirected to sit in the chair. Pharmacological Interventions: Night medication administered. List education provided: Summary/Outcomes: R1 sat on the floor witnessed by the CNA, resident then stood up by himself with no assistance needed. Resident currently on the chair near the nurse's station.8/22/25 V7 [Licensed Practical] Nurse Note:R1 observed to have yellowish purple bruise to top of right shoulder. V6 [Nurse Practitioner] notified, new orders to transfer R1 to emergency room for evaluation.8/23/25 at 12:42 AM Nurse Note:R1 admitted to hospital diagnosis: Fall. X-rays and CT scan was negative.8/27/25 at 1:09 PM Nurse note:R1 returned to facility. Nurse practitioner and family made aware.8/27/25 at 2:42 PM V7 [Licensed Practical Nurse] Nurse Note:Change in Condition: R1 witness fall, unresponsive verbally for approximately five minutes. Primary physician gave order to send to emergency room.8/31/25 at 9:25 PM Psych Note:Chart review, R1 was recently hospitalized from [DATE] to 8/27/25 for an unwitnessed fall. CT scan of head no acute findings. After R1 returned to the facility, R1 had a witnessed mechanical fall, evaluated at emergency room, EKG negative, pelvis and bilateral hips x-rays no acute findings. R1 returned in stable condition.Interviews:On 9/6/25 at 12:05 PM, V14 [Licensed Practical Nurse] and surveyor observed R1 sitting on the edge of his bed eating lunch alone, wearing socks. R1's call light was tangled on the floor underneath the head of bed. Water pitcher, tissue box or urinal was not in reach. R1 stood up and walked around in the room the bed alarm did not sound off. V14 stated, I am an agency nurse and work here often. I am familiar with R1. He [R1] is a high fall risk and a frequent fall resident. Nursing staff provides R1 with frequent monitoring and supervision. R1 needs stay in his room because he has a cough. R1 is negative for Covid and influenza, but in nurse-to-nurse report, R1 needs to stay in his room. R1 is not on isolation. R1's call light in tangled up on the floor, its supposed to be in reach at all times. I think the bed alarm is not on, because it did not sound when R1 stood up off the bed. I did not turn the bed alarm off, but the alarm needs to be on. R1 does not have any bruises now, but he had some face and shoulder bruises about a month ago from a fall.On 9/6/25 at 12:22 PM, V16 [Activity Assistant] stated, I am familiar with R1. He has not participated in activities for a couple of days because he must stay in his room due to coughing. R1 enjoys sensory, touching, music, exercise, and coloring. Typically, when is resident is on isolation I would go and complete one-to-one activities in their room. R1 has not had one-to-one activity in his room, but I can start today.On 9/6/25 at 2:33 PM, V7 [Licensed Practical Nurse] stated, R1 is alert but very confused, and requires constant supervision and monitoring due to wandering and frequent falls. On 8/22/25, R1's family member [V4] requested R1 to be sent out to the hospital due to bruising on his forehead and shoulder from a previous fall. All test results were negative for fractures. On 8/27/25 R1 returned back to the facility around 1:00 PM. Later around 3PM, R1 was in the dining room, I guess he tried to sit on another resident's lap, but he missed the chair and fell on his buttocks. R1 was alert when he came back from the hospital, but when I fell, he was unconscious for approximately five minutes. R1 was sent to the emergency room, all tests were negative for injuries. Some fall interventions for R1 are low bed, call light in reach, bed alarm, and activities. I try to keep my eyes on him at all times, but I also have other resident to monitor.On 9/6/25 at 3:00 PM, V6 [Nurse Practitioner] stated, I am R1's Nurse Practitioner, and I assessed R1 on 8/22/25. R1 had old bruises colored yellowish on his forehead and shoulder, all skin was intact from a previous fall on 8/15/25. R1 is a wander with a diagnosis of dementia. R1 has experience several falls, but with no major injuries. R1 is not on isolation. R1 returned from the hospital with a cough, R1 was negative for Covid and Flu, but positive for common cold. R1 is able to leave his room, staff encourages R1 to wear a face mask when possible. R1 needs close supervision and monitoring and re-direction to prevent further falls.On 9/6/25 at 3:50 PM, V2 [Director of Nursing] stated, I took over the fall coordinator responsibilities, until I find a replacement for the position. R1 is alert but confused and has a diagnosis of dementia. R1 has fallen 11 times from 3/25 to 9/25 with no major injuries. Some of R1 falls required him to be evaluated at the hospital, but each time the results were negative for fractures or injuries.On 8/21/25 R1's family member [V4] requested R1 to be sent to the hospital emergency room due to R1 having an old bruise on his face and shoulder from a previous fall on 8/15/25. R1 was doing well. R1 did not voice nor have any signs or symptoms dizziness, headaches, or difficulty moving. R1 only went to the hospital per V4's request. There was discoloration on his forehead and shoulder, no open areas, no bleeding.If the resident falls one time, they are automatically a high fall risk. For every fall there should be an individualized intervention in place to their care plan, hopefully preventing another fall from occurring. The nursing staff need to ensure they follow each resident's individualize care plan. R1's care plan fall interventions are to keep all needed items like water pitcher, tissue box, urinal within reach, provide a safe environment, and a working and reachable call light, Engage R1 in activities that interest him during the day, R1 to assisted putting on appropriate footwear when out of bed in the morning, and bed alarm. All R1's fall interventions should be in place and followed to help prevent further falls. R1 is not on isolation and does not have to stay in his room, and should be allowed to participate in activities, as it is part of R1's care plan as a fall intervention. However, if resident is on isolation and activity staff would go into their room to engage the resident with one-to-one activities. The bed alarm purpose to alert nursing staff that the resident has gotten off the pad, to prevent a fall. If the bed alarm is not turned on, the resident could get up and staff would not be alerted. Nurses should check the bed and chair alarms at the start of their shifts. All residents should have their call light and frequently used items in reach. R1 requires close monitoring and supervision. R1 needs one-to- one supervision, we are having a meeting with R1's family to discuss options.Policy documented in part:Fall Occurrence dated 6/30/25.It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are re-evaluated and revised as necessary. If a resident had fallen, the resident is automatically considered a high fall risk.The nurse may immediately start interventions to address falls in the unit, even prior to the fall's coordinator investigation. Ultimately, the fall coordinator may change the interventions provided by the nurse if the fall coordinator investigation identifies a more appropriate intervention for the individual fall. The fall coordinator will add the intervention to the resident's care plan.The fall interventions will be re-evaluated and] revised as necessary.

Based on observation, interview and record review the facility failed to address a resident's significant weight loss for 1 (R1) of 4 residents reviewed for weight loss. This failure resulted in R1 having a 30-pound weight loss in 4 months, 34 pounds in 6 months and 44.5 pounds in 7 months.Findings Include:Findings Include:R1 was admitted to the facility on [DATE] with diagnoses not limited to Asthma, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Intervertebral Disc Degeneration, Lumbar Region with Discogenic Back Pain Only, Cervical Disc Degeneration, Atherosclerotic Heart Disease, Low Back Pain, Essential (Primary) Hypertension, Idiopathic Gout, Gastro-Esophageal Reflux Disease, Depression, Obstructive Sleep Apnea, Cervicalgia, Mood Disorder due to known physiological condition with depressive features, symptoms and signs involving cognitive functions following unspecified Cerebrovascular Disease, Dementia and Dysphagia, Oropharyngeal Phase. R1 was unable to complete the Brief Interview for Mental Status. The review of R1's individualized, comprehensive care Plan document in part: Focus: R1 is at risk for alteration in nutritional status related to an active therapeutic diet and mechanically altered texture. Comparison Weight 06/15/25, 167.0 Lbs., -9.6%, -16.0 Lbs. Date Initiated: 01/20/25 Revision on: 08/21/25 Interventions: Provide assistance for meals if indicated. Provide diet and supplements as ordered. Date Initiated: 01/20/25. Focus: R1 requires assistance with ADL's (Activities of Daily Living) (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). Date Initiated: 01/16/25 Revision on: 07/03/25. Interventions: Eating: 1:1 staff assistance with all meals and as needed. Date Initiated: 07/03/25. Encourage participation in ADL's. Focus: R1 impaired cognitive function/dementia or impaired thought processes. Interventions: Ask yes/no questions in order to determine R1's needs. Focus: R1 has expressive communication barrier.A review of R1's weights reflected that the resident had a significant weight loss and was not on a physician prescribed weight loss regimen. R1's weights dated as follows: 01/15/25 201.0 Lbs., 02/18/25 180.3 Lbs., 03/11/25 178.0 Lbs., 04/09/25 177.5 Lbs., 05/14/25 171.0 Lbs., 06/15/25 167.0 Lbs., 07/10/25 156.5 Lbs. and 08/27/25 146.5 lbs. R1 had a 20.7-pound 10.30% weight loss from 01/15/25-02/18/25. R1 had an additional 8.7-pound 5.16% weight loss from 02/18/25-05/14/25, and an additional 14.5-pound 8.48% weight loss from 05/14/25-07/10/25 totaling a 44.5-pound 22.14% weight loss from 01/15/25-07/10/25 before the facility implemented a diet change on 07/15/25, Exam and modified barium swallow study completed 07/23/25, adding supplements on 07/24/25 and 07/25/25. R1 continued to lose weight, losing an additional 10 pounds 6.39% since the implementation of the interventions. R1 has a weight loss of 54.5 pounds 27.11% since admission on [DATE]-[DATE]. A review of the Dietary Progress Notes (DPN) completed by the dietician dated 03/06/25 reflected that the resident's weight of 180.3 pounds on (02/18/25) and 201 pounds on (01/15/25) with a -10.3% significant weight loss in a one-month time period. Now presents with significant unplanned weight loss > 1 month. The DPN further indicated that the resident reports a fair appetite depending on the meal, will request subs for menu dislikes, also states orders food out at times. Resident declined extra portions or ONS (oral nutritional supplements) offered. Updated food preferences and will relay to kitchen. The DPN indicated nutritional interventions: 1.) Add super cereal and double eggs at breakfast, ice cream at lunch and dinner. Dietician recommendation on 03/06/25 per progress note 1.) Add super cereal and double eggs at breakfast, ice cream at lunch and dinner. (Cereal, double eggs at breakfast, ice cream at lunch and dinner was recommended but never ordered or provided to the resident). A review of the Dietary Progress Notes (DPN) completed by the dietician dated 04/30/25 reflected that the resident weight of 177.5 pounds on (04/09/25), 178 pounds on (03/11/25), 180.3 pounds on (02/18/25) and 201 pounds on (01/15/25) significant weight loss -11.7% x 3 months from admission weight. Presents with significant unplanned weight loss > 3 months. Physician order document in part as follows: No Salt Packet diet, Regular texture, thin liquids consistency Diet dated 01/22/25, Discontinued 07/15/25. 1:1 Feeder & give medication one at a time or if trouble swallowing can crush medications dated 05/22/25, Discontinued 07/03/25 swallow eval (evaluation), noted cough with eating. ST (Speech Therapy) eval (evaluation) and treat 2-4x a week for 4 weeks for dysphagia follow up and safety dated 05/22/25. ST (Speech Therapy) eval (evaluation) and treat 2-3x a week for dysphagia management dated 07/15/25. No Salt Packet diet, Mechanical Soft texture, thin liquids consistency for diet dated 07/15/25 13:00, discontinued 07/23/2025. Exam and modified barium swallow study dx. (diagnosis) dysphagia 07/17/25. No Salt Packet diet, Mechanical Soft texture, Nectar Thick Liquids Consistency Diet dated 07/23/25 11:27. Super cereal one time a day with breakfast Supplement dated 07/25/25 09:00. Med Plus 2.0 two times a day 120 ml (med pass 2.0 or nectar-thick equivalent supplement) dated 07/24/25 17:00. Swallow evaluation to be scheduled at Hospital dated 08/01/25. Video swallow evaluation, DX CVA (Diagnosis Cerebral Vascular Accident) dated 08/04/25. DC ST (Discontinue Speech Therapy) services dated 08/11/25. GI (Gastrointestinal) consult 09/24/25 @ (at) 09:00am please schedule transportation and escort dated 08/27/25. Speech Therapy Evaluation and Plan of Treatment document in part: Staff will feed patient with 1:1 assist, small bites, slow rate, one sip at a time in 90% of [NAME] (opportunities) to decrease signs and symptoms aspiration (Target 06/04/25). Baseline (05/22/25) difficulty feeding self, coughing observed. Current referral: Reason for referral: Patient referred to speech therapy due to observed coughing/gagging during meals with concerns patient needs increased assist. Speech Therapy Treatment Encounter Note(s) Date of Service: 07/15/25 Precautions Details: Feeder, dysarthric, mechanical soft. Practiced strategies for small bites, alteration of bites/sips, slow rate, increased time between bites. Educated nursing on downgrade and plan of treatment. Speech Therapy Evaluation and Plan of Treatment document in part: Baseline 07/15/25 In order to safely consume highest level of oral intake, patient will use bolus size modifications, general swallow techniques/precautions, effortful swallow, rate modification and alteration of liquid/solids and upright posture during meals 90% of opportunities in order to decrease risk for weight loss, efficiently consume diet of choice, minimize aspiration and safely consume highest level of oral intake. Current referral: Reason for referral/Current illness: Patient referred to speech therapy due to noted difficulties swallowing, with observed coughing and need to remove from oral cavity from certified nurse assistant. Concerns/complaints: Certified Nurse Assistant and nursing with concerns with decline and choking risk. Malnutrition risk: Malnutrition Risk Factors Identified as part of Assessment = Need for altered diet, Poor PO (oral) intake. Swallow Strategies: 1:1 assist, small bites/sips, slow rate.Speech Therapy Treatment Encounter Note(s) Date of Service: 08/19/25 Precautions Details: Feeder, dysarthric, mechanical soft, nectar thick liquids. Modified Barium Swallow Study dated 07/23/25 document in part: Primary referral diagnosis Dysphagia. Clinical reason for referral: increased difficulty swallowing. Summary: Patient presents with a mild oral dysphagia and mild-moderate pharyngeal dysphagia. Swallow function declined as the study progressed: most likely due to muscular fatigue. Patient demonstrated trace silent aspiration of thin toward end of study with a liquid wash of solids. Question patient's ability to maintain adequate nutrition, as patient reported not eating very much at meals as well as reported weight loss. Given fatigue/decline in swallow function with exertion, patient may benefit from smaller meals with high calorie snacks between meals. Diet Recommendation: Solid soft and bite sized (Mechanical Soft). Liquid Mildly thick (nectar thick). Recommended swallow/feeding precautions to improve safety with PO intake: Care giver assist with feeding, No Straws, Supervision with oral intake 1:1. Swallow strategies should include: secondary swallow, alternate consistencies, no straws, patient should be upright in chair for all meals.On 08/26/25 at 12:36 PM R1 was observed in bed on a low air loss mattress with the setting of 160. Surveyor asked does she (R1) feed herself and R1 shook her head indicating no. On 08/26/25 at 01:14 PM R1 indicated yes when asked did the staff feed her and no, when asked did she like the food. R1 indicated yes when asked did she drink the juice and eat the grilled cheese sandwich. R1 indicated that her appetite is not good, she lost a lot of weight, and she drinks the supplements.On 08/28/25 12:22 PM Per telephone interview V14 (R1's Family Member) stated They called me yesterday at 06:16pm to let me know R1 lost 4 pounds. R1 is having difficulty swallowing liquids. I told them R1 does not like the food there. I was sending R1 food at least twice a week. I stay on top of them to make sure R1 is being fed. R1 has noticeable weight loss.On 08/27/25 at 12:31 PM V13 (Certified Nurse Assistant) was observed feeding R1 a tuna fish sandwich and red thickened juice. [NAME] beans, a banana, orange juice and a cup of thin lemonade was observed on the meal tray. R1 consumed 75% of the tuna fish sandwich. A large cup of water with no thickener and a straw was observed on the overbed table in front of R1. Restorative weighed R1 this morning. R1 will eats her food but it depends on what it is. Whatever R1 is able to eat she will eat.On 08/27/25 at 12:51 PM V12 (Registered Dietician) stated I have worked for the facility about a year, and I come see the resident once a week. R1 is someone who has been on my radar. R1 came in with diagnosis of failure to thrive and she stays in bed a lot. R1 has been losing weight and has a worsening swallowing disorder. R1 is working with speech therapy, updating preferences, ordered fortified cereal and liquid ensure supplement. The goal is to slow the weight loss and maintain the R1's weight. R1 was working with the speech therapist to see what diet is best for her. This is unplanned weight loss for R1. There is a potential for the development of wounds. The supplements would help prevent that from happening. On 08/27/25 at 02:30 PM Per telephone interview V18 (Nurse Practitioner) stated I was notified of R1's weight loss by speech therapy, and they did a video swallow evaluation. R1 has silent aspiration, and we recommended a gastric tube. We told R1's family she needed a gastric tube, and they said that they wanted a second opinion. I found someone at a Hospital and R1 has a follow-up appointment on 09/24/25. We started R1 on thicken liquids but R1 refuse. R1 is declining. On 06/16/225 R1 weighed 167.0 pounds, and I picked her up. R1 does not have a really good cough. The 6 pounds R1 lost in 12 days is water weight. That is my biggest complaint about the food, residents say it is awful. I spoke to the family myself. I peaked in on Friday and R1 was sleeping. On 08/08/25 I wrote a note. R1's weight loss is unavoidable. R1 really needs a gastric tube.On 08/27/25 at 02:05 PM Per telephone interview V15 (R1's Attending Physician) stated I was notified of R1's weight loss and they are doing nutritional support. I think they need to do a workup, CT (Computed Tomography) of the chest, an entire workup and try sending R1 to the hospital. The tests are normally done outpatient. I will have to probably try to get R1 admitted to the hospital. It is hard to say what the cause is of R1's weight loss, it can be thousands of causes, and it is not one test that can identify the weight loss. Surveyor informed V15 that R1 has had a weight loss of 54.5 pounds since her admission on [DATE]. V15 responded, that is a huge weight loss. Earlier it was not bought to my attention but recently it was brought to my attention in the last 2 months. This is alarming and I will address it right away.On 08/27/25 at 04:25 PM V20 (Contracted Speech Therapist) stated I have an outside contract and have worked here since November. I originally say R1 in January and February. R1 came from the hospital and had a decline in speech, slurred, was on thick liquids and was upgraded to thin liquids. At the end of May R1 was consulted for difficulty swallowing and coughing. There was no coughing or swallowing during being fed slow with the certified nurse assistant. In mid-July R1 was repeatedly coughing and there was a dramatic decline with R1's speech. R1's speech was more slurred, and it was difficult to understand. We did a down grade to a mech soft diet and downgrade to thick liquids on 07/23/25. R1's muscles got weaker, she had a trace aspiration and was unable to expel food from her airway. R1 would not be effectively getting it (food) out and had weak oral muscle skills. The plan was oral motor and pharyngeal exercises. I explained what we saw on video and our recommendation but R1does not like the soft food. R1refused the food in general and the option was soft food because of the risk of aspiration. The third option was a gastric tube so R1 could get the calories she needs if not eating. R1 does not want the gastric tube and wanted a second opinion. The interventions are small bites, small sips and if aspirating stop feeding. I educated the nurses, certified nurse assistants, explained to staff and family that R1 has a weak cough response. I called and told the family where we were at and saw R1 for 3 more sessions and education. I was not doing trials of thin liquids but would walk in R1's room and there would be thin liquids at the bedside. I would remove them and let the nurse know. R1 is not eating, and this is not sustainable for her. R1 would refuse the meals, and I got in touch with V18 (Nurse Practitioner) and asked was the gastric tube going to be inserted. It is up to the family to decide what the plan is going to be. That discussion was this month (August). R1 is refusing her food. The silent aspiration is just with the thin liquids which is why we recommended the nectar thick liquids. With solid foods R1 does gage and R1 is not to have any straws. I make recommendations and they are not followed through, this is frustrating. If R1 wants thin liquids for the quality-of-life R1 had to be a DNR (Do not Resuscitate) because she could end up with pneumonia and end up in the hospital. We recommended R1 be up in the chair when eating.On 08/27/25 at 03:48 PM V19 (Care Plan Coordinator) stated if there is a new problem that arises the care plan should be updated within 24 hours. If there is a change in dietary the dietary should update the care plan. For weight loss also I started tracking when a care plan is updated and revised. Silent aspiration should have been updated in the care plan. The care plans are supposed to be person centered. There is nothing in R1's care plan. I will probably talk to R1's family about the silent aspiration and the refusal of the gastric tube placement.On 08/27/25 at 04:21 PM V1 (Administrator) presented the surveyor with a physician order and stated, this is R1's recommended calorie count, and I am giving extra education.On 08/28/25 V1 (Administrator) emailed the revised care plan. Focus: Nutrition/Aspiration. R1 is at risk for alteration in nutritional status related to an active therapeutic diet and mechanically altered texture. R1 was observed that she is potential for aspiration related to diagnosis Cerebral vascular Accident, Hemiplegia and Hemiparesis. Diagnosis Dysphagia Oropharyngeal Phase, Silent Aspiration. Wallow evaluation to be scheduled. 08/27/25 - 3day calorie count. Revision on 08/28/25. Goal: Resident will be free from signs and symptoms of dehydration or malnutrition. Resident will maintain stable weight to next review. Will be able to have no undetected incident of aspiration x (times) 3 months. Date initiated 08/27/25. Interventions: Aspiration Precautions. Monitor for signs and symptoms of weight loss. Date initiated 08/27/24. 08/27/25 3 days calorie count. Date initiated 08/28/25. Monitor during mealtime, Keep head of bed elevated assist with ff (Free Fluid) swallowing strategies. Swallowing strategies should include secondary swallow, alternate consistencies, No Straws, R1 should be in upright position in chair for all meals, Registered Dietician Medical Doctor order. Monitor resident with difficulty swallowing, assess for signs of choking and/or aspiration. Provide thickened Nectar Thick liquids consistency. Date initiated 08/27/25. Other recommendations, R1/family education provided regarding study results and recommendations. Assess diet tolerance. Provide diet and supplements as ordered. Date initiated 08/27/25.Policy: Titled Weights revised 07/03/25 document in part: 3. Significant weight changes (monthly (5%), quarterly (7.5%), and every 6 months (10%) will be assessed and addressed by the IDT (Interdisciplinary Team) which includes but not limited to the Dietitian, Physician, Medical Specialist, Speech Therapist, Nutritionist, and Nurses.

