Every finding on record at Lacon Rehab and Nursing

Based on observation and interview the facility failed to maintain kitchen equipment to a safe, reliable standard. This failure has the potential to effect all 58 residents currently residing in the facility. Findings include:The facility's resident roster, dated 8/10/26, provided by the facility's Administrator documents 58 residents reside in the facility. During a tour of the Dietary Department on 8/10/26 at 9:00am, Out Of Order signage was taped to 2 upright freezers, a walk-in refrigerator, and an upright refrigerated unit. Also noted was a large double range with one of the flat/griddle cooktops, broken into three pieces. On 8/10/26 at approximately 9:05am, V3/Dietary Manager verified there were 2 range cooktop griddles, a smaller double oven was non-functional except for the pull-out toasting grill between the two ovens on the unit. V3 stated Dietary staff use the grill to toast bread for the residents' meals. V3 also confirmed the walk-in refrigerator, 1 upright refrigerator and 2 freezers in the Dietary department that were non-functional. V3 stated the double range cooktops are not functioning and the ovens are used as warming ovens to keep food warm prior to service.On 8/10/26 at approximately 9:20am a dish machine was present, but not on use. V3/Dietary Manager stated the facility's prior dish machine had been non-functional, and a new dish machine was ordered, but has not yet been installed/ completely, and is non-functional. V3 stated there had been no functioning dish machine for about 2 months, and disposable dishware and utensils were being utilized for meal service to the residents until such time as the new dish machine is completely installed and connected to electric and plumbing, and ready for use.On 8/11/26 at approximately 12:15pm an odor of natural gas was detected outside the entrance door to the kitchen. At that time V1/Administrator contacted the local Fire Department, who arrived shortly thereafter and determined the smaller double oven/toaster grill appliance had a small gas leak present. fire fighters stated the gas leak posed no danger to kitchen staff or residents at that time.

Based on interview and record review, the facility failed to honor a residents wishes for financial power of attorney for one (R59) of one residents reviewed for power of attorney rights in a sample of 34. Findings include: Facility Notice of Resident Rights and Responsibilities, revised 6/22/26, documents The facility shall inform the resident of his or her rights as a resident. Facility Advanced Directive, revised 4/28/22, It is the policy of this facility to ensure the resident's right to formulate an advanced directive. Facility Business Office Manager/BOM, undated, documents The BOM is to oversee various financial and administrative functions. Main Duties: Customer Service: Putting customer service first by ensuring residents and families receive the highest quality of service in a compassionate atmosphere that recognizes individual needs. R59's admission packet, dated 8/18/22, documents V5 as R59's POA/Power of Attorney. R59's electronic medical record has POA documentation uploaded indicating V5 as R59's POA for financial and medical. R59's (private dental/vision) insurance (offered by the nursing home) contract, dated 8/18/22, and signed by V5 POA documents an application for the limited benefit in-facility dental policy. R59's (private dental) insurance (offered by the nursing home) contract, dated 8/18/22, and signed by V5 (R59's) financial and medical POA, documents V5 is the responsible party and POA, and documents a dental policy effective 1/1/23 and cancelled 4/30/24. R59's (private vision) insurance (offered by the nursing home) contract, dated 8/18/22, and signed by V5 (R59's) financial and medical POA, documents V5 is the responsible party and POA, and documents a vision policy effective 3/1/23 and cancelled 5/30/23. On 8/10/26 at 12:07PM, V6 BOM/Business office Manager stated (R59) has been here since August of 2022 and her POA is V5. On 8/10/26 at 1:55PM, V5 R59's POA stated (V7) private dental/vision insurance and (V6) BOM have stopped taking my calls and refuse to talk to me. I have been helping (R59) for years, and I am her POA for financial and medical. On 8/11/26 at 11:50AM, V6 BOM stated (R59) can speak for herself so we talk to her about things and not (V5) R59's POA. At that time, V6 verified she knows V5 is R59's financial and healthcare POA. On 8/11/26 at 11:03AM, V19 Ombudsman stated (V5- R59's POA) told me that (V7) private dental/vision insurance offered by the nursing home is refusing to speak to (V5) due to the fact (R59) is of sound mind. (R59) told (V7) private dental/vision insurance that she has handled (R59's) financial for a long time. On 8/13/2026 9:22 AM, R59 stated I don't know everything with this money issue they have to speak to (V5) R59's POA. When I told R59 the facility is saying they have to speak to her about the concern because she is cognitively intact and can speak for herself, R59 stated They (facility, V6 and V7) know I have given them permission to speak to (V5) on everything about me and my financial with (V7), (V5) is my POA, I don't know why the nursing home keeps doing this and won't honor my request.

Based on interview and record review, the facility failed to keep accurate complete financial records of resident personal funds for one (R59) of one residents reviewed for personal funds in a sample of 34. Findings include: Facility Business Office Manager/BOM, undated, documents The BOM is to oversee various financial and administrative functions. Main Duties: Customer Service: Putting customer service first by ensuring residents and families receive the highest quality of service in a compassionate atmosphere that recognizes individual needs. Facility [NAME] Policy and Procedures, dated 2025, documents We are committed to complete an accurate billing of all services provided to residents for payment by resident or other third-party payors. R59's admission RFMS/Resident Fund Management Service, dated 8/18/22 by V5/R59's POA/Power of Attorney, documents V5 signed R59 up for the facility to manage R59's trust fund account. I direct the amount stipulated be withheld monthly for my personal use and the remainder be transferred to the facility for the payment of my care costs. R59's resident funds authorization letter, dated 8/18/22 by V5/R59's POA, documents I authorize (local) nursing home to deposit my funds in a resident trust account and to act as a fiduciary of the funds to hold, safeguard, manage, and account for these funds as required by federal regulation. R59's facility financial personal fund records did not include a copy of all account transactions and were not complete from admission to present. E-mails regarding R59's trust fund account and payments between V6 BOM and V8 Medicaid Specialist for the nursing home documents the following missing payments to V7 private dental/vision insurance: April 3, 2023 $149 for dental; May 11, 2023 $149 for dental; and June 12, 2023 $59 for vision. V7 private dental/vision insurance requested the nursing home to submit a copy of the cancelled checks as they have no proof of these payments being received. V8 documents their bank does not allow them to look that far back to verify the payments. On 8/10/26 at 12:07PM, V6 BOM stated Since (R59's) admission their have been two previous BOM's V9 and V10. (V5) is requesting (R59's) trust fund account ledger/transactions and copies from 2023 and we can't find them. At that time, V6 stated they keep resident financial records for five years. On 8/10/23 at 1:55PM, V5 R59's POA stated The nursing home can't find the ledger/statements they used to pay (V7) private dental/vision insurance, and this has been going on for 3.5 years. On 8/11/26 at 11:03AM, V19 Ombudsman verified V5/R59's POA has had a problem obtaining ledger/statements from the nursing home regarding R59's trust fund activity due to the nursing home stating they don't have the records. On 8/12/2026 9:32 AM V8 Medicaid Enrollment Specialist for the nursing home stated The payments made in April 3, 2023, May 11, 2023, and June 12, 2023 I cannot get because our banking system is not able to go back that far. On 8/12/2026 at 9:44 AM, V6 BOM Our resident trust funds are deposited in a (local) bank here in town. On 8/12/2026 at 9:52 AM, V18 Receptionist/Banker at local bank stated We hold the Trust Fund Accounts for individual residents at the nursing home. We hold banking records for seven years. At that same time, V18 verified no one from the nursing home has requested banking records from 2023 for R59. On 8/13/2026 at 9:22 AM, R59 verified the financial issue of not being able to find the trust fund financial statements between the nursing home, V5, V6, V7, and V8 has been going on for years.

