Every finding on record at Eden Vista Burr Ridge

Based on interviews and record review, the facility failed to follow its fall prevention policy and provide adequate supervision for one cognitively impaired resident who was identified as being at high risk for falls. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 having two unwitnessed, avoidable falls occurring on the same day, following the second fall R1 was transported to the hospital, where the resident was diagnosed with a spinal compression fracture.Findings include:On 6/30/26 at 1:21 PM, V4's RN (registered nurse) stated that R1 had an unwitnessed fall on the hallway floor on the morning of 5/25/26. V4 stated that R1 was confused, at baseline. V4 stated that at the time of R1's fall, V4 and CNAs (certified nurse aides) were in other residents' rooms providing care. V4 stated that R1was able to self-propel in wheelchair. R1 was assessed, no injuries noted. V4 stated that R1's vital signs were stable, and neurological checks were ordered due to it being an unwitnessed fall. V4 stated that neurological checks are documented in the residents' progress notes. When questioned regarding documentation that a bed/chair alarm in place and functioning, V4 responded R1 did not have a bed/chair alarm; she was referring to a floor mat next to bed and the call light kept within reach in room. V4 stated that R1 fell in hallway so no fall precautions were in place at time of fall. V4 stated that R1 had one floor mat next to bed in room. V4 stated that post fall she placed an additional floor mat on the other side of R1's bed.R1's medical record, dated 5/25/26, V4 RN noted V5 CNA notified V4 that R1 was on the hallway floor. Fall was unwitnessed. R1 noted to be confused at the time of incident. R1 stated he doesn't remember why he's here and he wanted to leave to go to his daughter. Assessment completed immediately. No apparent injuries were noted at this time. Vital signs obtained and monitored. R1 assisted off floor and returned to safe position. Fall precautions reinforced. Bed/ chair alarm in place and functioning. Call light place within reach. Frequent monitoring initiated, R1 reminded to use call light for transfers/ ambulation. Environment checked for safety. Family notified of incident. Physician notified. V2 DON (director of nursing) notified. Neurological checks continued. R1 closely monitored for any change in condition and follow facility fall protocol.On 6/30/26 at 2:22 PM, V8 RN stated that R1 was sent out via EMS (emergency medical services) 911 after second fall on 5/25/26. V8 stated that R1 was unable to state what happened; R1 just kept repeating my back. V8 stated that R1 is alert and oriented to person; baseline is confused. V8 stated that V8 did not perform any neurological checks or obtain vital signs prior to R1's fall; fall happened at beginning of her shift and EMS crew arrived soon after fall.On 6/30/26 at 2:30 PM, V7 CNA stated that R1 was in the common area, and she and the other CNA were in another resident's room providing care at the time of R1's fall. V7 stated that incident occurred just prior to dinner, about 4:45 PM - 5:00 PM.On 7/2/26 at 10:30 AM, when questioned if staff are expected to supervise residents, V2 DON (director of nursing) responded that V2 would prefer the staff to monitor the residents. V2 acknowledged that it is unclear if vital signs documented at 2:31 PM were obtained at 10:00 AM after first fall. V2 stated that R1 was sent out EMS 911 and does not believe vital signs were taken; R1 complained of back pain and was sent out immediately.R1's EMS report, dated 5/25/26, notes that the facility contacted EMS dispatcher at 3:53 PM. The crew were on scene at R1 at 4:03 PM. Staff stated that R1 attempted to stand up from wheelchair and walk when R1 stumbled and fell to the floor. R1 complained of neck and lower back pain.R1's hospital records, dated 5/25/26, were unavailable for review during this survey.R1's medical record, dated 5/25/26, V8 RN noted R1 noted in dining room on the floor after an unwitnessed fall. Assessment completed immediately. R1 alert and responsive with altered mental status noted to be at baseline. No loss of consciousness observed or reported. Pupils are equal, round, and reactive to light and accommodation. No visible lacerations, hematoma, or active bleeding noted to head. R1 complained of back pain following incident. No obvious deformities noted. Skin warm and dry. Vital signs are unremarkable. R1 transported to the emergency room further evaluation. R1 is admitted to hospital with the diagnosis of altered mental status, pneumonia, and compression fracture of the spine.There is no documentation found noting R1's vital signs were obtained after second fall.R1's falls report, dated 5/25/26 at 10:00 AM, notes R1 alert and oriented to person, baseline. Predisposing factors: confused, gait imbalance, and impaired memory.R1's admission fall risk assessment, dated 5/23/26, notes R1 is at high risk for falls.R1's prior to admission hospital record, dated 5/21/26, PT (physical therapy) noted R1 needs moderate assistance with transfers. Barriers identified by PT: limited safety awareness, impulsivity, cognitive deficit, confusion, decreased endurance, impaired balance, and impaired coordination. R1's gait unsafe, unsteady, shuffling gait with variable cadence, poor safety awareness, needs assistance with rolling walker management and sequencing, forward flexed posture.The facility's fall prevention, post fall, and communication policy, dated 1/21/26, notes in part to promote resident safety by identifying fall risk to prevent recurrence. Post fall response: check the vital signs, look for subtle cognitive changes, and check the pupils and orientation. Document the resident's condition and clinical findings, such as vital signs.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and safe transport technique and failed to implement care plan interventions to prevent an accident for a resident (R1). The facility failed to follow facility fall prevention policy, failed to develop and implement care plan interventions to prevent recurrent falls, and failed to complete post fall assessment for one of three residents (R2), reviewed for falls. These failures resulted in R1 falling and sustaining a closed head injury, abrasion of the forehead, avulsion of right elbow skin, and a closed nasal bone fracture, and R2 sustaining seven falls within sixteen days, hospitalization, scalp laceration requiring sutures, and a subdural hemorrhage. Findings include:R1 is an [AGE] year old resident with latest admission to the facility on 3/24/26. R1 has diagnoses which include but are not limited to Polyneuropathy and Generalized Anxiety disorder.R1's Records show the following:Fall Risk assessment dated [DATE] shows that R1 is at high risk for falls.Care Plan dated 3/24/26 states that R1 has mobility issues and uses a wheelchair, R1 requires total assistance with personal hygiene and ADL(Activities of Daily Living) care, and R1 requires safety checks at frequent intervals. Care plan dated 4/27/26 states Ensure the use of wheelchair leg rests when the resident is not propelling self. Additionally, a bag will be placed on the back of the wheelchair to store the leg rests when the resident is propelling self.MDS (minimum Data Set) section GG dated 2/26/26, under functional ability, states that R1 requires partial/moderate assistance for transport and requires a wheelchair for mobility, and that R1 is dependent on staff for some of the other functional abilities.Transfer and Mobility Evaluation dated 4/14/26 shows that R1 requires assistance for transfer.Mental Status assessment dated [DATE] indicates the resident has moderately advanced cognitive impairment.R1's Hospital Records dated 4/27/26 show R1 fell and R1's Diagnoses at the hospital emergency room are: Closed Fracture of Nasal Bone, Avulsion of Skin of Right Elbow, Abrasion of Forehead, and Closed Head Injury, from R1's fall.On 5/18/26, at 10:45 AM on the second floor, V1(Administrator) was observed pushing R1 from the Activity room, down the hallway, to the room in the wheelchair without a leg/footrest. R1's feet were dangling and dragging on the floor; the wheelchair footrests were not available for use. V1 told R1 twice during the transport to raise up R1's legs, but R1 was barely able to raise up her legs.On 5/19/26 between 10am and 11am during observation with V4(ADON/Assistant Director of Nursing), R1, R4 and R5 were observed in the activity room sitting in the wheelchair without leg/footrests, and V4 stated that the care plans were updated for the residents to have their legs on the leg rest while staff move them in the wheelchair, to prevent residents from falling forward like in the case of R1. However, only one pair of leg rest was available in the activity room where several residents were sitting in the wheelchair. Inquired from V4 why the residents did not have leg rests available; V4 made a phone call and later informed the surveyor that the leg rests were kept in the storage room of the medication room. Inquired from V4 if the CNAs have free access to the medication room to get leg rests for the residents before pushing the residents in the wheelchair from one place to the other, as it happened in the case of R1. V4 stated that the medication room is locked, but the CNA can find the nurse to open the medication room when they need the leg rest. R1's care plan states the leg rest should be placed on the back of the wheelchair.On 5/18/26, at 11:15 AM, V3 (Certified Nursing Assistant (CNA), was interviewed. V3 stated On that day, earlier in the morning, I noticed that her (R1)'s balance was a little off in the wheelchair, maybe she (R1) was not feeling well. After breakfast, maybe around 9:30am, I was pushing her in the wheelchair from the dining room to the activity room. Both of her feet were on only one leg rest, and she was not steady, her shoulder went close to her knees as I was moving her, and the next thing, she was on the floor. I immediately called the nurse for help, and the nurse sent her to the hospital. The surveyor inquired from V3 what V3 could have done differently to prevent the fall. V3 stated I probably could have monitored her more closely while pushing the wheelchair. The surveyor asked V3 if V3 had any training about transporting a resident in the wheelchair from one place to the other, V3 stated that she had training about mechanical lift transfer, but that she (V3) did not have any training about moving a resident in the wheelchair. V3 added that she(V3) started working at the facility about a year ago.Facility's incident report sent to the State Agency on 4/27/2026 at Approximately 9:30 AM states in part: R1 was being escorted by staff to activity. During transport, R1 placed her foot on the floor resulting in a fall from her wheelchair. R1 was sent to the hospital. R1 returned from the Hospital with Diagnoses of Closed Fracture of Nasal Bone, Avulsion of Skin of Right Elbow, Abrasion of Forehead, and Closed Head Injury.Final Incident Report dated 5/1/26 states in part: On 04/27/2026 at approximately 1:30 PM, R1 returned from hospital with Diagnoses: Closed Fracture of Nasal Bone, Avulsion of Skin of Right Elbow, Abrasion of Forehead, and Closed Head Injury.The report further states: In conclusion, following a thorough investigation, it was determined that during transport R1 placed her foot on the floor, resulting in a fall from her wheelchair. Staff responded immediately. MD (Medical Doctor) notified and issued orders for R1 to be sent to the hospital for further evaluation. The POC (plan of care) was reviewed and revised to ensure the use of wheelchair leg rests when R1 is not propelling herself. Additionally, a bag will be placed on the back of the wheelchair to store the leg rests when R1 is propelling herself.On 5/19/26 at 1:13pm, V8 (Physician) was interviewed regarding falls and residents' care plans. V8 stated, Of course, the staff should follow the fall prevention care plan. V8 added that fall care plan is individualized and different for each resident, and he (V8) could not speak to the care plan for any resident.On 5/18/26, at 11:30 AM, the Director of Nursing (DON) stated that staff have being retrained regarding safety when moving residents. At this time, V2 presented the Training In-service records that state: Chair safety inspection: Confirm leg rest are present and functional. Leg rest application and removal - Ensure leg rests are locked into place, Place both legs properly on footplates; Prevent residents' feet from dragging or slipping. Transfer technique: ensure residents stability before moving wheelchair. Demonstrate safe wheelchair transport. Wheelchair safety inspection: Ensure footrests are secure and properly positioned.V2 also presented the facility's policy on Fall Prevention, Post-Fall, and Communication. This policy dated 1/21/26 states in part: To promote safety by identifying fall risk, implementing individualized fall prevention interventions, ensuring timely post fall evaluation, and reviewing outcomes to prevent recurrence. Interventions will be individualized by the IDT (Interdisciplinary team) and may include supervision level, transfer status, mobility assistance, and therapy involvement and assistive device use, etc. Interventions must be implemented consistently and revised when not effective. V3 failed to ensure that R1 was safely positioned and failed to ensure that the wheelchair footrests were properly utilized during transport, resulting in R1 falling forward out of the wheelchair.R2 is a [AGE] year-old female admitted to facility on 4/3/2026 for rehabilitation following a fall with injury at home and subsequent hospitalization. R2's admission diagnoses included fracture of the superior rim of the right pubis, aftercare following total join replacement, urinary tract infection, dementia and history of transient ischemia attack and cerebral infarction without residual deficits. The Minimum Data Set (MDS) dated [DATE] noted a Brief Interview of Mental Status (BIMS) of 8 indicating moderate cognitive impairment. The Resident Mood Interview had a severity score of 14 indicating moderate depression. R2 was dependent for indoor mobility (ambulation) meaning R1 needed a helper to complete all activities for the resident. R2 was also dependent for functional cognition meaning R2 needed assistance with planning regular tasks prior to the current illness, exacerbation or injury. For toileting, R2 needed partial/moderate assistance meaning the helper did less than half the effort. For lower body dressing, R2 needed substantial/maximal assistance meaning the helper did more than half of the effort. For sit to stand or chair/bed to chair transfer or toilet transfer, R2 needed substantial/maximal assistance. R2 was assessed as being at high risk for falling upon admission to the facility on 4/3/2026.On 5/19/2006 at 10:53 AM V16 (Certified Nursing Assistant) stated we generally check on residents every 2 hours. If a resident is at risk of falling, we keep the bed in the low position. We make sure call light is close, but if a resident is confused, that doesn't help because they don't call for help. V16 could not think of anything else the facility does to prevent falls.On 5/19/2026 at 11:01 AM V17 (Lead Certified Nursing Assistant/CNA) stated some residents are confused. A urinary tract infection can cause confusion. V17 stated, I am expert in memory care, some CNAs have not dealt with it, so they don't know how to manage the residents. Some residents are at risk of falling. It is often because the resident has to go to the bathroom. R2 was nervous and anxious. R2 would try to use the bathroom without assistance, but R2 needed assistance to the bathroom. R2 was nervous to stand without assistance. R2 had a bladder infection, so R2 had to use the bathroom quite often. R2 could get up and stand and walk to the bathroom, but R2 wasn't safe. When walking, R2 would try to hold on to anything R2 could to prevent R2 from falling. R2 had a couple of falls. R2 had floor mats on both sides of R2's bed. R2 had blow up siderails or bolsters on the bed, but those were not good for R2 because R2 could put R2's legs over the bolster or between the bolsters so staff would find R2 sitting on the side of the bed when the bolsters were supposed to keep R2 in bed. R2 was confused about the call light and did not use the call light. We did not put R2 with a roommate who could have called for help. V17 found R2 after one of R2's falls. R2 was trying to get out of bed. R2 was found on the floor. R2 was getting up and fell because R2 had to go to the bathroom.On 5/19/2026 at 12:50 PM V3 (Assistant Director of Nursing/ADON) stated the facility does not have a fall prevention coordinator. We have an Interdisciplinary Team (IDT). No one is in charge of fall prevention. V2 oversees assisted living, and V2 (Director of Nursing/DON) oversees skilled nursing if there is a fall, but no one is the fall prevention coordinator.On 5/19/2026 at 1:01 PM V2 (DON) stated the facility does not have a fall prevention coordinator. If there is a fall, we talk about it at the morning meeting and then V2 closes the fall out in the risk management system if it is on the skilled side. ADON closes out the fall in the risk management system if the fall is on the assisted living side. If a resident falls, the nurse will call the DON or ADON and notify the family and the doctor. If the DON or ADON is not in the building at the time of the fall, the fall is discussed the next day. At the morning meeting, interventions and best practices are discussed, but that discussion is not documented anywhere. R2 was at the facility for two or three weeks. For each fall, there should be a progress note, risk management/incident reporting system documentation, and a care plan update. For each fall, at a minimum, the nurses document a post fall assessment each shift for at least 72 hours after the fall. Seventy-two hours of assessment would be 3 assessments per day/once per shift and nine post fall assessments for each resident fall.On 5/20/2026 at 9:58 AM V2 (Director of Nursing) stated all post fall assessments were provided to surveyor. V2 stated, That is all we have. We didn't do an assessment every eight hours for seventy-two hours after each fall.On 5/20/2026 at 11:10 AM V1 (Administrator) stated the facility does not have a fall prevention coordinator. DON and ADON have responsibility for fall prevention. When a resident falls, we have a post-fall huddle led by the charge nurse, ADON, DON or staff nurse. We conduct an investigation which is documented in electronic health record.On 5/20/2026 at 11:25 AM V2 (Director of Nursing) stated I don't see a progress note about R2's fall on 4/12/2026. I see documentation R2 returned to the facility after being at the emergency department, but there is no progress note about the fall on 4/12/2026. The nurse should have documented the fall and R2's assessment after the fall. None of that documentation is in the electronic health record (EHR). After a resident falls, V2 expects nurses to document in the progress notes of the EHR the resident's neurological assessment, any pain, any decrease in range of motion and any impairment of gait. Regardless of whether the assessment is normal or not, it should be documented which will allow staff to identify if there is any change in the resident over the 72 hours they are assessing and reassessing the resident. During the morning meeting, we try to determine the root cause of the fall. That discussion is not documented, We just talk about what the root cause could be and what interventions might be needed. Interventions to prevent further falling are put in the care plan. On 5/21/2026 at 9:16 AM V2 (Director of Nursing) stated for any resident at high risk of falls, the fall prevention interventions upon admission include low bed position and frequent rounding. We would implement floor mats upon admission if the resident had multiple falls, confusion, or a fall with injury prior to admission. R2 was at high risk of falling upon admission. Upon admission, R2's bed was placed in low position and we kept her in a supervised area during the day. At night, the CNAs and nurses would round hourly on R2. Sometimes the nurses would keep R2 at the nurses station at night if R2 was awake. V2 could not recall any other fall prevention interventions upon admission. After the 4/4/2026 fall, the care plan intervention was frequent rounding to anticipate needs. R2 had a UTI so that intervention meant staff should round on R2 to see if R2 had to go to the bathroom or needed water, but the staff were already rounding on R2 hourly before that care plan intervention on 4/4/2026, so no new fall prevention interventions were implemented after R2's 4/4/2026 fall. After the 4/7/2026 fall, the care plan intervention was keep bed in the lowest position, but the bed was placed in the low position upon admission, so no new fall prevention interventions were implemented after R2's 4/7/2026 fall. The bed was in low position upon admission because R2 had a history of falling and confusion upon admission. After the 4/8/2026 fall, the intervention was floor mats, however R2 had floor mats in place before the 4/8/2026 fall, so no new fall prevention interventions were implemented after R2's 4/8/2026 fall. After the 4/11/2026 fall, the intervention was frequent toileting every 2 hours, however V2 stated R2 was actually being rounded on hourly prior to the 4/11/2026 fall, so no new fall prevention interventions were implemented after R2's 4/11/2026 fall. After the 4/12/2026 fall, bed bolsters were implemented. Staff did not tell V2 that R2 was climbing over the bolters. After the 4/13/2026 fall, the intervention was medication review of all medications. V2 stated V2 looked at R2's medications to see if R2 had anything ordered for sleeping, anxiety or pain or if R2 needed something for pain. V2 spoke to V18 (Physician) who ordered a psychiatry evaluation V2 stated psychiatry should have seen R2 before the 4/19/2026 fall, but V2 could not find a psychiatry consult note in the EHR. V2 stated I don't know if R2 fell on 4/19/2026, because R2 was found in bed. There was a nightstand next to R2's bed. R2 could have hit R2's head on the nightstand. V2 could not say how R2 got injured on 4/19/2026. The IDT root cause analysis is completed the day after a resident fall unless it is the weekend. V2 stated the facility has up to four days to complete the IDT root cause analysis. A sitter could have helped prevent R2 from falling because someone would have been right next to R2 especially during the night hours. The facility does not provide sitters.On 5/21/2026 at 1:33 PM V2 (Director of Nursing) provided psychiatry consultation note by V21 (Psychiatry/Mental Heath Nurse Practitioner). Visit date was 4/17/2026 at 3:30 PM and consultation note was signed by provider on 5/21/2026 at 9:44 AM. V21 documented that R2 was approached for medication management. R2 declined to engage and appeared sedated and asleep. No concerns could be assessed due to limited participation by R2. Review of R2's fall incident reports document: On 4/4/2026 at 3:45 PM V10 (Nurse) documented in the risk management/incident report R2 was observed sitting on the floor in her room during rounds. Incident was unwitnessed. The fall prevention care plan intervention after the 4/4/2026 fall was frequent rounding to anticipate needs. On 4/7/2026 at 6:05 PM V9 (Nurse) documented in the risk management/incident report R2 was observed on the floor next to her bedside during rounding. Incident was unwitnessed. The fall prevention care plan intervention after the 4/7/2026 fall was keep bed in the lowest position. On 4/8/2026 at 8:30 AM V11 (Nurse) documented in the risk management/incident report R2 was on the floor with R2's wheelchair cushion underneath R2. R2's wheelchair was also facing R2. Incident was unwitnessed. Pain medication administered for back pain. The fall prevention care plan intervention after the 4/8/2026 fall was floor mats on both sides of the bed. On 4/11/2026 at 8:30 PM V12 (Nurse) documented in the risk management/incident report R2 was found on the floor next to the bathroom door by nursing staff. R2 stated R2 was trying to walk to the bathroom. Incident was unwitnessed. R2 was transferred to the hospital with pain score of 7. The fall prevention care plan intervention after the 4/11/2026 fall was frequent toileting (every two hours). On 4/12/2026 at 12:23 PM V19 (Nurse) documented in the risk management/incident report R2 was found sitting Indian style on the left side of R2's bed. R2's wheelchair was right next to R2. The bed was in the lowest position. R2 was trying to go to the bathroom. Incident was unwitnessed. The fall prevention care plan intervention after the 4/12/2026 fall was bed bolsters. On 4/13/2026 at 11:30 AM V9 (Nurse) documented in the risk management/incident report R2 was noted scooting on the floor to the door. R2 was trying to go to the bathroom. Incident was unwitnessed. Radiographs were ordered. The fall prevention care plan intervention after the 4/13/2026 fall was medication review of all medications. On 4/19/2026 at 5 AM V13 (Registered Nurse) documented in the risk management/incident report V13 was informed by Certified Nursing Assistant (CNA) R2 had blood on R2's bed. Upon assessment a small laceration was noted to the right top of R2's head. R2 was unable to recall what happened. Incident was unwitnessed. R2 was transferred to the hospital for head injury.Facility document titled Incidents by Incident Type was presented by V2 (Director of Nursing) as the list of all falls in skilled nursing and assisted living at the facility. Date range of the report 1/21/2026 - 5/19/2026. According to the Incident-by-Incident report, R2 sustained a fall on 4/4/2026, 4/7/2026, 4/11/2026, 4/12/2026 and 4/13/2026. The 4/8/2026 fall and 4/19/2026 falls were not listed on the fall summary report.Review of post fall assessments: R2 fell 4/8/2025 at 8:30 AM. No post fall assessment was completed 4/9/2026 day shift, afternoon shift or night shift (11PM-7AM). No post fall assessment was completed 4/10/2026 day shift or night shift (11 PM - 7 AM). R2 fell 4/11/2026 at 8:30 PM. No post fall assessment was completed on 4/11/2026 day shift or night shift (11 PM-7AM). R2 fell on 4/12/2026 at 12;23 PM. No post fall assessment was completed on 4/13/2026 night shift (11PM-7AM). R2 fell on 4/13/2026 at 11:30 AM. No post fall assessment competed 4/14/2026 day shift. No post fall assessment was completed on 4/16/2026 day shift. R2 fell on 4/19/2025 at 5 AM.Review of the Interdisciplinary Team (IDT) Post Fall Review/Summary: 4/4/2026 IDT post fall review was signed 4/6/2026. IDT post fall reviews dated 4/7/2026, 4/8/2026, 4/11/2026 and 4/12/2026, were signed 4/13/2026. The 4/13/2026 post fall review was signed 4/14/2026. No post fall analysis was provided by facility for the 4/19/2026 fall. For the 4/4/2026 fall, the root cause of fall was Resident is a poor historian and unable to recall. For the 4/7/2026 fall, the root cause of fall was Resident slid from bed to floor. For the 4/8/2026 fall, the root cause of fall was Resident was observed sitting near wheelchair with cushion underneath her. For the 4/11/2026 fall, the root cause of fall was I was trying to walk to the bathroom. For the 4/12/2026 fall, the root cause of fall was I was going to the bathroom. For the 4/13/2026 fall, the root cause of fall was I was trying to use the bathroom. To the question What is the effectiveness of those interventions put into place after the incident?, the response was reduction in fall and injury on 4/4/2026, 4/7/2026, 4/8/2026, 4/11/2026, 4/12/2026 and 4/13/2026.Fall prevention, Post Fall and Communication Policy dated 1/21/2026 stated the purpose is to promote resident safety by identifying fall risk, implementing individualized fall prevention interventions, ensuring timely post-fall evaluation, and reviewing outcomes to prevent recurrence. A fall is defined as an unintentional coming to rest on the ground, floor or a lower level, not as a result of an overwhelming external force. Risk is any condition, environment or process that increases the likelihood of a fall. The Interdisciplinary Team (IDT) participates in fall risk assessment, intervention planning post-fall review, plan of care revision and program evaluation. Fall risk factors include prior falls, gait instability, cognitive impairment, medication side effects, continence needs nutrition/hydration deficits, vision changes, illness and environmental hazards. Fall prevention interventions may include supervision level, transfer status, mobility assistance, therapy involvement, medication review, toileting plans, environmental safety measures, assistive device use, and resident preference considerations. Interventions must be implemented consistently and revised when not effective. The IDT will complete a root-cause analysis after each fall. This includes review of environmental, physiological, behavioral, medication -related and process factors. Care plans will be updated to include new or revised interventions.