Based on observation, interview, and record review, the facility failed to ensure that the development of individualized, comprehensive care plans had appropriate and measurable goals with target dates to address the resident(s) needs related to weight loss, difficulty swallowing and medical decline. This deficient practice was identified for 1 (R1) resident.Findings Include:R1 was admitted to the facility on [DATE] with diagnoses not limited to Asthma, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Intervertebral Disc Degeneration, Lumbar Region with Discogenic Back Pain only, Cervical Disc Degeneration, Atherosclerotic Heart Disease, Low Back Pain, Essential (Primary) Hypertension, Idiopathic Gout, Gastro-Esophageal Reflux Disease, Depression, Obstructive Sleep Apnea, Cervicalgia, Mood Disorder due to known physiological condition with depressive features, symptoms and signs involving cognitive functions following unspecified Cerebrovascular Disease, Dementia and Dysphagia, Oropharyngeal Phase. R1 was unable to complete the Brief Interview for Mental Status. The review of R1's individualized, comprehensive care Plan document in part: Focus: R1 is at risk for alteration in nutritional status related to an active therapeutic diet and mechanically altered texture. Comparison Weight 06/15/25, 167.0 Lbs., -9.6%, -16.0 Lbs. Date Initiated: 01/20/25 Revision on: 08/21/25 Interventions: Provide assistance for meals if indicated. Provide diet and supplements as ordered. Date Initiated: 01/20/25. Focus: R1 requires assistance with ADL's (Activities of Daily Living) (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). Date Initiated: 01/16/25 Revision on: 07/03/25. Interventions: Eating: 1:1 staff assistance with all meals and as needed. Date Initiated: 07/03/25. Encourage participation in ADL's. Focus: R1 impaired cognitive function/dementia or impaired thought processes. Interventions: Ask yes/no questions in order to determine R1's needs. Focus: R1 has expressive communication barrier.A review of R1's weights reflected that the resident had a significant weight loss and was not on a physician prescribed weight loss regimen.R1's weights dated as follows: 01/15/25 201.0 Lbs., 02/18/25 180.3 Lbs., 03/11/25 178.0 Lbs., 04/09/25 177.5 Lbs., 05/14/25 171.0 Lbs., 06/15/25 167.0 Lbs., 07/10/25 156.5 Lbs. and 08/27/25 146.5 lbs. R1 had a 20.7-pound 10.30% weight loss from 01/15/25-02/18/25. R1 had an additional 8.7-pound 5.16% weight loss from 02/18/25-05/14/25, and an additional 14.5-pound 8.48% weight loss from 05/14/25-07/10/25 totaling a 44.5-pound 22.14% weight loss from 01/15/25-07/10/25 before the facility implemented a diet change on 07/15/25, Exam and modified barium swallow study completed 07/23/25, adding supplements on 07/24/25 and 07/25/25. R1 continued to lose weight, losing an additional 10 pounds 6.39% since the implementation of the interventions. R1 has a weight loss of 54.5 pounds 27.11% since admission on [DATE]-[DATE]. A review of the Dietary Progress Notes (DPN) completed by the dietician dated 03/06/25 reflected that the resident's weight of 180.3 pounds on (02/18/25) and 201 pounds on (01/15/25) with a -10.3% significant weight loss in a one-month time period. Now presents with significant unplanned weight loss > 1 month. The DPN further indicated that the resident reports a fair appetite depending on the meal, will request subs for menu dislikes, also states orders food out at times. Resident declined extra portions or ONS (oral nutritional supplements) offered. Updated food preferences and will relay to kitchen. The DPN indicated nutritional interventions: 1.) Add super cereal at double eggs at breakfast, ice cream at lunch and dinner.Dietician recommendation on 03/06/25 per progress note 1.) Add super cereal at double eggs at breakfast, ice cream at lunch and dinner. (Cereal, double eggs at breakfast, ice cream at lunch and dinner was recommended but never ordered or provided to the resident). A review of the Dietary Progress Notes (DPN) completed by the dietician dated 04/30/25 reflected that the resident weight of 177.5 pounds on (04/09/25), 178 pounds on (03/11/25), 180.3 pounds on (02/18/25) and 201 pounds on (01/15/25) significant weight loss -11.7% x 3 months from admission weight. Presents with significant unplanned weight loss > 3 months.Physician order document in part as follows: No Salt Packet diet, Regular texture, thin liquids consistency Diet dated 01/22/25, Discontinued 07/15/25. 1:1 Feeder & give medication one at a time or if trouble swallowing can crush medications dated 05/22/25, Discontinued 07/03/25 swallow eval, noted cough with eating. ST (Speech Therapy) eval (evaluation) and treat 2-4x a week for 4 weeks for dysphagia follow up and safety dated 05/22/25. ST (Speech Therapy) eval (evaluation) and treat 2-3x a week for dysphagia management dated 07/15/25. No Salt Packet diet, Mechanical Soft texture, thin liquids consistency for diet dated 07/15/25 13:00, discontinued 07/23/2025. Exam and modified barium swallow study dx. (diagnosis) dysphagia 07/17/25. No Salt Packet diet, Mechanical Soft texture, Nectar Thick Liquids Consistency Diet dated 07/23/25 11:27. Super cereal one time a day with breakfast Supplement dated 07/25/25 09:00. Med Plus 2.0 two times a day 120 ml (med pass 2.0 or nectar-thick equivalent supplement) dated 07/24/25 17:00 Swallow evaluation to be scheduled at Hospital dated 08/01/25. Video swallow evaluation, DX CVA (Diagnosis Cerebral Vascular Accident) dated 08/04/25. DC ST (Discontinue Speech Therapy) services dated 8/11/25. GI (Gastrointestinal) consult 09/24/25 @ (at) 09:00am please schedule transportation and escort dated 08/27/25.Speech Therapy Evaluation and Plan of Treatment document in part: Staff will feed patient with 1:1 assist, small bites, slow rate, one sip at a time in 90% of [NAME] (opportunities) to decrease signs and symptoms aspiration (Target 06/04/25). Baseline (05/22/25) difficulty feeding self, coughing observed. Current referral: Reason for referral: Patient referred to speech therapy due to observed coughing/gagging during meals with concerns patient needs increased assist.Speech Therapy Treatment Encounter Note(s) Date of Service: 07/15/25 Precautions Details: Feeder, dysarthric, mechanical soft. Practiced strategies for small bites, alteration of bites/sips, slow rate, increased time between bites. Educated nursing on downgrade and plan of treatment.Speech Therapy Evaluation and Plan of Treatment document in part: Baseline 07/15/25 In order to safely consume highest level of oral intake, patient will use bolus size modifications, general swallow techniques/precautions, effortful swallow, rate modification and alteration of liquid/solids and upright posture during meals 90% of opportunities in order to decrease risk for weight loss, efficiently consume diet of choice, minimize aspiration and safely consume highest level of oral intake. Current referral: Reason for referral/Current illness: Patient referred to speech therapy due to noted difficulties swallowing, with observed coughing and need to remove from oral cavity from certified nurse assistant. Concerns/complaints: Certified Nurse Assistant and nursing with concerns with decline and choking risk. Malnutrition risk: Malnutrition Risk Factors Identified as part of Assessment = Need for altered diet, Poor PO (oral) intake. Swallow Strategies: 1:1 assist, small bites/sips, slow rate.Speech Therapy Treatment Encounter Note(s) Date of Service: 08/19/25 Precautions Details: Feeder, dysarthric, mechanical soft, nectar thick liquids.Modified Barium Swallow Study dated 07/23/25 document in part: Primary referral diagnosis Dysphagia. Clinical reason for referral: increased difficulty swallowing. Summary: Patient presents with a mild oral dysphagia and mild-moderate pharyngeal dysphagia. Swallow function declined as the study progressed: most likely due to muscular fatigue. Patient demonstrated trace silent aspiration of thin toward end of study with a liquid wash of solids. Question patient's ability to maintain adequate nutrition, as patient reported not eating very much at meals as well as reported weight loss. Given fatigue/decline in swallow function with exertion, patient may benefit from smaller meals with high calorie snacks between meals. Diet Recommendation: Solid soft and bite sized (Mechanical Soft). Liquid Mildly thick (nectar thick). Recommended swallow/feeding precautions to improve safety with PO intake: Care giver assist with feeding, No Straws, Supervision with oral intake 1:1. Swallow strategies should include: secondary swallow, alternate consistencies, no straws, patient should be upright in chair for all meals.On 08/26/25 at 12:36 PM R1 was observed in bed on a low air loss mattress with the setting of 160. Surveyor asked does she (R1) feed herself and R1 shook her head indicating no.On 08/26/25 at 01:14 PM R1 indicated yes when asked did the staff feed her and no, when asked did she like the food. R1 indicated yes when asked did she drink the juice and eat the grilled cheese sandwich. R1 indicated that her appetite is not good, she lost a lot of weight, and she drinks the supplements.On 08/28/25 12:22 PM Per telephone interview V14 (R1's Family Member) stated They called me yesterday at 06:16pm to let me know R1 lost 4 pounds. R1 is having difficulty swallowing liquids. I told them R1 does not like the food there. I was sending R1 food at least twice a week. I stay on top of them to make sure R1 is being fed. R1 has noticeable weight loss.On 08/27/25 at 12:31 PM V13 (Certified Nurse Assistant) was observed feeding R1 a tuna fish sandwich and red thickened juice. [NAME] beans, a banana, orange juice and a cup of thin lemonade was observed on the meal tray. R1 consumed 75% of the tuna fish sandwich. A large cup of water with no thickener and a straw was observed on the overbed table in front of R1. Restorative weighed R1 this morning. R1 will eats her food but it depends on what it is. Whatever R1 is able to eat she will eat.On 08/27/25 at 12:51 PM V12 (Registered Dietician) stated I have worked for the facility about a year, and I come see the resident once a week. R1 is someone who has been on my radar. R1 came in with diagnosis of failure to thrive and she stays in bed a lot. R1 has been losing weight and has a worsening swallowing disorder. R1 is working with speech therapy, updating preferences, ordered fortified cereal and liquid ensure supplement. The goal is to slow the weight loss and maintain the R1's weight. R1 was working with the speech therapist to see what diet is best for her. This is unplanned weight loss for R1. There is a potential for the development of wounds. The supplements would help prevent that from happening. On 08/27/25 at 02:30 PM Per telephone interview V18 (Nurse Practitioner) stated I was notified of R1's weight loss by speech therapy, and they did a video swallow evaluation. R1 has silent aspiration, and we recommended a gastric tube. We told R1's family she needed a gastric tube, and they said that they wanted a second opinion. I found someone at a Hospital and R1 has a follow-up appointment on 09/24/25. We started R1 on thicken liquids but R1 refuse. R1 is declining. On 06/16/225 R1 weighed 167.0 pounds, and I picked her up. R1 does not have a really good cough. The 6 pounds R1 lost in 12 days is water weight. That is my biggest complaint about the food, residents say it is awful. I spoke to the family myself. I peaked in on Friday and R1 was sleeping. On 08/08/25 I wrote a note. R1's weight loss is unavoidable. R1 really needs a gastric tube.On 08/27/25 at 02:05 PM Per telephone interview V15 (R1's Attending Physician) stated I was notified of R1's weight loss and they are doing nutritional support. I think they need to do a workup, CT (Computed Tomography) of the chest, an entire workup and try sending R1 to the hospital. The tests are normally done outpatient. I will have to probably try to get R1 admitted to the hospital. It is hard to say what the cause is of R1's weight loss, it can be thousands of causes, and it is not one test that can identify the weight loss. Surveyor informed V15 that R1 has had a weight loss of 54.5 pounds since her admission on [DATE]. V15 responded, that is a huge weight loss. Earlier it was not bought to my attention but recently it was brought to my attention in the last 2 months. This is alarming and I will address it right away.On 08/27/25 at 04:25 PM V20 (Contracted Speech Therapist) stated I have an outside contract and have worked here since November. I originally say R1 in January and February. R1 came from the hospital and had a decline in speech, slurred, was on thick liquids and was upgraded to thin liquids. At the end of May R1 was consulted for difficulty swallowing and coughing. There was no coughing or swallowing during being fed slow with the certified nurse assistant. In mid-July R1 was repeatedly coughing and there was a dramatic decline with R1's speech. R1's speech was more slurred, and it was difficult to understand. We did a down grade to a mech soft diet and downgrade to thick liquids on 07/23/25. R1's muscles got weaker, she had a trace aspiration and was unable to expel food from her airway. R1 would not be effectively getting it (food) out and had weak oral muscle skills. The plan was oral motor and pharyngeal exercises. I explained what we saw on video and our recommendation but R1does not like the soft food. R1refused the food in general and the option was soft food because of the risk of aspiration. The third option was a gastric tube so R1 could get the calories she needs if not eating. R1 does not want the gastric tube and wanted a second opinion. The interventions are small bites, small sips and if aspirating stop feeding. I educated the nurses, certified nurse assistants, explained to staff and family that R1 has a weak cough response. I called and told the family where we were at and saw R1 for 3 more sessions and education. I was not doing trials of thin liquids but would walk in R1's room and there would be thin liquids at the bedside. I would remove them and let the nurse know. R1 is not eating, and this is not sustainable for her. R1 would refuse the meals, and I got in touch with V18 (Nurse Practitioner) and asked was the gastric tube going to be inserted. It is up to the family to decide what the plan is going to be. That discussion was this month (August). R1 is refusing her food. The silent aspiration is just with the thin liquids which is why we recommended the nectar thick liquids. With solid foods R1 does gage and R1 is not to have any straws. I make recommendations and they are not followed through, this is frustrating. If R1 wants thin liquids for the quality-of-life R1 had to be a DNR (Do not Resuscitate) because she could end up with pneumonia and end up in the hospital. We recommended R1 be up in the chair when eating.On 08/27/25 at 03:48 PM V19 (Care Plan Coordinator) stated The care plan should be updated every 3 months, for newly admitted residents, within 24 hours and if there is a new problem that arises it should be updated within 24 hours. If there is a change in dietary the dietary should update the care plan. Sometimes I will oversee it, and it should be multidisciplinary. For weight loss also I started tracking when a care plan is updated and revised. Silent aspiration should have been updated in the care plan. The care plans are supposed to be person centered. There is nothing in R1's care plan. I will probably talk to R1's family about the silent aspiration and the refusal of the gastric tube placement.On 08/27/25 at 04:21 PM V1 (Administrator) presented the surveyor with a physician order and stated, this is R1's recommended calorie count, and I am giving extra education.On 08/28/25 V1 (Administrator) emailed the revised care plan. Focus: Nutrition/Aspiration. R1 is at risk for alteration in nutritional status related to an active therapeutic diet and mechanically altered texture. R1 was observed that she is potential for aspiration related to diagnosis Cerebral vascular Accident, Hemiplegia and Hemiparesis. Diagnosis Dysphagia Oropharyngeal Phase, Silent Aspiration. Wallow evaluation to be scheduled. 08/27/25 - 3day calorie count. Revision on 08/28/25. Goal: Resident will be free from signs and symptoms of dehydration or malnutrition. Resident will maintain stable weight to next review. Will be able to have no undetected incident of aspiration x 3 months. Date initiated 08/27/25. Interventions: Aspiration Precautions. Monitor for signs and symptoms of weight loss. Date initiated 08/27/24. 08/27/25 3 days calorie count. Date initiated 08/28/25. Monitor during mealtime, Keep head of bed elevated assist with ff (Free Fluid) swallowing strategies. Swallowing strategies should include secondary swallow, alternate consistencies, No Straws, R1 should be in upright position in chair for all meals, Registered Dietician Medical Doctor order. Monitor resident with difficulty swallowing, assess for signs of choking and/or aspiration. Provide thickened Nectar Thick liquids consistency. Date initiated 08/27/25. Other recommendations, R1/family education provided regarding study results and recommendations. Assess diet tolerance. Provide diet and supplements as ordered. Date initiated 08/27/25.Policy: Titled Care Plan revised 06/30/25 document in part: It is the policy of this facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. 5. These will be periodically reviewed and revised by a team of qualified person after each assessment.

Based on observation, interview and record review the facility failed to provide one resident (R1) with food that accommodates R1's food allergies and intolerances. This failure affected one resident (R1) out of three residents reviewed for food accommodations. Findings include: R1's medical diagnoses include but are not limited to type 2 diabetes mellitus, muscle weakness, major depressive disorder, essential hypertension, and blindness one eye. R1's Minimum Data Set, dated dated dated [DATE] has a Brief Interview for Mental Status score of 14, which indicates R1's cognition is intact. On 05/22/25 at 11:25am R1 stated that the facility gives R1 food that R1 is either allergic to or cannot tolerate. On 05/22/25 at 12:26pm, observed R1's lunch tray delivered to R1's bedside. R1's lunch tray observed with shrimp, rich, corn on the cob and apple pie alamode. R1's meal ticket on R1's lunch tray documents in part, Allergies: cheese, dairy products, ice cream, milk, yogurt .Dislikes: apple, applesauce, bratwurst sausage, corn. On 05/22/25 at 12:26pm V6 (Central supply) stated that R1's meal ticket states that R1 has an allergy to dairy, so R1 should not have ice cream served to R1 on the meal tray. V6 stated that R1's dislikes include apples and corn, so R1 should not have apples or corn served to R1 on R1's meal tray. On 05/27/25 at 9:33am V7 (Director of Dietary) stated that a resident's food allergies and dislikes should not be served to the resident. V7 stated that a resident with a dairy allergy should not receive ice cream. V7 stated that the resident could have an allergic reaction to the ice cream. V7 stated that the diet card of each resident should be followed. Facility's policy titled Food Preference Policy dated 07/26/24 documents in part, Purpose: The facility will provide food that accommodates allergies and preferences .Policy: 1. The facility will identify resident's allergies, intolerances, and preferences based on medical records and interviews. 2 The facility will ensure that residents will not be given good that they are allergic to or good that give them intolerance reactions.