Based on interview and record review, the facility failed to timely remit and provide final accounting of resident personal funds for one (R1) of three residents reviewed for personal funds and billing in the sample of three.Findings include:The facility's policy titled, [NAME] Policy and Procedure, dated 2025, documented billing was to be prompt, complete, and accurate. This same document included not refunding credit balances in a timely and appropriate manner as a listed Prohibited [NAME] Practice.R1's Resident Fund Management Service (RFMS) form, signed and dated 12/18/25, documented R1 authorized a transferring account, a $60.00 monthly allowance, and direct deposit of R1's Social Security benefit. The RFMS form does not document the facility was R1's Social Security representative payee.R1's Medicaid Notice of Decision, dated 2/28/26, documented R1's Medicaid coverage ended on 2/28/26.R1's Healthcare and Family Services (HFS) LTC (Long-Term Care) Discharge/Death Results, undated, documented R1 discharged from the facility on 3/9/26. This same documented included: Personal Funds Balance: $0.00; Other Funds Balance: $0.00, and a Room and Board Balance of $2,608.40.On 7/9/26 at 12:26 PM, V3, Business Office Manager, stated R1's HFS document was uploaded into R1's electronic health record on 3/10/26.On 7/8/26 at 3:33 PM, R1 stated R1 did not receive his April Social Security check after he discharged from the facility in March and has spoke with V3, Business Office Manager, and the Social Security office about it and is not getting anywhere. R1 stated he did receive a check, dated 6/29/26, in the amount of $112.60, mailed on 7/2/26, and received on 7/7/26. R1 stated R1 did not receive anything else from the facility.R1's March invoice statement, dated 3/31/26, documented R1 had a balance forward of $2,608.40 with a deposit of $1,627.00 on 3/3/26 and a description of, SSA TREAS 310 XXSOC, and a charge of $1,627.00 on 3/1/26 with a description of, Patient Liability Due March 01-8 2026. The ending balance due for the March invoice statement was $981.40. The invoice statement documented the invoice was sent to R1's Power of Attorney at the time.R1's April invoice statement, dated 4/30/26, documented a balance forward of $981.40. This same document includes a 4/3/26 SSA TREAS 310 XXSOC credit of $1,627.00 and included March room and board charges/adjustments with an ending credit balance of $309.80.An e-mail, dated 7/9/26 at 9:51 AM, from V3, Business Office Manager, showed correspondence between the [NAME] and Collections Department on 4/6/26 at 3:35 PM and stated, sent email to (V4, Chief Financial Officer); The 4-3 should be sent back since it was after DC (discharge), make sure to notify (unknown employee) timely when a RFMS resident has a final DC or passes away. Send (R1) his $60 now and we'll send the refund for the SSA (Social Security Administration) once he catches up on his bill and we can release it.R1's Trust Transaction History document, dated 7/9/26, shows a $60.00 deposit to R1's trust account on 4/3/26 and then a trust refund of $60.00 (check number 1065) with an ending trust account balance of $0.00.R1's final invoice statement, dated 6/30/26, documented a balance forward credit of $309.80 and showed adjustment entries dated 6/23/26 with an ending balance of $0.00.On 7/9/26 at 10:44 AM, V3, Business Office Manager, stated R1's final bill in the electronic health record was prior to R1's refund and was R1's overpayment if R1 had remained Medicaid. Once the facility initiated the ledger review for the refund, they identified that Medicaid dropped coverage on 2/28/2026 which changed the credit to $112.60. Check #11744, dated 6/29/26, was refunded directly to R1.On 7/9/26 at 1:33 PM, V4, Chief Financial Officer, stated R1 neglected to notify Social Security of R1's discharge from the facility in March, which caused the facility to receive R1's April Social Security check on 4/3/26. V4 stated R1's account was fluid and stated trust funds and Accounts Receivable were separate. V4 stated Medicaid reimbursement in Illinois was slow and questioned what the company was supposed to do when residents owed money and reimbursement was delayed.On 7/9/26 at 2:54 PM, V1, Administrator, confirmed R1's personal funds credit balance should have been sent to R1 within 30 days. The credit balance should not have been withheld pending reimbursement from Medicaid. V1 stated any debts owed after the refund was issued and reimbursement went through should have been billed to R1 after.

Based on observation, interview, and record review, the facility failed to maintain the building in good repair and cleanliness for three of four (R3, R4, and R7) residents reviewed for homelike environment in a sample of seven. The facility's Homelike Environment/Maintenance policy, revised 12/1/25, documents that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. This form documents that the facility is to be comfortable and have safe temperature levels. The facility's Resident Call Bells policy, revised 11/5/24, documents that the facility will be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to centralized staff work area from each resident's bedside, toilet, and bathing facilities. The communication system shall be checked regularly to ensure operability and that it can be reached by the resident. The facility's Resident Council Meeting Minutes, dated 1/8/26, documents that Housekeeping Staffing and Cleaning Standards: Low-staff spot clean approach used: trash removal, quick sweep, mop obvious spots, wipe surfaces; deep cleaning limited. This form documents that if missed areas are observed (corners, under chairs); residents can request thorough cleaning. On 2/20/26 at 9:20am, R3's bathroom sink did not have any running water. The sink bowl had a black, slimy ring around it. There was a sign on the mirror documenting Do not turn on water. The wallpaper inside of the door was ripped off from the ceiling to about 3 feet from the floor. The missing wallpaper patch was approximately 2 feet wide. There was also a large piece of wallpaper missing from the wall next to the heating vent. V3, Assistant Maintenance Director, verified that R3's sink was not working and the wallpaper was peeled off the walls. On 2/20/26 at 9:30am, R4 was sleeping in his bed with his call light activated. V8, Certified Nursing Assistant, was walking in the hallway. V8 stated that R4's call light is always on, there is a short or something. V8 stated that he should have a handheld bell to ring if he needs assistance. V8 searched R4's room and could not find a handheld bell. V8 was asked how R4 is supposed to ask for help if he should fall, she said, I just don't know. R4's bathroom had a strong urine aroma, and the floor had a large puddle of yellowish liquid in front of the toilet. There were footprints on the floor going from the toilet to R4's bed. At 1:20pm, the bathroom floor remained wet, but there were paper towels covering the large, yellowish colored puddle on the floor. The strong urine odor remained the same. On 2/20/26 at 9:40am, R7's toilet had dry bowel movement on the seat, around the top rim of the toilet, and down the front of the toilet bowl. There was a strong smell of urine noted in his room, going into the hallway. The enabler bars appeared to have yellow and brown substance splatter on them. At 9:50am, V7, Housekeeper, stated that she was finished cleaning R7's room. V7 stated that she empties garbage, cleans the floors, and will drop off paper towels and toilet paper if needed. R7's toilet and bathroom remained the same.On 2/20/26 at 1:20pm, V9, Registered Nurse, stated that R7 will often take off his soiled briefs and leave them lying around his room. V9 stated that housekeeping is supposed to go into the room several times a day to empty the garbage. V9 verified that the rooms are to be fully cleaned, including bathrooms on a daily basis and as needed. V9 also stated that housekeeping should have cleaned the floor in R4's room.

Based on observation, interview, and record review, the facility failed to implement menus that addressed residents' dislikes for two of six residents (R5 and R6) in a sample of seven. Findings include: The facility's substitutions policy, revised 12/30/24, documents that residents' likes and dislikes will be considered when making substitutions.On 2/20/26 at 12:20pm, R5 was sitting at the dining room table with a plate of baked fish, broccoli, hash brown casserole, and baked apples. R5 looked at the meal for several minutes, then finally asked V6, Nursing Assistant/Housekeeper, for some tartar sauce. R5 used three packages of tartar sauce on his fish. R5 stated that he does not like fish, so he is drowning the taste in tartar sauce so he can eat it. R5 stated that if he doesn't eat this, then he won't get anything. R5 stated that the substitute is always peanut butter and jelly, which he does not like either. R5 also stated that peanut butter and jelly is not a good substitute for the main meal of the day. R5 ate his meal but did not eat his baked apples. R5 stated that he does not like them either. R5 was not offered a substitute for the dessert. On 2/2/26 at 12:25pm, R6's tray sat on the dining room table opened. R6 was not in the dining room. V6 entered the dining room and stated that R6 had food delivered, so she would not be eating lunch today. 1:00pm R6 stated that she does not like fish, so she had food delivered. On 12/20/26 at 12:35pm, V5, Dietary Manager, stated that the facility does not offer an anytime menu. V5 also stated that the only substitutes available are a peanut butter and jelly sandwich or maybe a cheese sandwich. V5 verified that the substitutes are not equal in nutritional values.

Based on observation, interview, and record review, the facility failed to cover individual plated lunch meals during transport for three of three residents (R5, R6, and R8) reviewed for meal service in a sample of eight. Findings include: The facility's Transportation of Food policy revised 11/5/19, documents that all food being transported from the kitchen to other parts of the building must be done in a safe and sanitary manner. This form also documents that all food must be covered during transportation and that food must maintain proper temperatures while being transported. The facility's Resident Council Meeting Minutes, dated 1/8/26, documents multiple complaints about meal execution: Burnt/overcooked items (breadstick, items left in the oven), cold food (Spaghetti), undercooked/soggy eggs/omelets. The facility's Resident Council Meeting Minutes, dated 2/12/26, document multiple complaints about the execution: cold food/meals late. On 2/20/26 at 12:05pm, a cart with already-plated lunch was taken from the kitchen across the hall to the dining room. There were no covers or warmer plates to protect the main meal. The plates were then set on the table, uncovered. R5, R6, and R8 were not yet at the table. On 2/20/26 at 12:17pm, R5 propelled himself up to the dining room table in front of his open plate. R5 picked up his fish and tossed it back down on his plate. R5 stated that the food was slightly warm, but there was no one in the dining room to reheat the meal. R5 stated that it happens all the time. R6 and R8's plates sat on the table uncovered until 12:30pm, when V6, Nursing Assistant/Housekeeper, picked up the plates. V6 stated that the plates are usually covered, but she does not know why they aren't today. On 2/20/26 at 12:35pm, V5, Dietary Manager, stated that any food being transported is to be covered. V5 stated that there are several covers sitting next to the service line and does not know why the plates were not covered. V5 verified that there are no warming plates used during meal service. V5 stated that there have been complaints concerning cold food, and she is trying to change the serving process. V5 stated that with the dining rooms being so close, the meals should be plated and served as residents enter the dining room.