Based on interview and record review facility failed to initially report a severe injury of unknown origin to the Illinois Department of Public Health (IDPH) no later than two hours after the incident for one resident (R2) of eight residents in the sample. This injury resulted in R2 being hospitalized for scalp laceration requiring sutures, and a subdural hemorrhage. Findings include: On 4/19/2026 at 5:00 AM V13 (Registered Nurse) documented in the risk management/incident report V13 (Nurse) was informed by Certified Nursing Assistant (CNA) R2 had blood on R2's bed. Upon assessment a small laceration was noted to the right top of R2's head. R2 was unable to recall what happened. Incident was unwitnessed. R2 was transferred to the hospital for head injury. On 4/19/2026 at 6:24 AM V13 (Nurse) documented in the electronic health record (EHR) V13 was informed by CNA that R2 was noted with dried blood on linens and floor near bed. Upon assessment, R2 was observed with a 1-inch laceration to right top of head. R2 complained of pain to right hip and sacral area. Physician notified with order to send R2 to the emergency room for evaluation. V2 (Director of Nursing) was made aware.On 4/19/2026 at 11:05 AM V13 (Nurse) documented in the EHR R2 is admitted to the hospital with a diagnosis of subdural hemorrhage and laceration to right top of head requiring five staples.On 4/20/2026 at 8:50 AM V2 (Director of Nursing) emailed the initial report of severe injury of unknown origin to Illinois Department of Public Health (IDPH). Incident category was severe injury of unknown origin. R2 was not interviewable.On 4/24/2026 at 12:35 PM V2 (Director of Nursing) emailed the final incident reporting for R2's injury of unknown origin on 4/19/2026.On 5/20/2026 at 11:25 AM V1 (Administrator) stated the initial report of a fall with severe injury needs to be submitted to IDPH within 24 hours.On 5/20/2026 at 11:40 AM V2 (DON) stated we have 24 hours to send the initial report of injury of unknown origin to the state.Fall Prevention, Post Fall and Communication Policy stated 1/21/2026 stated the purpose is to promote resident safety by identifying fall risk, implementing individualized fall prevention interventions, ensuring timely post-fall evaluation and reviewing outcomes to prevent recurrence.