Based on observation, interview, and record review, the facility failed to ensure that a fall intervention was in place for one resident (R2) who is high risk for falls; and failed to provide adequate supervision for five residents (R2, R3, R4, R6 and R7) who are high risk for falls. These failures resulted in R2 sustaining a fall which required R2 to go to the local hospital due to sustaining a acute right femoral fracture; R3 sustaining a fall which required R3 to go to the local hospital due to sustaining a left femur intertrochanteric fracture; R4 sustaining a fall which required R4 to go to the local hospital due to sustaining an acute fracture of T12 vertebral body; R6 sustaining a fall in the bathroom which required R6 to go to the local hospital due to sustaining a T12 (Thoracic) superior endplate fracture and acute nasal septal fracture; and R7 sustaining a fall from the wheelchair which required R7 to go the local hospital due to sustaining a left eyebrow laceration with repair. Findings include: R2's Initial Reportable Incident to the state agency dated 01/07/25 at 2:20 pm, documents, in part: At approximately 3:20 PM nurse and CNA/Certified Nursing Assistant on duty heard a thud in room XXX and immediately responded. Observed resident lying on the floor on her right side in front of the room closet. Resident unable to relay what happened they're all body assessment conducted, observed with cut approximately 1 cm (centimeter) by .2 cm to the right side of eyebrow site cleanse with normal saline and applied pressure dressing. Resident grimaced and moan with the right arm movement. R2's Final Reportable Incident to the state agency dated 01/13/25 at 5:55 pm, documents, in part: On 01/07/25 obtain update from hospital that resident is admitted for acute right femoral fracture. R2's hospital records dated 01/09/25 documents in part: [AGE] year-old female with past medical history of dementia, thrombocytopenia, hypertension, heart failure per ejection fraction, prior to transient ischemic attack (TIA), atrial fibrillation on Eliquis depression who presents as a trauma activation following an unwitnessed fall around 2:30 pm. Was found down alert and oriented times one at baseline per nursing home unknown level of consciousness and blood thinners positive. Injuries acute committed fracture right proximal humeral neck 1.5 cm (centimeter) laceration right temporal with ecchymosis right cheek mild right parietal scalp contusion. R2's Brief Interview for Mental Status (BIMS) dated 01/06/25 does not show a score for R2 and indicates that R2 has memory problems. R2's Minimum Data Set (MDS dated [DATE] shows that R2 requires supervision or touch assistance with putting on/taking off footwear, and walking 10 feet, 50 feet, and 150 feet. R2's Face sheet shows that R2 has diagnoses which include but not limited to other nondisplaced fracture of upper end of right humerus, subsequent encounter for fracture with nonunion, unsteadiness on feet, difficulty walking, other lack of coordination, unspecified dementia, and history of falling. R2's progress note date 01/06/25 at 3:20 pm and authored by V4 (Registered Nurse, RN), documents in part: Writer called into a room by staff and observed the patient on the floor next to the bed. When I asked resident what happened the resident seemed confused. Resident is assessed and laceration noted to right eye and right arm is injury to the right arm. Resident is assisted to the bed by staff and pressure dressing applied to right eye. MD (Medical Doctor) and public guardian office notified . emergency services is called to transport patient to hospital for evaluation. R2's fall assessment dated [DATE] shows that R2 has a score of 11 and indicates that R2 is high risk for falls. R2's care plan dated 10/28/24 documents, in part: Focus: R2 is at high risk for fall related to weakness, limited mobility, decrease activity endurance, cognitive impairments due to dementia Intervention: Purposeful rounds by staff (pain, positioning, potty, personal items, and parting). The facility's undated and titled document from third floor Certified Nursing Assistance (CNA) help book presented on 04/21/25 by V5 (RN) shows R2's fall intervention include but not limited to call light within reach and encourage to use it for assistance. The facility's document dated January 2025 through April 2025 titled Incident by Incident report shows that R2 sustained a fall with injury on 01/06/25 at the facility. On 04/16/25 at 2:06 pm, V9 (Certified Nursing Assistant, CNA) stated that V9 is familiar with R2 and that V9 was the CNA assigned to R2 on 01/06/25 and recalls R2's sustaining a fall on 01/06/25 at the facility. V9 stated that V9 heard a Boom loud noise like someone had fallen. V9 stated that V9 believes that V9 was down the hall charting when V9 heard the loud noise and that V9 went to R2's room because V9 felt that is where V9 heard the loud noise come from. V9 explained that R2 Sun Downs every evening, verbalizes that R2 is going to the Polish neighborhood, tries to obtain her R2's coat from R2's closet, and then attempts to leave the facility to go to the Polish neighborhood. V9 further explained that on 01/06/25 the day of R2's fall in question after it was after 3:00 pm when V9 heard a loud Boom went to R2's room and observed one of R2's arms underneath R2 and R2's head was bleeding above R2's eyebrow (V9 was unsure of which one of R2's eyebrows was bleeding). V9 stated that she observed R2 wearing only a night gown and no shoes. V9 stated that R2 frequently walked independently up and down the hallways by herself exit seeking the unit after 3:00 pm every day and that V9 believes this is what R2 was about to do prior to R2's fall. V9 explained that the last time V9 saw R2 prior to R2's fall on 01/06/25, R2 was walking independently in R2's room, throughout the unit independently. V9 explained that R2 would also go to the bathroom and toilet herself (R2) without staff assistance or supervision independently. V9 stated that after R2's fall on 01/06/25, R2 is now supervised by staff and R2 is placed in the dining room with staff. On 04/17/25 at 9:12 am, V4 (Registered Nurse, RN) stated that V4 is an agency nurse that works at the facility occasionally. V4 stated that V4 recalls R2 at the facility and that the day R2 had a fall on 01/06/25 V4 was at lunch when R2 fell . V4 stated that V4 believes that R2 was trying to walk in R2's room by herself and fell . V4 doesn't remember if R2 was a resident who cared for themselves or required supervision. V4 stated that V4 believes R2 used a walker to ambulate but doesn't recall if R2 had R2's walker when R2 fell . When V4 return from lunch V4 stated that the nurse that V4 was working with (V4 could not recall the nurses name) and V9 (CNA) had already assisted R2 off the floor from R2's fall. When V4 asked when was the last time V4 saw R2 prior to R2's fall V4 stated that V4 rounded on all of V4's residents prior to V4 going on break and that V4 believes that R2 was in the bed when V4 left the unit for lunch. When V4 was asked regarding how V4 knows what each resident's care requirement is at the facility, V4 stated that the previous nurse will give V4 report regarding the resident's care and that V4 also relies on the regular CNAs at the facility to let V4 know what kind of care each resident requires. On 04/17/25 at 10:10 am Surveyor attempted to reach V10 (Registered Nurse, RN) and was unsuccessful. On 04/21/25 at 8:35 am, R2 was in bed resting and R2's call light on the floor behind R2's bed not in reach. Surveyor brought this observation to V5 (Registered Nurse, RN, Falls Coordinator) and V5 stated the resident's call light should not be on the floor or behind the bed and should be in reach of the resident. When V5 was asked regarding the importance of residents call lights being within reach when the resident is in bed and V5 stated, So the resident can notify staff when they need something. The resident can soil themselves or try to get up without calling for help and fall. On 04/21/25 at 10:41 am, V27 (R2's Nurse Practitioner) stated that R2 is a resident who is a high risk for falls resident at the facility and requires supervision from staff due to R2's dementia and safety awareness. When V27 was asked regarding what could happen to R2 if R2 is in R2's room unsupervised and walking alone. V27 stated that R2's risk for falls will increase and that R2 could fall. V27 explained that R2 should be supervised by staff when R2 is walking for R2's safety. On 04/22/25 at 10:52 am, V2 (Director of Nursing, DON) stated that R2 is a resident who is high risk for falls and requires supervision from staff. V2 stated that the facility cannot provide R2 with one-to-one supervision at all times however when R2 is ambulating staff should be supervising R2 for R2's safety to prevent R2 from falling. When V2 was asked regarding fall interventions such as R2's call light V2 stated that R2's call light should be within R2's reach and accessible at all times to R2 to call for staff when R2 needs help. When V2 was asked regarding what could happen if R2's call light is not within reach and V2 stated, If the call light is not accessible then staff won't be able to know that the resident needs anything. When V2 was asked regarding what could happen if a resident who is at risk or high risk for falls is not being supervised by staff and V2 stated that it could be a risk for the resident to get out of bed, fall or other situations can happen if the resident is not being monitored. R3's Initial Reportable Incident to the state agency dated 01/11/25 at 1:45 pm, documents, in part: Unwitnessed fall with injury . on 01/11/25 approximately responded. Observed resident lying on the floor on her right side between bed and closet in R3's room. Resident unable to relay what happened head to toe assessment done, no apparent injury. Resident sent out to local hospital for further evaluation. R3's Final Reportable Incident to the state agency dated 01/17/2025 at 6:45 pm, on 01/20/2025 at 4:00 PM obtain update from hospital that resident is admitted for left femur intertrochanteric fracture and further evaluation. R3's hospital records dated 01/13/25 documents in part: The patient is a [AGE] year-old female with history of hypertension, hyperlipidemia, and remote history of breast cancer status post lumpectomy who presents complaining of left hip pain after an accidental fall. The patient states that she felt like there might have been some soap on the floor, and she stepped into an area and slipped landing on her left hip. She (R3) then had left hip pain, so she (R3) was brought to the emergency department. She (R3) did not hit her head or lose consciousness. X-ray femur two or more views left clinical indication trauma pain findings impression displaced and angulated intertrochanteric fracture proximal left femur. R3's Brief Interview for Mental Status (BIMS) dated 01/16/25 shows that R3 has a BIMS score of 7 which indicates that R3 has some cognitive impairments. R3's Minimum Data Set (MDS dated [DATE] shows that R3 required supervision or touch assistance with toilet transfer, and walking 10 feet, 50 feet, and 150 feet. R3's Face sheet shows that R3 has diagnoses which include but not limited to displaced intertrochanteric fracture of left femur, history of falling, difficulty in walking, other symptoms and signs involving the musculoskeletal system, and need for assistance with personal care. When surveyor requested R3's progress notes regarding R3's fall on 01/11/25 V5 (RN) stated, We don't do progress notes. Its all-risk management. I did an incident report about the fall (referring to R3's fall on 01/11/25). R3's progress notes dated 01/11/25 at 4:26 pm and authored by V5 (RN) documents, in part: Nurse on duty spoke with local hospital and resident admitted for further evaluation. R3's fall assessment dated [DATE] shows that R3 has a score of 17 which indicated that R3 is high risk for falls. R3's care plan initiated 03/03/24 documents, in part: Focus: R3 is at a high risk for falls related to unsteady gait, disease process, anxiety, hypertension, and anemia, cataract at left and right eye . Intervention: Provide safe environment clutter free from spills. The facility's document for R3's tilted Falls Without Injury Report shows that on 01/11/25 9:00 am, documents, in part: Resident noted during rounding by CNA at approximately 8:30 am, on side of bed with breakfast tray resident clean and dry resident noted with nonskid shoes on feet. Resident bed noted in lowest position and call light within reach. At approximately 8:45 am, resident noted on the floor lying on the right side at 15 angle at the foot of bed. Resident glasses on floor. Resident with 1 shoe snugly with the other off her foot in lying next to her on the floor. The facility's document dated January 2025 through April 2025 and titled Incident by Incident report shows that R2 sustained a fall with injury on 01/11/25 and 01/17/25 at the facility. On 04/16/25 at 10:18 am, R3 was observed in bed, awake, predominately Spanish speaking and unable to answer surveyor's questions. On 04/16/25 at 1:18 pm, V5 (Registered Nurse, RN, Falls Coordinator) stated that V5 has been the Falls Coordinator at the facility since March 2025. V5 stated that V5 was R3's floor nurse on 01/11/25 when R3 sustained a fall at the facility. V5 stated that after R3 had been served her (R3's) breakfast on 01/06/25, V5 was alerted to R3's room by V8 (Certified Nursing Assistant, CNA). V5 explained that V8 stated The resident is on the ground. V5 then explained that V5 and V8 went into R3's room and observed R3 laying on her right side between the pathway from bed to R3's bathroom. V5 explained during the time of R3's fall, R3 ambulated without assistance, did not require supervision for walking, R3 walked by herself and was independent with ambulation. V5 stated when V5 went into R3's room, R3 was screaming and moaning out in pain and that R3 was trying to get herself off the ground and attempting to get up on her own. V5 further explained that V5 and V8 assisted R3 to taking a 1/2 step from the floor to bed and laid R3 down on her (R3's) left side. V5 then stated that V5 assessed R3 in bed and observed R3 guarding the injured side but was able to move all other limbs. V5 explained that R3 was sent to the local hospital for evaluation. V5 then explained that V5 spoke with R3's son who was with R3 at the local hospital and that R3's son stated that R3 informed her (R3's) son that she (R3) was trying to go to the bathroom and fell . V5 then reiterated that at the time of R3's fall on 01/06/25 R3 was independent with R3's care and it wasn't unusual for R3 to take R3 to the bathroom without staff. When V5 was asked regarding what can happen if a resident who requires assistance from staff for ambulating and toileting does not receive assistance from staff and V5 stated that the resident can soil themselves, they can get confused and not know where to go or they can be physically harmed if they encounter obstructions. On 04/16/25 at 1:40 pm, V8 (Certified Nursing assistant, CNA) stated that V8 vaguely recalls R3 having a fall on 01/11/25. V8 stated that V8 gave R3 her breakfast and R3 sat on the side of the bed and that V8 left out of R3's room. V8 stated that when V8 returned to R3's room to give R3's roommate their breakfast tray V8 observed R3 on the floor near the bathroom and R3's closet area. When V8 was asked regarding if V8 performed any Activities of Daily Living (ADL) care for R3's on the day of R3's fall (01/11/25), V8 stated that V8 don't recall given R3 ADL care or assistance on the day of R3's fall. V8 stated it was around 8 am and that V8 only provided ADL care before breakfast to the residents who ask for ADL care prior to breakfast. V8 stated that V8 didn't recall if R3 was a resident who was able to communicate her (R3's) needs. V8 stated when V8 saw R3 on the floor, V8 yelled out for the nurse and V5 (RN) assisted R3 to bed, assessed R3, called the ambulance, and had R3 transport to the local hospital. On 04/22/25 at 10:41 am, V27 (R3's Nurse Practitioner) stated that R3 is a resident who is a high risk for falls resident at the facility and requires supervision from staff due to R3's safety awareness. When V27 was asked regarding what could happen to R3 if R3 is in R3's room unsupervised and walking alone and V27 stated that R3's risk for falls will increase and that R3 should be supervised by staff when R3 is walking for R3's safety. On 04/22/25 at 10:52 am, V2 (Director of Nursing, DON) stated that R3 is a resident who is high risk for falls and requires supervision from staff. V2 stated that the facility cannot provide R3 with one-to-one supervision at all times however when R3 is ambulating staff should be supervision R3 for R3's safety and to prevent R3 from falling. When V2 was asked regarding what could happen if a resident who is at risk or high risk for falls is not being supervised by staff and V2 stated that it could be a risk for the resident to get out of bed, fall or other situations can happen if the resident is not being monitored. R4's Initial Reportable Incident to the state agency dated 01/26/25 documents, in part: at approximately 6:50 PM nurse heard a loud thud on 3 north hallway and immediately responded. Observed resident sitting on the hallway across room XXX door. Resident unable to relay what happened. A visitor of another resident told nurse that R4 was walking in hallway, fell and hit her head against the wall. Head to toe assessment done, no visible injury. Resident nonverbal no grimaces no sign of pain. Physician and family informed. Residents sent to local emergency room for further evaluation. R4's Final Reportable Incident to the state agency dated. 01/31/25 documents, in part: On 1/26/25 at 4:00 AM obtain update from local hospital that resident is admitted for acute fracture of T12 vertebral body. R4's hospital record dated 01/27/25 documents, in part: [AGE] year-old female with a past medical history of diabetes, falls, seizures, severe dementia sent here for a fall unable to obtain review of systems giving her severe dementia . Fall T12 fracture states acute on CT (Computed Tomography) scan. R4's Brief Interview for Mental Status (BIMS) dated 02/02/25 shows that R4 does not have a BIMS score and indicates that R4 has memory problems. R4's Minimum Data Set (MDS) dated [DATE] shows that R4 requires supervision or touching assistance with walking 10 feet, 50 feet, and 150 feet. R4's Face sheet shows that R4 has diagnoses which include but not limited to wedge compression fracture of T11-T12 (Thoracic) vertebra, difficulty in walking, other lack of coordination, syncope, and collapse, need for assistance with personal care, history of falling, and unspecified dementia unspecified severity, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R4's progress note dated 01/25/25 at 7:44 pm, and authored by V6 (LPN, Agency) documents, in part: Resident observed sitting on the floor in hallway near her room, visiting witness stated that resident observed falling and hitting the back of her head on wall. Resident transferred to local hospital for medical evaluation to rule out head injury. 911 call for transfer, Power of Attorney (POA) notified of transfer, nursing manager informed of this incident. The facility's undated document titled Post Fall Investigation/RCA (Root Cause Analysis) Investigation documents, in part Activity at the time of Incident: Ambulating independently R4's fall assessment dated [DATE] documents R4 has a score of 13 and which indicates that R4 is high risk for falls. R4's care plan dated 01/21/25 documents, in part: Focus: R4 is at high risk for falls related to muscle weakness, activity intolerance, and cognitive impairment due to Dementia. The facility's document titled Incident by Incident report shows that R4 sustained a fall at the facility on 01/25/25, 02/02/25, 02/06/25, 02/16/25, 03/14/25, 02/26/25 03/20/25. On 04/16/25 at 10:04 am, R4 was observed sitting in the third-floor dining room. R4 was not able to answer surveyor's questions. On 04/17/25 at 10:11 am, V11 (Certified Nursing Assistant, CNA) stated that V11 works part time at the facility. V11 stated that V11 recalls caring for R4 at the facility. V11 stated, R4 requires a lot of attention because R4 is a wanderer who will fall if you are not watching her (R4). If she (R4) is not supervised she will also put things into her mouth. She requires a lot of redirection. V11 stated that R4 requires minimal assistance from staff for ambulation and that if R4 is not kept entertained she will wander off. V11 also stated that the facility's activities only keep R4's attention for a minute and then V11 will wander off throughout the unit ambulating alone. When V11 was asked regarding R4's fall on 01/25/25, V11 stated that V11 was not assigned to R4 the day of R4's fall and that V11 came back the next day to work and was told that R4 had a fallen. V11 stated that V11 does not recall caring for R4 on 01/25/25 or ever caring for R4 on a day that R4 has fallen. V11 stated that V11 was never R4's CNA when R4 sustained a fall at the facility. The facility's document dated Saturday January 25, 2025, shows that V11 (CNA) worked on 01/25/25 during the 3:00 pm, - 11:00 pm shift on the 3rd floor unit. On 04/17/25 at 11:16 am, surveyor attempted to reach V6 (Licensed Practical Nurse, LPN, Agency) and was unsuccessful. On 04/17/25 at 11:22 am, attempted to reach V17 (CNA) and was unsuccessful. On 04/17/25 at 11:24 am, V18 (CNA) stated that V18 is familiar and has cared for R4 at the facility. When V18 was asked regarding R4 sustaining a fall at the facility V18 stated, I don't recall caring for R4 at the facility when R4 had a fall. I (V18) never cared for R4 when R4 had a fall. V18 stated that R4 is a resident who walks all day and requires constant redirection and will get right back up after staff seats R4. V18 also explained that R4 wanders in the hallways alone at times when staff walks away from R4. V18 explained that R4 walked constantly alone throughout the facility and was given activities to do however R4 would still walk throughout the unit when staff would leave R4. On 04/22/25 at 10:14 am, V26 (R4's Nurse Practitioner, NP) stated that R4 is a resident who has dementia and wanders throughout the unit at the facility and is a high risk for falls. V26 also stated that R4 will sometimes walk backwards really increasing R4's risk for falls due to R4's safety awareness. V26 stated that R4 requires supervision from staff at all times due to R4's safety awareness. V26 also explained that R4 has sustained falls at the facility and staff was unaware that R4 had fallen until staff observed R4 on the unit on the ground. When V26 was asked regarding what could happen if R4 who is at risk or high risk for falls is not supervised by staff and V26 stated that R4 could fall, and staff not be aware for a while. On 04/22/25 at 10:52 am, V2 (Director of Nursing, DON) stated that R4 is a resident who is high risk for falls and requires supervision from staff. V2 stated that the facility cannot provide R4 with one-to-one supervision at all times however when R4 is ambulating staff should be supervising R4 for R4's safety and to prevent R4 from falling. When V2 was asked regarding fall interventions for R4 V2 stated that staff will take R4 to activities however R4 will often leave activities and wander throughout the unit. When V2 was asked regarding what could happen if a resident who is at risk or high risk for falls is not being supervised by staff and V2 stated that it could be a risk for the resident to get out of bed, fall or other situations can happen if the resident is not being monitored. On 04/22/25 at 11:24 am, surveyor attempted to reach V6 (Licensed Practical Nurse, LPN, Agency) and was unsuccessful. On 04/17/25 surveyor requested a Resident Supervision Policy and V1 (Administrator) stated that the facility does not have a policy regarding supervising the residents at the facility. On 04/22/25 at 9:45 am, V1 (Administrator) stated that the facility identified the increased falls from January and that the facility has undergone a lot of changes regarding staffing to improve supervision and fall occurrences. The facility's document dated 07/26/24 and tilted Fall Occurrence documents, in part: Policy Statement: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary . 2. Those identified as high risk for falls will be provided fall interventions. The facility's document dated 05/20/2022 and titled Certified Nursing Assistant documents, in part: summary objective in keeping with our organization's goal of improving the lives of the guests we serve, the certified nursing assistant (C.N.A.) plays a role in providing superior customer service in nursing care to all guests. The CNA safeguards the health, safety, and welfare of all guests under their care by following applicable laws, regulations, and establish nursing policies and procedures . 4. Attends to individual needs of all guests in regard to incontinent care, transferring, ambulation, range of motion, communication, and other needs . 7. Must be knowledgeable of individual care plans and support the care planning process by providing supervisors the specific information and observations of the guests needs, preferences and report any behavioral changes. The facility's document dated 12/1/2019 and titled LPN (Licensed Practical Nurse) Floor Nurse documents, in part: Summary/Objective and keeping with our organization's goals of improving the lives of the guests we serve the licensed practical nurse LPN plays a critical role in providing superior customer service and nursing care to all Guests and guests. The L. P. N. provides supervision of staff and will safeguard the health, safety, and welfare of all Guests/guests yes under their care by following applicable laws, regulations, and established nursing policy and procedures . 14. Must be knowledgeable of individual care plans and support the care plan process by reporting specific information observation of guest needs, preferences and report any behavioral changes. The facility's document dated 12/1/2019 and titled RN (Registered Nurse) Floor Nurse documents, in part: Summary/Objective and keeping with our organization's goals of improving the lives of the guests we serve the licensed practical nurse RN plays a critical role in providing superior customer service and nursing care to all Guests and guests. The R.N. provides supervision of staff and will safeguard the health, safety, and welfare of all Guests/guests yes under their care by following applicable laws, regulations, and established nursing policy and procedures . 14. Must be knowledgeable of individual care plans and support the care plan process by reporting specific information observation of guest needs, preferences and report any behavioral changes. 45644 A facility incident report to IDPH (Illinois Department of Public Health) initial report dated 2/2/25, documents in part, on January 31,2025, R6 was observed laying on her left side in the washroom in R6's room, with a nosebleed and cut to left forehead. On 2/2/25 received an update from hospital that R6 was being admitted for an acute T12 (Thoracic) superior endplate fracture and acute nasal septal fracture. R6's admission record diagnoses include but not limited to cerebral infarction, hypertension, heart disease, difficulty in walking, unsteadiness on feet, lack of coordination, need for assistance with personal care, history of falls, fracture of nasal bone, wedge compression fracture of T11-T12 vertebra, and dementia. R6's (2/6/25) Brief Interview of Mental Status (BIMS) score is 10, which indicates R6 has moderate cognitive impairment. R6's Functional abilities for chair/bed to chair transfer is coded a 2 that requires substantial/maximal assistance. R6's 1/31/25 hospital records documents in part, CT (Computed Tomography) of head: acute nasal septal fractures as well as suspected nondisplaced depressed fracture of the anterior nasal arch. Small forehead contusion with laceration. CT of C/A/P (Chest/Abdomen/ Pelvis) impression: acute T12 superior endplate compression fracture or dislocation. diagnoses T12 compression fracture and nasal septal fracture. On 4/17/25 at 2:20 pm, V24 CNA (Certified Nursing Assistant) stated, I (V24) had just left out of R6's room. I was in the room assisting R6's roommate. I heard a boom like something falling from the hallway. It was her (R6) falling in the bathroom. I went into the bathroom she was laying on the floor. I called for the nurse and the nurse came in and assessed her. When we (staff) lifted her head up, we saw blood coming from her face, and 911 was called. Sometimes she (R6) doesn't use her call light, and we'll see her standing. Her gait is not steady. At that point she did not have a bed alarm on. She needs assistance, but sometimes do not always wait for it. She is not safe being alone. She needs to be supervised because she thinks she can do things on her own. She is a 1:1 assist. She can walk just need someone on her side because of her unsteady gait. On 4/22/25 at 10:29 am, Surveyor inquired about R6's falls in the facility? V27 (Nurse Practitioner) stated, I (V27) am aware of R6 having a history of falls. She (R6) is a high risk for falls. She does require supervision and is a 1 person assist because she is wheelchair bound. She is cognitive sometimes she has poor insight on her medical condition is why she requires supervision. She should not be walking without supervisor. If she walks without supervisor she will fall. On 4/22/25 at 10:52 am, V2 DON (Director of Nursing) stated that R6 is a high risk for falls, that require supervision. If a resident that requires supervision is not supervised, they can fall. Surveyor asked V2, why no injury was observed at time of incident, on R6's fall injury report when R6 was bleeding from her nose and head? V2 stated, The nurse documented wrong, the injuries should have been on the report. Surveyor inquired about a bed alarm for R6? V2 stated, Bed alarms are used for residents who get up on their own. We try not to use bed alarm because the alarm startles the resident. Facility's fall with injury report for R6 dated 1/31/25 documents in part, Injury Observed at Time of Incident: No injuries observed at time of incident. R6's Post Fall Investigation /RCA (Root Cause Analysis) Investigation dated 2/2/25, documents in part unwitnessed fall with injury, ambulating independently, alert oriented x/times 2, and poor safety awareness. R6 is a fall risk and has a history of falls. Facility's fall list reviewed from January 2025 to April 2025. R6 had a fall on 1/12/25 and 1/31/25 in the facility. R6's (1/12/25) fall risk evaluation documents in part, fall risk score is 13 which indicates high risk. R6's (1/31/25) fall risk evaluation documents fall risk is 11 which indicates high risk. R6's (7/2/24) care plan documents in part, Focus: R6 is at high risk for falls related for current medication use, poor safety awareness, unsteady gait, diminished perception/sensations of urge to void, impaired mobility. A facility incident report to IDPH (Illinois Department of Public Health) initial report dated 2/2/25, documents in part, CNA (Certified Nursing assistant) reported to nurse that R7 abruptly leaned forward in her wheelchair and fell face forward on the floor. Observed cut to forehead with moderate bleeding observed. Final report dated 4/7/25 documents Laceration and age indeterminate anterior right 3rd rib fracture. R7's admission record diagnoses include but not limited to fracture of right-side rib, lac[TRUNCATED]

Based on review of records and interviews the facility failures are as follows: Failed to maintain the right of every resident to be safe from accident and hazard. Failed to identify risks for prevention of fall. Failed to ensure adequate supervision and assistance were provided. Failed to place applicable patient centered and effective interventions to prevent fall for 2 out of 3 residents (R6 and R3) reviewed for hazards, incidents, and accidents. These failures resulted in 1 resident (R6) falling multiple times sustaining multiple injuries including right arm/shoulder (humerus) fracture, subdural hemorrhage, and subdural hematoma. And 1 resident (R3) fall resulted to closed fracture of the right wrist (distal radius). Findings include: R6 is [AGE] years old, initially admitted to skilled nursing facility on 2/7/2024 with medical diagnosis includes dementia (11/7/2019), orthostatic hypotension (2/15/2024), injury (2/6/2024), traumatic subdural hemorrhage (4/3/2024), fracture of shaft of humerus, right arm (4/3/2024). R6 was not present during review per resident record. R6 fall risk assessments dated 2/13/2024, 4/2/2024 and 4/16/2024 documents that R6 is at high risk for falls. Per facility reported incident dated 4/1/2024, documents: Approximately at 10:20 PM, R6 was observed laying on the floor and was assessed to have cut to right eyebrow, pain on her right upper extremity on the scale 10/10. R6 claimed that she attempted to get her wheelchair but slipped and fell . Per report, R6 sustained injury right humerus fracture and subdural hematoma. Per facility reported incident dated 4/16/2024, documents: On 4/15/2024 at around 8:15 PM R6 was observed laying on the floor in prone position or face down. R6 was transferred to the emergency room and sustained subdural hematoma. Progress Notes of R6 are as follows: Per V34 (Medical Doctor) dated 2/6/2024 during initial admission of R6 from assisted living to skilled nursing facility, documents that R6 was transferred from hospital to facility due to fall. Per V15 (Registered Nurse) dated 2/13/2024, documents that R6 was seen laying on the floor. R6 claimed that she hit her head. R6 was transferred to the hospital and was admitted for observation due to fall. Per V14 (Registered Nurse) dated 4/2/2024, documents that around 10:10 PM R6 was found laying on her left side on the floor with bleeding on her head. Per documentation by V14, R6 stated that she wants to get her wheelchair and slipped and fell . V35 (Registered Nurse) documents that R6 was admitted with broken right shoulder in the hospital. Per V27 (Registered Nurse) dated 4/16/2024, documents that R6 was found on the floor bleeding on the left side of her face. On 4/16/2024 at 2:37 PM, V17 (Nurse Practitioner) stated that R6 was very impulsive and has dementia. R6 cannot remember that she cannot get up and because of that R6 falls are mostly due to not remembering her capacity to transfer and gets up and falls. At times V17 saw R6 trying to get up, but partly her fall was related due to dementia. V17 stated that staff needs more engagement with R6 because R6 likes to have conversations. When asked about preventive measures during nighttime while resident is in bed, V17 stated, It is hard to say. On 4/17/2024 at 10:09 AM, with V2 (Director of Nursing) and V3 (Psychotropic and Fall / Registered Nurse). V3 stated that R6 requires extensive assistance in all transfers. V2 stated that R6 had a fall when originally admitted on [DATE] from assisted living to the skilled floor, R6 has impairment on right shoulder upper extremity. On 4/1/2024, R6 fell and sustained right arm fracture and subdural hematoma. On 4/15/2024, R6 fell again close to the bathroom and sustained hematoma on her head and was brought to the hospital. Both falls happened during nighttime while resident was already placed in bed. After review of R6's progress notes, V3 stated, Yes, she (R6) also fell on [DATE] around 10:00 PM. Plan of care of R6 were reviewed by V2 and V3 for fall intervention(s) related to fall during nighttime after R6 was placed in bed and fell on [DATE], 4/1/2024 and 4/15/2024. V2 stated, The only one I can see was to use call light. Both V2 and V3 were asked since R6 is diagnosed with Alzheimer and Dementia what is the guarantee that she will remember to use the call light during nighttime? V2 stated, I understand, we can use bed alarm or toilet R6 before putting her to bed at night. On 4/18/2024 at 8:06 AM, V27 (Registered Nurse) stated she was the nurse when R6 fell on Monday 4/15/2024. V27 stated that R6 fell around 8:15 PM after R6 was placed on bed. R6 was found near the entrance door near the toilet. R6 position was face down, when she (V27) tried to move R6's head up there was blood on the floor. V27 stated that she does not know how R6 was able to get from the bed to the door, and the hospital informed her (V27) that R6 sustained subdural hematoma. V27 stated that R6 trying to get out of the bed is her usual behavior or baseline, and R6 needs help during transfers because R6 is unstable. V26 said, Everyone knows that R6 is a huge fall risk, and she has no bed alarm. If they only put bed alarm, we can respond every time it sounds and alert us. On 4/18/2024 at 10:22 AM, V14 (Registered Nurse) stated that she was the nurse when R6 fell on [DATE]. V14 described the fall stating that R6 hit her head resulted to laceration and dislocation of her right arm or shoulder. R6 cannot be moved because of pain on her right arm. V14 stated that R6 was found near the window which was located left side of R6's bed. V14 stated that R6 tried to get her wheelchair that was located in between R6's bed and the window. V14 stated that she always instructs R6 to use her call light, and sometimes R6 uses her call light. V14 said that R6 is oriented but forgetful. V14 stated that R6 is forgetful, and that sometimes she needs to cut R6's pill into half so that if R6 insist that she did not get her pill V14 gives the other half. V16 did not respond when asked how can R6 remember to use her call light if she cannot remember that she just taken her pill? On 4/18/2024 at 11:23 AM, V30 (Psychiatric Nurse Practitioner) stated that R6 is her patient and was seen, R6 has dementia that is getting worse. Per V30's assessment, R6 was becoming more forgetful and increased depression. V30 stated that staff told her that R6 wants to leave the facility, and R6 was started with hydroxyzine an anti-anxiety medication as needed because R6 tends to be anxious. V30 stated that part of her dementia is R6 forgets about her ability that she cannot go to the bathroom, and forgets to use the call light. Food and Drug Administration (FDA) and Pfizer Drug Information on VISTARIL- hydroxyzine pamoate capsule, reads: Under Geriatric Use, hydroxyzine is a sedating drug that may cause confusion and over sedation in the elderly; elderly patients generally should be started on low doses of VISTARIL and observed closely. After the fall on 4/1/2024 that resulted in R6 right arm fracture and traumatic subdural hemorrhage, hospital records documents that R6 was receiving levetiracetam / Keppra via intravenous infusion. During R6 re-admission to the facility dated 4/3/2024, R6 was ordered by physician to receive 500 MG of levetiracetam / Keppra Food and Drug Administration (FDA) drug information is an anti-seizure or antiepileptic drug /medication. After reviewing no seizure assessment or plan of care related to seizure were documented on R6 clinical records. V1 (Administrator) and V2 (Director of Nursing) were made aware. R6 fell on [DATE] sustaining subdural hematoma on Keppra medication from 4/4/2024 to 4/10/2024. Fall Occurrence Policy, dated 7/17/2023 reads: It is the policy of the facility to ensure that residents are assessed for risk of fall, that interventions are put in place, and interventions are reevaluated and revised as necessary. Those identified as high risk for falls will be provided fall interventions. Ultimately, the Falls Coordinator may change the intervention to address falls in the unit, even prior to the Fall's Coordinator's investigation. The Falls Coordinator will add the intervention in the resident's care plan. The interventions will be reevaluated and revised as necessary. 49783 Findings Include: R3's current face sheet documents in part, R3 is a [AGE] year-old individual, admitted to the facility on [DATE], and his medical diagnosis include but not limited to: Dementia severity without behaviors disturbance, spinal stenosis, history of falls, low back pain, essential hypertension, cerebral infarction and hyperlipidemia. R3's (Minimum Data Set) MDS 3.0 Section C - Cognitive Patterns document resident is rarely/never understood. No BIMS score recorded. C1000. Cognitive Skills for Daily Decision Making-severely impaired. MDS 3.0 Section GG - Functional Abilities and Goals document R3 requires, A. Self-Care: Code the resident's need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury. B. Indoor Mobility (Ambulation): Code the resident's need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury. R3's Care Plan dated initiated 2/20/2024 documents in part, R3 is at high risk for falls related to impaired Safety awareness, impaired balance and impaired mobility associated with the disease processes/conditions of: Cerebral infarction, Dementia, Essential hypertension, Pneumonia, spinal stenosis, chronic hepatitis C, lower back pain, wedge compression fracture first lumbar vertebra as evidenced by a recent fall prior to admitting to the skilled care facility and an actual fall as resident of the skilled care facility. FOCUS: R3 attempted to get out of bed to use bathroom and slid out of bed. Resident fell to the floor. FOCUS: R3 chose to be independent and attempted to walk without assistive device and fell on the floor. On 4/17/2024 at 11:00AM V13 states I am the POA for R3. She was discharged from the hospital on 2/20/2024 and sent to the nursing home and was there only three days. R3 ended up in the emergency room three times for falls within three days. The first hospitalization was 2/21/2024. I Left her that evening on the 2/20/2024 when R3 was admitted to that facility. I got a call around six o'clock in the morning from the hospital informing me that R3 had a fall at the nursing home. The nursing home did not make me aware and that was a red flag. They found R3 on the floor between the bed and the hallway. R3 cannot ambulate and if she tries it would take her a while. The hospital ran diagnostic testing and R3 was clear of injuries. R3 was sent back to the facility, there was no reason to admit her. I went back with R3 to get her settled in bed. I came back the next day to talk to the administrator to see how R3 fell . I couldn't speak with him; however, I was notified by staff at that time that R3 had another fall. They informed me that R3 fell around one o'clock in the morning. I had no idea R3 was taken to the emergency room for the second time. Later that day while visiting after she returned, I noticed R3 right wrist was bothering her. R3 has dementia and she can't explain her needs at times. R3 was trying to wrap a sheet around her wrist when I was visiting her. I wasn't thinking about her wrist being affected because the hospital did do more x-rays of her elbow. I left the facility immediately started looking for other nursing homes. V13 states on 2/23/2024 I went to work that Friday and had my daughter to go and check on R3. My daughter called me and informed me that R3 right wrist was with swelling, redness and felt warm and looked painful. My daughter informed me that the nurse gave R3 pain medication and ordered the in- house Xray. I went to the facility and demanded them to send R3 to the emergency room . When I arrived at the hospital, I found out R3 had a fracture to her right wrist. I asked the hospital to keep her overnight and they admitted R3. I refuse to let them discharge her back to that facility. I felt like I could no longer trust them with R3.They didn't do anything to prevent her from falling. R3 was only at the facility for three days and it ended up falling and obtaining another fracture. On 4/16/2024 at 11:00AM V3(Fall Nurse/Registered Nurse) state we should follow our policy regarding any fall. Every admission should have a fall risk assessment completed. If the resident is admitted with previous fall or high risk, then it's not required we just follow the protocol. When a resident fall staff should assess them notify provider for further instructions and notify the family. If the resident is on blood thinners or it is unwitnessed, we should send them out to the hospital for further evaluation. After a fall we should re-evaluate the interventions in place or immediately start interventions and add or update the interventions to the care plan. On 4/17/2024 at 1:30PM V12(Assistant Director of Nursing) states we follow regulation and policy when we send residents out for falls. If they are on blood thinners or if the fall is unwitnessed, hit their head, spine or hip we call 911 and send them out immediately. After any fall staff should be completing fall risk assessment, pain assessment, neuro checks if unwitnessed and a post seventy-two hour follow -up. Fall coordinator and myself investigate the falls we should also be updating interventions or putting something else in place. Nurse note dated 2/21/2024 01:58 Change of Condition (SBAR) Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: Patient noted sitting on the floor in the hallway. Patient very anxious with no visible signs of injury noted. Patient is on heparin and Plavix. 911 local emergency services notified to transport resident to local hospital for further evaluation due to blood thinning medications. Nurse note dated document in part, on 2/22/2024 00:44 Change of Condition (SBAR) Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: Fall. Nurse note dated 2/23/2024 08:02 Health Status Note document, Note Text: Resident is c/o right wrist pain this morning. Area is red and she is protecting it. Administered prn oxycodone and placed ice pack. Also place her lidocaine patch to the RFA. Checked resident records from both ER visits yesterday. There is no record of right wrist x-ray. 2/23/2024 15:06 General Progress Note Note Text: Resident c/o right wrist pain this morning. Noted area is red and she is protecting it. Administered prn oxycodone and placed an ice pack. Notified NP with an order to have an x-ray of right wrist. Placed x-ray order at All-Stat, spoke to technician will come anytime today. Notified [NAME](daughter) by Pan coordinator and informed of patient's current condition. Around 1:00 pm the patient's daughter came into the facility, was informed that she cannot wait for the x-ray technician to come and wants the patient to transfer to the ER as soon as possible. Informed NP of daughter's request, order to transfer patient to AIMMC-ER. Report given to emergency command center and lifeline ambulance with 2 paramedics picked-up patient at 1:40pm to AIMMC-ER. Will follow-up. 2/23/2024 18:33 General Progress Note Note Text: Follow up at AIMMC-ER, patient admitted Dx: Right Radius fracture. Emergency department provider noted dated 2/23/2024 documents in part, ED Provider Note Patient presents with oWrist Swelling [AGE] year-old female with a history of chronic hepatitis dementia, TIA, GERD, gout, and hyperlipidemia presents from the nursing home for evaluation of a fall. Patient was just here on the 21st for fall and had some x-rays and CT. patient also is grimacing at the right tib-fib and has an abrasion over the tib-fib area. Patient is nonverbal, no other visible injuries are noted, no evidence of respiratory distress, no other complaints reported by the nursing home. Patient is currently being treated for UTI. Hospital medical records dated 2/23/2024 confirmed R3 diagnosis of closed right wrist fracture of distal end of right radius. Reviewed facility reported incident/FRI dated 2/23/2024 reported R3 was sent to hospital for pain and swelling of right wrist. Hospital reported right wrist fracture to facility. Resident did have a fall incident day prior. No updated care plan or updated interventions dated after fall 2/21/2024. No updated care plan or updated interventions dated after fall 2/22/2024. Facility document dated 08/03/2016, titled Fall Occurrence documents in part, Policy statement: It is the policy of the facility to ensure that the residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary.