Facility failures resulted in two deficient practices.A. Based on observation, interview, and record review, the facility failed to provide adequate heating to the St. [NAME]/100 Hallway and rooms and failed to follow facility emergency protocol. These failures have caused R1 to have increased pain from muscle spasms due to being tense from the cold. These failures have the potential to affect all 31 residents residing on St. [NAME] wing, R1, and R3-R32. This failure resulted in an Immediate Jeopardy.B. Based on observation, interview, and record review the facility failed to provide adequate hot water to the entire building. This has the potential to affect all 59 residents residing in the facility. Findings include:A. The Immediate Jeopardy began on 1/12/26 around 8:00 AM. While the Immediate Jeopardy was removed on 2/3/26, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. The facility's Homelike Environment policy, initiated 12/27/23, documents the facility is to have comfortable and safe temperature levels. The facility's Cold Weather policy, revised 11/24/25, documents not in its entirety, Extreme cold can occur independent of any snow, ice, or storm systems. Extreme cold events involve an extended period of temperature at or below 32 degrees F (Fahrenheit). The risk to the health and personal safety during extreme cold is exacerbated by utility service interruption or loss. Therefore, the facility maintains its building systems ahead of any extreme weather projections. The facility acknowledges and prepares for the possibility of short staffing due to road conditions. Conduct regular building maintenance and inspections, including maintenance of heating and air conditioning systems and thermostats.Routinely monitor the indoor facility temperature when the outdoor temperature is below 65 degrees Fahrenheit to ensure the indoor temperature in residents' rooms and all common areas is maintained. Develop resident assessment protocol, including vital sign checks focusing on core temperature and comfort checks. Develop procedures for internal relocation of residents to warmer parts of the facility. Document vendors for additional heating units.Conserve heat: avoiding unnecessary opening of doors/windows; close off unoccupied rooms; cover windows. If heating equipment has failed, regularly monitor individual room temperatures.R1's admission record documents R1's date of admission to the facility was 10/1/25 and his diagnoses include but not limited to Spinal Stenosis, Site Unspecified, Diabetes Mellitus due to Underlying condition with foot ulcer, Morbid (Severe) Obesity due to excess calories, and Restless Legs Syndrome.R1's Minimum Data Set (MDS) assessment, dated 10/3/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition intact and document that R1 has frequent, severe pain.R1's current care plan documents R1 currently takes an Opioid Pain Medication and has chronic lower back pain.On 1/29/26 at 9:00 AM tour of facility was conducted with the temperature on the St. [NAME] wing (100 Halls) noted to be chilly with hallway thermostat reading 64 degrees Fahrenheit on the Northwest wing and 65 degrees on the Northeast wing. Multiple room thermostats observed to be running 62-68 degrees Fahrenheit.On 1/29/26 at 10:00 AM, R1 stated that it has been cold in his room (117) since it got cold out earlier in the month and has not changed. R1 is lying in bed covered with multiple blankets. R1 stated, Being cold all the time has me all tense which causes an increase in my back spasms and pain. I just can't get comfortable when I'm cold all the time.On 1/29/26 at 10:55 AM, R4 stated, It's always cold down here and especially in my room (106-1). It really messes with my breathing.On 1/29/26 at 10:58 AM, V5 (Licensed Practical Nurse/LPN) stated he has worked on the St. Jospeh wing for the past two days and it has been cold both days. V5 is noted to be wearing a fleece jacket.On 1/29/26 at 11:00 AM, V6 (Certified Nursing Assistant/CNA) stated, Honestly, I couldn't tell you when it hasn't been cold down on this wing, it's been too long. They say the heat is working down here but you can see it's still cold down here. V6 is noted to be wearing a fleece jacket.On 1/29/26 at 11:30 AM, V4 (Maintenance Director) observed using temperature gun to check air temperature on the hallways of St. [NAME] wing and multi rooms down both halls. Temperatures noted to range from 54-63 degrees Fahrenheit. V4 stated, The boiler is running great since being fixed on 1/9/26 and again on 1/18/26. Not sure why the temperatures down here are fluctuating so much. Seems to be an airflow issue.1/29/26 at 3:00 PM, V2 (Director of Nursing/DON) stated I can't answer why residents haven't been moved to open rooms on St. [NAME] wing (200 Hall) or why we haven't gotten any other heating sources. I'm not part of those conversations with Corporate. The Administrator (V1) would be, and she is on vacation. On 1/30/26 at 9:05 AM, V1 (Administrator) who stated with V4 (Maintenance Director) present, when asked what the facility's process is if staff notice temperatures getting colder, staff are instructed to contact the Maintenance Director and/or the Administrator, or if the Administrator is unavailable, the Director of Nursing. When asked whether colder temperatures would warrant implementation of the facility's Emergency Protocol, V1 (Administrator) stated, yes. When asked if V1 (administrator) felt this process had been followed, V1 stated, I'm not entirely sure at that moment, as the situation was ongoing. Immediately following the interview, V1 came to surveyor and explained that staff did, in fact, contact her on Wednesday morning at approximately 2:00 a.m. when they began to feel that temperatures were dropping. Upon notification, V1 contacted V4 (Maintenance Director), who came into the building and checked temperatures on both hallways. He (V4/Maintenance Director) reported that the supply air temperature on the St. [NAME] wing was approximately 95 degrees, and the St. [NAME] wing was approximately 74 degrees.On 1/30/26 at 9:05 AM V4 (Maintenance Director) stated that he was not aware the temperature had dropped Wednesday, 1/28/26, after he left the building until Thursday, 1/29/26, morning when this surveyor arrived at the building.On 1/30/26 at 10:00 AM R5 stated that it has been constantly cold in her room (118) and the wing. R5 stated, The constant cold makes me tense up and increases my pain.On 1/30/26 at 11:11 AM V1 (Administrator) stated that State surveyors have been to the facility for heating issues on 1/12/26 and was cited so they found the issue and fixed corroded pipes on the boiler and then stated State surveyors were back on 1/18/26 for heating issues and cited for a second time so the facility found another issue with the boiler having a crack and had that repaired.Immediate Jeopardy Removal Plan:The facility submitted its original Abatement plan on 2/1/26 at 7:10pm.Regional Office returned Abatement plan for corrections on 2/2/26 at 1:41pm.The facility submitted the Abatement plan with corrections on 2/2/26 at 2:02pm.Regional Office returned Abatement plan with more corrections on 2/2/26 at 2:25pm.The facility submitted plan with corrections on 2/2/26 at 3:26pm.Regional Office returned Abatement plan for additional corrections on 2/2/26 at 4:54pm.The facility submitted the Abatement plan with more corrections on 2/2/26 at 5:05pm.The facility's Abatement plan was accepted on 2/3/26 at 7:13am.On 2/3/26 this surveyor confirmed through interview and record review that the facility took the following steps to remove the immediacy:1. On 1/30/26 all staff members present were in-serviced on the facility's Comprehensive Emergency Manual Policy by V1 (Administrator) and V18 (Human Resources). 2. On 1/30/26 V4 (Maintenance Director) was in-serviced on the facility's Cold weather Policy by V1 (Administrator).3. On 1/30/26 V19 (Medical Director) was notified of the Immediate Jeopardy and updated on the plan by V1 (Administrator).4. On 1/29/26 11 residents on the St. [NAME] wing were moved to available rooms on the St. [NAME] wing. All remaining residents on the St. [NAME] wing were offered a transfer to another facility or warmer parts of the building. Those who chose to stay were provided with extra blankets and warm beverages. This action was directed by V1 (Administrator). 5. On 1/30/26 R1, R4, and R5 were immediately assessed by V2 (Director of Nursing/DON) and V20 (Nurse Practitioner) to ensure their needs were met and they were comfortable. All other residents were assessed by nursing staff and outside physicians. 6. On 1/30/26 V4 (Maintenance Director) assessed the air handler and determined the fluctuating temperatures were due to an airflow issue. Two new blower fans were installed into the air handler on 01/30/2026, to ensure adequate hot air circulation, and repairs were completed by 7:00 PM on 1/30/2026. 7. On 1/30/26 V1 (Administrator) prior to the completion of the fan installation temperatures in each resident room on the affected unit were monitored every hour. 8. On 1/30/26 V1 (Administrator), after fan installation, initiated shift-by-shift temperature monitoring completed and shift by shift monitoring will continue until the extreme cold weather has abated as determined by the QAPI committee. 9. On 1/30/26 all residents remaining on the St. [NAME] unit were assessed and continuously monitored for pain, respiratory comfort, and general comfort until heat is fully stabilized by the shift nurses on duty at that time. If any distress or pain is identified, on duty nursing staff will implement interventions to address the root cause and monitor effectiveness. 10. On 1/31/26 V13 (Housekeeping) and V21 (Dietary) installed temporary flannel window coverings to reduce heat loss in rooms on St. [NAME] wing. 11. On 1/30/26 and 1/31/26 V1 (Administrator), V18 (Human Resource), V22 (Housekeeping Director), V23 (Minimum Data Set Coordinator) educated all staff via phone or in-person on the Comprehensive Emergency Management Plan and the Cold Weather policy. Staff unavailable will be educated prior to their next scheduled shift. 12. Quality Assessment and Assurance (QAA) Committee has developed and implemented a plan to monitor preventative maintenance for the heating system. This plan includes regular audits that began on 01/30/2026 of maintenance logs by the Administrator to ensure all HVAC inspections (Daily) and radiator filter cleanings (Quarterly) are completed according to the established schedule. The results of these audits will be reviewed during scheduled QAA meetings to ensure ongoing compliance and system reliability. The duration of these audits will be continuous.13. The facility has implemented a mandatory education schedule ensuring all staff are educated on the facility Emergency policies and procedures. This training is now a permanent part of the orientation for all new hires and will be conducted annually for all existing staff by V18 (Human Resources). Completion Date 1/30/26. B. The facility's Water Temperatures Policy, revised December 30, 2024, documents not in its entirety, It is the policy of this facility to maintain temperatures comfortable for residents. The facility's Homelike Environment policy, initiated 12/27/23, documents the facility is to have comfortable and safe temperature levels.On 1/29/26 at 10:20 AM R1 stated that they have had hot water issues on the other side of the building (St. [NAME] side) that has been going on for a while now so those people have to come over here to take showers.On 1/29/26 R2 stated the facility had been without hot water a few weeks ago.On 1/30/26 at 11:30 AM temperatures performed on the hot water in the building with the following findings: This building has two distinct sides and there is zero hot water on the St [NAME] wings room [ROOM NUMBER]-18.1 F (Fahrenheit); room [ROOM NUMBER]-24.9 F; and room [ROOM NUMBER]- 15.4 F. On the other side, St. [NAME] wings, shower room temped at 93.6 F, room [ROOM NUMBER]- 93.7 F; room [ROOM NUMBER]-91.4 F; room [ROOM NUMBER]-91.8 F; room [ROOM NUMBER]-93.6 F; room [ROOM NUMBER]-86.7 F; room [ROOM NUMBER]-90.2 F and room [ROOM NUMBER]-87.4 F.On 1/30/26 at 11:32 AM, V17 (Registered Nurse/RN) stated that there has not been hot water for a couple of weeks on the St. [NAME] side, some days better than others but they are using kettles to warm up water for face, hands, armpits and peri-areas.On 1/30/26 at 1:06 PM, V1 (Administrator) stated not all the mixing valves have been replaced on St. [NAME] wings so that is why there is still no hot water. V1 stated that they had to order more mixing valves to finish so that side of the building has been without hot water since State was in for complaint survey on 1/12/26.On 2/3/26 R2, R16, R34, R40, R48, and R49 all verified that there has been no hot water on their side of the building (St. [NAME]) for about a month.On 2/3/26 at 12:50 PM, V4 (Maintenance Director) and V8 (Regional Maintenance Director) stated that the St. [NAME] side of the building has been with and without hot water this whole month, spotty, then lose it; intermittent problem. V4 stated, I've been chasing mixing valves. Replaced the main mixing valve the first week or two of January. V5 stated then the mixing valve in the main shower on St. [NAME] was not working around the middle of January, leaking the cold water into the hot water so that was replaced and every individual room on the St. [NAME] side of the building has a shower in the bathroom which has a mixing valve component so all rooms were checked; verified that there are 5 (five) rooms that were broken so parts were ordered and arrived so they are now replacing those.