Based on observation, interview and record review, the facility failed to provide mechanically altered food consistency for residents prescribed the level 6 soft and bite sized diet. This applies to 4 of 4 residents (R1, R16, R19, R30) reviewed for altered consistency diets in the sample of 12. The findings include:The Facility's diet type report dated December 29, 2025, showed R1, R16, R19, and R30 were prescribed the #6 soft and bite sized diet. R1's face sheet showed R1 was [AGE] years old, admitted to the facility on [DATE], and had multiple diagnoses including sepsis, protein calorie malnutrition, vascular dementia, presence of gastrostomy tube, Dysphagia, pharyngeal phase, and type 2 diabetes.R1's physician order showed Regular diet, Level 6 Soft & Bite Sized texture, Level 0 Thin (Regular) consistency initiated on December 16, 2025. R1's Speech Therapy recommendations dated December 5, 2025, showed to initiate po (oral) diet of mechanical soft/thin using small bites/sips and slow rate. R1's therapy recommendations also showed to advance R1's diet with the presence of speech therapy.On December 29, 2025, at 12:20 PM, R1's lunch meal as served included pork roast in larger cut pieces, whole California medley vegetables with large pieces of cauliflower, broccoli, and carrot slices with firm texture, mound of whole scalloped potatoes. The meal consistency served was the same as for the regular diets. R1 was not served the strawberry shortcake slurry for dessert.The lunch menu for the #6 soft and bite sized lunch meal showed roast pork, California vegetables and scalloped potatoes were to be served cut into small pieces and dessert was to be a slurry biscuit with strawberry glaze.On December 29, 2025, at 5:00 PM R1's dinner meal served included bratwurst sausage with the skin on cut on large slices, lettuce, tomato, and cucumber salad, with skin on the cucumber. The pieces of tomato chunks, pieces of lettuce were large and half slices of cucumber. R1 was attempting to cut the tomato with his knife and was not eating the sausage. R1 had no bread slurry served and had large slices of peaches and half strawberries and chunks of melon for fresh fruit.in liquid in the bowl.V4 (Culinary Director) came to R1's table and was asked about the size of the food served. V4 stated the pieces of the bratwurst were too big and the salad as served pieces were too large. V4 stated for the soft and bite sized diet, the food was supposed to be only as big as the tines of a fork. V4 was asked what a slurry bun was and replied it is the bread softened in milk and stated it was not prepared and served.The menu for the dinner meal for the #6 soft and bite sized, showed for the dinner meal the bratwurst sausage was to have the skin removed and was to be cut into small pieces, there was no salad on the menu to be served, there were no green beans prepared as described on the menu, no bread slurry prepared, and fruit was not prepared into soft and bite size pieces. R19's face sheet showed R19 was admitted to the facility on [DATE],was [AGE] years old and had multiple diagnoses including pneumonia, polyneuropathy, chronic diastolic congestive heart failure, gastro esophageal reflux disease, and taeniasis.R19's physician order showed diet order initiated on December 15, 2025, showed Regular diet, Level 6 Soft & Bite Sized texture, Level 0 Thin (Regular) consistency liquids.On December 29, 2025, at 12:20 PM, R19's tray ticket showed diet order was for 6 soft and bite size diet. R19 was served pork roast that was cut into large pieces, whole California medley vegetables including large pieces of cauliflower, broccoli, and carrots that were firm texture and mound of scalloped potatoes. There was no strawberry shortcake slurry served to R19.On December 29, 2025, at 5:00 PM, R19 was served bratwurst sausage with the skin still on and cut into slices, large pieces of lettuce and tomato salad, there was no bread slurry, no green beans nor fruit served to R19. R19 was pushing the food around on his plate. R16's face sheet showed R16 was admitted to the facility on [DATE], R16 was [AGE] years old, and had multiple diagnoses including Alzheimer's disease, chronic diastolic congestive heart failure, type 2 diabetes, and unspecified protein calorie malnutrition.R16's physician orders showed diet order initiated on October 21, 2025, was Regular diet, Level 6 Soft & Bite Sized texture, Level 0 Thin (Regular) consistency liquids. R30's face sheet showed R30 was admitted to the facility on [DATE], was [AGE] years old, and had multiple diagnoses including chronic obstructive pulmonary disease, protein calorie malnutrition, type 2 diabetes, gastroesophageal reflux disease, and metabolic encephalopathy.R30's diet order initiated on December 24, 2025, showed regular diet, Level 6 Soft & Bite Sized texture, Level 0 Thin (Regular) consistency liquids.On December 28, 2025, at 10:50 AM during the initial kitchen observation, V4 identified there was 1 resident prescribed a puree diet and 4 residents prescribed mechanically altered diets. There was no mechanically altered consistency food prepared for the lunch meal.The December 28, 2025, lunch meal menu for the #6 soft and bite sized menu showed the entree was roast beef and roasted vegetables to be served in small and bite sized pieces without skin, a slurry bread roll with margarine and no crust cherry pie.The facility's policy, undated, for texture modification diets in accordance with IDDSI (International Dysphagia Diet Standardization Initiative) showed #6 soft and bite sized diet are foods that can be mashed/broken down with pressure from a fork, into bite sized pieces, soups and fruits are drained, bread is soaked. No regular dry bread, sandwiches, or toast of any kind. Additional instructions for IDDSI level 6 soft and bite sized diet showed foods are cut into pieces no larger than 1.5 cm (centimeter) x 1.5 cm, and no mixed consistencies such as liquids mixed with solids (i.e. like chunky vegetable soup, or fruit cups in juice).

Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions of incontinence care and administration of medication. The facility also failed to ensure that staff would wear complete PPE (personal protective equipment) during provision of care for residents who are on EBP (Enhance Barrier Precaution). This applies to 5 of 12 residents (R2, R3, R7, R10, R18) reviewed for infection control in the sample of 12. The findings include: 1. On December 29, 2025, at 10:23 AM, V5 (Nurse) administered multiple medications to R10. When R10 showed sign that she was having difficulty swallowing her medications, V5 took the CO Q10 capsule and Acidophilus capsule of R10, without hand hygiene she opened it with her bare hands mixed it to an apple sauce and gave it to R10. Prior to directly touching R10's medication, V5 was touching different objects and other surfaces. On December 30, 2025, at 2:57 PM, V12 (Nurse) stated when opening a capsule medication, they are supposed to sanitize their hands first and don't touch anything prior to touching a medication to prevent contamination of medication. 2. During initial rounds on December 28, 2025, at 10:30 AM, there was an EBP (Enhance Barrier Precaution) signage on R18's door. V2 (Director of Nursing/DON) stated that R18 has a wound on his leg that requires wound care which was the reason for EBP. On December 29, 2025, at 11:56 AM, V6 and V7 (Both Certified Nursing Assistant/CNA) rendered incontinence care to R18 who had a bowel movement and was wet with urine. V6 and V7 wore gloves but did not wear complete PPE. During the provision of incontinence care, V6 donned double layers of gloves and proceeded to clean R18 from front to back of the perineum. Then V6 removed the first layer of gloves and applied barrier cream, with the same gloves V6 applied new incontinence brief. V6 removed her second layer of gloves and without hand hygiene continued to assist R18 to dress. 3. On December 29, 2025, at 12:08 PM, V6 (CNA) assisted R7 to the toilet to urinate. V6 assisted R7 to sit on the toilet riser and ensure that R7's urine will flow inside the toilet bowl. Afterwards, V6 cleaned R7's perineum, removed soiled brief and placed a new clean brief, pulled brief and pants up and assisted R7 back to the wheelchair while wearing same soiled gloves, and without hand hygiene from dirty to clean tasks. 4. On December 30, 2025, at 9:44 AM, V6 and V7 rendered incontinence care to R3. V6 cleaned R3 from front to back of his perineum, she applied new incontinence brief, repositioned R3, and straightened his bed linen, while wearing the same soiled gloves. She removed the PPE right after completion of care and left the room without hand hygiene. On December 30, 2025, at 10:43 AM, V2 (Director of Nursing/DON) stated staff must wear complete PPE when providing direct care to residents on EBP to prevent potential spread of infection or cross contamination. 5. On December 29, 2025 at 3:56 PM, V9 (CNA) with the assistance of V10 (CNA) provided incontinence care to R2. R2's disposable brief was wet with urine and the resident also had pasty stool. While donning a pair of gloves, V9 cleaned R2's anal and perineal areas, then using the same soiled gloves, V9 applied a clean disposable brief to the resident, pulled-up R2's pants and then touched the bed control to lower R2's bed. On December 29, 2025 at 4:20 PM, V9 acknowledged that she did not remove her used/soiled gloves and did not perform hand hygiene after providing incontinence care to R2, before applying clean disposable brief, pulling R2's pants and touching the resident's bed control. On December 30, 2025 at 10:43 AM, V2 (Director of Nursing) stated that after providing incontinence care to a resident, the staff should remove their gloves and perform hand hygiene either by washing their hands or using alcohol rub/sanitizer before proceeding to perform clean task including application of clean disposable brief, touching resident's garment and touching resident's equipment such as bed control to prevent cross contamination and to maintain infection control. The facility's hand hygiene policy and procedure last revised by the facility on May 8, 2024 showed, To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. Under procedures it showed, 2. The use of gloves does not replace hand hygiene. 3. Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE). The policy under, washing hands with soap and water showed, 1. Staff will perform hand hygiene by washing hands for at least twenty (20) seconds with antimicrobial or non-antimicrobial soap and water should be performed under the following conditions: . b. Before applying gloves and after removing gloves or other PPE.d. After handling items potentially contaminated with blood, body fluids, or secretions. e. Before moving from a contaminated body site to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier or other treatments. The same policy under, using alcohol-based hand gel showed, 1. If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations: . d. Before applying gloves and after removing gloves or other PPE; e. After handling items potentially contaminated with blood, body fluids, or secretions; f. Before moving from a contaminated body sites to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier or other treatments; .l. Before moving from a contaminated body site to a clean site during resident care; m. After contact with inanimate objects (for example medical equipment) in the immediate vicinity of the resident. The facility's policy and procedure regarding EBP (Enhanced [NAME] Precautions) dated March 26, 2024 showed, It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk of acquiring a multidrug- resistant organism (MDRO) such as a resident with chronic wounds requiring a dressing, indwelling medical devices or residents with infection or colonization with an MDRO. The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of MDROs to employee's hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids. The same policy under procedure showed, 5. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities including changing linens and changing briefs or assisting with toileting. The facility's policy and procedure regarding PPE (Personal Protective Equipment) last revised by the facility on June 14, 2024 showed that glove use does not replace hand hygiene and to immediately complete hand hygiene after removing gloves. The same policy showed that after applying non-sterile gloves, the said gloves should be removed after a procedure, discard the used gloves in appropriate containers and perform hand hygiene.

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming.This applies to 4 of 4 residents (R7, R9, R10 and R16) reviewed for ADL (activities of daily living) in the sample of 12.The findings include:1. R10 has multiple diagnoses including, unspecified dementia without behavioral disturbance, based on the face sheet. R10's admission MDS (minimum data set) dated November 13, 2025 showed that the resident was severely impaired with cognition and required total assistance from the staff with most of her ADLs including upper body dressing and personal hygiene. On December 28, 2025 at 11:18 AM, R10 was in her wheelchair inside the dining room. R10 was alert and was able to respond appropriately to simple questions. R10 had long curling facial hair above her lips mostly on the right side, her fingernails were uneven (some were long and some were short), some were jagged with chipped red nail polish and under her fingernails were dark substances. R10 was wearing a black shirt that had white stains and food debris on the front by the chest and abdominal areas. According to R10 she needs the staff assistance, and she wanted the staff to remove her facial hair, clean and trim her fingernails and change her shirt. On December 29, 2025 at 9:59 AM, R10 was sitting in her wheelchair inside the dining room. R10 had long curling facial hair above her lips mostly on the right side, her fingernails remained uneven (some were short, and some were long), some were jagged with chipped red nail polish and under her fingernails were dark substances. V3 (ADON, Assistant Director of Nursing) was present during the observation. R10's active care plan last revised by the facility on November 10, 2025 showed that the resident has an ADL self-care performance deficit. The care plan showed the facility's goal for R10 was to receive assistance with ADLs as evidenced by the resident's well-groomed appearance. The same care plan showed multiple interventions including provision of assistance with dressing and personal hygiene. 2. R9 has multiple diagnoses including, diabetic mellitus with diabetic chronic kidney disease, absolute glaucoma and unspecified rheumatoid arthritis, based on the face sheet. R9's admission MDS dated [DATE] showed that the resident was moderately impaired with cognition and required total assistance from the staff with most of her ADLs including personal hygiene. On December 28, 2025 at 10:56 AM, R9 was in bed, alert and oriented. R9 had accumulation of long facial hair above her lips and on her chin area. R9's fingernails were long; some were jagged with black substances under the nails. According to R9 she needs the assistance of the staff to remove her facial hair and provide nail care. R9 stated, I do not know how much they charge but I want my facial hair shaven, and my fingernails trimmed and cleaned. On December 29, 2025 at 11:27 AM, R9 was in bed, alert and verbally responsive. R9 had accumulation of long facial hair above her lips and on her chin area. R9's fingernails were long; some were jagged with black substances under the nails. V2 (DON, Director of Nursing) was present during the observation and had acknowledged that R9 needs staff assistance with nail care and shaving of facial hair. R9's active care plan last revised by the facility on December 22, 2025 showed that the resident has an ADL self-care performance deficit. The same care plan showed multiple interventions including provision of assistance with personal hygiene. 3. R16 had multiple diagnoses including, unspecified Alzheimer's disease and unspecified dementia without behavioral disturbance, based on the face sheet. R16's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition and required total assistance from the staff with most of her ADLs including upper body dressing and personal hygiene. On December 28, 2025 at 11:33 AM, R16 was sitting in her wheelchair inside the dining room. R16 was confused. R16 was wearing an orange shirt with printed design and a light blue zip up hoodie. R16's orange printed shirt had food debris and the resident's fingernails were uneven (some were short, and some were long) with most of the fingernails jagged and some with black substances under the nails. On December 29, 2025 at 10:05 AM, R16 was in bed, alert and verbally responsive. R16's fingernails remained uneven (some were short, and some were long), most of the fingernails were jagged and some had black substances under the nails. V3 (ADON) was present during the observation and stated, Yes, her fingernails need care. R16's active care plan last revised by the facility on October 20, 2025 showed that the resident has an ADL self-care performance deficit. The care plan showed the facility's goal for R16 to receive assistance with ADLs as evidenced by the resident's well-groomed appearance. The same care plan showed multiple interventions including providing assistance with dressing and personal hygiene/grooming due to R16's dependence. On December 29, 2025 at 11:31 AM, V2 (DON) stated that it is part of the facility's nursing care and services to provide assistance to all residents requiring help with nail care, dressing and removal of unwanted facial hair to ensure the residents maintain personal hygiene and grooming. 4. Face sheet shows R7 is 91 years-old who has multiple medical diagnoses including dementia, diabetes, and muscle wasting and atrophy. R7's Minimum Data Set (MDS) dated [DATE], shows R7 requires assistance with grooming and hygiene. From December 28 to 30, 2025, R7 was observed multiple times in the dining room and his bedroom. R7 displayed unkept overgrown facial hair and jagged, uneven, dirty fingernails with black/brown substance underneath. On December 29, 2025, at 12:18 PM, R7 stated he wanted his fingernails clipped and facial hair shaven.