Based on interview and record review the facility failed to recognize, monitor, and provide needed services for a resident who had been noted with swelling of right leg and decline in activity for one resident (R2) out of three residents reviewed for quality of care, causing R2 to continue with a swollen leg for several days. R2 sustained an acute right hip fracture and underwent surgery to fix the fracture. Findings includes: Facility reported incident/FRI dated 03/18/2024 documents that the facility reported an unwitnessed fall with injury. FRI documents that R2 sustained an acute right hip fracture. FRI documents 03/18/24 physician was notified with orders to send out R2 to hospital for further evaluation. R2's hospital record date 3/18/2024 8:57 PM documents in part: Xr femur 2 or more views right final result Findings and impression: Complete transverse impacted fracture of the base of the Right femoral Neck/intertrochanteric region with varus deformity. No other Location. Osteopenia. Vascular calcifications. Degenerative changes Lower lumbar Spine. R2's face sheet dated 04/17/2024 documents that R2 is a [AGE] year-old female with diagnoses not limited to: nondisplaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, encounter for other orthopedic aftercare, muscle weakness, dementia, history of falling. R2's MDS (Minimum Data Set), dated 03/27/2024, shows R2 is rarely/never understood and cognitively impaired. Facility reported incident/FRI dated 03/12/2024 documents that the facility reported an injury of unknown origin. FRI documents that V1 (administrator) was notified by V32 (director of guest relations) that V39 (R2's daughter/Power of Attorney) noticed discoloration on R2's right lower face cheek and R2 was unable to state what happened. FRI documents that nurse on duty performed skin check and discoloration noted to lower right cheek, right arm, and hand. FRI documents that R2's doctor was notified. On 04/16/2024 surveyor reviewed R2's health records and no documentation of R2's provider being notified/consulted of discoloration to R2' right lower cheek, right arm, and hand. No documentation in R2's health records of any thorough assessment or treatment done on or after 03/12/2024. On 04/17/24 at 11:35 AM V39 (R2's Power of Attorney/POA) states that she would inquire about R2's right leg swelling to the nurses on duty each day she was there, and the nurses would respond to her that R2 has arthritis. V39 states that R2 would be screaming dolor which means pain in Spanish and staff would not pay attention to her. V39 states that she noticed a decline and change with R2 since that morning that V39 noticed R2's discoloration to right side of face, right arm, right hand, and right leg swelling. 04/18/24 at 9:51 AM V43 (Assistant Administrator) states that she investigated the injury of unknown origin. V43 states that R2 didn't know where she got it, initial investigation started on 03/12/24. V43 states that date 03/06/24 documented in the FRI is an error. V43 states that nursing is responsible to document assessments and documentation of notification to the residents' provider. V43 states that it is important for the resident's provider to know so if he wants to give new orders for in house treatment or send out to hospital for further evaluation. V43 states that no staff stated witnessing R2 falling. On 4/17/2024 at 12:29pm via telephone call, V22 (Registered Nurse) states that she cannot remember what happened to R2's face. V22 states that she remembers R2 being in pain. V22 does not remember the exact dates. V22 states that what was unusual, was R2 was rubbing part of her leg. V22 is not sure what part, but seemed like R2 was in pain. V22 states that she could not even touch R2 without everything hurting. V22 states that she notified the attending provider and there was an order for x-ray of her right knee. V22 states R2 was in a lot of pain and that was not her usual. V22 states that she had worked with her a week before that, and she was always wanting to stand up. V22 states that R2's daughter came up to V22 and said this is not like mom, she usually gets up. V22 states that she assessed R2's vital signs and documented in progress notes. V22 states that she is not sure exactly what she said to the provider over the phone. V22 states that she was trying to lift her leg and R2 was moaning and even if V22 lay her hand on her leg gently, R2 complained of pain. R2's change in condition form (03/10/2024) documents in part: right knee pain started on 03/08/24 .unable to stand without pain .R2 has pain to right knee when attempting to perform ROM (range of motion). R2's ADL (Activity of daily living) mobility task (03/06/2024) V38 documented R2 required partial/moderate assistance supervision/touch assistance with bed mobility, transfers between surfaces. R2 tasks that V36 documented (03/07/2024) R2 required substantial/maximal assistance supervision/touch assistance with bed mobility, transfers between surfaces. R2 tasks that CNA documented (03/08/2024) R2 dependent for supervision/touch assistance with bed mobility, and for transfers between surfaces not applicable. R2 tasks that CNA documented (03/09/2024) R2 dependent for supervision/touch assistance with bed mobility, transfers between surfaces. No ADL (Activity of daily living) mobility documentation noted for dates 03/10/2024 and 03/11/2024. R2 tasks that V36 documented (03/12/2024) R2 required substantial/maximal assistance supervision/touch assistance with bed mobility, transfers between surfaces. R2 tasks that CNA documented (03/13/2024) R2 required substantial/maximal assistance supervision/touch assistance with bed mobility, and for transfers between surfaces not attempted due to medical condition or safety concerns. R2 tasks that CNA documented (03/14/2024 05:53 AM) R2 required partial/moderate assistance supervision/touch assistance with bed mobility, and for transfers between surfaces not attempted due to medical condition or safety concerns. R2 tasks that V36 documented (03/14/2024 8:03 PM) R2 required substantial/maximal assistance supervision/touch assistance with bed mobility, transfers between surfaces. R2 tasks that CNA documented (03/14/2024 11:41 PM) R2 required dependent supervision/touch assistance with bed mobility, and for transfers between surfaces not applicable. No ADL (Activity of daily living) mobility documentation noted for date 03/15/2024. R2 tasks that CNA documented (03/16/2024) R2 required substantial/maximal assistance supervision/touch assistance with bed mobility, transfers between surfaces. R2 tasks that CNA documented (03/17/2024) R2 required substantial/maximal assistance supervision/touch assistance with bed mobility, and for transfers between surfaces dependent. R2 tasks that CNA documented (03/18/2024) R2 required dependent supervision/touch assistance with bed mobility, transfers between surfaces. On 04/16/2024 at 3:31 PM V36 (CNA) V36 states she saw R2's leg was swollen. V36 states she reported it Saturday and the discolorations and swelling weren't there Friday, March 15, 2024. On 04/16/2024 at 12:59 PM V37 (CNA) states the importance of notifying the nurse when a resident has had a fall whether unwitnessed or witnessed, V37 states because resident could have broken something or could have hit their head. V37 states that staff will not know what is going on internally. V37 states that R2 says dolor, and V37 states that she reports it to the nurses. V37 states that she cannot recall the dates and times that she reported to the nurses about R2's pain. On 04/18/24 at 11:42 AM V42 (Director of Rehabilitation) states that if a fracture occurred then you can assume that the patient will show a decline in activity. R2's physical therapy note, (03/06/24) documents in part: R2 had gait training. R2's physical therapy note, (03/08/24) documents in part: R2 had gait training. R2's physical therapy note, (03/11/24) no documentation that R2 had gait training. R2's physical therapy note, (03/13/24) documents in part: R2 refused gait training. R2's physical therapy note, (03/14/24) documents in part: R2 refused gait training. R2's physical therapy note, (03/15/24) documents in part: R2 low tolerance for standing. R2 refused gait training. On 04/16/2024 at 2:35PM, V17 (Nurse Practitioner) states R2 was having swelling. V17 states that she ordered the ultrasound doppler because if there is no sign of infection, no trauma or report of a fall and staff didn't tell V17 that R2 had any laceration, V17 states she will typically do a Doppler to rule out a blood clot because that is biggest thing that can harm. V17 states that she did not see R2 before V17 ordered the ultrasound doppler. V17 states that certainly a fall can cause a fracture. On 04/17/24 at 10:53 AM V40 (Licensed Practical Nurse/LPN) states that when R2's daughter informed her about R2's leg being swollen, V40 states that R2 was sitting on the wheelchair in front of the nurse's station. V40 states that she checked the lower part of the legs, just to see if it was swollen or not. V40 states that she escorted R2 to her room. V40 states that she pulled R2's pants down and noticed the right thigh was bigger than the other thigh. V40 states that she reported to V17, and she ordered ultrasound doppler only at that time. V40 states that when her leg was swollen, R2 still had fading bruises on her face and arm. R2's Health Status Note, 3/16/2024 15:29, documents in part: R2's daughter complained that R2's right leg is slightly bigger than her left leg .V17 (Nurse Practitioner) order for venous doppler of right leg to rule out blood clot. No documentation of R2's assessment including pain assessment noted in R2's health record on 03/16/2024. R2's General Progress note, 03/16/2024 21:30, documents in part: V15 (Registered Nurse) was notified by CNA that while changing R2, noted to have swelling of right leg from hip down and complained of pain with movement .attending physician was notified with orders to do x-ray of right thigh and hip. R2's right hip radiology results report documents examination date 03/18/2024 at 12:00 AM. Medical Professional Progress Note, 3/18/2024 12:09, documents in part: Per nursing staff R2 is reporting pain when transferring, and with changes R2 has had no behavioral changes besides continued fatigue . swelling present in right leg, very limited ROM in right leg, R2 report pain with all movement of right extremity .hip pain and swelling noted over the weekend x-ray of the right hip and doppler of the right lower leg ordered .Right hip x-ray shows a complex right intro, chant, moral hip fracture, no dislocation or vascular necrosis diffuse osteopenia. On 04/18/24 at 10:42 am, V2 (Director of Nursing) states that she reported the unwitnessed fall with injury on March 18th. 2024, because V2 states that she was made aware of the x-ray, resulting as a positive acute fracture. V2 states when R2's x-ray results came in, V2 went to see R2 and there was swelling on the right leg, V2 states that she asked R2 if she was in dolor which means pain in Spanish. V2 states that R2 responded with face gesture in some way acknowledging it is discomfort. V2 states that she asked R2 if she had a fall, and R2 said yes to V2. V2 states that she asked R2 when her fall occurred and R2 responded like some 5 days or 3 days ago. Facility policy titled Notification for Change of Condition (12/27/2023) documents in part: The facility will provide care to residents and provide notification of resident change in status . The facility must immediately inform the resident; consult with the resident's physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention.

Based on interviews and records review, the facility failed to keep one resident (R4) free from abuse in a sample of three reviewed. This deficiency resulted in R4 being hit by R5 with a walker, and R4 sustained a laceration to the forehead requiring five sutures. Findings include: Facility Reported Incident Report (FRI) dated 3/20/2024 documents: -Physical abuse and documents R4 stated R5 picked up walker and pushed it towards his face. Investigations stated R4 sustained 5 sutures to right eyebrow, right hand skin tear and mid back abrasion. Hospital records dated 3/20/2024 document: -R4 assaulted by another resident with a walker. Patient c/o (complaining) of mild headache. Sustained laceration to forehead and skin tear to right hand. R4 is alert and oriented X4 (Person Place, time, situation). -R4 has two inches laceration superior right eyebrow, 5 cm in length, and 2 cm in depth. Laceration repaired with 5 sutures. R4's current face sheet documents R4 is a [AGE] year-old individual last admitted to the facility on [DATE] and discharged on [DATE]. R4's medical conditions include but not limited to: Cerebral infarction, unspecified, syncope and collapse, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R4's MDS (Minimum Data Set) section C -Cognitive Patterns documents R4's Brief Interview for Mental Status (BIMS) dated [DATE], as 14/15, indicating R4 has intact cognitive funtion, and R4's MDS section GG - Functional Abilities and Goals dated [DATE], document R4 needs partial/moderate assistance with showering/toileting, eats independently, and uses a manual wheelchair. R5 is a [AGE] year-old individual admitted to the facility on [DATE] and discharged on [DATE]. R5's current face sheet documents R5's medical conditions to include but not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R5's Brief Interview for Mental Status (BIMS) dated [DATE], document R5 has a BIMS score of 11/15, indicating R4 has moderate cognitive impairment. Section GG - Functional Abilities and Goals dated March 20, 2024, document R5 needs partial/moderate assistance with showering/toileting, eats independently, and R5 uses a walker for mobility. On 04/18/2024 V30 (Psychiatric Nurse Practitioner) said R4 was alert and oriented to person, place and sometimes to time, because R4 sometimes would forget where he was. V30 said R4 was not violent, and R4 mentioned to V30 that R5 threw a walker at him, and V30 observed a bruise on R4's forehead. V30 said R4 told her that he was not happy at being in the facility and he wanted to leave and go home especially after he was hit by R5, and he was disturbed that R5 hit him, and he did not understand why this could happen to him while he was at the facility. V30 said R5 was moved to another room and R4 felt safe but wanted to go home after the incident. On 4/16/2024 at 2:47 pm, V8 (Certified Nursing Assistant-CNA) said she was in another residen'st room, when V10(Licensed Practical Nurse-LPN) asked her to go to R4's room and assist her. V8 said R4 and R5 were fighting, and R5 hit R4 with a walker. V8 further said when she last checked on R4 and R5 at about 2:40am, they were both in bed watching TV. V8 said she asked R4 what happened, and R4 said R5 threw something at him, and he threw it back at him. V8 said she saw R4 with gash between his forehead and nose, and he was bleeding. V8 said she assisted V9 and V10(LPNs) to clean R4. V8 said residents are not supposed to hit each other, and that's a form of abuse. On 4/16/2024, at 3:00pm, V9(Licensed Practical Nurse-LPN) she as she was coming out of another resident's room when she saw R4 in the hallway with V10(LPN). V9 said she went to find out what was happening and to assist because R4 was her resident that night. V9 said she saw R4 has a gash on his forehead and was bleeding, and R4 kept saying a resident (R5) hit him, pointing to his roommate (R5). V9 stated she started cleaning R4 up and put pressure on the gash, then called V12(ADON) who was in the building, called the physician, family and 911, and orders were given to send R4 to the nearby hospital. V8 stated hitting is not allowed in the facility and this is a form of abuse. On 4/16/2024 at 3:18pm, V10(Licensed Practical Nurse) said she was at the nursing station when she saw R4 at the nursing station with a [NAME] on his head, V10 provided care and notified V9(LPN), who was R4's nurse that night. V10 stated residents should not hit each other because that is a form of abuse. On 04/17/2024 at 12:16am, V2(Director of Nursing-DON) V2 said residents should not hit each other, because that's physical abuse, and the facility has to intervene and separate residents before the abuse happens. V2 stated what happened between R4 and R5 would be considered resident to resident physical altercation, which is a form of abuse. On 04/17/2024 at 12:32pm, V1(Administrator) she got a call in the middle of the night on 3/20/2024 by nursing staff letting her know there were two residents (R4, R5) appeared to have had a physical altercation, which is a form of physical abuse. V1 said residents should not hit each other. V1 stated R5 has dementia, and he was startled when R4 put on the rights in their room, which prompted R5 hit R4 with his walker.V1 said R4 was sent to the hospital and received a few sutures to the head. On 4/17/2024 at 1:36pm, V12 (Assistant Director of Nursing-ADON) said V8 & V9 (LPNs) called him to the unit and informed him that there had been an alteration with injuries between R4 and R5. V12 said upon entering the unit, he observed R4 by the nursing station near the North Hallway, and the V8 and V9 were attending to him. V12 said R4 had a laceration on his forehead which was bleeding, and the nurses were putting pressure on it. V12 said he called 911 immediately, because R4 has a wound on the head that was bleeding. V12 said R5 was in the room with a CNA (cannot remember the name of CNA). V12 said he then called V1(administrator) who is the abuse coordinator and notified her of the alteration between R4 and R5. V12 stated what happened between R4 and R5 was physical abuse. V12 said physical contact between residents is not allowed in the facility. Facility Policy Titled Abuse and Neglect, dated 07/14/2023 documents: Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Abuse: Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling. Police Report Number: JH194447.