Based on interview and record review, the facility failed to implement care plan discharge interventions for four of five residents (R1-R4) reviewed for discharge plans in a sample of five. Findings include:The discharge Care Plan policy, dated 11/6/25, documents that when a resident is discharged , a post-discharge plan shall be provided to the resident and or his or her representative (sponsor). This form documents that a description of the resident and family's preferences for care; a description of how the resident and family will access and pay for such services; a description of how the care should be coordinated if continuing treatment involves multiple caregivers; the identities of specific resident needs are discharge (I.e. personal care (ADL's, self-administration of medication's, diet, etc.) sterile dressings, physician therapy, etc.) Appropriate referrals when necessary are made by social services and documented in the medical record, and a description of how the resident and family need to prepare for the discharge. Social Services will review the plan with the resident and family before the discharge is to take place. The facility's Comprehensive Care Plan policy, revised 6/25/25, documents that an individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident.1.On 1/23/26 at 10:00am, R1 stated that discharge plans had not been discussed until the involuntary discharge was given to him. R1's electronic medical record documents that R1 was admitted to the facility on [DATE]. R1's current care plan does not document a discharge plan or interventions. 2. R2's electronic medical record documents that R2 was admitted to the facility on [DATE]. R2's current care does not document a discharge plan or interventions. 3. On 1/23/26 at 11:00am, R3 stated that he is going home after he finishes his therapy. R3 verified that no one has talked to him concerning his discharge plans. R3 stated that he has his family looking into home health for him. R3 stated that his discharge was never discussed in his care plan meeting. R3's electronic medical record documents that R3 was admitted to the facility on [DATE]. R3's current care plan does not document a discharge plan or interventions. 4. R4's electronic medical record documents that R4 was admitted to the facility on [DATE] and discharged home on [DATE]. R3's care plan did not document a discharge plan or interventions. On 1/23/26 at 12:30pm, V8, Minimum Data Set Director/Registered Nurse, stated that a discharge plan is supposed to be initiated upon admission. V8 stated that V3, Social Service Director, is supposed to document the discharge portion of the care plan. On 1/23/26 at 12:50pm, V3 stated that she is responsible for care planning discharges but has fallen behind. V3 verified that R1-R4 did not have a discharge plan on their care plans.

Based on observation, interview, and record review, the facility failed to ensure the boiler was in working order to provide heat. This failure has the potential to affect 60 residents residing in the facility. The facility's Homelike Environment/Maintenance policy, revised 12/1/25, documents that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. This form documents that the facility is to be comfortable and have safe temperature levels. The facility's Cold Weather policy, revised 11/24/25, documents that the facility will conduct regular building maintenance and inspection, including maintenance of heating and air conditioning systems and thermostats. On 1/18/26 at 1:30pm the temperatures throughout the facility ranged from 56.0 degrees Fahrenheit to 58.0 degrees Fahrenheit. On 1/18/26 at R1 was in bed with several blankets and a stocking cap on to keep him warm. V6, R1's Family, stated that R1's room is very cold. V6 stated that when she entered his room, he didn't even have a stocking cap on, and his head was cold to the touch. R2 was in her room with her winter coat on and several blankets on her. R3 was sitting in the front hall, with his winter coat, stocking cap, and several blankets on his lap. R3 stated that it is very cold in the facility. On 1/18/26 at 1:00pm, V3 verified that a seam broke in the boiler, so there is no heat. V3 stated that a [NAME] is enroute to fix it. V3 verified that the temperatures were running in the mid to upper fifties. On 1/18/26 at 1:30pm, V1, Administrator, verified that the heat is out in the facility. V1 stated that an emergency evacuation plan is set up if needed. On 1/20/26 at 2:00pm, V1 verified that the census on 1/18/26 was 60. The facility's Daily Census sheet, dated 1/17/26, documents 60 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to provide adequate heating and hot water and failed to maintain the building in good repair. This has the potential to affect 59 residents residing in the facility. Findings include: The facility's Homelike Environment/Maintenance policy, revised 12/1/25, documents that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. This form documents that the facility is to be comfortable and have safe temperature levels. The facility's Cold Weather policy, revised 11/24/25, documents that the facility will conduct regular building maintenance and inspection, including maintenance of heating and air conditioning systems and thermostats. The facility's Resident Call Bells policy, revised 11/5/24, documents that the facility will be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to centralized staff work area from each resident's bedside, toilet, and bathing facilities. The communication system shall be checked regularly to ensure operability and that it can be reached by the resident. On 1/12/25 at 10:30am, a tour was conducted throughout the facility with V3, Maintenance Director. Water temperatures were taken in various rooms, and observations were made of the bathrooms and shower rooms. The water temperatures on the 100 hall ranged from 110 degrees Fahrenheit to 116 degrees Fahrenheit. The water temperatures on the 200 hall ranged from 75 to 77 degrees Fahrenheit. V3 stated that there has been a problem with a mixing valve on the 200 hall, which was supposed to be fixed last week when the plumber was here, but apparently it is not. R8's bathroom had paint chipped underneath the sink, with a large piece of drywall missing. R4's bathroom (room [ROOM NUMBER]) did not have running water to the sink or the toilet. There was a wet bath blanket on the floor under the sink and a black slimy-looking substance in the toilet. room [ROOM NUMBER]'s bathroom did not have running water. There were wet, yellow-stained bath blankets on the floor under the sink. The toilet had a black, slimy-looking substance in it, and a black mold-like area in front of the toilet. V3 stated that the sink and the toilet are clogged, and he has not had a chance to fix them. V3 stated that he was going to check the mixing valve for the hot water on the 200 hall side and turn up the boiler. At 2:30pm V3 verified that the water and room temperatures remained the same. The ceiling tiles across the entire front hallway were discolored with brownish stains, and a mildew smell was noted. V3 stated that when they turned up the boilers, the condensation leaked into the tiles. V3 stated that he is the only maintenance person and tries to keep up with all the repairs, but it is hard. On 1/12/26 at 11:15am, R1 was sitting in his room with a jacket on and wrapped in a blanket. R1 stated that it is always cold on the southeast side of the building. R1 also stated that it smells moldy in the front of the building, and the ceiling tiles appear to be wet. The walls behind R1's chair had gouges in the wall, with the plaster crumbling out onto the floor. R1 pushed his call light, which came on, but when he released his thumb from the button, the call light shut off. The call light on bed two was only open wires; there was no call button at the end of the cord. At 11:30am, R2 was in his room with a long-sleeve shirt on and a coat. R2 stated that it was warm in his room till Saturday afternoon. R2 stated that he told staff on Saturday and Sunday that it was too cold in his room, but did not get a response. R2 stated that he stayed in his bed on Sunday, wrapped in his covers. At 11:45am, R3 was in her room with a long-sleeve shirt on and a shawl over her shoulders. R3 had a blanket over her legs. R3 stated that it is cold in her room. R3 had a clock on the wall in her room, which showed the time and temperature, which was 63 degrees Fahrenheit. On 1/13/26 at 9:30am, R5 was ringing a handheld bell to call for assistance. R5 stated that he does not have a call light, but his roommate does. R5 also stated that there is no hot water in his room. R6 and R7 verified that there is no hot water in their rooms. room [ROOM NUMBER] and 211 call lights stayed on the entire day, and room [ROOM NUMBER]'s call light would go on by itself. On 1/13/26 at 9:30am, V1, Administrator, verified that the water and room temperatures are not at the proper temperatures. V1 verified that there are a lot of repairs that need to be done, but with only one person, it is hard to keep up. V1 stated that the condensation built up on the pipes and leaked onto the ceiling tiles.On 1/13/25 at 10:00am, V9, Certified Nursing Assistant, stated that room [ROOM NUMBER] and 211 call lights ring all the time. V9 stated room [ROOM NUMBER]'s call light will go on by itself. V9 also verified that the water gets warm on the 200 side of the building, but not hot. V9 stated that water is heated in an electric tea pot at the nurses' station, then used to shower or wash up. V9 stated that the issues with the water and the call lights have been going on for quite some time. On 1/13/26 at 10:30am, V3 stated that water temperature on the 200 side of the building was running in the mid-seventies. V3 stated that there is a problem with the mixing valve. V3 also stated that the boiler was just fixed, but it is not heating right on the 100 side of the building. The facility's Daily Census Sheet, printed 1/12/26, documents a census of 59.