Based on observation, interview, and record review, the facility failed to apply a recommended device for contracture management to resident who has contractures. This applies to 2 of 3 residents (R3, R11) reviewed for contractures in the sample of 12. The findings include: 1. Face sheet shows R3 is 78 years-old who has multiple medical diagnoses including hemiplegia and hemiparesis affecting left non-dominant side. R3 is under hospice care. The therapy services/screening form dated September 16, 2025, shows R3 was provided a resting hand splint but it was missing, the facility notified hospice nurse. R3's care plan with a target date of January 1, 2026, shows, R3 has an ADL (Activities of Daily Living) self-care performance deficit related to hemiplegia, and left-hand contracture. This same care plan shows multiple interventions including application of left-hand splint, on for 12 hours and off for 12 hours. On December 28, 2025, at 10:48 AM, R3 was observed multiple times resting in bed, he was alert with periods of confusions. R3 displayed contracted to left arm and hand. R3's left hand was tightly clenched with his fingers digging onto his palm. There was no palm protector or resting hand splint on his hand. From December 28 to December 30, 2025, multiple observations were conducted to R3 who was resting in bed. R3's left hand remained clenched with no resting splint nor rolled towel on his hand. On December 30, 2025, at 9:44 AM, V6 (Certified Nursing Assistant/CNA) provided incontinence care to R3 who was totally dependent on staff for his ADL care. R3 was pleasant and cooperative. R3's left hand was tightly clenched, and remained with no resting splint, there was a thin dressing on his left palm which V6 stated to protect his skin from his fingernails. V6 stated that R3 used to have a carrot splint. There was no resting hand splint/carrot splint, nor rolled washcloth present anywhere on R3's bedroom during observations from December 28 to 30, 2025. 2. Face sheet shows R11 is 73 years-old who has multiple medical diagnoses including dementia, functional quadriplegia, and contracture, unspecified joint. The therapy services/screening form dated September 16, 2025, shows R11 has contractures of upper and lower extremities. R11 needs cuing to relax limbs and needs pillow placement to increase comfort and decrease skin breakdown. On December 28, 2025, at 10:45 AM, R11 was resting in bed, her hands, wrists, and bilateral lower extremities were contracted. R11's lower extremities were contracted and adducted with skin touching and rubbing on one another, there was no wedge pillow in between the knees. R11 was totally dependent on staff for ADL care. From December 28 through December 30, 2025, R11 was observed multiple times in bed. There was no pillow in between her lower extremities which was pressed and rubbing together R11's care plan with target date of January 1, 2026, shows R11 has contracture, quadriplegia and chronic pain syndrome. This same care shows multiple interventions including use of non-pharmacological pain mechanisms such as positioning comfortably.

Based on observation, interview, and record review, the facility failed to follow physician order and manufacturer's recommendation for medication administration. There were 26 medication opportunities with 2 administration errors resulting to 7.69% medication error rate. This applies to 1 of 2 residents (R10) reviewed for medication administration in the sample of 12. The findings include:Face sheet shows that R10 is 92 years-old who has multiple medical diagnoses including dementia, dysphagia, hypertension, tachycardia, and hypothyroidism. On December 29, 2025, at 10:23 AM, V5 (Nurse) administered multiple medications to R10 including Levothyroxine and Aspirin chewable tablet. Both medications were crushed upon administration, which made the Aspirin medication an immediate release dose. V5 said that R10 already ate breakfast prior to administration of morning medications. On December 30, 2025, at 12:57 PM, V1 (Administrator) stated they expect the nurses to relay pharmacy recommendation to the physician and follow physician's instructions/orders. Synthroid is given early in the morning on an empty stomach to get its full effect or to ensure optimal absorption of the medication On December 30, 2025, at 3:00 PM, V12 (Nurse) stated Synthroid is given at 6 AM before breakfast on an empty stomach to increase effectiveness of medication. It is less effective after resident has eaten. R10's Physician Order Summary (POS) shows: Levothyroxine Sodium Oral Tablet 50 mcg. Give 1 tablet by mouth one time a day for hypothyroidism. This medication is time sensitive, should be given at 6 AM, earliest time to give is at 5AM. Aspirin 81 Oral Tablet Delayed Release. Give 1 tablet once a day for VTE (Venous Thromboembolism). Manufacturer's recommendation for the Levothyroxine showed to administer this medication on an empty stomach, one half hour to one hour prior to breakfast with a full glass of water.

Based on observation, interview and record review, the facility failed to clean and sanitize kitchen equipment, failed to label/date potentially hazadardous stored food, failed to store cooked meat to prevent cross contamination, and failed to perform hand hygiene per facility policy. This applies to all 22 residents residing in the facility. The findings include: Facility Long-Term Care Facility Application for Medicare and Medicaid, dated January 27, 2025, shows the facility census was 22 residents. On January 27, 2025, at 9:38 AM, during initial tour of the kitchen with V9 (Food Service Manager), the area behind/between large cooking equipment had a large amount of food splatters and food build up as well as dust with loose particles located behind and slightly above a pan of margarine melting on the flat top. The equipment hoses/cords and the back panels of equipment were covered in large amounts of dust and food splatter. On January 27, 2025, at 9:38 AM, during initial tour of the kitchen with V9, there was a package of four hot dogs (identified by V9) in the walk in cooler stored on a full sheet pan without a label/date and loosely packaged stored above packages of raw Swiss steak. V9 stated he was unsure when the hot dogs were opened or when they should be discarded because they were not labeled or dated. The raw Swiss steak blood leaked from the packaging and there was blood pooling in the bottom of the sheet pan. Below the sheet pan of raw Swiss steak were packages of fully cooked bratwurst. V9 stated the bratwurst was already cooked. V9 removed the pan of cooked bratwursts from below the raw Swiss steak pan and placed it above the Swiss steak pan on the cart. V9 stated the staff know when to discard food in the cooler by the time it is kept in the cooler but they would be unable to determine when it should be discarded unless the food is dated. Food delivery invoice, number 114326, shows the bratwurst purchased by the facility was delivered fully cooked. On January 27, 2025, at 12:30 PM, V11 (Food Service Worker) served food and coffee to a resident, removed her gloves and placed clean gloves on her hands without washing her hands. V11 then served food on to a resident tray which was served to the resident. With the same gloves she placed a raw lemon wedge on a different resident tray and then retrieved a wipe cloth from the counter and wiped the counter using the same gloves. V11 then placed the wipe cloth back on the counter and using the same gloves served food items on to a resident tray. Facility policy Basics for Handling Food Safety, undated, shows Don't cross cross-contaminate. Keep raw meat, poultry, fish and their juices away from other food Facility Dishwashing Procedure, undated, shows, .9. Before any dish machine operator moves from soiled dishes to clean dishes, one of the following must occur: a. Hands shall be washed using proper hand washing procedures. B. If using gloves, soiled gloves shall be removed, hands shall be washed using proper hand washing procedures and clean, unused gloves must be put on Facility policy/procedure, revised 5/8/24, shows, .4. Dietary employees will adhere to the facility hand washing policy. Hand washing is required: a. Before preparing food or putting on gloves g. After engaging in any activities that might contaminate the hands, such as taking out garbage, handling soiled utensils or equipment or handling cleaning chemicals. h. Directly before touching ready-to-eat food or food-contact surfaces 9. Single use gloves may be used as necessary to prevent bare hand contact with ready-to-eat food or to cover an open sore. Gloves shall be changed when switching tasks, when gloves become soiled or torn or when 4 hours has elapsed. Facility policy/procedure Sanitation and Cleaning Schedule, reviewed 8/15/23, shows, The Dietary Department shall be responsible for maintaining sanitary conditions in the kitchen, all storage and dining areas, including all equipment located and/or utilized in these areas Storage .2. All raw meat must be stored on the bottom rack of the refrigerator for thawing. 3. All refrigerated and prepared food must be covered, labeled and dated with a use-by date that is a maximum of 7 days from date of preparation. Label must include the name of the food and the date by which it should be used Equipment 1. All equipment must be cleaned and sanitized with approved sanitizer after each use.

Based on observation, interview, and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to perform hand hygiene during provisions of care, failed to follow the EBP (Enhanced Barrier Precautions) policy, and clean medical equipment between resident use. This applies to all 22 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 27, 2025, showed the facility census was 22 residents. The facility's Water Management Pan dated November 7, 2024, showed Purpose: The purpose of this Water Management Plan (WMP) is to establish the minimum legionellosis risk management requirements by illustrating the procedures for minimizing the risk of Legionnaires' disease within the building water systems of one facility . Control Measures: Cold Water Systems, Risk Factor: Eyewash Station, Control Measure: Plumbed units are to be activated weekly to flush the line and verify operations; at least a three minute flush is recommended . Frequency: Weekly, Monitoring: Execute the control measure based on the stated frequency and the type of eyewash station present as indicated in the control measure . Control Measures: Hot Water Systems, Risk Factor: Water Heater, Control Measure: Check flow and return temperatures at hot water heater. Location: Boiler Room. Frequency: Monthly or as required or recommended by AHJ (Authority Having Jurisdiction) or your water treatment professional. Monitoring: Supply temperature should be checked at the outlet of the Hot Water Heater and should not be lower than 140 degrees Fahrenheit. The return temperature should also be checked monthly and should not be lower than 122 degrees Fahrenheit. Control Limits (Lower): 122 degrees Fahrenheit, Control Limits (Upper): 140 degrees Fahrenheit, Corrective Actions: If unable to maintain desired temperatures; the Program Team shall consider alternate methods to conform with compliance to reduce risk of legionella. NOTE: State and local regulations limit the temperature set-points of water heaters due to scald protection. This places most facilities out of control limits set by the scientific community. Accordingly, the only way to confirm legionella is under control is to test specifically for legionella. [Water Safety Company] suggests performing at a minimum two (biannual) tests per year, with four (quarterly) being more ideal. By doing so, the Program Team responsible has documented evidence that the hazard of legionella is under control . Control Measures: Hot and Cold Water Systems, Risk Factor: Check for Residual (Free) Disinfectant (Chlorine) Levels, Control Measure: Measure and record Residual (Free) Disinfectant (Chlorine) levels on the incoming city water supply as well as a representative most distal location within the facility. NOTE: A Free and Total Chlorine test kit that reads at least zero to six PPM (Parts per Million) as 'Cl' should be utilized to complete this test. Location: At any or multiple locations throughout the building. Frequency: Weekly, Monitoring: Use a chlorine test kit to measure the residual (free) disinfectant (chlorine) levels on the incoming city water supply as well as representative most distal location within the facility and record the results. Control Limits (Lower): 0.5 PPM, Control Limits (Upper): 3.0 PPM not to exceed 4.0 PPM, Corrective Actions: If disinfectant (chlorine) levels exceed 4.0 PPM (Parts per Million) on the upper level, please notify your municipal water supplier. If no chlorine levels are detected, please speak to your water supplier to see if they can increase the disinfectant levels. NOTE: [Water Safety Company] recommends a minimum of 0.5 PPM of Free Chlorine. Contact [Water Safety Company] with questions or concerns. If the free residual chlorine is less that 0.5 PPM, then it is recommended that special medical-grade 0.2-micron inline filters be installed for the ice machines . On January 29, 2025, at 10:44 AM, V12 (Maintenance Director) said the facility has two eye wash stations which are plumbed in. V12 continued to say every week, V12 turns the eye wash stations on to ensure they work and then V12 turns the eye wash station off. V12 demonstrated his check of the eye wash station in the soiled linen room. V12 turned the lever and activated the eye wash station, water flowed from the eye wash spouts for one to two seconds, V12 immediately turned the faucet off to the eye wash station. V12 said that is how he does his weekly check of the eye wash stations. V12 said he checks the temperatures on the hot water tank and hot water return weekly. V12 said the temperatures on the hot water tank are 120 degrees Fahrenheit and the return is 110 degrees Fahrenheit. V12 said he does not perform weekly chlorine testing of the water. V12 continued to say he does not have any chlorine testing kits. V12 said he has the test kit to collect samples for legionella testing but has not sent them to the laboratory. V12 continued to say the last test result for the facility's legionella testing is from August 2023. V12 said he does not have any test results for legionella since May 2023. The facility's Weekly Boiler and Tanks Water Temp Log showed the facility's Domestic Boiler and Return temperatures from September 2, 2024, to January 27, 2025, were 120 degrees Fahrenheit at the boiler and 110 degrees Fahrenheit at the hot water return. These readings are outside of the control limits per the facility's Water Management Plan. The facility does not have documentation to show biannual testing for legionella was completed in 2023 or 2024. The facility does not have documentation to show chlorine testing of the facility's water was being performed weekly. On January 29, 2025, at 11:37 AM, V1 (Administrator) and V3 (Regional Director of Clinical Operations) said V12 should be following the facility's Water Management Plan for legionella including performing control measures and legionella testing. V3 said V12 should be flushing the eye wash stations for at least three minutes. 43389 2. R176's Resident Information sheet showed an [AGE] year old male admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Dysphagia following Cerebral Infarction, Encounter for attention to Gastrostomy, and Type 2 Diabetes Mellitus. R176's Physician order dated January 15, 2025 showed the following: Resident is on Enhanced Barrier Precautions due to Gastrostomy tube (G-tube). Personal Protective Equipment (PPE) is to be worn during high contact activities. R176's G-Tube Care plan dated January 23, 2025, showed an intervention of Enhanced Barrier Precautions. On January 28, 2025, between 8:36 AM and 9:34 AM during medication administration observation with V6 (Licensed Practical Nurse), observed the following: V6 took a rolling blood pressure cuff out of R12's room that she had just used on him and did not perform hand hygiene, nor did she sanitize the blood pressure cuff. V6 took the blood pressure cuff to R176's room. R176 has an Enhanced Barrier Precautions (EBP) sign on the outside of his door and Personal Protective Equipment in a bin outside the door. The EBP sign says stop: Everyone Must: Clean their hands including before entering and when leaving the room. Providers and staff must also wear gloves and gown for High Contact Resident Care Activities that include device care or use of feeding tubes. V6 entered R176 room and did not perform hand hygiene on the way into the room nor did she put on a gown. After taking the R176's blood pressure, V6 left the room and went to her medication cart outside of the room and started getting R176's medication ready. V6 did not perform hand hygiene when exiting the room. V6 then crushed all 6 of R176's medications separately and put them in separate medication cups. After crushing each medication, V6 picked up the garbage can lid to threw away the plastic sleeve she crushed the medication in. V6 then crushed another medication and repeated for all 6 medications. V6 then said she was going to get warm water from R176's restroom. V6 went into R176's room grabbed and open the restroom door and then came out 5 seconds later with a cup of water. V6 exited R176's the room with the water and applied gloves without performing hand hygiene. V6 then brought the medication into R176 room. R176 then asked for a cloth to wash his hands. V6 gave him a dry cloth and R176 asked if she can wet it. V6 with her gloves on grabbed the restroom door with her right hand, disposable cloth in the left hand and went into the restroom. V6 emerged from the R176's restroom [ROOM NUMBER]-5 seconds later with gloves still on and handed R176 the wet cloth. V6 then removed the covers from over R176 and lifted up his shirt. V6 turned and poured water into each cup and started one by one injecting the medication into R176 G-tube. After injecting each medication, and with the same gloves on. V6 grabbed the restroom door and went into the restroom, came out of the restroom [ROOM NUMBER] seconds later with water and then flushed 30 ml of that water into the R176's G-tube. V6 adjusted resident, gave juice, opened and placed straw in juice all with the same gloves on. V6 took off gloves and put on new ones on without performing hand hygiene, then cut up R176's pancakes. V6 removed her gloves and left the room without using hand sanitizer or performing hand hygiene. At no point did V6 put on an isolation gown while passing medication to R176 who was on Enhanced Barrier Precautions. V6 went to her cart and pulled it to R20's room. V6 pulled the blood pressure cuff with her that she used on R12 and R176 which was still not sanitized. V6 then opened the garbage can connected to her medication cart and threw something away with her right hand. V6 grabbed the blood pressure cuff she used on R12 and R176 (which was still not sanitized) and took R20's blood pressure. V6 left the room without performing hand hygiene, prepared and grabbed the medications and went into R20's room and administered 9 oral medications. V6 then went back out to her cart, got R20's inhaler put gloves on without performing hand hygiene and administered R20's inhaler. V6 then prepared and administered a stool softener and placed a pain patch on R20 back and still had not performed any hand hygiene yet. V6 then removed her gloves left the room and took her medication cart to R16's room and started preparing 4 medication for R16. V6 then poured R16 a cup of water. V6 then went to clean utility room down the hall with R16's medication in one of her hands and opened the door with the other and got a box of gloves while holding door open with her left foot. V6 went back to R16's room and put on new gloves. V6 still had not performed hand hygiene yet. V6 then took the same blood pressure cuff she had used on R12, R176, and R20 (without sanitizing the cuff in between residents) and checked R16's blood pressure. V6 then retrieved R16's water and put a straw in the water while touching the straw with the gloved hands. V6 took off gloves did not perform, put on new gloves adjusted R16 in the bed with gloves on and gave her the medication. V6 then removed the gloves and for the first time since the medication observation started, V6 performed hand hygiene with hand sanitizer that was hanging in the hallway outside the room. On January 28, 2025, at 9:34 AM, V6 stated that when providing care and passing medication via G-tube to R176 who is on EBP isolation, she should have performed hand hygiene. V6 stated she should have used hand sanitizer or perform hand hygiene when going in and out of all rooms and when going from clean to dirty. V6 stated she should have performed hand hygiene after removing gloves. V6 stated she should have sanitized the blood pressure cuff in between residents. On January 29, 2025, at 4:13 PM, V3 (Regional Nurse Consultant) stated that before donning gloves or utilizing a resident's G-tube, staff should perform hand hygiene. V3 stated that before providing care to a resident on Enhanced Barrier Precautions, the nurse should perform hand hygiene, and don gloves and a gown. V3 stated, after performing care or using a resident's G-tube, staff should remove their gown and gloves before leaving the room, and perform hand hygiene. V3 stated soap and water should be used and hands washed for 20-30 seconds and dried. V3 stated hand sanitizer is acceptable to use unless hands or gloves are soiled. V3 stated the reason for preforming hand hygiene before and after resident care and before and after using a resident's g-tube is to prevent the spread of infection. The facility's Hand Hygiene policy dated May 8, 2024, showed the following: Purpose to provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of transmission of infections. Procedure 2. The use of gloves does not replace hand hygiene. 3. Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE). Washing Hands with Soap and Water 1. Staff will perform hand hygiene by washing hands for at least twenty (20) seconds with antimicrobial or non-antimicrobial soap and water should be performed under the following conditions: b. before applying gloves and after removing gloves or other PPE. h. After using a restroom. Using Alcohol-Based Hand Gel: 1. If hands are not visibly soiled, use and alcohol-based hand rub for the following situations: b. Before entering and leaving an isolation room, c. Before preparing or handling medications, d. before applying gloves and after removing gloves or other PPE. g. After providing direct care, i. After using a restroom. m. after contact with inanimate objects (e.g., medical equipment) in the immediate vicinity of the resident. The facility's Isolation precautions Policy dated May 8, 2024, showed the following EBP: 1. Expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The facility's Cleaning and Disinfection of Resident Care Equipment policy dated May 8, 2024, showed the following: Procedure: 1. Reusable equipment will be cleaned and disinfected after used of one resident and before use of another resident. The facility's Personal Protective Equipment policy dated June 14, 2024, showed the following: Procedure: PPE will be worn for residents requiring Enhanced Barrier Precautions.