Based on interview and record review, the facility failed to supervise a cognitively impaired resident (R8) who is at risk for falls and has a history of falls from having repeated falls; failed to ensure that a licensed staff member assesses a resident who has fallen prior to moving the resident; failed to create and implement fall prevention interventions; and failed to follow their facility's fall policy and procedure in a total sample of 10 residents. As a result, R8 fell and sustained a sub capital left femoral neck fracture that required left hip hemiarthroplasty surgery. Findings include: R8's Admission Record, documents, in part, diagnoses of dementia, traumatic subdural hemorrhage, cognitive communication deficit, chronic obstructive pulmonary disease, hypertension and history of falling. R8's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R8 has severe cognitive impairment. R8's Functional Status for walk in room (how resident walks between locations in his/her room) and walk in corridor (how resident walks in corridor on unit) is coded for a resident's performance of supervision - oversight, encouragement or cueing. R8's Fall Risk Screen, dated 5/2/23, documents, in part, that R8 is at risk for falls with a history of falls within the last six months as 1-2 times. Fall report, titled Incidents by Dates, with date range of 4/1/23 to 7/19/23, documents, in part, that R8 had two fall incidents: 7/6/23 at 10:23 am and 7/12/23 at 2:30 pm. R8's hospital radiology results, dated 7/13/23, from X-ray of left hip, pelvis, and femur show sub capital left femoral neck fracture with half shaft width superior migration of the distal fracture fragment. On 7/24/23 at 12:05 pm, V15 stated that R8 is alert, walks around, will frequently change clothes throughout the day, and will have a full blown conversation that makes sense then will be confused and is going to get on the bus. V15 (Licensed Practical Nurse, LPN) stated that on 7/13/23, V15 stated, I (V15) came in and was doing my med pass. (R8) was sitting on the bed, and I am used to seeing (R8) up walking. I told (V9, Certified Nursing Assistant, CNA) that R8 needed to be changed because R8 was sitting with R8's clothes half off. V15 stated that V9 went into R8's room to change R8, and then V9 reported to V15 that R8 won't stand up for V9's care and is in pain. V15 stated that V15 went to assess R8 and asked where the pain was, and R8 was pointing to R8's left side. V15 stated that R8 said repeatedly, I (R8) can't get up. V15 stated that V15 notified V21 (Nurse Practitioner, NP) who was in the facility. V15 stated that V21 and V15 went to R8's room together, and V21 assessed R8. V15 stated that when V15 assisted with removing R8's pants, R8 had left hip swelling, and when touching R8's left hip, R8 said, Yes, it hurts right here. V15 stated that V21 ordered an X-ray of R8's left hip. When asked about supervision of R8 for fall prevention, V15 stated, Everybody should do that. It depends on the time of the day. How many CNAs we have. I (V15) am passing meds. I can't monitor everyone. On 7/13/23 at 10:50 am, V15 documented in R8's electronic medical record (EMR) in a Health Status/Progress Note, During med pass (R8) c/o (complained/of) pain to left hip. Head to toe assessment done, and when touching left side of hip (R8) stated that hurts right there. Call was placed to (V21, NP) to inform of (R8) c/o pain and stating it hurts when (V15) asked to complete ROM to left leg. PRN (whenever needed) order for (Acetaminophen) was given. (V21) came to assess (R8) and after assessment (NP) ordered STAT X-ray of L (left) hip. On 7/24/23 at 12:36 pm, V21 (NP) stated that R8 is confused, alert to person, is social on the unit speaking to peers and employees, and wanders, but is redirectable. V21 stated that V21 rounds on residents in the facility five days a week, and if a resident would have a fall incident or change of condition while V21 was in the facility, V21 stated, I (V21) would see them that day. When asked if on 7/12/23, was V21 notified about R8's fall incident that occurred on 7/12/23, and V21 stated, No. I (V21) was called by (V15) on 7/13/23. (V15) called and said that (R8) was not (R8's) self and having pain. Not able to ambulate. This was an acute change. V21 stated that V21 went to R8's bedside to examine R8 and that V9 (CNA) and V15 (LPN) were there. V21 stated that R8 was in pain, rubbing R9's left hip and could only move R8's left leg a little bit while complaining of pain. V21 stated that V21 questioned aloud if R8 had fell again? V21 stated that V9 (CNA) said, '(R8) did fall yesterday.' I (V21) was never notified of that and that's why I got X-rays. V21 stated that V21 immediately reported not being notified of R8's fall from 7/12/23 to V24 (Assistant Director of Nursing, ADON #2), and that V24 came up to R8's floor to speak with V21 who said that V24 was aware of R8 complaining of pain on 7/12/23 but was not aware of R8's fall on 7/12/23. V21 stated, I (V21) was not made aware of (R8's) pain on 7/12/23. If I would have, I would have seen (R8). V21 stated that V21 had saw R8 in the morning on 7/12/23 (prior to the fall) and that R8 was not complaining of pain at that time. V21 stated that on 7/13/23 with R8's left hip pain and with V21 having knowledge now of R8 having a mechanical fall on 7/12/23, V21 ordered the stat X-ray of R8's left hip. V21 stated that on 7/13/23 at around 4:00 pm, V21 received a call from V15 (LPN) alerting V21 that R8's X-ray results showed a fracture, so V21 ordered R8 to be transferred to the hospital. R8's Radiology Results Report for X-ray left hip (performed in facility on 7/13/23 at 12:11 pm and reported on 7/13/23 at 3:21 pm) documents, in part, Findings: Mildly displaced sub capital left femoral neck fracture. On 7/25/23 at 11:14 am, V11 (CNA) stated that R8 has dementia, is alert, is not 100% there mentally and that V11 assists R8 with getting dressed in the mornings. V11 stated that R8 will be dressed and then will be taking off R8's clothes to put on different or another resident's clothes. V11 stated that R8 is a busy body. V11 stated that R8 will walk the unit, that R8 doesn't interact with activities (in dining room) and won't sit for long at the nurse's station before getting up and walking again. V11 stated that R8's gait is steady, but not steady like ours, and when asked if R8 is a fall risk, V11 stated, Absolutely. (R8's) a fall risk. When asked how does V11 prevent R8 from falling, V11 stated, From time to time, I (V11) step out to monitor. When I am doing patient care and need to step out (to the hallway) to get something. It's kind of hard. V11 stated that on 7/12/23, V11 stated, I (V11) was walking past (R8's) room, and I saw (R8) on the floor. We were passing lunch trays. V11 stated, (R8) is by (R8's) roommate's (R10) bed. (R8) is long, and I saw(R8's) feet from the hallway. (R8) was laying on the floor on (R8's) back. I went in (to R8's room) and then out. I tiptoed out trying to find someone in the hall, and I found (V9, CNA) passing trays. V11 stated that V9 and V11 went into R8's room and that R8 was laying on floor, reaching for us. We (V9, V11) assist (R8) up. We grabbed under (R8's) arms and supported (R8). And (R8) was walking. I was holding onto (R8) when (R8) walk back to bed. (R8) couldn't tell us what happened. (R8) sat on (R8's) bed. (R8) complained of pain on left side. We informed (V20, LPN) about the pain, and (V20) did assessment. V11 stated that V11 was R8's assigned CNA on 7/12/23 for the 7:00 am to 3:00 pm shift. V11 stated that when V20 was in R8's room (along with V9), V11 informed V20 that V11 found R8 on the floor. V11 stated that R8 stayed in bed on 7/12/23 for the remainder of the day shift. V11 stated that the procedure for when a resident fall in the facility is to inform the nurse let him or her proceed to check out the resident. Proceed to do what is necessary to get (resident) in a safe place on bed. It's the nurse's call. V11's statement about the facility procedure for not moving a resident prior to a nurse's assessment contradicts V11's actions on 7/12/23. On 7/24/23 at 1:03 pm, V9 (CNA) stated that R8 is alert, confused and walks around on (R8's) own. V9 stated, (R8) does (R8's) own thing. You let (R8) do (R8's) own thing. (R8's) fine. We are just watching (R8). V9 stated that R8 had a fall on 7/12/23 at lunch time while V9 was passing trays around 12:00 pm to 12:30 pm. V9 stated that V11 came for help from V9 because V11 found R8 on the floor. V9 stated that V9 and V11 went to R8's room and that V9 saw R8 laying on the floor next to the wall closest to R10's bed. V9 stated that R8 was reaching up, and V9 and V11 transferred R8, each under R8's arm, and walked R8 to R8's bed closest to the window. V9 stated that V9 heard V11 then tell V20 (LPN) about R8's fall and that V9 went to resume passing lunch trays to residents. V9 stated that about one hour later, V9 went back to R8's room to collect R8's lunch tray, and R8 was asking for pain medication. V9 stated that V9 informed V20 of R8's request for pain medication. V9 stated that the proper procedure when a resident fall is to inform the nurse to assess the resident. V9 stated that it was impulse that V9 moved R8 from the floor on 7/12/23 prior to V20 assessing R8. V9 stated that for the day shift on 7/13/23, V9 was assigned to R8, and was getting R8 dressed for the day. V9 stated that V9 was trying to get R8 to stand from the bed position and that R8 completely couldn't stand and that R8's left hip was hurting. V9 stated that V9 informed V15 (LPN) of R8's pain, not allowing V9 to dress R8, and R8 not being able to stand. V9 stated that V9 and V15 returned to R8's room to check on R8. V9 stated that V21 (NP) then came to R8's bedside, and V9 let V15 and V21 know about R8 being found on the floor on 7/12/23. On 7/25/23 at 10:00 am, V20 (LPN) stated that V20 primarily works R8's floor where residents have dementia, Alzheimer's, are confused and wander. V20 stated that V20 is familiar with R8 and that R8 has dementia, is alert, wanders everywhere. V20 stated that V20 instructs the CNAs to monitor R8 and to make sure that we see (R8) all the time. But it's hard to do when we have short staff. V20 stated that R8 is a fall risk resident, and R8 is constantly moving, won't stay in chair, won't stay in room. When asked if R8 has had a fall incident when V20 was working in the facility, V20 stated, No, never that I (V20) can recall on my shift. No one reported to me that (R8) fell . In my shift, (R8's) at risk, and I would endorse to the other nurse if (R8) had fallen. (R8) had pain, and I reported to nurse to monitor (R8) after pain medication. When asked about V20's documentation in R8's EMR dated 7/12/23 about R8's pain, V20 stated that V9 and V11 (CNAs) informed V20 that R8 was complaining of pain. V20 stated that this was round 2:00 pm on 7/12/23 and that R8 was in bed. V20 stated that V20 assessed R8, asking R8 where the pain was, and that R8 was pointing to R8's left hip and lower back and was asking for pain medication. V20 stated that V20 assessed R8's skin near R8's left hip (with assistance from CNA (V9) to pull down elastic waistband pants) and that V20 had R8 move R8's left leg. V20 stated that when R8 moved R8's left leg, R8 was guarding the left hip, and V20 did stand (R8) up and sit down but that R8 didn't go anywhere else. V20 stated that R8 cannot tell V20 a number of the pain scale, so V20 scored R8's pain as a 4 out of 10 scale and administered Acetaminophen to R8 for pain. V20 stated that on 7/12/23 around 6:30 pm to 7:00 pm, V20 reassessed R8's pain level and that R8 stated that R8 was fine. When asked about R8's activity on 7/12/23 from 2:00 pm to 7:00 pm, V20 stated, I (V20) didn't lay eyes on (R8) and to be honest. I didn't know if (R8) was in (R8's) room or the activity room. CNAs are monitoring (R8). They will let me know. V20 stated that R8's pain was just normal and that V20 did not inform V21 (NP) of R8's left hip pain on 7/12/23. When asked about V20's late entry documentation (for R8's pain on 7/12/23, V20 created a progress note on 7/14/23), They just remind you. (R8) may have some fall. V20 stated that V12 (ADON #1/Fall Coordinator) reminded V20 to perform documentation for R8 in R8's EMR. V20 stated that V20 documented R8's fall incident charting documents on 7/13/23, and V20 documented a recent fall for R8. V20 stated that on 7/13/23, V15 (LPN) reported to V20 (LPN) that R8 had a fall on 7/12/23, so V20 then connected R8's left hip pain to an unwitnessed fall. When asked V20 to describe a resident's change of condition, V20 stated that if a resident cannot walk, cannot lie down, crying out, blood pressure out of limits, then V20 will notify the in-house nurse practitioner. V20 stated, That's my job, my priority is their health. Make sure they (residents) are well taken care of. On 7/14/23 at 5:00 pm, V20 (LPN) created (documented) this late entry Health Status/Progress Note with effective date of 7/12/23 at 6:00 pm, (R8) received at 9:00 am up and about in the hallway with good steady gait. Alert, oriented x 1-2. Quiet, calm with periods of confusion noted. Redirected as needed. Has good appetite for breakfast and adequate fluids intake. Compliant with all due meds without on towards side effect. Needs one staff assist with ADL's (activities of daily living). Vital signs are within normal range. Approximately around 2pm, (V20) informed by (V9, V11, CNAs) that (R8) is complaining of pain. (V20) assessed (R8). (R8) sitting on bed, verbalized that (R8) had pain on (R8's) left side and back pain. Vital signs stable, able to move (R8's) lower and upper extremities without any discomfort. (R8) was medicated with (Acetaminophen), PRN, and was relieved with positive result in an hour. 7:00 pm: F/U (follow/up) (R8) pain currently. (R8) verbalized (R8) was relieved and remain verbalize on (R8's) baseline. (R8) return to (R8's) baseline until end of shift. Endorse to 2nd shift nurse 7p-7a to check and monitor (R8). R8's Fall Risk Screen (7/13/23 at 6:58 pm), R8's SBAR (Situation, Background, Assessment and Recommendation) Report (7/13/23 at 6:52 pm), R8's Follow Up/Monitoring: Falls (7/13/23 at 6:54 pm) and Pain Evaluation (7/13/23 at 6:36 pm) were documented by V20 for R8's left hip pain and unwitnessed fall on 7/12/23. On 7/25/23 at 1:34 pm, V12 (ADON #1/Fall Coordinator) stated that R8 has dementia, is a wanderer and walks freely on R8's locked unit. V12 stated that R8's fall interventions include staff keeping R8 within their vision and being mindful of where (R8) is throughout the shift. V12 stated that a resident's care plan for fall prevention is done on admission, quarterly and when a resident has a fall occurrence. V12 stated that V12 performs an investigation when a resident has a fall incident to determine the root cause to see what happened. V12 stated that V12 will then update the resident's care plan with a new intervention to prevent a fall from happening again. To prevent further falls. V12 stated that fall risk screenings are done on admission, readmission, quarterly and when a resident falls. V12 stated that the rescreening when a resident fall is to see if functional status has changed, medication have change or resident may require an assistive device. V12 stated that the nurse will document in the resident's EMR of a fall occurrence which triggers 5 risk management forms to complete: fall risk screen, fall event form, pain risk screen, SBAR, and follow up monitoring. V12 stated that the follow up monitoring for a resident post fall occurrence is done for 72 hours (3 days). When asked how a nurse can document follow up monitoring after a resident's fall when the follow up monitoring is backdated greater than 3 days from the fall incident, V12 stated, It should be in the forms if they (nurses) are following procedure. It doesn't transfer into the progress notes. V12 stated that if a CNA finds a resident on the floor, the nurse is to do an assessment prior to moving the resident. V12 stated, To ensure that it's safe to transfer, to safely transfer to wheelchair or bed. V12 stated that it's important not to move a resident that has fallen without a nurse assessing the resident because the resident may have hit his/her head, have pain to neck or down the back, or have broken legs. V12 stated that the nurse will assess the resident who has fallen with checking range of motion (ROM) of extremities, searching for bony prominences, severe pain on palpation, and leg length shortening. V12 stated that the purpose of having a nurse assess a resident who has fallen prior to moving the resident, To have a trained person with a license and education. Passed their state boards. Qualified to assess the resident for safety. When asked if a nurse assessed R8 prior to moving R8 who was on the floor on 7/12/23, V12 stated, That did not occur. They (V9, V11, CNAs) just assisted (R8) up. Not part of policy. What a CNA should do is notify the nurse prior to getting resident up and moving resident. V12 stated that it's important for nurses to timely document a resident's fall incident in the EMR because it's safety to resident. If nurse not doing follow up with risk management, it could lead to delay of care. It's for our policy. On 7/13/23 at 3:17 pm, V12 (ADON #1/Fall Coordinator) documented, in part, in an Interdisciplinary Note, Incident: (R8) found lying on the floor at the bedside on 7/12/23. Root Cause: (R8) lost (R8's) balance while transferring from the bed and fell to the ground. On 7/24/23 at 12:36 pm, V21 (NP) stated that on 7/6/23, I (V21) was on the unit. I was talking to (V15, LPN). (V15) was down the corridor (hallway). (R8) was seated in a regular chair facing the desk (at nurse's station). I was walking towards that area. Out of my periphery of my eyes, I see (R8) attempting to get out of the chair. (R8) seemed to loss balance and fell on to two knees. It was in hallway in front of one that leads to elevator. V21 stated that V21 was walking towards the nurse's station when V21 observed R8 falling. When asked if there was any staff at nurse's station at that time, V21 stated, I don't recall. When asked where V15 was at when R8 fell on [DATE], V21 stated, (V15 was) at the med cart. A few rooms down the hallway back from where I come from. V21 stated that the time of R8's fall on 7/6/23 was around 10:00 am. V21 stated that V15 came to assist V21, and that R8 didn't have pain with V21's assessment. V21 stated that V21 performed a head-to-toe assessment, that R8 did not hit R8's head and that V15 and V21 performed a 2 person transfer to place R8 back into the chair. V21 stated that V21 informed V15 to monitor (R8) and follow the facility's fall protocol. When asked about expectations of facility staff with notification of a resident's fall event, V21 stated, I (V21) expect to be notified of a fall. At that point, with a previous fall on 7/6/23, it is indication (for R8) with the fall on 7/12/23 that I considered blood work and concern for UTI (urinary tract infection). Working up something other for potential sources leading to seeing if there's a functional decline for (R8). (R8) had a fall (7/12/23) with delay of treatment. When asked if R8 experienced harm with having an unwitnessed fall on 7/12/23, then R8 being moved after the fall by staff with complaints of pain, and V21 not being notified until 7/13/23 of R8's fall on 7/12/23 with pain complaints, Yes. Additional harm. When asked what are V21's expectation of facility staff when a resident falls in the facility, It's up to their protocol. When asked what are V21's expectation of facility staff to help prevent a resident like R8 (alert, confused, wandering with dementia) from falling, V21 stated, I (V21) expect for any patient who has those behaviors to have frequent visual observation. V21 stated that R8 is at risk for falls. On 7/24/23 at 12:05 pm, V15 (Licensed Practical Nurse, LPN) stated that R8 is confused and mobile who walks everywhere. When asked if R8 is a fall risk resident, V15 stated, Yes. V15 stated that on 7/6/23, V15 was in the hallway, and V21 (Nurse Practitioner) was at the nurse's station when R8 fell from a sitting position to the floor on R8's knees. V15 stated that V15 walked up the hallway and assisted V21 with transferring R8 back to the chair in the nurse's station. V15 stated V21 assessed R8 and performed R8's vital signs. V15 stated, (V21) was basically doing everything. There wasn't anything else for me to do. When asked if there were any further orders from V21, V15 stated, To monitor (R8). When asked about when V15 documented in R8's electronic medical record (EMR) about R8's fall incident on 7/6/23, V15 stated, I did documentation that day, yes. When this surveyor showed V15 the details of V15's documentation on 7/17/23 (11 days later) about R8's fall from 7/6/23, V15 stated, I was so busy too. I forgot to do it. (V21) had documented everything. I probably forgot to put it in on 7/17/23. V15 stated that V12 said for me (V15) to put in my own note and that V15 is responsible for R8's care documentation. I was busy, and it's not an excuse. On 7/24/23 at 2:35 pm, V15 (LPN) stated that V15 did not notify V1 (Administrator) or V2 (Director of Nursing, DON) about R8's fall incident on 7/6/23. When asked who V15 notified in management, V15 stated, Nursing supervisor. The ADON. When asked if V15 notified either ADON for R8's fall incident on 7/6/23, V15 stated, No, I don't recall. On 7/17/23 at 4:50 pm, V15 (LPN) created (documented) this late entry Health Status/Progress Note with effective date of 7/6/23 at 10:48 am, (R8) witnessed transferring without staff assistance from regular chair at nurse station. (R8) went to stand and lost (R8's) balance and fell down to the ground on (R8's) knees. (V21, NP) witnessed incident and was unable to catch (R8) in time before (R8) fell (to) the ground. Head to toe assessment performed by (V21) and nurse on duty (V15), no injuries were found. (R8) did not hit (R8's) head. (R8) is pleasantly confused. (R8) denies any pain and no s/s (signs/symptoms) of pain observed. Vital signs obtained and recorded: BP (blood pressure) 133/63, P (pulse) 77, R (respirations) 16, T (Temperature) 97.9, O2 (oxygen) Sat (saturation) 97% on room air. Neuro check performed. PERRLA (pupils equal, round, reactive to light and accommodation). (R8) was assisted up and into chair with 2-person extensive assistance without issues. (R8) remained comfortable in chair. (R8) remain at baseline mentation. No new orders received from (V21). Staff monitoring ongoing as per facility protocol. Family and management made aware. On 7/6/23 at 3:21 pm, V21 (NP) documented, in part, in R8's Progress Notes, that (R8) with fall this morning. (R8) was attempting to stand up from chair near the nurse's station, lost (R8's) balance and fell to ground, landing on knees. On 7/17/23 at 4:38 pm, V15 (LPN) created (documented) this late entry SBAR (Situation, Background, Assessment and Recommendation) with effective date of 7/6/23 at 4:45 pm, Reason for report: s/p (status/post) fall. New orders: Continue to monitor (R8) as per facility protocol. On 7/17/23, V15 (LPN) created (documented) the additional fall incident forms for R8's fall on 7/6/23 including the Follow Up/Monitoring, Pain Evaluation, Fall Risk Screen, and Fall Event. On 7/18/23 at 10:50 am, V12 (Assistant Director of Nursing, ADON #1/Fall Coordinator) stated that any time a resident fall in the facility, staff is to report the fall to V12. V12 stated that V12 ensures that the staff does the proper documentation and notifications. V12 stated, I try to come up with an intervention to prevent a fall from occurring again. On 7/25/23 at 1:34 pm, V12 (ADON #1/Fall Coordinator) stated that V12 was notified about R8's 7/6/23 fall from V21 (NP) on 7/13/23 when R8's X-ray results showed a left femur fracture and was notified about R8's 7/12/23 fall on 7/13/23 by V15 (LPN). V12 stated that R8's risk management forms (7/13/23 risk management. I can't recall the date. If there is a incident for fall. Proper notification of md and family. It's safety to resident. If not follow up with risk management, it could lead to delay of care. It's for our policy. V21 stated that for R8's fall on 7/6/23, I (V12) didn't update the care plan. I didn't know about it (R8's 7/6/23 fall). R8's Care Plan, dated 7/14/23, documents, in part, a focus of (R8) had an actual fall on 7/12/23 with a goal of (R8) will have minimized risk for fall(s) with interventions (with created dates) as follows: Educate staff making sure (R8) is in line of vision as much as possible *For Fall on 7/12/23* (created on 7/14/23); Increase purposeful rounds by staff (pain, positioning, potty, personal items and parting) *For Fall on 7/12/23* (created on 7/14/23); Refer to activities department for participation *For Fall on 7/12/23* (created on 7/14/23); Refer to skilled therapy (PT{physical therapy}/OT{occupational therapy}) *For Fall on 7/12/23* (created on 7/14/23); Get to know (R8) habits to anticipate (R8's) needs (created on 2/7/23); and Provide safe and secure surroundings (created on 2/7/23). No interventions were documented in R8's care plan for the fall on 7/6/23. On 7/25/23 at 12:32 pm, V24 (ADON #2) stated that on 7/13/23, V21 (NP) notified V24 about ordering R8 an X-ray for left hip pain and that V24 had no knowledge of R8's 7/6/23 fall and R8's 7/12/23 fall. On 7/25/23 at 2:12 pm, V2 (DON) stated that residents are assessed, identified for risk for falls and a care plan is developed to institute interventions to prevent falls. V2 stated that when a resident falls in the facility, the nurse will do a new fall risk screen, and the care plan is reviewed for existing interventions and to add, change or modify interventions to prevent a fall from happening again. V2 stated that the nurse will notify the provider (doctor or nurse practitioner), family member and the supervisor when a resident falls in the facility. V2 stated that either V2, V12 and V24 are to be notified in the supervisor team. V2 stated that V2 was notified of R8's 7/6/23 fall from V21 (NP) on 7/13/23 and was notified of R8's 7/12/23 fall on 7/13/23 from V12. V2 stated that a follow up assessment is done after every fall for monitoring of the resident for a change of condition after the fall. V2 stated that the nurse has the whole shift to document the fall incident forms, and that the follow up assessments (Follow Up Monitoring: Falls) is to be done ideally for 72 hours. V2 stated that the follow up monitoring documentation pops up in the resident's EMR after a fall when the nurse initiates the fall incident forms in the EMR. V2 stated that the follow up monitoring won't appear in the forms in a resident's EMR if the nurse has not documented the fall occurrence. V2 stated that the nurse should document a fall incident if the nurse is aware of the fall, and it's the nurse's responsibility to notify the resident's family and practitioner. V2 stated, It's part of our policy. Standard of care. They (nurses) are the one seeing the patient. Notification should be charted to communicate a change in condition. Change of condition is a fall. V2 stated that when a resident if found on the floor, the nurse is to assess the resident prior to moving because, they (nurses) are trained, went to school for that, a standard of care. V2 stated that if a CNA moves a resident prior to the nurse assessing the resident on the floor, Hypothetically if there is an injury, we could further comprise the injury that's why it's important to absolutely make sure that resident is not injured before moving resident to a comfortable position. Facility policy dated February 2023 and titled Falls Management, documents, in part, 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 falls, plan for preventative strategies, and facilitate as safe as environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as necessary. Responsible Party: RN, LPN, DON. Fall Prevention Guidelines for all residents upon Admission/Re-admission: 1. A Fall Risk will be completed on admission, readmission, and quarterly, with each significant change and after each fall. 2. Residents at risk for falls will have Fall Risk identified on the interim plan of Care with interventions implemented to minimize fall risk. Facility Guideline following a fall incident: 1. Evaluate the resident for any injury and alert the Health Care Provider and Emergency Contact. 2. Complete a fall event. This event includes the circumstances surrounding the fall, devices in use, full body observation for injury, pain, range of motion and neuro checks as needed. 3. A Fall Risk Screen is completed by the Nurse at the time of the fall and then reviewed by clinical leadership. Facility policy dated September 2022 and titled, Safety and Supervision of Residents, documents, in part, General: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident-Oriented Approach to Safety: 1. Our resident-oriented approach to safety addressed safety and accident hazards for individual residents. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff b. assigned responsibility for carrying out interventions c. providing training, as necessary d. ensuring that interventions are implemented; and e. documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently b. evaluating the effectiveness of interventions c. modifying or replacing interventions as needed; and d. evaluating the effectiveness of new or revised interventions. Systems Approach to Safety: 2. Resident supervision is a core component of the systems approach to safety. Facility policy dated May 2022 and titled Dementia, documents, in part, General: A resident who displays or is diagnosed with Dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being Treatment and Services: 4. The facility's approach to care for a resident living with dementia follows a systematic care process to ensure that residents' individualized dementia care needs are met. Facility policy dated September 2016 and titled Care Plans, documents, in part, General: Each resident will have a care plan that is current, individualized and consistent with their medical regimen. Facility job description dated 2003 and titled Charge Nurse, documents, in part, Purpose of Your Job Position: The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is always maintained. Duties and Responsibilities: Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility. Fill out and complete accident/incident reports. Submit to Director as required. Chart all reports of accidents/incidents involving residents. Follow established procedures. Implement and maintain established nursing objectives and standards. Facility job description dated 2003 and titled Certified Nursing Assistant, [TRUNCATED]