Based on observation, interview and record review the facility failed to ensure the dishwasher was reaching 180 degrees Fahrenheit to sanitize the dishes and prevent cross contamination. This applies to all 56 residents in the facility. The findings include: On 8/22/25 the facility census showed a total of 56 residents residing in the facility. On 8/22/25 at 9:30AM Surveyor asked V8 (Dietary Aid) to check the Sanitizer level in the dishwasher. V8 used a Quaternary Ammonia strip and ran it through a cycle of the dishwasher. The strip came out a light blue color. Comparing it to the key and the package of strips V8 stated, It's supposed to be between this one (400ppm) and that one (500ppm). We check the dishwasher once a day. Surveyor then showed V7 (Dietary Manager) the test strip and V7 looked at the dishwashing machine and stated she would have to get maintenance because she doesn't know anything about it.At 9:45AM V4 (Maintenance Director) Came to inspect dishwasher. V4 tried to run the final rinse cycle with no numbers showing on the screen for the final rinse temperature. V4 stated, I didn't know I was responsible for the dishwasher.At 9:50AM V7 (Dietary Manager) stated, I have never had to have the dishwasher serviced. I'm not sure who we use.On 8/22/25 at 12:03PM V5 (Maintenance Director from a Sister Facility) stated, The dishwasher is a high temp machine- the machine is designed to get to 190 degrees but I don't know why it is not displaying the temp. The wash temp is reading fine, but I can't get the final rinse temp to show. The machine is showing 200 on the strips. Surveyor asked to accompany V5 to the dishwasher for another test. V5 again used Quaternary strips and ran one through a cycle on the dishwasher. The strip did not register any quaternary ammonia. Surveyor pointed out that the strips were to test quaternary ammonia and this is a hot water machine. V5 then went to look for strips to test for hot water and returned stating they did not have any hot water test strips available in the building. At 12:10PM Surveyor requested temperature logs for the dishwasher from V7 and V7 stated, we don't have those. The facility policy entitled Dish Machine Use dated December 30, 2024 states, Dish machine hot water sanitation rinse temperature may not be more than194 degrees F, or less than 180 degrees F for all other machines.

Based on observation, interview, and record review the facility failed to ensure that water was delivered at a safe and comfortable temperature. This applies to 6 of 7 residents (R2, R4, R6, R7, R9 and R10) reviewed for safe water temperatures in a sample of 10. The findings include: On 8/22/25 at 10:05AM the temperatures of the water coming out of the bathroom sinks on the St. [NAME] wing of the facility were checked. The readings were as follows: R2 and R4's room [ROOM NUMBER].9 degrees Fahrenheit, R6's room [ROOM NUMBER].3 degrees Fahrenheit, R7's room [ROOM NUMBER] degrees Fahrenheit, R9's room [ROOM NUMBER].6 degrees Fahrenheit and R10's room [ROOM NUMBER].7 degrees Fahrenheit.On 8/22/25 at 10:30 AM R9 stated, Sometimes the water is too hot.On 8/22/25 at 1:00PM V4 (Maintenance Director) stated, The water should be 110 degrees in the resident areas and 160 in the kitchen. I am supposed to do water temps but I am not going to lie, I have not had time to do them and I have not been doing them.The facility policy entitled Water Temperatures dated 12/30/2024 states, Water temperatures in resident rooms should not exceed 110 degrees Fahrenheit.

Based on interview and record review the facility failed to obtain treatment orders for a resident with pressure injury for 1 of 3 residents (R1) reviewed for pressure injury in the sample of 10.The findings include:R1's Electronic Face Sheet documents R1 was admitted to the facility on [DATE] with diagnosis of Alzheimer's dementia, depression, and anxiety. R1 was on hospice services due to Alzheimer's dementia.R1's Braden Scale (assessment use to predict pressure risks) show R1 was high risk to for pressure injury. R1's admission assessment under skin dated 4/2/25 by V15 (former Administrator/LPN) documents pressure to coccyx as non-staged. Under treatment: {Wound Company} notified, will see R1 on next visit due (4/8/25)R1's Wound Assessment and Plan with initial visit dated 4/15/25 by V17 (Wound MD) show: Wound Location-coccyx, Wound Type-Pressure Injury, Wound Measurements-1.5 centimeters (cm) x 1cm x 0.1 cm. Wound Order: Coccyx wound- cleanse with normal saline or sterile water apply Hydrocolloid to wound every 2 days and PRN.On 8/22/25 at 1PM. V2 (Director of Nursing-DON) said R1 was admitted with pressure injury. V2 (DON) said she thought R1 had wound treatment upon admit. R1 had dressings to coccyx when she checked R1's coccyx wound. V2 also said R1 was supposed to see V17 (Wound Md) on 4/8/25 to obtain treatments but R1 was not on the list to be seen at that time.R1's Electronic Treatment Sheet documents: coccyx wound- cleanse with normal saline or sterile water apply hydrocolloid to wound bed every two days and as needed. Start date 4/15/25 (approximately 13 days after admission).On 8/22/25 at 2:30 PM, V16 (Asst Director of Nursing) said wound treatment should be obtained as soon as the wound was discovered to promote wound healing.The Facility Policy on Skin Prevention, Assessment and Treatment dated 5/7/2024 show, to identify factors that place the residents at risk for the development of pressure ulcers, to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown and to promote healing of existing pressure ulcers.

Based on observation, interview and record review the facility failed to allow one resident (R18) to make her own decisions of sixteen residents reviewed for choices in a total sample of fifty-seven. This failure caused R18 emotional distress and crying. Findings Include: The Facility's undated Resident Rights Policy and Procedure documents Self-determination. Every resident has the right to, and the facility must promote and facilitate, resident, self-determination through support of resident choice, including but not limited to the rights specified in this section. A. each resident has right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care. B. Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. R18's MDS (Minimum Data Set) dated 4/21/2025 documents R18's BIMS (Brief Interview for Mental Status) score as 15 out of 15, indicating R18 is cognitively intact. On 5/21/25 at 12:11 PM R18 was in dining room on her hallway, had hands over her eyes and was crying. When asked what was wrong, she stated Is this some sort of punishment? I don't want to be up. I want to be in bed. I hurt, I am miserable, the light is directly in my eyes and every time I ask to go back to bed, they say they are going to go get help and then they do not come back. On 05/21/25 at 12:13 PM V16 (Certified Nurse Aid) stated that this resident never wants to get up, but the nurses say to get her up for at least every meal. V16 confirmed that R18 told her while she was getting her out of bed that R18 did not want to get up. On 05/21/25 12:13 PM V17 (Licensed Practical Nurse) stated (R18) does not want to get up, if we would let her she would just drink her chocolate shakes and eat those big chocolate bars she has in her freezer down there. (in her room). V17 confirmed that this resident is able to make her needs known and does make her own care decisions but maybe shouldn't, she doesn't take care of herself, she is diabetic, she needs food, not shakes and chocolate. She needs to be up and moving. V17 denied ever telling any staff member to get R18 out of bed when she did not wish to. On 5/22/25 at 11:02 AM V1(Administrator) stated that no resident should be gotten up against their own wishes. On 5/22/25 at 11:03 AM V4 (Social Service Director) stated that R18 should not have been gotten out of bed if she did not want to. V4 confirmed that V16 (Certified Nurse Aid) came to her after she was questioned about getting R18 up. V4 stated I think (V16/CNA) thought she was doing the right thing, but I educated her that we do not get people up against their wishes ever.