Based on interview and record review, the facility failed to provide the minimum required servings of fruits/vegetables and grains/breads on their planned menus as per facility policy. This applies to 15 of 15 residents (R1, R3, R7, R10, R11, R14, R15, R16, R18, R20, R127, R128, R129, R130, R176) reviewed for menu planning. The findings include: Facility Diet Type Report, dated January 29, 2025, shows R1, R3, R7, R10, R11, R14, R15, R16, R18, R20, R127, R128, R129, R130, R176 had physician orders for Regular and/or No Added Salt diets. Review of facility Regular/NAS (No Added Salt) menu, dated Week 3 Sunday through Week 3 Saturday, shows the facility failed to provide at least 5 fruits/vegetables planned on the daily menus 4 of 7 days (Sunday, Tuesday, Friday, and Saturday). The menu shows the facility failed to provide at least 6 servings of grains/breads on 2 of 7 days (Monday and Saturday). Review of facility Regular/NAS (No Added Salt) menu, dated Week 1 Sunday through Week 1 Saturday, shows the facility failed to provide at least 5 fruits/vegetables planned on the daily menus 4 of 7 days (Tuesday, Wednesday, Friday and Saturday). The menu shows the facility failed to provide at least 6 servings of grains/breads on 5 of 7 days reviewed (Sunday, Wednesday, Thursday, Friday and Saturday). Review of facility Regular/NAS (No Added Salt) menus, dated Week 2 Sunday through Week 2 Saturday, shows the facility failed to provide at least 5 fruits/vegetables planned on the daily menus 3 of 7 days (Tuesday, Thursday and Saturday),. The menu shows the facility failed to provide at least 6 servings of grains/breads on 3 of 7 days reviewed (Sunday, Tuesday, Friday). Review of facility Regular/NAS (No Added Salt) menus, dated Week 4 Sunday through Week 4 Saturday, shows the facility failed to provide at least 5 fruits/vegetables planned on the daily menus 1 day (Saturday). The menu shows the facility failed to provide at least 6 servings of grains/breads on 5 of 7 days reviewed (Monday, Tuesday, Thursday, Friday, and Saturday). On January 29, 2025 at 1:57 PM, V9 (Food Service Manager) stated the menus were reviewed by the corporate dietitian. V9 reviewed the menus and was unable to identify any of the missing servings of fruits/vegetables or grains/breads on the menus. Facility Menu Planning Guide, dated November 2023, shows the Regular/No Added Salt menus are designed to include foods in amounts that will meet or exceed the Dietary Reference Intakes (DRIs) for older adults. The following components are included daily: . Vegetables and Fruit: 5 or more servings, Grains: 6 or more servings.

Based on observation, interview and record review, the facility failed to ensure a resident with significant weight loss was reviewed by a dietitian upon readmission to the facility from the hospital, failed to provide nutritional interventions to assist in preventing weight loss, and failed to obtain weekly weights as ordered by the physician. This applies to 1 of 1 residents (R3) in the sample of 12. The findings include: Face sheet, dated January 28, 2025, shows R3's diagnoses included pneumonitis due to inhalation of food and vomit, methicillin resistant staphylococcus aureus infection, osteomyelitis, severe protein-calorie malnutrition, acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebral infarction, dysphagia, muscle wasting and atrophy, sepsis, iron deficiency anemia, vitamin D deficiency, major depression, epilepsy, chronic kidney disease, and hypoglycemia. Nutrition note, dated November 20, 2024, shows R3 had a history of significant weight loss and was receiving nutrition supplements 120 milliliters twice daily. On January 27, 2025, at 11:15 AM during initial tour, R3 appeared very thin. Weights and Vitals Summary, dated 12/1/24 to 1/30/25, shows the following weights were obtained by the facility for R3: December 6, 2024 - 126.6 pounds December 7, 2924 - 126.5 pounds December 22, 2024 - 125.5 pounds December 29, 2024 - 126.6 pounds January 5, 2025 - 127.4 pounds January 27, 2025 109 pounds - 14% weight loss MAR (Medication Administration Record), dated January 1-29, 2025, shows R3 had a physician order for weekly weights one time a day every Sunday ordered on December 25, 2024, and discontinued January 27, 2025. Review of the December 2024 MAR shows R3's weight was obtained on December 29, 2024. Review of the January 2025 MAR shows R3's weight was only obtained on January 5, 2025. No weights were obtained between January 5-26, 2025 as ordered by the physician. MAR, dated December 1-31, 2024, shows R3 had a physician order for a nutritional supplement 120 milliliters twice daily ordered on September 17, 2024, and discontinued on December 10, 2024, when R3 was transferred to the hospital. Review of R3's clinical record shows R3 was admitted to the hospital on December 9, 2024, with a diagnosis of pneumonia and returned to the facility on [DATE]. The clinical record shows R3 was again admitted to the hospital on December 23, 2024, with a diagnosis of hypoglycemia and returned to the facility on [DATE]. The clinical record showed R3's nutritional supplements were not reordered upon either readmission to the facility and R3 was not reviewed by the facility dietitian until January 27, 2025. On January 28, 2025, at 2:16 PM, V6 (Licensed Practical Nurse) stated R3 required staff to feed him for approximately a month and also had difficulty swallowing. V6 stated sometimes R3 would eat and sometimes he would not. Progress note, dated January 16, 2025, shows R3 was identified by the clinical director to have poor appetite and signs of dehydration. The note shows R3's physician ordered three liters of intravenous fluids. No referral to the dietitian was identified. MAR, dated January 2025, shows R3's nutritional supplement was reordered on January 20, 2025. Nutrition note, dated January 27, 2025, shows R3's weight was obtained and R3 weighed 109 pounds. The facility dietitian documented R3 experienced a significant weight loss which was confirmed by reweighing the resident. The note shows R3's usual body weight was 125-135 pounds and his meal intake varied between 25-75% at meals. On January 19, 2025 at 10:29 AM, V23 (Dietitian) stated on approximately January 20, 2025, the facility Director of Nursing informed V23 that R3 was not eating well so V23 reordered R3's nutrition supplements. R3 stated she believed R3's supplements were not reinstated when he returned from the hospital in December 2024. V23 stated she had not seen R3 at the facility since her November 2024 nutrition note, was not notified regarding R3's December 2024 hospitalization s and readmissions to the facility. At 11:45 AM, V23 stated, It would have been resumed had I seen him on admission. On January 29, 2025, V9 (Food Service Manager) stated normally a nurse would email the dietitian and let them know if they should see a resident if needed. On January 29, 2025, at 11:12 PM, V19 (Physician) stated R3's nutritional supplement not being reinstated upon readmission from the hospital may have contributed to some of R3's weight loss he experienced during the month of January 2025. V19 stated she defers to the dietitian for resident supplements because they should be performing a readmission assessment and periodically doing an assessment of facility residents. V19 stated she expected if nurses notice some changes in appetite or condition, they should refer a resident to the dietitian.

Based on interview and record review, the facility failed to identify resident specific behaviors to monitor the effectiveness of psychotropic medications. This applies to 3 of 5 residents (R3, R5, and R75) reviewed for unnecessary psychotropic medications in the sample of 12. The findings include: Review of R3, R5, and R75's Documentation Survey Report, dated January 1, 2025 to January 29, 2025 showed all three residents were being monitored for the same behaviors. These included: 1. grabbing, 2. pinching, 3. scratching, 4. hitting/punching, 5. kicking, 6. pushing, 7. spitting, 8. biting, 9. sexually inappropriate, 10. verbal threatening, 11. screaming at others, 12. cursing at others, 13. hitting self, 14. scratching self, 15. pacing, 16. public sexual acts, 17. disrobing in public, 18. rummaging, 19. throwing/smearing food, 20. throwing/swearing bodily waste, 21, screaming/yelling out, 22. disruptive sounds, 23. attention seeking, 24. refusing care, 25. exit seeking, 26. wandering, 27. no behaviors observed. On January 29, 2025 at 9:53 AM, V18 (Social Services) stated the nurses let her know if the residents express comments or feelings related to depression. V18 stated she completes the mood assessment and then visits residents on the weekend to check in to see if they have any further symptoms of depression. V18 stated she was not aware of any facility assessments to identify specific resident behaviors to assess the effectiveness of psychotropic medications. V18 stated she was not aware of any ongoing, daily monitoring of resident-specific behaviors to monitor the effectiveness of resident psychotropic medications. V18 stated resident information regarding their psychotropic medications was located in their care plans. 1. R5 was admitted to the facility on [DATE], with diagnoses that included unspecified psychosis not due to a known substance or physiological condition, anxiety, and unspecified dementia with behaviors, and suicidal ideations. R5's MDS (Minimum Data Set) dated January 16, 2025, showed R5 had severe cognitive impairment. R5's care plan identified depression as a condition for R5 and the goal was for R5 to remain free of signs symptoms of distress, symptoms of depression, anxiety, or sad mood. Interventions included to discuss with resident, family, and caregivers any concerns fears, or issues, regarding health. R5 uses antidepressant medications and interventions included administer medications as ordered by physician, monitor/document side effects and effectiveness. R5 also had potential for behavior symptoms (Psycho-active adaptation and/or psychotropic medication use) related to unspecified dementia, unspecified severity, with behavioral disturbances, suicidal ideations. The goal is to have fewer episodes of TARGET BEHAVIORS by the review date. Interventions included anticipate and meet my needs, consult psychiatry for recommendations, monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situation. R5's psych note dated September 11, 2024, showed, R5 has multiple psychiatric complexities and would benefit from continued management with monitoring of mood and behavior, Will titrate medication based on current symptom progression. R5's psych note dated October 17, 2024, showed to continue current treatment. Administer antipsychotic medication as ordered by physician, monitor for side effects and effectiveness. Monitor target behaviors, number of behaviors and document episodes. Consent for Lexapro (Antidepressant) and Seroquel (Antipsychotic) was signed and dated January 25, 2025. R5's behavior monitoring was reviewed from January 1, 2025 to January 28, 2025. Target behaviors were not identified and behavior monitoring was vague and not resident specific. During this time period, there were 14 shifts where no behavior monitoring was completed. 35267 2. MAR, dated January 2025, shows R75's diagnoses included depression. MAR, dated January 2025, shows R75 had a physician order, initiated January 18, 2025, for escitalopram oxalate daily for depression. Review of R75's clinical record shows no assessment which determined R75's specific behaviors indicative of R75 experiencing depression. Care plan, revised January 14, 2025, shows R75 has an actual/potential psychosocial well-being problem r/t (related to). R75's interventions show no resident-specific behaviors identified to monitor R75's depression or the effectiveness of his anti-depression medication. On January 29, 2025 at 10:07 AM, V18 stated no resident-specific behaviors were identified to monitor for the effectiveness of R75's newly-prescribed antidepressant medication. 3. Face sheet, dated January 28, 2025, shows R3's diagnoses included depression. MAR (Medication Administration Record) shows R3 had a physician's order for mirtazapine daily for depression. Review of R3's clinical record shows no assessment to determine R3's specific behaviors indicative of R3 experiencing depression. Review of R3's care plan, revised 4/4/24, shows, I exhibit Behavior Symptoms (Psycho-social adaptation and/or Psychotropic Medication use) related to 10/24/22 [R3] is refusing skin interventions of protective boots. Interventions include, Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. R3's care plan, revised 8/25/24, shows The resident has depression due to the passing of his son. Interventions include, Monitor/document/report PRN (As Needed) any s/sx (signs/symptoms) of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, tearfulness. R3's care plan, revised 6/20/24, shows The resident has potential psychosocial well-being problem r/t (related to) depression diagnosis. R3's care plan, initiated 3/26/24, shows, Resident uses antidepressant medication r/t depression. Review of R3's behavior tracking records, Documentation Survey Report January 2025, shows none of the signs/symptoms which are listed to be monitored include the symptoms/behaviors indicated in R3's care plan. Facility Policy/Procedure Psychotropic Medication, revised 9/6/24, shows 1. An assessment must be conducted to identify specific behaviors/symptoms, potential causative factors and recommendations for managing identified behaviors. 2. The medical record documentation must reflect the specific behaviors/symptoms and the resident's response to non-pharmacological interventions to manage the behaviors/symptoms.