Based on interview and record review, the facility failed to provide adequate fall prevention and supervision for two residents (R7, R8). This failure resulted in R7 sustaining a fall with sutures noted on right side of forehead, bridge of nose and above right eyebrow. R8 resulted sustaining a fall with stitches on the forehead. Findings include: R7 is [AGE] years old. R7 diagnoses include but are not limited to hepatic encephalopathy; alcoholic cirrhosis of liver with ascites; unspecified asthma; hyperlipidemia; anemia; thrombocytopenia; history of falling; esophageal varices without bleeding; other abnormalities of gait and mobility; other symptoms and signs involving the musculoskeletal system; cognitive communication deficit; Covid-19. According to MDS (Minimum Data Set), date 11/15/2022, R7 has a BIMS (Brief Interview for Mental Status) score of 13/15. R7 requires extensive assistance with two-person physical assist for bed mobility and transfer. R7 requires extensive assistance with one-person physical assist to walk in room, for locomotion on/off unit and for toilet use. R7 is not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking (with assistive device if used), turning around while walking, moving on and off toilet, surface-to-surface transfer. R7 uses a walker, wheelchair. According to progress note, date 12/11/2022, R7 returned from hospital after sustaining a fall the morning of 12/10/22, sutures noted on right side of forehead, bridge of nose and above right eyebrow. R7 New Admission Fall Risk Screen, date 11/8/2022, categorizes R7 as a high risk with a score of 20. R7 Recent Falls Fall Risk Screen, date 11/26/2022, categorizes R7 as a high risk with a score of 18. On 3/1/23 at 9:15 AM, V7 (Assistant Director of Nursing/Falls Coordinator) stated Upon admission, R7 was cognitively intact and had a BIMS (Brief Interview for Mental Status) of 13 according to the MDS. After R7 had Covid in December R7 wasn't the same. R7 was not cognitively intact. R7 could ambulate with a walker. R7 was capable to use the call light. R7 was impulsive, liked to do things on own. Due to impulsiveness R7 was a high fall risk. R7s fall interventions included bed in lowest position with wheels locked, call light within reach, floor mats, education to use the call light, especially with transferring, environment clutter free, purposeful rounding, referred to skilled therapy. R7 was in the bed and got up on own, lost balance while transferring and fell . R7 was unable to provide details. R7 told the nurse I fell , I don't know. The nurse found R7 on the floor, did an assessment, there was bleeding on the forehead. The nurse cleaned the area and put a dressing, did vitals, neuro check, range of motion. R7 was put back in bed. The nurse called the NP (Nurse Practitioner) who gave orders to send R7 to the ER (emergency room ). The hospital did a CT (Computerized Tomography) of head, negative of abnormalities, CT of spine negative of fractures. R7 came back with 3 sutures on the forehead. According to Covid 19 Abbott Binax Now Antigen Test Results, date of test: 12/3/22, R7 test result: positive On 3/1/23 at 11:56 AM, V21 (Rehab Director) stated R7 had PT (Physical Therapy), OT (Occupational Therapy), and ST (Speech Therapy) from 11/22-12/22. R7 was fairly high level/independent. R7 was confused. R7 was mobile, unsteady, agitated, verbally/physically aggressive toward therapy staff. R7 goals for PT were to increase lower extremity strength, transfers, standing balance, walk with walker, getting in/out of bed. R7 goals for OT were toileting transfers, total body dressing, arm strength. R7 goals for ST were insight into deficits, increase safety awareness, problem solving. R7 reached highest potential due to confusion level and lack of cooperation. R7 was confused and forgetful. R7 had the physical ability to use a call light but not the cognitive ability even with education. On 3/2/23 at 11:38 AM, V5 (Social Service Director) stated R7 was here long term due to declining physically and mentally. Upon admission R7 was cognitively intact, after R7 had Covid, R7 declined mentally and physically. According to Illinois Department of Public Health Report of Resident Incident/Accident, on 12/10/2022 at around 8:30AM, R7 was noted on the floor by staff doing purposeful rounds, alert, awake, verbally responsive and not in any form of distress. It was determined that fall occurred due to R7s intention to get out of bed and transfer self to wheelchair without assistance, R7s action resulted to accidental fall as R7 was unable to maintain balance and ended up on the floor, beside R7s bed. According to R7 care plan, initiated 11/8/2022, bed in lowest position with wheels locked, floor mats to both sides of bed added 12/10/2022 after R7s fall. R8 is [AGE] years old. R8 diagnoses include but are not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; unspecified dementia; traumatic subdural hemorrhage with loss of consciousness of unspecified duration; hypothyroidism; hyperosmolality and hypernatremia; hyperkalemia; personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; unspecified psychosis not due to a substance or known physiological condition; other symptoms and signs involving the musculoskeletal system; aphasia; cognitive communication deficit; chronic kidney disease; atherosclerotic heart disease of native coronary artery without angina pectoris. According to MDS, date 1/28/2023, R8 has a BIMS score of 4/15. R8 requires extensive assistance with two-person physical assist with bed mobility and transfer. R8 requires extensive assistance with one-person physical assist for locomotion on unit. R8 is totally dependent for toilet use requiring one-person physical assist. R8 is not steady, only able to stabilize with staff assistance when moving from seated to standing position and surface-to-surface transfer. R8 has impairment with upper and lower extremities on both sides in range of motion. R8 uses a wheelchair. According to progress note, date 1/9/2023, staff found R8 lying on the floor at the side of the bed during rounds. Laceration immediately noted to R8's head with fresh blood. R8 New Admission Fall Risk Screen, date 11/26/2021, categorizes R8 as a high risk with a score of 19. R8 New Admission Fall Risk Screen, date 1/5/2023, categorizes R8 as a moderate risk with a score of 13. On 3/1/23 at 9:15 AM, V7 (Assistant Director of Nursing/Falls Coordinator) stated R8 was not cognitively intact, had a BIMS (Brief Interview for Mental Status) of 4. R8 was in bed, wanted to get up, lost balance while trying to get up on own. R8 fell and hit head. The CNA (Certified Nursing Assistant) found R8 and called the nurse who did an assessment. R8 had blood on the forehead. The nurse cleaned the sight, did vitals, neuro checks. They put R8 back in bed, called the NP (Nurse Practitioner) who ordered to send out to the hospital. A CT (Computerized Tomography) of the head and spine was negative of abnormalities and fractures. R8 came back to the facility with stitches on the forehead. R8 had no falls before then so was not a high fall risk. R8 was not able to use the call light. R8s fall interventions included fall mats, bed in lowest position with wheels locked, purposeful rounding. Purposeful rounding is checking the resident for pain, positioning, if need changing, personal items close to patient, comfortable in bed. They are done every 1 to 2 hours. On 3/1/23 at 10:28 AM, V19 (Certified Nursing Assistant) stated I didn't see R8 fall. Nobody witnessed the fall. Another CNA found R8. We went to R8s room with the supervisor. R8 was on the floor by his bed. There was bleeding from R8s forehead. R8s bed was low, the fall mats were on the floor. R8 didn't tell us what happened. R8 was mumbling, nothing we could understand. The nurse assessed R8. We got R8 into bed. The nursed called the ambulance. On 3/1/23 at 11:35 AM, V20 (Certified Nursing Assistant) stated It was an unwitnessed fall. I was R8s CNA (Certified Nursing Assistant) that day. I was rounding on R8. I was checking on R8 more often because previously R8 went out for a stroke. The fall was after I put R8 to bed after dinner. R8 was on the floor. I asked R8 what happened. R8 was not able to tell me what happened. I got the nurse who assessed R8. R8 had a cut on his head. I saw blood. I monitored R8 until the ambulance came. R8 was not able to walk. R8 was total assistance. R8 was not able to use a call light because of dementia/cognitive impairment. R8 was never a high fall risk until after the stroke. I was told by the nurse that earlier that day R8 had been anxious to get out of the bed alone. The fall happened second shift. I got R8 up to a chair and put R8 at the nursing station because the nurse told me R8 was trying to get up on the previous shift. R8s bed was low, fall mats on the floor. R8 could not walk, R8 could only pivot. On 3/1/23 at 11:56 AM, V21 (Rehab Director) stated R8 was evaluated for Occupation Therapy the day of the fall, before the fall. R8 was receiving PT (Physical Therapy), OT (Occupational Therapy), and ST (Speech Therapy) 1/17/23-2/10/23. The PT goals were increasing leg strength, siting balance, standing balance, bed mobility, transfers, eventually walking, wheelchair mobility. The OT goals were splint/orthotic device to manage tone in upper extremities, dressing, shoulder range of motion, increased sitting balance during ADLs (Activities of Daily Living). The goals of ST were improve producing automatic speech, expressive communication, verbally respond to yes/no questions, tolerate thin liquids, least restrictive diet to minimize aspiration. R8 plateaued/reached highest potential. R8 was receiving OT 11/2/22-11/23/22. R8 last had PT in 4/22-5/22. R8 was dependent with mobility, no assistive devices. R8 was not able to use a call light cognitively or physically. R8 was discharged from therapy due to family choosing hospice placement. On 3/1/23 at 3:31 PM, V27 (Licensed Practical Nurse) stated R8 had an unwitnessed fall during the evening. The CNA (Certified Nursing Assistant) heard something. We went into R8s room. R8 was sitting on the floor near the bed, with right arm on the bed. I did an assessment, vitals, and cleaned R8s wound. There was a cut on R8s forehead with little bleeding. We got R8 back in bed. The CNA stayed in the room with R8 while I went to call the on-call NP (Nurse Practitioner) who ordered to send R8 out. R8 could walk but needed assistance, R8 was unsteady. R8 has dementia. R8 was not able to use the call light. We treat everyone as a fall risk and keep beds in lowest position and do frequent rounding. On 3/2/23 at 11:38 AM, V17 (Social Service) stated R8 was on the 3rd floor (dementia unit). R8 was transferred closer to the nursing station after the fall. R8 had severe dementia and was not able to make decisions. According to Illinois Department of Public Health Report of Resident Incident/Accident, on 1/9/2023 at around 9:00PM, staff doing purposeful rounds noted R8 lying on the floor at the side of the bed: alert, awake, and responsive. Findings revealed that accidental fall occurred due to R8s intention to get up from bed on own without staff assistance. R8 has the capability to get up from the bed and sit on the edge of the bed but requires staff assistance to actually transfer from the bed. R8 attempted to transfer from the bed on own, with the intention to stand, without staff assistance, lost balance due to bilateral lower extremity weakness, and as a result, fell to the ground. According to R8 care plan, initiated 11/26/2021, bed in lowest position and wheels locked, floor mats to both sides of bed added 1/9/2023 after R8s fall. On 3/2/23 at 11:38 AM, V5 (Social Service Director) and V17 (Social Service) stated BIMS 0-7 is severe cognitive impairment, not able to make decisions. BIMS 7-12 is moderate cognitive impairment. BIMS 13-15 is cognitively intact. BIMS is just one aspect to determine if cognitively intact, it can fluctuate depending on what's going on with the resident. Facility policy Falls Management, review date 2/23, documents in part: While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. Facility policy Safety and Supervision of Residents date 10/2021, documents in part: Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.

Based upon observation, interview, and record review, the facility failed to ensure staff are aware of resident fall prevention interventions, failed to implement fall prevention interventions, and failed to provide supervision for three of three residents (R5, R6, R7) reviewed for falls. These failures resulted in R5 sustaining skin tears and a right femoral neck fracture, R6 sustaining a scalp laceration which required staple repair, and R7 sustaining a forehead laceration which required suture repair. Findings include: 1. R5's (8/19/22) BIMS (Brief Interview Mental Status) determined a score of 13 (cognitively intact). R5's (8/19/22) functional assessment affirms extensive assistance is required for transfers and toilet use. R5's (8/1/22) fall risk screen determined a score of 13 (moderate risk). R5's (7/21/22) care plan includes potential for falls, resident at risk for injury from falls. Intervention: Anticipate and meet resident needs. Have commonly used items within reach. R5's (8/16/22) 4:00 AM fall event states prior to fall resident lying on the bed. Per patient, he was trying to reach for his walker. Last time the resident was observed: 2:00 AM. Did the resident hit their head? Not witnessed. Left elbow skin tear. R5's new fall intervention includes floor mats to be put at bedside when resident in bed. R5's (8/19/22) fall event states prior to fall resident lying on the bed. Resident stated, I want to get up and walk so I can go home. My legs are weak that's why I fall. Did resident hit their head? Not witnessed. Right elbow, right arm skin tears. Right trochanter redness, complained of pain. Range of motion painful in upper/lower extremities. R5's (8/19/22) progress notes state CNA (Certified Nursing Assistant) doing rounds, patient observed on the floor. Patient is alert and oriented to self with confusion and forgetfulness. Bed in lowest position, call light within reach. [floor mats were excluded]. R5's (8/21/22) hip x-ray includes mildly displaced/angulated fracture of the right femoral neck. On 9/7/22 at 12:02 PM, surveyor inquired about R5's functional status. V11 (Registered Nurse) stated, He cannot even stand up, he's like really weak in the knees. Surveyor inquired about R5's fall prevention interventions. V11 responded, We put like the bed in lowest position, and we put the call light within reach. We (me and the CNA) also do rounding like every hour. That's what I remember. Surveyor inquired about R5's (8/19/22) incident. V11 responded, As far as I remember the CNA passed by the room and he (R5) was already on the floor. What was in place is the bed in the low position and call light was in reach, but because of the mentation, he (R5) was not able to use the call light. I cannot remember if there was a floor mat. 2. R6's (8/5/22) BIMS determined a score of 2 (severely impaired). R6's (8/5/22) functional assessment affirms extensive assistance is required for transfers and toilet use. R6's (5/4/22) fall risk screen determined a score of 12 (moderate risk). R6's (7/16/22) initial facility reported incident states resident was noted on the floor. Laceration noted on midline scalp. MD (Medical Doctor) notified with order to transfer resident to emergency room for evaluation. Resident returned to facility, received one staple on her midline scalp. New fall interventions in place. R6's fall care plan includes the following interventions (6/21/18) Call light within resident reach when in room. (7/26/18) Bed in low position. On 9/6/22 at 12:31 PM, surveyor inquired about R6's fall prevention interventions V4, LPN (Licensed Practical Nurse), stated, I'm a floater but we try to put her in the dining area for activity, we lower the bed, and put the call light in reach. R6 was lying in bed (in high position), and the call light was out of sight and reach. Surveyor inquired about the location of R6's call light. V4 responded, I'm trying to find it cause it's not next to her, it was on the floor. Surveyor inquired about the height of R6's bed. V4 replied, To me it's a little higher than, I need to lower it. Surveyor inquired if R6's bed was waist high at this time. V4 replied, I think so. On 9/7/22 at 2:25 PM, surveyor inquired about R6's functional status. V9 (Licensed Practical Nurse) stated, She can't walk; she's wheelchair bound. Surveyor inquired about R6's (7/16/22) fall. V9 responded, I saw her sitting in the wheelchair, I turned my back and started doing something. I heard a noise, turned around and she fell out the wheelchair. She was sitting in the hallway. She had a cut on the back of her head, so they put a staple in there. Surveyor inquired about R6's fall prevention interventions. V9 replied, I don't know what was in place for her. 3. R7's (7/30/22) BIMS determined a score of 7 (severely impaired). R7's (7/30/22) functional assessment affirms extensive assistance is required for transfers and toilet use. R7's (7/29/22) fall risk screen determined a score of 7 (moderate risk). R7's care plan states (6/4/21) resident needs assistance to ambulate. (8/3/22) ensure call light button is within resident easy reach at all times while in room. R7's (8/1/22) initial facility reported incident states staff doing rounds noted resident on the floor. Laceration with small amount of blood noted on left forehead. MD notified with order to send resident to hospital. Resident returned to facility, received sutures on the left forehead. R7's fall event includes Effective Date: 8/1/22 (6:59 AM). When was the resident last toileted 12:16 AM, when was the last time resident was observed 3:45 AM. On 9/6/22 at 12:45 PM, surveyor inquired about R7's fall prevention interventions. V5 (LPN) stated, He has a low bed, non-skid socks and call light within reach. R7 was lying in bed, however, the call light was out of reach, and on the floor. [R7's call light cord was tied to the side rail and the side rail was below the mattress]. Surveyor inquired about the location of the call light. R7 was able to reach the call light cord, however, was unable to easily access the button, because it was caught between the mattress and side rail. On 9/8/22 at 10:14 AM, surveyor inquired about R7. V21 (LPN) stated, When I first got there, he (R7) was able to walk around and go to the bathroom, but now he's not able to function like he used to. Now he has to be changed and washed-up cause he can't. Surveyor inquired about R7's fall prevention interventions. V21 responded, We check on him and have like normal protocol for that, and he can use the light. Surveyor inquired about the facility protocol for checking on residents. V21 replied, I check on the residents every hour cause some are functioning less than others, and some of them are a fall risk. Surveyor inquired about R7's (8/1/22) incident. V21 stated, The CNA was doing rounds when she found him on the floor. He was going to the bathroom and laid outside the (bathroom) door. He has a walker and didn't have his walker with him. He didn't have any socks on his feet. I saw a gash on his head so I called 911 and sent him out. He did get stitches. On 9/8/22 at 2:19 PM, surveyor inquired about potential harm to a resident that sustains an unwitnessed fall. V30 (Assistant Medical Director) stated My first concern would be a head injury, skin and soft tissue injuries, and fractures of the spine and long bones. There's an infinite number of possibilities. The falls management policy (revised 6/21) states the facility will identify and evaluate those residents at risk for falls, plan for preventive 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. A fall risk will be completed upon admission, readmission, and quarterly, with each significant change and after each fall. Residents at risk for falls will have Fall Risk identified on the interim plan of care with interventions implemented to minimize fall risk.

Based on interview and record review, the facility failed to ensure correct administration of medications for two (R3, R5) of four residents reviewed for medication administration. This deficient practice resulted in R3's emergent transfer to a local hospital with cardiac implications that required hospitalization for close monitoring. Findings include: R3's Admission Record documents the following medical Diagnoses: [REDACTED]. R3's [DIAGNOSES REDACTED]. R3's MDS (Minimum Data Set) dated 1/15/2020 documents that R3 is severely cognitively impaired. R3 could not be interviewed. The Census List documents that R3 was admitted to the facility as 11/27/17 and indicates that R3 was transferred to a local hospital on [DATE]. R3's Progress Note dated 6/28/19 at 1:15 am and authored by V7 (Licensed Practical Nurse) reads: Resident received medication other than the medications prescribed by MD (Medical Doctor). This note documents that V8 (Physician) was called with an order to transfer resident to a local hospital for medical evaluation. A facility incident report subtitled Medication Error and dated 6/27/19 reiterates that R3 was administered the wrong medication. R3's Physician order [REDACTED]. Instead, R3 received medications that were not ordered by V8. R3's Hospital Record dated 6/28/19 documents a note authored by V12 (Hospital Cardiologist) that reads: Allergic Reaction: patient sent from NH (nursing home) due to her being given a Keflex tab around 2100 (9:00pm) which was not for her, she has a history of ([MEDICATION NAME]) allergy. This note continues to document that R3 mistakenly received Keflex 500 mg, [MEDICATION NAME]-[MEDICATION NAME] (20 mg/10 mg) and one dose of [MEDICATION NAME] 100 mg. The note reads: Brought to ER (emergency room ) and admitted to telemetry for observation given the potential for QT prolongation. Concern was raised about the interaction between the [MEDICATION NAME] and the [MEDICATION NAME]. R3's hospital note documented: EKG's were suggestive of significant prolongation of the QT interval. For this reason a cardiology consultation was obtained and (R3) was observed an extra day. According to R3's history, the EKG from 6/28/19 had changes when compared to an EKG dated 10/17/2012. The hospital plan was to continue cardiac management, monitor blood pressure closely, continue telemetry monitoring and repeat EKG's every six hours. It was noted that the [MEDICATION NAME]/[MEDICATION NAME] and Keflex medications that were mistakenly given to R3 were ordered to be administered to R5. R5's POS documented an order dated 12/21/18 which read, Give Keflex 500 mg every 12 hours indefinitely for suppression due to infected prosthesis. This POS also documents [REDACTED]. V8 (Medical Doctor/R3's Primary Doctor) was not available for interview. On 3/10/2020 at 11:10am, V9 (Cardiologist) stated, The combination of [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]), especially when given with antibiotics, can cause QT wave to be prolonged. It is an adverse reaction. It requires monitoring of the QT wave by EKG. If QT prolonged, it can lead to an arrhythmia or an abnormal heart rhythm. On 3/11/2020 at 1:26 pm, V13 (Pharmacy Manager) stated, Cardiac implication with [MEDICATION NAME] and [MEDICATION NAME] and Keflex when given in combination. QT prolongation between [MEDICATION NAME] and [MEDICATION NAME] can cause a severe interaction. If this is a brand new combination (of medications) for a resident, it would put a resident at a higher risk versus someone that's been on the medications for number of years. Also if brand new meds for patient, would let facility know to monitor QT status. A facility policy dated May 27, 2011 and titled, 8 rights of medication administration documents: 1. Right patient - Check the name on the order and the patient. Use 2 identifiers. Ask patient to identify himself/herself. 2. Right medication - Check the medication label. Check the order 3. Right dose A facility policy dated 7/14 and titled, Medication Administration documents: GENERAL: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. GUIDELINE: 1. An order is required for administration of all medications. 5. Check Medication Administration Record [REDACTED]. 15. Identify resident using two resident identifiers.