Based on observation, interview, and record review, the facility failed to ensure the lids of trash dumpsters, located outside, are closed/secure to prohibit pests/animals from gaining access to discarded food/trash. This failure has the potential to effect all 57 residents residing in the facility. FINDINGS INCLUDE: Centers for Medicare and Medicaid Services [CMS] Form 671 [Long-term Care Facility Application for Medicare and Medicaid], dated 5/20/25, signed by V1/Administrator, document 57 residents reside in the facility. Facility policy, entitled Food Related Garbage & Rubbish Disposal, Revised 12/30/2024, document, 2. All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use; 5. Garbage and rubbish containing feed wastes will be stored in a manner that is inaccessible to vermin. On 5/20/2025, at 9:10 a.m., during the initial kitchen tour, with V19/Dietary Manager, the lids of the trash dumpster, located outside, were missing two lids and trash was piled above the top of the trash dumpster. The large, steel, trash dumpster, is not secured by any walls/access doors. On 5/20/2025, at 9:10 a.m., V19 confirmed, the trash dumpster was missing two lids and the dumpster should be kept closed/secured in order to prohibit access by pests/animals.

Facility failures resulted in two deficient practices. A. Based on observation, interview, and record review the facility failed to store medications in a secure environment for one (R57) of 15 residents whose rooms were assessed for cleanliness and safety in a sample of fifty seven. This failure has the potential to affect all 20 wandering residents (R3, R4, R5, R8, R11, R12, R13, R16, R22, R23, R28, R34, R36, R37, R41, R44, R45, R46, R51, R52) residing in the facility. B. Based on observation, interview and record review the facility failed to address confused residents (R11 and R28) entering a room of one resident (R49) and failed to investigate an report of an injury of one resident (R49) of fifteen residents reviewed for choices in a total sample of fifty-seven. Findings include: A.The facility's policy titled Storage, Labeling of OTC (Over the Counter) Medication, Destruction and Disposal of Medication, revised November 9, 2024, documents, To ensure that medications and biologicals are stored in a safe, secure storage and safe handling. Compartments containing medications should be locked when not in use. Trays or carts used to transport such items should not be left unattended. (Note: Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes). Medications will be stored in an orderly manner in cabinets, drawers, or carts. Each resident is assigned a cubicle or drawer to prevent the possibility of a drug for one resident being given to another. R57's Admission record documents that R57's date of admission to the facility was 4/2/25 and her diagnoses include Encounter for other Orthopedic Care, Displaced Intertrochanteric Fracture of Left Femur, and Iron Deficiency Anemia. R57's current care plan documents R57 has alteration to her Integumentary (skin) System due to pressure ulcer to coccyx and skin impairment to bilateral heels. R57's Physician Order dated 5/21/25 documents R57 coccyx wound care treatment for Alginate with AG (Silver), cleanse wound bed with normal saline (NS) or sterile water, loosely apply Dakins (mixture bleach and boric acid diluted in water/antimicrobial solution) soaked gauze wet to moist dressing and cover daily and as needed (PRN) every four hours for wound care. On 5/20/25 at 10:30am, a bottle of Dakins (antimicrobial) Full Strength solution and a 1.5-ounce tube of Therahoney (medical grade honey dressing) noted sitting on top of R57's counter just inside doorway of room. On 5/20/25 at 2:15pm, V6 (Licensed Practical Nurse/LPN) verified the bottle of Dakins Solution and tube of Therahoney remained in R57's room and V6 stated it should be in the locked treatment cart when not being used. V6 also stated, We have a lot of wanderers that like to go in other resident rooms, this (referring to Dakins Solution and Therahoney) should not be left in here. On 5/21/25 at 2:00pm V1 (Administrator) stated that medicated treatment supplies should not be kept in resident rooms when not performing an active treatment. 33970 Findings Include: B. On 05/20/25 at 10:30 AM R49 was lying in bed and talking on her cell phone. (R28/another wandering resident) entered resident room with shuffling gait and mumbling. R49 stated Hi (R28), this isn't your room, turn around. R49 kept talking on her phone. R28 continued into the room. R49 stated into the phone I am going to have to let you go, I have to get her out of here. R49 transferred herself to her wheelchair and put on slippers and said come on (R28), you walk in front of me. R28 grabbed R49's hand and was easily walked out the residents door and continued on down the hallway. On 5/20/25 at 10:35 AM R49 stated this happens all the time. (R28) doesn't really bother me because she will leave easily, she's just very confused. (R11) is the one who wanders in and won't get out. (R11) comes in and uses my bathroom gets the seat all gross, gets water everywhere when she is washing her hands, goes through my stuff and has tried to get into my bed with me. Just this morning around 6:30 AM (R11) slammed open my door and came in and started going through my stuff. They (staff) don't keep a good enough eye on either one of them, but I am scared of (R11), I am going home on Thursday because I can get more rest there when I am not chasing those two (R11 and R28) out of my room. R11's Physician Order Sheet for May 2025 documents diagnosis to include but not limited to Alzheimer's Disease. R11's current Care Plan documents resident current risk for Wandering/Elopement is high risk and her safety will be monitored every shift by staff. R11's MDS Minimum Data Set, dated dated dated [DATE] documents R11's BIMS (Brief Interview for Mental Status) score as 5 out of possible 15, indicating R11 is severely cognitively impaired. R11's MDS dated [DATE] documents that the behavior of wandering behavior of this type occurred daily. R28's Physician Order Sheet for May 2025 documents diagnosis to include but not limited to anxiety and dementia. R28's current Care Plan documents Resident's current risk for wandering/elopement is high risk 7 or higher and her safety will be monitored every shift by all staff. R28's MDS (Minimum Data Set) dated 5/2/25 documents R28 is rarely/never understood. R28's MDS dated [DATE] documents that the behavior of wandering behavior of this type occurred daily. Throughout the survey R28 walked up and down all of the hallways in the facility and went in and out of resident rooms and offices. Throughout the survey R11 propelled her wheelchair up and down the three hallways on the side of the building that she lives on. R11 ran into stationary objects frequently and became irritated and readjusted and continued on down the hallway. R49's Nurse's Note dated 4/7/25 at 7:15 PM documents (R49) claimed, that she tried catch another resident and now she has sore in abdomen (right) and (left) upper quadrants, bruises not present, pain medication was administrated. On 5/22/25 at 8:52 AM R49 stated that the incident documented on 4/7/25 at 7:15 PM was about a time R11 came in R49's room and was trying to get past me but stubbed her toe on my wheelchair and fell on to me landing in my lap, I instinctively wrapped my arms around her to keep her from falling on the ground herself. I had a light purple bruise for a couple of days where her elbow or shoulder hit me and I was sore for a week. Even after that, they (facility) did not stop her from coming and going out of my room. R49's Medical Record does not contain any follow up documentation of the area on R49's abdomen from R11 landing in her lap. On 5/23/25 at 11:00 AM V1 (Administrator) could not provide any further information on any steps to take to prevent confused residents from entering R49's room. V1 could not provide any investigation into the documented incident of R11 falling into R49's lap.