Based on interview and record review, the facility failed to give a resident a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) at the end of a resident's Medicare Part A stay. This applies to 1 of 3 residents (R225) reviewed for beneficiary notices in the sample of 12. The findings include: The facility's SNF (Skilled Nursing Facility) Beneficiary Notification Review for R225 showed R225's Medicare Part A Skilled Services started on October 10, 2024 and last covered day of Part A services was November 14, 2024. The documentation continued to show R225 was not given a SNF ABN form. The EMR (Electronic Medical Record) showed R225 was admitted to the facility on [DATE], and was discharged from the facility on November 19, 2024, to the local hospital. On January 28, 2025, at 12:18 PM, V18 (Social Services) said R225 did not receive a SNF ABN form because V18 did not know R225 was going to remain in the facility after his last covered day of Medicare Part A. On January 28, 2025, at 1:02 PM, V18 said a SNF ABN should be given to resident and/or their representative if the resident is staying in the skilled nursing unit as a private pay resident. V18 said the SNF ABN goes over the charges the resident will be responsible for paying if they chose to stay in the skilled unit. V18 continued to say the SNF ABN should be given two days before the last covered day so the resident and/or representative has time to appeal if they would like. The facility did not have documentation to show R225 received a SNF ABN form prior to his last covered day of Medicare Part A services.

Based on interview and record review, the facility failed to provide to the resident or resident's representative in writing the facility's bed hold policy when being transfer to the local hospital. This applies to 2 of 3 residents (R4 and R5) reviewed for hospitalization s in the sample of 12. The findings include: Facility provided their bed hold form titled, BEDHOLD AGREEMENT- TRANSFER NOTICE. The form showed the following information was required to be filled out: resident's name, date, the reason the resident being transferred to/for, why the transfer or discharge is necessary for the resident's welfare and the resident's needs, what was the bed hold decision, signature of facility representative, signature of resident/representative/responsible party who was given written notice of transfer, if needed phone confirmation, date, time, bed hold requested by, relationship to resident, confirmation received by facility representative signature. 1. R5's EMR (Electronic Medical Record) showed R5 was admitted to the facility on [DATE], with diagnoses that included combined systolic (congested) and diastolic (congested) heart failure, unspecified dementia, cognitive communication deficit, severe kidney failure stage 4, unspecified psychosis not due to a substance for known physiological condition, anxiety, and atrial fibrillation. R5's MDS (Minimum Data Set) dated January 16, 2025, showed R5 had severe cognitive impairment. R5's progress notes showed R5 was sent to the local hospital three times from August 2024 to present. There was no documentation to show the bedhold policy was discussed with R5 or her representative with any of these transfers. On August 21, 2024, R5 was sent to the local hospital for an evaluation after she was found on the floor in her room. R5 was admitted to the hospital and returned to the facility on [DATE]. R5 was sent to the local hospital on December 2, 2024 after she was found on the floor in her room with some confusion. R5 was admitted to the hospital and readmitted to the facility on [DATE]. Facility provided BEDHOLD AGREEMENT- TRANSFER NOTICE with the dates of August 27, 2024 and December 2, 2024. Both forms were left empty except for R5's signature, V18's (Social Services) signature, and a box checked I do not want a bed hold. R5 did not go to the hospital on August 27, 2024, R5 was sent to the local hospital on August 21, 2024. On December 24, 2024, R5 was sent to the local hospital for shortness of breath and fever. She was admitted to the hospital and was readmitted to the facility on [DATE]. There was no BEDHOLD AGREEMENT- TRANSFER NOTICE provided. The facility provided a BEDHOLD AGREEMENT- TRANSFER NOTICE form for July 11, 2024. The form was left blank except for R5's signature, V18's (Social Services) signature, and a box checked I do not want a bed hold. The same was true for a BEDHOLD AGREEMENT- TRANSFER NOTICE provided for R5 and dated September 4, 2024. Review of progress notes showed R5 remained in the facility on those dates and was not transferred anywhere. On January 29, 2025, at 12:57 PM, V18 (Social Services) said when she is doing a new admission assessment, the bed hold policy is discussed with the resident and/or resident representative. V18 said at this time she will ask them if there is a time when the resident needs to be sent out to the hospital would they want us to issue a bedhold. V18 said most will decline. V18 said she understands that on admission she is asking them about possible future transfer but asks them anyway. V18 said once a resident is sent out to the hospital, she will call and ask again, but most say no. V18 said her conversation will be documented on the resident's progress notes. 43389 2. R4's Resident Information sheet showed her to be a [AGE] year old female admitted to the facility on [DATE]. R4's progress notes dated January 11, 2025 showed that R4 was sent out to the hospital at approximately 11:10 PM related to symptoms of congestion and a chest x-ray showing atelectasis, pneumonia, or edema. Review of R4's Bed Hold Agreement in the resident's Electronic medical record showed it was uploaded on January 2, 2025. This form was not signed by V18 (Social Services) and there were no dates on the form. This same form was then presented to the surveyor on January 29 2025, now with a handwritten date of January 11, 2025 and electronically signed by V18, but otherwise empty of detail like what hospital the resident was discharged to. On January 29, 2025 at 12:51 PM and 1:10 PM, V18 stated that the Bed Hold Agreement form for R4 that was in the computer was uploaded on January 2, 2025. V18 stated she had R4's representative party sign the Bed Hold Agreement on admission. V18 stated she then signed and put the date that R4 was discharged on that form. V18 also stated this is what she does for all residents. V18 stated she does not speak to the resident, family, or resident representative, nor does she give them a copy of the Bed Hold Agreement form at the time of discharge. The facility's Admission, Readmission, Bed Hold, and Transfer/Discharge policy dated October 12, 2021 showed the following: Bed Hold: At the time of transfer of a resident for hospitalization or therapeutic leave, the facility will provide to the resident and the resident representative written notice which specifies the duration of the bed-hold, during which the resident is permitted to return and resume residence in the facility, the reserve bed payment policy in the state plan, and the facility policies regarding bed-hold periods. The facility's admission packet, Attachment I, Notice of Bed-hold information showed the following: Federal Law requires Nursing homes to give written notices to Residents and/or Responsible party at the time of the resident transfer to a hospital or overnight Leave of Absence.

Based on observation, interview, and record review, the facility failed to verify the placement and patency of a resident's gastrostomy tube (G-tube) before administering medication through it. This applies to 1 of 1 residents (R176) reviewed for gastrostomy tubes in the sample of 12. The Findings Include: R176' Resident Information sheet showed an [AGE] year old male admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Dysphagia following Cerebral Infarction, Encounter for attention to Gastrostomy, and Type 2 Diabetes Mellitus. On January 28, 2025, at 8:36 AM, during medication administration observation, V6 (Nurse) entered R176 room with medications she had prepared outside of the room. V6 then removed the covers from over R176, lifted up his shirt. V6 picked up the end of R176's G-tube (where the catheter accesses were located), looked at it in her hand, and said, it look's okay. V6 then grabbed one of the prepared cups that contained crushed medication and water put it in a large syringe and started injecting it into the resident's G-tube. Before injecting the medication into R176's G-tube catheter, V6 did not aspirate (pull back on the plunger of the syringe) to see if there was any residual gastrointestinal fluid, nor did she flush the catheter. On January 29, 2025, at 4:13 PM, V3 (Regional Nurse Consultant) stated that before using a resident's G-tube, she expects the staff to check for proper placement and patency of the G-tube by checking for residuals and flushing the G-tube. The facility's Tube Feeding: Administering Medications Policy dated September 8, 2023, showed the procedure includes: 7) prepare ordered medication, 8) unclamp tube, 9) Verify placement of feeding tube: Verifying Placement of feeding Tube policy, 10) Insert syringe (without plunger) and flush tube with 30 milliliters of water or as ordered. The facility's Verifying Placement of Feeding Tube policy showed the following: Gastric aspirate will be visually inspected prior to initiation of feeding. Aspirate will be observed for changes in volume and appearance.

Based on observation, interview, and record review, the facility failed to follow their policy to answer call lights promptly and failed to provide timely incontinence care to a resident. This applies to 3 of 3 residents (R1, R3, R4) reviewed for call light response times in the sample of 4. The findings include: 1. The EMR (Electronic Medical Record) shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, diabetes, atrial fibrillation, chronic kidney disease, heart disease, hypertension, difficulty walking, unsteadiness on the feet, morbid obesity, glaucoma, and dementia. R3's MDS dated [DATE] shows R3 is cognitively intact, requires setup with eating and oral hygiene, substantial/maximal assistance with bed mobility, and is dependent on facility staff for all other ADLs. R3 is always incontinent of bowel and bladder. R3's care plan entitled, At risk for alteration in skin integrity related to decreased mobility on a wheelchair, incontinent of bowel and bladder, and history of pressure ulcer initiated on April 19, 2024 shows multiple interventions revised on April 22, 2024 including, Keep skin clean and dry. R3's care plan entitled, The resident has an ADL self-care performance deficit r/t (related to) impaired mobility, weakness. Interventions updated on April 22, 2024 include, Toilet use assist - two staff assistance. On January 15, 2025 at 9:50 AM, R3 was lying in bed in his room. A strong odor of stool was present in the room. R3 said his incontinence brief was last changed at 5:00 AM before the night shift went home. R3 said, The last time I was changed was 5:00 AM today. Shortly after being changed, I had a bowel movement. I know not to press the call light during shift change or when they pass breakfast because no one will come. Around 7:30 AM or 7:45 AM, when they brought my breakfast tray, I told them that I needed to be changed. She said she would come back at 8:30 AM to clean me up. As of 9:50 AM, no one has come, and I have been sitting in poop for many hours. My butt is burning from sitting in poop this long. I press the call light and when no one comes, I just hold down the button continuously because I think that sets off an alarm somewhere else showing I really need assistance. When that doesn't work, I just start screaming out loud for help. They don't like that very much. During the conversation with R3, R3 pressed the call light to request assistance. No audible call light alarm could be heard, and the facility does not have illuminated lights over the resident's doorways to show which room is calling for help. A scrolling sign was located at the other end of the hallway, at the nurse's station, showing R3's call light was activated. V9 (LPN-Licensed Practical Nurse) was passing medications near R3's room. V9 did not stop administering medications to answer R3's call light. No CNAs were visible in the hallway. After 10 minutes and 25 seconds, V5 (SS) came to R3's room to ask if he needed help. R3 told V5 he needed assistance with incontinence care. V5 said she would find a staff member to assist R3. After a total call light response time of 13 minutes and 26 seconds, V8 (CNA) came to R3's room. R3 said he felt like he had waited too long to receive incontinence care. V8 said she was assigned to twelve residents and was busy providing incontinence care to two other residents and had not been able to answer R3's call light or attend to his need for incontinence care. At 10:09 AM, V8 (CNA) turned R3 to his right side and removed his incontinence brief. R3 had stool caked on the back of his legs, from his mid-thighs up to his buttocks. R3's entire buttocks was covered in stool. Stool had also leaked out of the top of R3's incontinence brief and had spread up R3's lower back. V8 (CNA) had to use multiple disposable wipes, and wiped multiple times over the same area to remove the stool because the stool was caked to R3's skin and did not wipe off easily. As V8 (CNA) used disposable wipes to clean stool from R3's legs, buttocks, and lower back, R3 cried out several times and said his skin felt sensitive and was burning. The skin on R3's buttocks was bright red in the areas where stool had been caked on his skin. 2. On January 15, 2025 at 9:27 AM, R4 was lying in bed in his room. R4 said, I have lived here less than a month. It takes them a very long time to answer call lights. One time it took over an hour. Forget calling for help around here. It takes too long for them to come to help. If I could do it myself I would, but obviously that's why I am here, because I can't do things for myself. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, hypotension, acute kidney failure, heart failure, atrial fibrillation, COPD (Chronic Obstructive Pulmonary Disease), hyponatremia, cognitive communication deficit, difficulty walking, and macular degeneration. R4's MDS (Minimum Data Set) dated December 29, 2024 shows R4 is cognitively intact, requires setup assistance with eating, substantial/maximal assistance with oral hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R4 is always incontinent of bowel and bladder. On January 8, 2025 at 10:32 AM, V5 (SS-Social Services) documented, Main topics discussed: Call response times: SS contacted [V17] (Daughter of R4) regarding a complaint about call times related to [R4]. The call light records were reviewed from the 1st to the 8th (January 2025). Average call response time was approximately 29 minutes. The longest recorded wait time was on the 6th (January 2025) from 7:00 AM to 10:46 AM, likely due to high call volume. Specific concerns: [V17] (Daughter of R4) noted concerns about two call times exceeding an hour. One confirmed incident was on the 6th (January 2025). An additional concern for the 5th reported by [V17] (Daughter of R4), though exact timing was unclear. Follow-up Actions: SS is actively working on resolving the issues and request that [V17] (Daughter of R4) reach out if she has further questions. On January 16, 2025 at 9:15 AM, V5 (SS) said, [R4's] family had concerns regarding call lights taking too long to be answered. I forwarded the concerns to [V2] (DON-Director of Nursing), and she said she would take care of it and make sure it didn't happen anymore. 3. The EMR shows R1 was admitted to the facility on [DATE] and was discharged to home on January 9, 2025. R1 had multiple diagnoses including, subluxation of C1/C2 cervical vertebrae, chronic osteomyelitis, displaced fracture of the second cervical vertebra, displaced posterior arch fracture of the first cervical vertebra, heart failure, rheumatoid arthritis, presence of bilateral artificial hip joints, dysphagia, spinal stenosis, and adjustment disorder. R1's MDS dated [DATE] shows R1 had moderate cognitive impairment and was dependent on facility staff for all ADLs. R1 was always incontinent of bowel and bladder. R1's MDS continues to show R1 was admitted to the facility with an unstageable pressure ulcer. On January 14, 2025 at 1:06 PM, V1 (Administrator) reviewed the call light logs for the entirety of R1's stay at the facility. V1 said, There were call light response times over 45 minutes. On January 1, 2025 the call light log shows it took 85 minutes for [R1's] call light to be answered. On January 5, 2025 the call light log shows it took 55 minutes for [R1's] call light to be answered. The facility's policy entitled Call Light Use and Response, issued 1/14/19 with revision dated of 5/20/20 and 7/18/23 shows: Purpose: 1. To respond promptly to resident's call for assistance. 2. To assure call system in proper working order. Procedure: 1. Facility personnel will be aware of call lights. 2. Answer call lights promptly whether or not the staff person is assigned to the resident or not. 3. Answer call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room and attend to the resident needs .