Based on interview and record review the facility failed monitor anticoagulation medication according to manufactures guide lines for the initial use of the medication. This failure affects one of three residents (R1) reviewed for anticoagulation therapy. As a result, R1 had excessive bleeding from a surgical wound after a knee replacement, due to a high level of the anticoagulation medication and sent to the hospital for treatment. Findings Include: R1 is [AGE] years old and was admitted to the facility for post knee replacement rehabilitation. R1 was at the facility from 8/18/15 through 9/30/15. R1 has [DIAGNOSES REDACTED]. During telephone interview on 11/22/16 at 2:15PM Z1 Orthopedic Surgeon stated R1 had poor anticoagulation therapy at the facility. It should have taken three to four days on [MEDICATION NAME] to get the [MEDICATION NAME] to a therapeutic level. R1 was on both drugs [MEDICATION NAME] and [MEDICATION NAME] for 10 days. R1 had bleeding in the surgical site (knee) and subsequently developed a hematoma which became infected. R1 has had several surgeries to this knee and currently has nerve damage. During telephone interview on 11/23/16 at 230PM Z2 Pharmacist stated [MEDICATION NAME] and [MEDICATION NAME] can be taken together for five days, until the INR (blood test to monitor [MEDICATION NAME] level) is at or above 2.0. If the INR level is not at 2.0 keep taking [MEDICATION NAME] until the INR level is 2.0. The INR level should be checked daily until stable, then depending on clinical need every one to four weeks. The POS (Physicians Order Sheet) admitting orders on 8/18/15 document [MEDICATION NAME] 120 mg (milligrams) subcutaneously every 12 hours for [MEDICATION NAME] until INR 2.5 then discontinue. [MEDICATION NAME] 5 mg give 1 tablet by mouth at bedtime for Aortic Valvular Prosthesis .The MARS (Medication Administration Sheet) documents [MEDICATION NAME] 120 mg was given 8/18/15 through 8/24/15. [MEDICATION NAME] 5mg was given 8/19/15 through 8/23/15. Progress Notes document Z4 (Nurse Practitioner) initial visit was 8/21/15. Z4 ordered an INR for 8/22/15. The INR was done on 8/24/15; the value was 1.86. Progress Notes dated 8/24/15 document R1 was sent to the local hospital to see Z1 (Surgeon) for wound dehiscence. The hospital laboratory INR dated 8/26/15 had a result of 2.8. R1 was readmitted to facility on 8/26/15. The [MEDICATION NAME] was discontinued at the hospital. Z4 saw R1 on 9/1/15 and ordered an INR for 9/3/15. The INR value for 9/3/15 was 1.68. Progress Notes dated document Z3 MD (Medical Doctor) ordered [MEDICATION NAME] 5.5mg and INR lab draw on 9/10/15. Progress Note dated 9/10/15 document Z4 orders continued [MEDICATION NAME] dose 5.5 mg and recheck INR on 9/17/15. The Laboratory report documents the INR value is 3.53 (high). The laboratory report documents an INR dated 9/9/15 with a value of 3.03 (high). The Progress Notes do not document who ordered the INR or who received the result. Progress Notes document R1 is started on [MEDICATION NAME] 300mg four times a day per orders from Z1 (Surgeon) after visit with Z1 on 9/15/15. Progress Notes dated 9/16/15 document to hold [MEDICATION NAME] and recheck in the morning. Notes 9/17 to hold [MEDICATION NAME]. Lab report INR value 9/17/15 is 5.03 critical high. Progress Notes dated 9/18/15 document Z3 orders [MEDICATION NAME] held and repeat INR on 9/19/15. Lab report 9/18/15 INR value 3.69 high. The MARS document [MEDICATION NAME] 5.5mg was given to R1 on 9/18/15 by E4 RN (Registered Nurse). Progress Notes dated 9/19/15 document Z3 ordered [MEDICATION NAME] held tonight then start [MEDICATION NAME] 5mg 9/20/15 and recheck INR 9/21/15. The laboratory report documents the INR was not checked until 9/24/15. The value was 2.19. Progress Note dated 9/22/15 documents R1's right knee incision bleeding large amount of bright red blood. R1 was sent to hospital at 3:55PM by medical transport. Interview on 11/23/16 E2 DON (Director of Nursing) stated, E4 no longer works here. The progress notes dated 9/18/15 state to hold the [MEDICATION NAME]. It should not have been given. Z3 Physician was unavailable for interview. Telephone interview on 11/23/16 at 1:10PM Z4 Nurse Practitioner stated, I would check INR weekly if it was not high. I would not order daily INR's if not high. It should not have taken that long to reach a therapeutic level for R1. [MEDICATION NAME] Prescribing Information from the manufacturer documents in part: Dosage and Administration. Individualize dosing regimen for each patient and adjust based on INR response. Monitoring. Obtain daily INR determination upon initiation until stable in the therapeutic range. Obtain subsequent INR determination every 1 to 4 weeks.

Based on interview and record review facility failed to follow their falls prevention clinical guidelines for two residents (R1, R2) out of four residents reviewed for falls. This failure resulted in R1 not being properly supervised 1:1 after staff noted that R1 ' s gait was unsteady, then falling and sustaining a small subarachnoid and possible tiny parenchymal contusion, and staff not repositioning R2 in her wheel chair correctly before transferring her and subsequently led to R2 falling forward onto the floor and sustaining a spinous process fracture. Findings Include: R1 ' s care plan dated 2-25-15 denotes at risk for injury from falls and impaired balance secondary to dementia; requires staff participation to reposition and turn; resident in visible view of staff when up in chair, and encourage resident to transfer positions slowly. R1 ' s nurse's note dated 4-27-15 denotes R1 is noncompliant with walker; numerous attempts made to redirect; R1 becomes combative when redirected. Unit manager notified, resident in need of one to one care due to combativeness and being noncompliant with walker and wheelchair. E1 (Licensed Practical Nurse) stated on 4-30-15 at 1:15 pm she works the day shift mainly and that R1 is alert and oriented x2 and is noncompliant sometimes with using her walker and tries to walk without it, and when she is redirected she gets agitated. E1 stated R1 was able to walk with her walker , but had history of removing her bed alarm and would get out of bed. E1 stated R1 ' s medication made her drowsy and the doctor was notified and the medication was discontinued. R1 ' s physician progress notes [REDACTED]. Was not so hyper now but watched 1to1. Was not so anxious and did stand with assistance and is now alert and not really sedated as she was when AM dose held. Will stop Depakote as not tolerated. E9 (Certified Nurse Aide) stated on 5-1-15 took care of R1 on the pm shift of 4-27- E9 stated she noted during her shift R1 was drowsy and not steady and she was not as active as she usually was but continued to get up by herself and get out of bed. E9 stated that when she left R1 was in the bed, alarm was in place and R1 was supposed to be monitored 1:1. E10 (Licensed Practical Nurse) stated on 5-1-15 at 9:40 am worked the pm shift (3-11) on 4-27-15 and she reported to night nurse (E7) that R1 was to have 1:1 because her gait was unsteady and she was attempting to walk without walker. E10 stated when she left that night R1 had a chair and bed alarm on . E10 stated during her shift R1 was continuously monitored and did not fall. Facility ' s shift report sheet denotes 3-11 shift update one on one sitter/CNA due to risk for falls, noncompliant with staff. Resident (R1) won ' t stay in one place, constantly getting up, unsteady gait. E7 (Registered Nurse) stated on 4-30-15 at 3:30 pm that she worked the night shift (11-7) and that R1 slept during the night of 4-27-15 and early am 4-28-15 and R1 had her bed alarm in place. E7 stated around 2 am the CNA (E9) reported that she had to do rounds and E7 went to monitor R1 1:1 until CNA did her rounds and came back to R1 ' s room and was supposed to be watching R1. E7 stated she gave the CNA (E9) specific instructions that R1 needed 1:1 monitoring during the night shift. E7 stated she did not see R1 fall during the night. E11 (Certified Nurse Aide) stated on 5-1-15 at 10:10 am R1 was one of the residents assigned to her during the night shift (11-7) on 4-27-15 thru 4-28-15. E11 stated she did patient care on all of the residents assigned to her during the night as she usually does. E11 stated was never told by the night nurse (E7) that R1 needed 1:1 monitoring but was just told to monitor R1 for behavior problems. E11 stated prior to 4-28-15 R1was a fall risk and knew how to take her alarm off her body, turn her bed alarm off and would carry it around. E11 stated in the past she did inform one of the nurses about R1 removing her alarm but could not recall which nurse she told that R1 would remove her bed alarm. E11 stated during the night shift (11-7) on 4-27-15 thru 4-28-15 saw the nurse (E7) mainly sitting at the nurses ' station doing charting while she was going around from room to room giving patient care to her assigned residents. E7 stated she did not see R1 fall during the night. E6 (Registered Nurse) stated R1 is alert times 1-2, was working am shift (4-28-15) and doing med pass when noted bruise to R1 ' s left face and complained of left hip hurting called doctor and got order for X-ray. E6 stated R1 was sent to the hospital afterwards. E6 stated was not told in report that R1 had fallen during the night. R1 ' s nurse's note dated 4-28-15 denotes observed bruise to the left side of face close to R1 ' s eye. Doctor and family notified ; insisted resident go to hospital. R1 ' s hospital record dated 4-28-15 denotes physical Ecchymosis of left upper face including eye and forehead. Computed Tomography scan dated 4-28-15 denotes suspicious for small subarachnoid and possible tiny parenchymal contusion. Z1 Doctor) stated on 5-1-15 at 10:40 am that R1 sustained a subarchnoid hemorrhage which she probably sustained from a fall. . Z1 stated R1 is capable after a fall to get back up on her own. Z1 stated she did not know that staff did not see R1 fall. R1 's progress note dated 4-29-15 denotes spoke to doctor at hospital R1 admitted for hematoma on the brain. E4 (Director of Nursing) stated on 4-30-15 at 2:10 pm that there is no documentation in R1 ' s chart/records that she would remove her bed alarm and was not aware that R1 would remove her bed alarm. E4 stated E11 never reported to nursing staff that she would remove her alarm. E4 stated if they had known would had to change her fall care plan and implement other effective interventions because at that point when she was removing her alarm made it ineffective. Facility ' s fall clinical guideline denotes 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 falls, plan for preventive strategies, and facilitate as safe an environment as possible. Residents at fall risk will be identified for staff awareness. Residents at risk for falls will have Fall risk identified on the interim plan of care with interventions implemented to minimize fall risk. R2 ' s care plan dated 12-26-14 had fall related impulsiveness and poor safety awareness and poor balance. R2 ' s fall risk screen dated 2-18-15 denotes R2 cannot walk even when assisted by staff, confined to a wheelchair and disoriented. R2 ' s nurse note dated 4-19-15 denotes R2 found on the floor face down by the activity aide, placed in bed and assessed bump middle of forehead, doctor notified and to send R2 to hospital. R2 ' s hospital records dated 4-19-15 denotes physical exam large frontal hematoma with ecchymoises bilateral eyelids swollen shut and Computed Tomography Scan denotes non-displaced fracture of the distal tip of the C5 spinous process. Z2 (Doctor) stated on 5-6-15 at 11:35 am R2 ' s fracture was a consequence of her falling. E1 (Licensed Practical Nurse) stated on 4-30-15 at 1:15 pm R2 is alert to name only, unable to ambulate but can scoot a little with her feet in her wheel chair. E1 stated was passing noon medications on 4-19-15 when the CNA reported that R2 had fallen in the dining room. E1 stated went to the dining room and saw R2 on the floor faced down in front of her wheel chair and saw the activity aide trying to pick R2 up by her arms. E1 stated assessed and noted a bump on the middle of R2 ' s forehead. E1 stated the three of them put R2 in the wheel chair. E1 stated asked activity aide (E5) what happened and he informed her that while he was pushing R2 to her table to eat , R2 fell forward onto the floor. E1 stated called her doctor and sent R2 to the hospital. E2 (Certified Nurse Aide) stated on 4-30-15 at 1:50 pm was in the hallway walking towards the nurses ' station and heard a loud thump from the dining room. E2 stated went the dining saw R2 lying face down on the floor in front of her wheel chair. E2 stated activity aide was standing near R1 and told activity aide not to touch R2. E2 stated went and told the nurse (E1) and went back to the dining room and they picked R2 up to her knees then the three of them put her in her chair and then took R2 to her room. E3 (Unit Manger) stated on 4-30-15 at 2:15 pm reviewed from the dining room video (4-19-15) saw R2 was sitting on the edge of the chair leaning forward when activity aide (E5) pushed the wheel chair and R2 fell out of the chair onto the floor. E3 stated before a staff member pushes a resident in a wheel chair they should make sure the resident is sitting back all the way in the chair and sitting up. E5 (Activity Aide) stated on 4-30-15 at 2:30 pm was in the dining room giving another resident water. E5 stated saw R2 across the room scooting herself in her wheelchair and she was leaning forward while she was moving her feet and bumping into another resident. E5 stated went over to help get past the other resident and got behind her wheelchair while she was leaning forward and pushed her wheelchair when she suddenly fell forward and hit her face on the floor. E5 stated he had intended to reposition R2 by sitting her up and leaning her back her wheelchair but R2 fell out the wheelchair before he got a chance to. E5 stated was only in-serviced after the incident that they should make sure residents are sitting all the way in their wheelchairs before they are moved. E4 (Director of Nursing) stated on 4-30-15 at 2:10 pm had reviewed the dining room footage (4-19-15) and noted that R2 was in the dining room trying to move by another resident in her wheelchair using her feet and was leaning forward in her wheel chair when activity aide came behind R2 ' s wheel chair and started pushing R2 ' s wheelchair at the same time while R2 was leaning forward and saw from the video R2 fall forward out of the chair and land on the floor. E4 stated E5 was written up for R2 ' s fall incident. E5 ' s employee report dated 4-19-15 denotes employee action/discipline: E5 failed to supervise the dining room resulting leading to a resident to fall. E5 in-serviced on fall precautions.

Based on interview and record review, the facility failed to ensure that a working device to prevent further falls was put in place to prevent falls with injury for 1 resident ( R3 ) out of 4 reviewed for falls. The facility also failed to investigate this fall adequately to determine what caused the fall and put in place appropriate interventions. As a result, on 10/30/12, R3 sustained a fractured right clavicle after a fall incident. Findings include : R3 has [DIAGNOSES REDACTED]. As early as 2/18/10, R3's MDS/ Minimum Date Set assessment coded R3 as with memory problem and has moderate impairment of Cognitive skils for Daily Decision Making. R3's incident report on 10/30/12 indicated that at 6:40 PM, R3 was observed sitting on the floor in her room. R3 was unable to recall what happened. R3 was assisted back to her wheelchair and physical assessment indicated that no visible injury was observed. R3's 10/30/12 fall risk assessment showed that R3 scored 50. Fall risk assessment tool indicated that for score 15 and above, a fall precaution should be implemented. Review of R3's record showed that on 2/6/10, R3 slid out from her wheelchair and sustained a left femoral neck fracture. Facility's Summary of Investigation of the 10/30/12 incident stated that no environmental, behavioral, or human factor led to R3's fall. The investigation cited that decrease in muscle strength and decrease in safety awareness might be the factors that had contributed to the 10/30/12 fall. This investigation also indicated that as a corrective action, the facility should continue use of mobility alarm and hip hugger as fall preventive devices. R3 was also reeducated to the use of call light, encouraged to call for assistance prior to transferring. This facility investigation however did not mention if R3's chair mobility alarm was triggered or not during the fall. This mobility alarm was a fall risk intervention in R3's care plan to prevent falls when R3 is up on her wheelchair. During 3/26/13 phone interview at 12:56 PM, E3 ( certified nurse aide / CNA ) said that on 10/30/12, she went to R3's room to look for R3 after she noticed that R3 is not in the dining room during meal time. R3 said that R3's room was dark, and she could only see R3's wheelchair at first. E3 said that when she went inside R3's room, E3 saw R3 laying on the floor on her side. E3 said that she also called E4 ( nurse ) and another CNA. E3 said she did not hear R3's mobility alarm triggered when she found R3 on the floor. On 3/26/13 at 3:13 PM, E4 said that on 10/30/12 she was called by E3. When she went to R3's room, R3 was sitting on the floor mumbling. E4 said that she also did not hear R3's chair alarm when she went inside R3's room. E4 said that she thought E3 turned it off. E4 continued that previously, she remembered R3 triggering her chair alarm when she moves while in her wheelchair. Similarly on 3/26/13 at 3:55 PM, E5 ( 3-11 CNA ) said that she also did not hear R3's chair alarm when she entered R3's room after being told R3 was on the floor. E5 said that she was not the first staff to respond to R3's fall on 10/30/12. E5 also said that she saw R3 in the dining room before E5 took her break that evening. E5 said that during that time, R3 was sitting on her wheelchair with the chair mobility alarm pad on. E5 said that when she came to work at 3 PM, R3 was already on her wheelchair with the chair alarm. E5 said that R3 is able to propel her wheelchair, and probably wheeled herself to her room when E5 took her break. E5 also said that R3 is "busy" and fidgety while on her wheelchair and had triggered her wheelchair alarm in the past. E5 added that R3 would try to get up from her wheelchair, but is normally unsuccessful to fully stand by herself. On 3/28/13 at 10:32 AM, E6 ( Asst. Director of Nursing ) said that she investigated R3's 10/30/12 fall incident. R3's Investigation Form on 10/30/12 showed that E6 indicated that R3's chair alarm was in place and working on 10/30/12. E6 however admitted that she did not ask E3 if she heard the alarm trigger, when E3 first saw R3 on the floor. E6 said that she just asked the staff if R3's chair alarm was on, but did not ask if it was working and thus was triggered when she got off the wheelchair and landed on the floor. As a result, there was no investigation to determine why R3's chair alarm did not make a sound on 10/30/12 to alert staff that R3 was trying to get up from her wheelchair. There also was no explanation why no one checked if the alarm was working at the start of the shift, to ensure that it rings when R3's buttocks gets off the alarm pad. Similarly staff did not make sure that R3 stayed in the dining room where she could be visually monitored by staff, as she is a fall risk resident. E6 said that there is no ON/OFF button on the facility's mobility alarm. It is a pad attached to a machine by a cord. E6 said that if the battery is low, it will beep continuously until the battery is changed. The only time it won't trigger, is if the cord is disconnected from the pad or it malfunctioned. Even though there is no determination why R3's chair alarm did not trigger when she fell on [DATE], R3's care plan indicated that after the 10/30/12 fall, the mobility alarm (which did not work to alert staff and prevent further falls) should still be used thereafter. The continued use of hip hugger was also recommended, although this device does not prevent further falls, but just prevents hard impact on the resident's hips if her hips hit the floor. Additionally, the reeducation to use the call light was also added as intervention, although R3 is cognitively impaired, does not use the call light, and had fallen from her wheelchair not from her bed where the call light is normally placed. On 11/1/13 R3 developed bruising and pain ion the right shoulder. R3's 11/1/12 right shoulder X-ray showed fractured clavicle.