Facility failures resulted in two deficient practices. A. Based on observation, record review and interview the facility, the facility failed to wear appropriate Personal Protective Equipment/PPE in a transmission-based precautions room and failed to perform hand hygiene after exiting the room. This failure has the potential to affect all residents whose medications were stored in the medication cart (R9, R18, R22, R25, R31, R35, R36, R39, R40, R47, R49, R50, R111). The facility also failed to follow its policy for Isolation Precautions for two of two residents (R18, R40) reviewed for Contact Precautions in the sample of 57. B. Based on observation, interview and record review the facility failed to perform hand hygiene between glove changes for one of one residents (R57) reviewed for wound care in a sample of 57. Findings include: A. The Facility's Isolation Precautions policy dated 8/20/2020 documents the policy is to establish transmission-based precautions for residents who are suspected or confirmed to have communicable diseases/infections that can be transmitted to others. The Facility's Isolation Precautionspolicy documents Contact Precautions: 1. Implemented for residents suspected or confirmed to be infected with a communicable disease/infection that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces/equipment in the resident's environment. Prior to entering the isolation room, the following steps are required: a. perform hand-hygiene and apply gloves and gown prior to entering room; b. While providing direct resident care, wear gloves and wash hands after coming in contact with infectious material; c. remove gloves and perform hand-hygiene before leaving room (do not use alcohol-based hand gels for isolation due to suspected or confirmed Clostridium difficile); d. adequately clean/disinfect an item with an approved solution prior to removing the item from there room and before use on another resident. R18's Physician Order Sheet dated May 2025 documents Contact Precautions for ESBL (Extended-Spectrum Beta Lactamases) in the urine. R18's MDS (Minimum Data Set) dated 4/16/25 documents R18 is always incontinent of urine. R18's MDS documents that she is dependent on staff for incontinent cares. R18's door had 2 sheets of paper taped to it. The papers documented R18 was in contact precautions. R18's contact precaution sign on the door indicated to perform hand hygiene and don gloves and gown before entering the room. On 5/22/25 at 11:12 AM V18 (Licensed Practical Nurse) went up to the sign and stated I am just going to be real with you, I do not usually put on all the PPE (Personal Protective Equipment) when I go in R18's room to give her insulin because I do not touch anything other than her arm. V18 donned gloves without performing hand hygiene and entered R18's room. R18 was drowsy and mumbling. V18 touched her shoulder, shaking her saying Wake up, I have your insulin. R18 stated I need my purse; I was just putting everything in it. No purse could be obviously seen. V18 leaned over R18, causing the entire front of her scrub top and the top of her scrub pants to be touch R18 and/or her bed. V18 pulled the covers back and ran her hands up and down R18's body to demonstrate to R18 that her purse was not in the bed. V18 opened closets, drawers and went in the bathroom. V18 told R18 that she would give her insulin and then go check her old room for her purse. V18 administered the insulin and left R18's room with insulin pen still in her gloved hand. V18 returned to the medication cart in the hallway and opened drawers and removed the needle off the insulin pen and put it back in the cart with the other insulin pens. R18 then removed her gloves and threw them away but still did not perform hand hygiene in any manner. On 5/22/25 at 2:00 PM V18 confirmed she should have put a gown on prior to entering R18's room. V18 reported that the following residents have their medications stored in the same medication cart: (R9, R18, R22, R25, R31, R35, R36, R39, R40, R47, R49, R50, R111). On 5/22/25 at 2:30 PM V1 (Administrator/Infection Preventionist) stated that all staff should wear the designated PPE in all transmission-based precautions rooms every time they enter. 38805 2. Documentation and staff interviews indicated that R18 has Extended-Spectrum Beta-Lactamases/ESBL of urine; and R40 has Vancomycin-Resistant Enterococcus/VRE bacteria in urine. Signage posted on R18 and R40's doors documents Contact Precautions. (5/22/25 Internet definitions: ESBL: Makes some antibiotics ineffective in treating bacterial infections. ESBLs break down certain antibiotics, making some infections caused by ESBL-producing Enterobacterales difficult to treat. VRE: It is an infection with bacteria that are resistant to the antibiotic called Vancomycin.) On 5/21/25 at 9:45am, V12 Speech Therapist was noted in R40's room and was not wearing an isolation gown. V12 stated that she had speech therapy with R40's roommate (R47). V12 stated, I only wear gloves when I go in to see (R47); was not aware I was supposed to wear a gown. At this same time, V12 stated that she was not supposed to wear a gown because she was not doing patient care with R40; and stated that R47 was not on isolation. On 5/21/25 at 9:50am, V11 Housekeeping was noted doing housekeeping chores on R18 and R40's Unit. V11 stated that when she goes in resident contact isolation rooms, that usually she wears only gloves and stated that Administration staff may have educated her on wearing full PPE (Personal Protective Equipment), she does this sometimes, but usually just wears gloves. V11 stated, It depends on how rushed I am feeling, sometimes I put on all the PPE and gloves. On 5/21/25 at 9:57am, V3 Assistant Director of Nursing/ADON stated that PPE, gloves and gowns, should be worn by all staff when going into rooms of residents who were on contact precautions, and this included Housekeeping and Therapy staff. 50962 B. The facility's policy titled Hand Hygiene, reviewed/revised 4/24/24, documents, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. R57's Admission record documents that R57's date of admission to the facility was 4/2/25 and her diagnoses include Encounter for other Orthopedic Care, Displaced Intertrochanteric Fracture of Left Femur, and Iron Deficiency Anemia. R57's current care plan documents R57 has alteration to her Integumentary (skin) System due to pressure ulcer to coccyx and skin impairment to bilateral heels. R57's Physician Order dated 5/21/25 documents R57's left heel wound care treatment as left heel cover with bordered gauze as needed to protect from friction every Tuesday, Thursday, Saturday and right heel order dated 5/13/25 as apply barrier wipe daily and as needed. R57's current care plan documents R57 has an alteration to her Integumentary (skin) System due to pressure ulcer to coccyx and skin impairment to bilateral heels. 05/22/25 11:45 AM V2 (Director of Nursing/DON) noted to do hand hygiene, don gown and gloves and enter R57's room to perform treatment on bilateral heels. Once in room V2 obtained permission from R57 to do wound care and R57 agreed. V2 removed R57's heel boot to left foot, removed sock and opened up barrier wipe, wiped left heel wound, removed gloves and placed new gloves without doing hand hygiene, then opened dressing of bordered gauze and placed to left heel wound. V2 then removed gloves, placed new gloves without performing hand hygiene, removed R57's right heel boot and sock, then opened barrier wipe, wiped right heel wound and replaced sock and boot. V2 verified that she did not perform hand hygiene between glove changes and stated she should have.

Based on record review and interview the facility failed to track specific behaviors for the use of an antipsychotic and failed to document any non pharmalogical interventions used prior to psychotropic medication use for two residents (R24 and R32) of five residents reviewed for unnecessary medications in a total sample of fifty-seven. Findings Include: The Facility's Psychotropic Medication Management policy dated 11/1/2015 documents the purpose of the policy is to provide guidance for the psychopharmacological drug treatment for a resident with specific conditions, including but not limited to dementia and other cognitive disorders, and/or behaviors as documented in the resident's clinical record. The medical record documentation must reflect the specific behaviors/symptoms and the resident's response to non-pharmacological interventions to manage the behaviors/symptoms. The Facility's Psychotropic Medication Management policy also documents A plan of care will be developed to include precipitating factors, non-pharmacological interventions and potential side effects. R24's Physician Order Sheet for May 2025 documents that he takes the anti-anxiety medication Buspirone 10 mg twice a day for anxiety, the sedative/hypnotic medication Melatonin 5 mg every night for sleep aid, the antidepressant medication Sertraline 100 mg twice daily and the anti-psychotic medication Risperidone 0.25 mg every day for developmental disorder and unspecified psychosis and anxiety. R24's current care plan documents resident currently has an alteration in his behavior status related to fetal alcohol syndrome, intellectual disabilities. Urinating in windows, having bowel movements in inappropriate areas, restlessness, cussing, delusions, taking others belongings, hallucinations, psychosis, aggression, refusing cares, agitating staff and other residents. R24's care plan documents Interventions as Behaviors: Hallucinations; Behaviors: Hitting walls, slamming walker down; Behaviors: Negative Comments; Behavior: Physical Aggression; Behavior: taking items that are not mine; Behavior: Verbally aggressive/yells at staff during cares, Behaviors: Yells out/moans. R24's Medication Administration Record for May 2025 documents Behavior Monitoring: rejection of cares (Medications), (Activities of Daily Living), abs, meals, therapy. Document 14 for no behavior, document 15 for behavior. PN (Progress Note) interventions and outcome every shift. R25's Medication Administration Record for May 2025 either had a check mark or a 14 documented for every day. On 5/22/25 at 9:00 AM V1 (Administrator) stated she believes the check mark indicates that a behavior did occur. R25's May MAR documents a check mark on: 5/1/25,5/2/25,5/5/25,5/6/25,5/9/25,5/10/25,5/11/25,5/12/25,5/13/25,5/15/25,5/16/25.5/18/25,5/19/25,5/20/25,5/22/25,5/24/25,5/25/25,5/26/25,5/27/25,5/29/25 and 5/30/25. On 5/22/25 at 9:00 AM V1 (Administrator) confirmed that none of the check marks had corresponding progress notes to describe what behavior was occurring and what non pharmalogical interventions were attempted and how the resident responded to the interventions. V1 also confirmed that the behaviors listed on the care plan are not the same. Throughout the survey R25 walked throughout the facility, was pleasantly confused and interacted with staff and other residents with no agitation or aggression noted. 50962 2. R32's Admission Record documents that R32's date of admission to the facility was 3/5/25 and his diagnoses on admission include Unspecified Dementia, Severe, with agitation, Anxiety Disorder, Depression, Hypertension, Altered Mental Status and Adult Failure to Thrive. R32's Minimum Data Set (MDS) dated [DATE] documents cognition as severely impaired and Section E documents physical behaviors, verbal behaviors, and behavioral symptoms directed toward others. R32's Physician Order dated 3/7/25 documents that R32 has an order for Quetiapine Fumarate/Seroquel (antipsychotic) 50mg (milligrams) by mouth twice a day for agitation related to Unspecified Dementia, Severe, with agitation and Ativan 1mg-Benadryl 25mg-Haldol 2mg (combination of antianxiety, antihistamine, antipsychotic) cream apply one milliliter (ml) topically every four hours as needed for aggression/anxiety. R32's current care plan documents R32 receives antipsychotic therapy and antianxiety therapy with no indication for use. R32's Medication Administration Records for March 2025, April 2025, and May 2025 documents behavior monitoring with behaviors occurring, but no specific behavior documented, or non-pharmacological interventions documented. R32's progress notes dated 3/6/25, 3/8/25, 3/9/25, 3/10/25, 3/16/25, 3/18/25, 3/19/25, 4/10/25 and 4/11/25 document combative and resistive behaviors with no attempted interventions during behaviors or prior to administering psychotropic medications.

Based on observation, record review, and interview, the facility failed to update/revise Care Plans, to include contact precautions, for one resident (R48), of one resident, reviewed for Care Plan revisions, in a total sample of 57 residents. FINDINGS INCLUDE: Facility policy, entitled Comprehensive Care Plan, Revised 6/25/2024, documents, 3. Each resident's comprehensive care plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect treatment goals and objectives in measurable outcomes; e. Identify the professional services that are responsible for each element of care f. Aid in preventing or reducing declines in the resident's functional status and/ functional levels; and g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program. 4. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment. 5. Care plans are revised as changes in the resident's condition dictate. On 5/20/2025, at 10:00 a.m., R48's room door was observed to be closed with contact isolation signs and a personal protective equipment/PPE cart by R48's door. On 5/20/2025, at 10:25 a.m., V1/Administrator confirmed R48 is on contact isolation precautions. R48's Electronic Medical Record/EMR document, Physician Order, dated 1/21/2025, Infection Precautions - contact Isolation: Resident is isolated in room, without a roommate or cohort with like pathogen, due to active infection with transmissible significant pathogens. Above standard transmission precautions maintained, with activities and all service brought to the resident. On 5/20/2025, at 1:00 p.m., V1 confirmed R48's Care Plan should have been revised to include R48's contact isolation precautions.