Based on observation, interview, and record review, the facility failed to ensure that medications were present for a resident with recurrent diarrhea and to notify the Physician about the medications, failed to ensure lab testing was completed in a timely manner for the resident, and failed to ensure staff responded to the resident's stool incontinence in a timely manner. These delays in treatment resulted the addition of a third medication, and the resident experiencing increased weakness and skin irritation. This applies to 1 of 4 residents (R14) reviewed for nursing cares in a sample of 26. Findings include: R14 was admitted to the facility on [DATE]. R 14 has diagnoses that includes congestive heart failure, muscle weakness, and enterocolitis due to clostridium difficile. R114's MDS (Minimum Data Set) shows he is cognitively intact and requires staff assistance for mobility using a walker. R14's care plan dated 2/11/24 includes actual impaired skin integrity, MASD (Moisture-Associated Skin Damage) to buttocks with risk for further skin breakdown including skin tears, bruising and /or pressure related to decreased mobility. On 4/18/24 at 10:05 AM, the call light computer display showed R14's call light had been unanswered since 8:56 am (one hour and nine minutes). On 4/18/24 at 10:19 AM, V12 (Family Member) stated R14 has recurrent C diff (Clostridium Difficile) infections. V12 stated R14 had been having diarrhea stools since Saturday 4/13/24 (five days). V12 stated, on Tuesday, 4/16/24 R14 was seen by the NP (Nurse Practitioner) at which time fidaxomicin and metronidazole were ordered. V12 stated she told the NP, V4 (RN), and another staff member she would pay out of pocket and retrieve the prescriptions if necessary. V12 stated staff never told her R14 had not been started on the medications and R14 seemed weaker since she saw him on Saturday. V12 also stated she had put the call light on at around 9am for stool incontinence. V12 stated V4 came in the room but did not provide incontinence care, and that R14 had a second stool incontinence episode since and still had not been cleaned. On 4/18/24 10:25 AM, V3 ADON (Assistant Director of Nursing) was asked by the Surveyor to have staff provide incontinence care for R14. V14 CNA (Certified Nursing Assistant) was sent to room to provide incontinence care. On 4/18/24 10:30 AM, V5 (Physician) stated he saw R14 on Tuesday, 4/16/24 and had ordered labs, IV (Intravenous) fluids, and called the ID (Infectious Diseases) Practitioner to see R14. V5 stated ID was at the bedside within an hour of his call and ordered fidaxomicin and metronidazole. V5 stated the fidaxomicin and metronidazole had still not been administered, and the ID called the facility Nurse Manager on 4/17/24 to follow up about the two medications. V5 stated the NP is now adding Vancomycin. V5 stated the C diff and urine labs he ordered two days earlier still had not been collected. V5 stated R14 seems weaker since he saw him on 4/16/24 but they were trying not to send him to the hospital. V5 stated the delay in treatment definitely had a negative impact on R14. On 4/18/24 10:45 AM, Surveyor in hallway heard R14 calling for assistance from his closed bathroom door. Surveyor requested V3 ADON and another staff member sitting at nursing station to aid R14. R14 buttocks were observed while he was in the bathroom with V3. The toilet seat was covered with liquid brown stool and the area between R14's rectum and buttocks to his upper thighs was fiery red and excoriated. On 4/18/24 at 5:05 PM, V2 DON (Director of Nursing) stated she did not have documentation of stool and urine specimens being sent for R14. V2 stated, the first dose of metronidazole ordered on 4/16/24 was administered 4/18/24 at 11:12 AM. There was no documentation of administration for the fidaxomicin ordered on 4/16/24, and V2 verified there was no nursing documentation showing the physician was notified that the fidaxomicin was not available. V2 stated the medication order should have been sent to the pharmacy and delivered by 10pm the same day or on the next delivery the following day after it was ordered and the physician should have been notified about the medication delay.

Based on observation, interview and record review, the facility failed to maintain the kitchen in a manner that prevents foodborne illness. This applies to all 26 residents that reside in the long-term care unit. Findings include: On [DATE] at 2:10 PM, V2 DON (Director of Nursing) stated the kitchen serves all 26 skilled residents. On [DATE] at 10:09 AM, the facility kitchen was toured with V9 (Cook / Kitchen Supervisor). V9 was observed with uncovered facial hair while working in the kitchen. The ice cream cooler had mint chocolate chip ice cream open and uncovered. On [DATE] at 10:12 AM, the dry storage area was toured. Blue bag filled identified by V9 as Raisins not labeled and without a date. Blue bag with identified by V9 as Craisins not labeled without a date. blue bag with identified by V9 as chocolate chips open to air. Bag identified by V9 as vermicelli not labeled or dated. Two 6lb cans of world horizon peaches dented in dry storage. V9 stated, the cans should not be in use as the dents cause the product to be compromised and it can get rust or grow bacteria. On [DATE] at 10:23 AM, the walk-in cooler was observed. Sour cream not in original manufacturer container dated [DATE]. Cole slaw not in original manufacturer container dated [DATE]. 1 gallon thousand island dressing opened on ,d+[DATE]. 1 gallon [NAME] raspberry vinaigrette [DATE] expired on [DATE]. Zippered bag with 17 peeled hard-boiled eggs dated ,d+[DATE]. Zippered bag with sliced turkey dated ,d+[DATE]. On [DATE] at 10:34 AM, the walk-in freezer was observed. Food item identified by V9 as chicken tenders 3 in bag without a label or date. Food item identified by V9 as chicken breast chunk fritters without a label or date. Food item identified by V9 as seasoned potato wedges open to air. On [DATE] at 10:40 AM, the reach in cooler was observed. Cinnamon apple sauce not in original manufacturer without any dates. On [DATE] at 10:43 AM, V9 stated the sanitizer for the three-compartment sink should be between 200 and 400ppm (part per million). The sanitization sink was tested , and the strip turned blue -- color not on chart range. V9 stated, if we can't get a good reading it isn't safe to use. V9 stated maybe the strips are old. On [DATE] at 10:46 AM, the meat slicer was uncovered and crusts and debris particles on it. The flour bin use by date was [DATE]. The oatmeal bin use by date was ,d+[DATE]. On [DATE] at 10:48 AM, the vents over cooking area and stove were dusty. On [DATE] at 10:56 AM, V9 stated they did not have any logs to document the facility testing of the three-compartment sink or the sanitization buckets. On [DATE] at 1:10 PM, during kitchen tour, V19 Dietary Aide was in the kitchen without hair covering. V9 and V16 had facial hair not covered. The vents over cooking area and stove were still dusty. On [DATE] at 4:38 PM the first-floor skilled unit nourishment room had personal food bowl with brown meat like substance carrots and cabbage. The personal food bowl did not have a name or date. A black plastic bag with red Spanish rice and corn tortilla was claimed by V18 dietary aide. The bag did not have a name or date. On [DATE] at 12:17 PM, V9 stated, staff should not be keeping their lunch in the nourishment refrigerator. Residents' personal outside food should not be kept in this refrigerator either. On [DATE] at 4:59 PM, during the kitchen tour V16 (Dietary Aide) facial hair was not covered. The two dented cans of peaches were still in dry storage. V16 stated this is the only place we keep the cans. V17 CNA entered the kitchen without hair covering. The facility food storage chart shows hard cooked eggs are good for 3 days. Deli meats are good for 3 days. Sour cream is good for 6 days. Fruit puree is good for 1 month. Prepared salads (coleslaw) are good for 3 days. Salad dressing is good for one month after opening. The facility policy Antibiotic Stewardship dated [DATE] states, each time the solution is changed in the sanitization solution is changed the solution should be tested and logged. The facility policy Personal Cleanliness and Hygienic Practices dated [DATE] states the purpose to prevent the spread of food borne illness and to promote cleanliness and infection control in the kitchen areas where food is prepared or served. All dietary staff, including the dietary manager and any person entering the kitchen, must wear an approved hair restraint to keep hair and particles in the hair from falling into the food. Hair restraints must entirely cover all hair. Food handlers with facial hair should also wear beard restraints. The facility policy Sanitization and Cleaning Schedule dated [DATE] states all refrigerated and prepared foods must be covered, labeled and dated with a use by date. Label must include the name of the food and the date by which the food should be used. All equipment must be cleaned and sanitized with approved sanitizer after each use.

Based on observation, interview, and record review, the facility failed to assist residents with their ADL (Activities of Daily Living) needs in a timely manner. This applies to 3 of 6 (R173, R18, R7) residents reviewed ADLs in a sample of 26. The findings include: 1. On 4/18/24 at 11:55 AM, R173 was observed sitting on the side of the bed in t shirt and disposable underpants. R173 stated it takes too long for staff to answer the call light and it makes her feel like they don't have enough help. R173 stated it took staff about 30mins to answer her call light, then she was left on the toilet waiting for staff to return to her. R173 stated she was not dressed because another staff member is supposed to assist her in getting dressed. R173 put her call light on while surveyor was in room. Surveyor went in hallway observed nursing staff at the nursing station and observed two nursing staff walk by R173 room without addressing call light. At 12:21 PM (26 minutes later), non-nursing staff noticed the Surveyor and answered R173's call light. R173 was admitted to the facility on [DATE] with diagnoses that include wedge compression fracture of T11-T12 vertebra, age related osteoporosis, osteo arthritis, ulcerative proctitis and unsteadiness on feet. R173's MDS (Minimum Data Set) dated 4/8/24 shows moderate cognitive impairment and she requires partial / moderate staff assistance with most activities of daily living. R173's care plan dated 4/3/24 shows an ADL self-care performance deficit related to back pain. 2. R18 was admitted to the facility on [DATE] with diagnoses that includes a displaced subtrochanteric fracture of left femur, traumatic ischemia of muscle, acute respiratory failure with hypoxia, non-displaced fracture of medial malleolus of left fibula, displace fracture of medial malleolus of left tibia, fracture of upper end of left humerus, morbid obesity, and suicidal ideations, R18's MDS (Minimum Data Set) dated 4/1/24 shows he is cognitively intact and he requires substantial / maximal staff assistance with ADLs (Activities of Daily Living). R18's care plan dated 3/27/24 includes an ADL self-care performance deficit related to impaired mobility, multiple fractures with no weight bearing to left upper arm. On 4/16/24 at 11:37 AM, R18 stated staff are slow to respond to the call lights on the second and third shifts. He has had to wait as long as two hours for staff to respond. R18 stated he has had to get up in his wheelchair to find staff assistance. 3. R7 was admitted to the facility on [DATE] with diagnoses that includes Parkinsonism, neurocognitive disorder with Lewy bodies, dementia and overactive bladder. R7's MDS (Minimum Data Set) dated 4/6/24 shows moderate cognitive impairment and he requires substantial staff assistance with ADL (Activities of Daily Living). R7's care plan dated 3/26/24 shows an ADL selfcare deficit and is risk for falls related to Parkinson's Disease and Lewy body dementia. Interventions include to check for unmet needs, pain, toileting, hunger, thirst and temperature. On 4/18/24 at 10:05 AM, the call light computer display showed R7's call light had been unanswered since 7:45 AM (two hours and 20 minutes). At 10:11 AM, V8 CNA (Certified Nursing Assistant) was observed taking R7 into his bathroom (two hours and 26 minutes later). On 4/18/24 at 4:39 PM, V2 DON (Director of Nursing) stated the call light computer system is accurate for time and location. Depending on what a patient needs, 30mins it too long to wait for staff assistance. V2 stated, staff should clean residents up immediately if they are incontinent. V2 stated it is a problem if a resident must wait an hour for call light assistance. The facility policy Call Light Use and Response dated 7/18/23 states facility personnel will be aware of call light and answer call lights promptly whether the staff person is assigned to the resident or not. The facility policy Activities of Daily living dated 3/15/21 states the facility will provide care and services for activities of daily living includes elimination - toileting. On 04/16/24 at 1:16 PM , V10 CNA (Certified Nursing Assistant) stated she does not always get her tasks done in caring for residents. V10 stated it is hard to get everyone up, especially if they require two assistants to transfer. The nurses are not always available to assist. The message bar lets us know if a resident is calling for assistance. I have to keep an eye on it but if I'm with another resident, I won't know another resident needs assistance. I'm use to the auditory call light system

Based on observation, interview and record review, the facility failed to prevent accidents for a resident who fell off the bed during an assisted transfer resulting in a subdural hematoma and shoulder dislocation and another resident who sustained a facial laceration while being transferred on a mechanical lift. This applies to two of three residents (R1, R2) reviewed for falls in the sample of three. The findings include: 1. R1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The final incident report sent to the State Survey Agency on October 20, 2017 showed that R1 sustained a fall from her bed on October 15, 2017. R1 had a loose stool and the certified nursing assistant (CNA) assisted her from the wheelchair into bed to change her. While R1 was holding on to the mobility assist handle on her bed, the handle swung open and the resident fell from the bed. R1 was admitted to the hospital with [REDACTED]. Investigation result showed that the mobility assist handle was not locked when the incident occurred. On November 13, 2017 at 4:25 PM, R1 was in her room sitting in her wheelchair talking on the phone. R1 was wearing a neck brace due to neck contracture. There was skin discoloration on the forehead. On November 14, 2017, R1 was not in her room at 10:30 AM and 3:40 PM due to being in therapy or activities according to staff. On November 15, 2017 at 3:30 PM, R1 was in her room sitting in her wheelchair talking on the phone. R1 was asked if writer could talk to her and she agreed. When asked how she was doing, R1 stated terrible because she had to take a shower and she preferred a bed bath. Informed R1 this would be relayed to staff but R1 stated not to bother informing staff because it was not the writer's business to tell staff. R1 was wearing her neck brace and had some discoloration on the forehead. R1 stated the rail was not locked and why she fell from the bed. The attending physician's hospital history and physical final report on October 17, 2017 included the radiology result for CT Head/Brain without contrast a right-sided subdural hematoma. The result of the CT Upper Extremity without contrast showed anterior dislocation of the humeral head with pseudoarthrosis. The October 20, 2017 nursing admission progress notes showed R1 returned to the facility with four sutures on the forehead measuring 2.0 cm (centimeter) by 0.8 cm. On November 14, 2017 at 3:10 PM, E3 (CNA) stated that on October 15, 2017 during the evening shift, she was assigned to care for R1. E3 stated that R1 had a big bowel movement while sitting in her wheelchair. R1 put the call light on while E3 was passing out water to residents. E3 went in R1's room to answer the call light and explained to R1 that she will be right back after passing out the water to the resident next door to R1. E3 returned to the room with supplies and proceeded to transfer R1 from wheelchair to the bed via sliding board by herself. E3 stated she removed R1's clothes and turned her on her right side to hold on to the bed mobility device on the right side of the bed. E3 stated during this time R1 kept complaining of about her doctor not taking her off the stool softener. While R1 was holding on to the mobility device, the side rail device opened, swinging upward towards the head of the bed. R1 was also on an air mattress which was operating. R1 rolled off the bed when the device opened up. E3 stated R1 hit the floor landing on her left side and her head hit the floor. E3 stated she ran to the other side of the bed and placed a pillow under R1's head and placed a towel on her bleeding forehead. E3 called for help and the nurse arrived immediately. Paramedics arrived and took R1 to the hospital. E3 was asked why she was providing care to R1 by herself. E3 stated it was busy during the shift and in fact, another CNA (E5) knocked on the door to ask E3 for assistance with another resident. On November 14, 2017 at 3:40 PM, E3 demonstrated in R1's room how the bed mobility device should lock. E3 stated she did not check if the device was locked prior to instructing R1 to grab on the device because the device was in the upright position but later found out it was not properly locked. On November 15, 2017 at 2:40 PM, E5 (CNA) stated she needed assistance with another resident and went to R1's room to request help from E3 (CNA). E5 stated when she knocked on R1's room and E3 announced, Patient care. E5 opened the door and saw E3 providing care to R1. E5 requested help from E3 who agreed to help after she was done caring for R1. E5 stated she saw R1 was turned towards the window (right side) holding on the bed mobility device while cleaning R1. E5 stated as she turned to leave, she heard a big boomed and saw R1 had fallen on the floor. E5 stated she told R1 to stay where she was at since R1 wanted to get up. E5 stated R1 was bleeding and had blood on her hair. E5 stated she did not assist E3 with the transfer and hygiene care prior to the fall. The MDS (Minimum Data Set) dated September 25, 2017 coded bed mobility as total dependence and two or more persons physical assist. Transfer was coded as total dependence and two or more physical assist. Personal hygiene was coded as extensive assistance with two or more persons physical assist. The latest MDS dated [DATE] remained the same in these areas. On November 15, 2017 at 4:25 PM, Z1 (Attending Physician) stated R1's left shoulder was contused, bruised and had a dislocation but that R1 had arthritis and inflammation. R1 was given an injection on the left shoulder in the hospital by orthopedic staff. No physician order was found for a bed mobility device on the October 2017 orders. A verbal order was not obtained until November 14, 2017 according to the Medication Review Report (physician orders) from October 1, 2017 - November 15, 2017. The care plan showed the bilateral Joerns Deluxe Assist Handles were used. The facility policy titled, Bedside Mobility Aid, last revised November 2016, requires, 4. A health care provider order for the use of any bedside mobility aid should be obtained prior to its use. The healthcare provider must indicate that the bedside mobility aid is to be used for mobility and positioning. Bedside mobility aids should be installed per manufacturer's guideline. The User-Service Manual Joerns Deluxe Assist Handle Model F028 showed a Warning: Risk of Serious Injury or Death. Do not use this assist device until you have verified that it is locked in place. Injury to resident or caregiver may result if this procedure is not followed. 2. R2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The incident report sent to the State Survey Agency on September 22, 2017 showed R2 sustained a laceration on the right side of the head during a transfer. R2 was sent to the hospital and returned to the facility with three staples on her head. On November 13, 2017 at 4:30 PM, R2 was observed in the dining room in her wheelchair falling asleep. R2 was unable to answer when asked questions but nodded her head. R2 was the only resident in the dining room. On November 14, 2017 at 3:40 PM, R2 was sitting in her wheelchair in her room with the television on. E3 (CNA) asked if everything was ok and R2 smiled and said yes. R2 responds by either nodding her head or one-word answer according to E3. On November 15, 2017 at 11:55 AM, R1 was sitting in the dining room asleep, while waiting for lunch to be served. On November 15, 2017 at 3:30 PM, R2 was sitting in her wheelchair in her room with the TV on falling asleep. On November 14, 2017 at 4:10 PM, E2 (Director of Nursing/DON) stated that a mechanical lift device and a sit to stand device both require two-persons assist. The CNA would be aware of the number of staff required to perform the care tasks by checking the task section in the computer. The nurses would also inform the CNAs during report of the needs of the residents. On November 15, 2017 at 12:55 PM, E4 (CNA) stated she works every other week-end. E4 stated that on September 22, 2017 during the morning shift, they were short-handed and they were rushing to get residents up to take to the dining room for breakfast. E4 stated she transferred R2 by herself from the bed to the chair by herself via a mechanical lift device. E4 stated the pad was properly hooked and she raised R2 with the lift and brought the seat backward towards the wheelchair. E4 stated she almost had R2 on the chair but the lift tipped backward. The arm of the lift hit R2 on the head causing a laceration. E4 stated she held on the metal of the lift while trying to get help on the walkie talkie with the other hand. A nurse arrived shortly and obtained more help from other staff. R2 was sent to the hospital. On November 14, 2017 at 4:10 PM, E2 (Director of Nursing/DON) stated that a mechanical lift device and a sit to stand device both require two-persons assist. The CNA would be aware of the number of staff required to perform the care tasks by checking the task section in the computer. The nurses would also inform the CNAs during report. On November 14, 2017 at 3:10 PM, E3 stated there are no readily available care information on residents regarding the number of staff required for transfer and ADL (activities of daily living) E3 was not sure if they are in the computer. On November 15, 2017 at 12:55 PM, E4 stated the CNAs were not informed by nurses as to the number of staff required to perform particular care of residents. E3 stated she did not check in the computer at the start of shift and no preparation was done regarding the requirements of residents. The MDS (Minimum Data Set) dated September 7, 2017 coded bed mobility as extensive assistance and two or more persons physical assistance. Transfer was coded as total dependence and two or more persons physical assist. The Task List Report showed, Use caution during transfers using hoyer lift x 2 assist at all times and bed mobility to prevent striking all body surfaces against any sharp or hard surface. (Initiated on June 15, 2017).

Based on interview and record review the facility failed to provide prompt assistance and failed to monitor one resident who was assessed as high risk for falls. This applies to 1 of 3 residents (R1) reviewed for falls. This failure resulted in R1 sustaining a right comminuted fracture of the proximal femur on 12/5/13 after a fall. The findings include: R1 was originally admitted to the facility on [DATE] from the hospital. R1's admission record shows that the resident has multiple [DIAGNOSES REDACTED]. R1's history & Physical examination dated 9/11/13 showed that the resident has mild Dementia. R1's hospital record dated 8/29/13 showed that the resident was on hospice care at home for end stage COPD (Chronic Obstructive Pulmonary Disease). The same hospital record documented that R1 walked to the bathroom without her walker and fell to the floor. R1 sustained a right hip fracture. R1's admission progress notes dated 9/4/13 shows that the resident was admitted to the facility with s/p (status [REDACTED]. R1's quarterly MDS (Minimum Data Set) dated 12/4/13 shows a BIMS (Brief Interview for Mental Status) score of 14, indicating that the resident has a recall problem. The same MDS also showed that R1 required extensive assistance x two or more person physical assist for transfers and toilet use (how resident uses the toilet room; transfer on/off toilet; cleanses self after elimination; changes pad; and adjusts clothes). R1's fall risk assessment dated [DATE], shows that the resident has history of multiple falls within last six months, uses medications such as Diuretics, Narcotic's and Sedative/ Hypnotics, has inadequate vision, severely impaired with hearing and would require assistance for toileting. This fall assessment did not indicate R1's fall risk level, whether R1 was a low, moderate or high risk for fall. In an interview held on 2/11/13 at 1:00 PM, E2 (Director of Nursing) stated that there were no further fall assessment in the computer system for R1. Per E2, the facility did not have a quarterly fall assessment for R1 as per facility policy. E2 also stated that the facility's fall assessment does not give any information as to the fall risk level of the resident Review of the facility policy and procedure regarding Fall Risk assessment dated [DATE] indicated that the facility will complete a fall risk assessment/evaluation for every resident at the time of admission, quarterly and when significant change in condition occur. R1's care plan initiated on 9/4/13, indicated that the resident is high risk for falls related to Psychoactive drug use and history of fall with fracture. This fall care plan had the following interventions initiated on 9/4/13, Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance and bed in low position at all times; Keep all areas well lit and clutter free, adequate glare-free light; The resident needs activities that minimize the potential for falls while providing diversion and distraction. R1's care plan initiated on 9/4/13, indicated that the resident has an ADL (Activities of daily living) Self Care performance deficit r/t (related to) hip fracture and weakness. This ADL care plan had multiple interventions which includes R1's total dependence on staff for toilet use. Further review of R1's care plans showed no treatment plan in place to indicate how the facility will monitor the resident to ensure safety and to prevent re-occurrence of fall. R1's Event Management report dated 12/5/13 (12:45 PM)showed that the resident fell and sustained fracture. The report indicated that the cause of the fall was, "Resident got up without waiting for assistance." The same event report showed, "CNAs found resident on the floor. Resident states I got up, I was going to try and wipe myself, I couldn ' t then I fell . Rt (right) knee bent under/behind her left leg. C/O (complaint of) severe R (right) hip pain." 911 was called and R1 was admitted to the hospital. R1's hospital x-ray of the right hip dated 12/5/13 showed that the resident had comminuted fracture of the proximal femur, including fracture of the proximal femoral shaft which is at the level of the distal aspect of the intramedullary rod. In an interview held on 2/11/13 at 11:21 AM, E5 (CNA/ Certified Nursing Assistant) stated that on 12/5/13, she was the staff assigned to take care of R1. Per E5, on 12/5/13 after lunch, R1 requested to go to the washroom, so she (E5) took R1 to the washroom inside the resident's room. E5 stated that she transferred R1 to the toilet with the use of a gait belt without any assistance from other staff. Per E5 she instructed R1 to use the call light when she is ready and left R1 on the toilet by herself, to assist other residents in the unit dining area (55 feet away from R1's room, measured by E10 (maintenance personnel)). E5 stated that R1 was on the toilet for about 5 minutes, before the resident activated the call light. According to E5 when she saw R1's activated call light, she went to room 109 (another resident's room/30 feet away from R1's room, measured by E10) to ask E9 (CNA) for help in transferring R1 off the toilet. Per E5, by the time she reached E9, she (E9) was done taking care of the resident inside room 109, so they both (E5 & E9) proceeded to R1's room. E5 stated that when they reached R1's washroom, R1 was on the floor. Per E5, she called E4 (nurse) to assess R1. Further interview with E5 stated that R1 is a medium risk for fall and was aware that R1 had a history of [REDACTED]. In an interview held on 2/11/14 at 10:56 AM, E4 stated that on 12/5/13 at around 12:45 PM, she heard the CNA yelling for help because R1 was on the floor. Per E4 she went immediately to R1's room and observed R1 on the washroom floor with her right leg bent in an awkward position. E4 stated that upon assessment, R1 complained of right leg pain and was unable to move her lower extremities. Per E4, she called 911 while E5 and E9 (CNA) stayed with R1. E4 stated that no one moved R1 until the 911 personnel came and transferred the resident to the hospital. According to E4, R1 had a history of [REDACTED]. In an interview held on 2/11/14 at 1:05 PM, E7 (COTA-L/Certified Occupational Therapy Assistant-Licensed) stated that she was the therapist providing OT (occupational therapy) for R1. E7 stated that OT does training for toileting ( includes cleaning up after using toilet, pulling up clothing) and toilet transfer (from wheelchair to toilet and vice-versa) for R1. E7 reviewed R1's weekly progress report dated 11/7/13 and stated that this report was the last one on file before R1's fall on 12/5/13. Per E7 the 11/7/13 report documented that for toileting and toilet transfer, R1 was a maximum assist/dependent from staff and would require to 2 staff assist. Further interview with E7 stated that since she is the therapist who does OT training with R1, she is very familiar with the resident's capabilities and limitations. Per E7, based on this, 2 staff should assist R1 to the toilet and while R1 is on the toilet, 1 staff should be waiting, in close proximity (at least by R1's room door) to monitor R1, ensure R1's safety and to prevent R1's potential fall . E7 stated that R1 could be impulsive at times, "if she needs to get up, it is possible she would stand up without staff assistance or she would try without staff present." According to E7, R1 has a history of fall at home and that the residents in general, at times think they can stand up and do things but might not be able to because they are weak, that is why they are receiving therapy in the facility. In another interview held on 2/11/14 at 1:43 PM, E7 stated that R1 has poor safety awareness, very forgetful and that R1 needed repeated instructions/reminders during OT training, to be safe in getting up and transferring. Per E7, that is why staff should be in close proximity (at least by R1's room door) for staff to be able to monitor R1 and for staff to promptly respond to her call for assistance, because R1 has the potential to do things, like standing up without present. Review of R1's physician order dated 9/5/13 showed an order for [REDACTED]. Review of the OT therapy log from November 2013 showed that E7 provided therapy to R1 for 8 out of 15 days. Review of the OT therapy log from December 2013 showed that E7 provided therapy to R1 for 3 out of 3 days, on 12/2/13, 12/3/13 and 12/4/13 (for 3 consecutive days prior to R1's fall on 12/5/13). In an interview held on 2/13/14 at 12:55 PM, E8 (Program Director for Therapy/Rehab) stated that she reviewed R1's PT (Physical Therapy) daily treatment notes dated 12/2/13 which shows that R1 was noted with length discrepancy on the right leg. Per E8, R1's right leg was shorter than her left leg, so an orthopaedic shoe was provided for R1 on 12/4/13. E8 stated that on 12/5/13 (during R1's fall incident), R1 was wearing the newly provided right shoe. In an interview held on 2/19/14 at 1:20 PM, Z1 (Physiatrist) stated that because one of R1's limb was shorter than the other,r R1 had some limitations because of it. Per Z1, it normally takes a while to get use to the new shoe but R1 probably got confident with it, attempted to stand up without assistance and fell . Review of R1's care plans showed no plan in place to address and monitor the use of the new right orthopaedic shoe which was provided to the resident a day before her fall incident.