Based on interview, and record review, the facility failed to safely assist a resident during re-direction for one resident (R1) of three residents reviewed for falls in a sample of three. This failure resulted in R1 sustaining pain and a fractured femur. Findings include: The facility's Fall Reduction policy, revised 11-5-19, documents To provide an environment that remains as free of accidents hazards as possible. To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. R1's clinical record documents R1 has diagnoses including [CONDITION(S)] with Behavioral Disturbance, General Anxiety Disorder, and Unspecified Dementia without Behavioral Disturbance. R1's Fall Risk Assessment, dated 3-19-22, documents R1 as a medium risk for falling. R1's Minimum Data Set/MDS assessment, dated 1-14-22, documents R1 as severely cognitively impaired. This assessment also documents R1's functional status for locomotion off unit as requiring supervision (oversight, encouragement or cueing) for self-performance and one person for physical assist. Locomotion off unit is described as how a resident moves to and returns from off-unit locations (e.g., areas set aside for dining, activities or treatments). If facility has only one floor, how resident moves to and from only one floor, how resident moves to and from distant areas on the floor. If in a wheelchair, self-sufficiency once in chair. The facility's incident investigation report for R1, dated 5-5-22, documents On 5-5-22, at 4:15pm (R1) had a witnessed fall from wheelchair, resident was observed to be sitting on edge of wheelchair, CNA (Certified Nurse Assistant) (V4) attempted to assist (R1). (R1) fell from wheelchair onto (R1's) bottom, hitting (R1's) head on the wall. R1's Nursing Progress Note, dated 5-5-22 at 7:29pm, documents Moaning crying and holding right hip. Face grimacing present. R1 received pain medication and an X-ray of the right hip. R1's X-ray report, dated 5-5-22, documents Findings: An intertrochanteric fracture is identified on the right. Superior medial displacement of the distal fracture fragment is noted. On 5-20-22, at 11:12am, V3 Registered Nurse/RN/MDS Coordinator stated the following: I was in the conference room and heard yelling that someone was on the floor. (R1) was in the entry way past the dining room. I heard a CNA (V4) yell out that someone fell . (V4) told me that (V4) was trying to keep (R1) on the unit. When (V4) turned (R1's) wheelchair around (R1) fell out onto (R1's) bottom .(R1) kind of leans forward in (R1's) wheelchair and scoots with (R1's) feet . (Afterwards) we educated the staff on making sure a resident's positioning is correct in the wheelchair before moving them. R1's Incident note, dated 5-5-22 at 5:30pm, titled Technical Error and signed by V3 RN documents a struck-out note stating the following: (R1) was wheeling towards going off the unit before dinner. CNA went to redirect (R1) and started to turn (R1's) wheelchair around. (R1) was sitting towards the front of the wheelchair and fell on to her bottom and fell back and hit her head on the wall .CNA was educated to notice patient positioning in wheelchair before moving/turning them around CNA acknowledged understanding . On 5-23-22, at 8:03am, V3 RN stated that the struck-out incident note from 5-5-22 was struck out by the electronic system due to V3 deleting the first incident note and creating a second incident with major injury note. At this time, V3 confirmed that the information in the struck-out incident note is correct in how (R1's) fall happened. V3 stated the CNA stated she had turned (R1) around. (R1) leans forward in the wheelchair so her butt is not completely all the way back. That is normal for (R1) when she's scooting along. On 5-20-22, at 1:01pm, V4 CNA stated the following: I came back from the kitchen and noticed (R1) by the double doors leading out of the unit. I went to flip (R1) around to take (R1) to the bathroom. I had another resident with me who was standing next to me. I noticed (R1) was sitting like she normally does - halfway in the wheelchair with her bottom not to the back of the wheelchair and (R1) was leaning a little forward. I'm not sure if I maybe turned her a little too fast. She had slid out from the chair from me moving her. She landed on her bottom and hit her head on the wall .I should have pushed her back more into the wheelchair and gone a little slower. We were educated the next day on those things in order to prevent it from happening again. The facility's Employee Performance Improvement form, dated 5-6-22, documents for employee V4 CNA: Ensure resident safety with transfers .Employee Comments: I was bringing (R1) back down to take (R1) to the bathroom before dinner. I am regretful for this experience and will make sure the residents are in proper position to move and minimize my distractions. On 5-20-22, at 2:32pm, V2 Director of Nursing/DON stated that (V4 CNA) was trying to guide (R1) and turned (R1's) wheelchair to bring (R1) back to the unit. (R1) had poor posture in the wheelchair. I told (V4) to make sure next time to check (R1's) position in the wheelchair for safety concerns.

Based on observation, record review and interview, the facility failed to implement interventions and provide adequate supervision and assistance to prevent 11 falls for one of eight residents (R7) reviewed for falls on the sample of 16 residents. R7 fell and received a laceration to the forehead requiring staples. Findings include: R7 has a [DIAGNOSES REDACTED]. R7 was observed in an enclosed walker from 11:00-12:00 pm on 3/18/13, 10:00 am to 11:30 am, and on 3/20/13 from 9:30 am to 11:00 am with frequent attempts to stand up. At intervals R7 was transferred to a high back wheelchair after being toileted to "reduce agitation" as verified by the charge nurse, E9, on 3/20/13 9:30 am. R7 is not interviewable with [DIAGNOSES REDACTED]. R7's Minimum Data Set (MDS) of 7/16/12 notes under Section G Functional Status R7 to be needing extensive assistance of two plus persons physical assist for walk in room and corridor. Under Section J Health Conditions noted that R7 has had falls since admission. R7's admission minimum data set of 7/26/12 section J. coded falls without fractures being addressed on the care area assessment for falls as follows: "Note 1: (R7) is at a very significant risk of falls related to his medication, impaired balance, impulsiveness/anxiety related to new environment and Parkinson tremors, dementia, depression, his need for physical support to walk, unsteady gait, and total hip replacement. Fall risk assessment score rated R7 as a high risk for falls. Fall interventions are in place and (R7s) fall on the day of admission was addressed with a anti-roll back device due to falling while pushing off of the unlocked wheelchair. No injury noted. R7 does have poor safety awareness and strength and physical ability. Will continue to monitor safety throughout stay." R7's Current Careplan of 1/29/13 " Mobility-Ambulating" states "I require extensive assist of two staff at times to maintain my balance and safety. I can walk safely in an arm-in arm fashion with the extensive assist of two staff members. I use an enclosed walker due to my extensive fall history secondary to my bouncy-lurching gait. Release me from the enclosed walker every two hours that I am in it." R7 has 26 recorded falls since admission from 7/19/13 through 2/18/13 with "Resident Incident Report" filled out for each occurrence with an investigation summary and interventions suggested. E3, Registered Nurse/Careplan and MDS Coordinator, on 3/19/13 at 1:00 pm verified that the resident incident reports are kept in her office and not available to floor staff to refer to the up-dated careplan interventions. R7 has a physician order [REDACTED]." Physical Therapy notes of 10/9/12 for R7 states " High fall risk Left side weakness and decreased use on the left upper extremity. PT (physical therapy) consulted regarding appropriate fit of ambulating walker for (R7). (R7) is a [AGE] year old with a [DIAGNOSES REDACTED]. Resident placed in ambulating walker to decrease fall risk. (R7) has tipped the merry walker on three occasions. Resident currently uses a ambulating walker that is 291/2 inches high (arm height) the walker comes to mid thigh level on (R7). At this time (R7's) center of gravity is above the level of the ambulating walker. (R7) would benefit from walker being waist high in order to place his center of gravity within the balance of support of the ambulating walker to reduce the risk of tipping. Interview with E10, Physical Therapy Assistant, on 3/21/13 at 11:15 am stated that the therapy department was not asked to evaluate the use of the enclosed ambulating walker before first initiated, rather facility did not request consultation until 10/9/12. E10, PTA, verified that in her opinion the first " enclosed ambulating walker should have been evaluated by the therapy department before use because it is a restraint." E10, PTA, stated when R7 was discharged from physical therapy on 11/1/12, he was not appropriate to use a enclosed ambulating walker due to increased lethargy as written in the discharge summary of 11/1/12 "Patient has been unable to participate in therapy since 10/26/12 due to increased lethargy - not able to progress at this time." E10, PTA, verified that the facility "had not requested any other evaluations of R7's falls and/or enclosed ambulating walker use since 10/9/12." The following ten Resident Incident Reports noted falls from 10/3/13 through 2/18/13 involving R7 in the ambulating walker without up-dating the careplan with new interventions: 1. 10/3/12 Resident was trying to get out of the ambulating walker et tipped over on to the floor with no intervention for fall/ incident for R7 but did educate a staff person without describing what was taught.. 2. 10/4/12 10:00 pm Resident attempting to stand up in enclosed ambulating walker and was off balance tilting walker to the-fall stopped by chair. No apparent injury noted." The intervention suggested "assist resident out of enclosed ambulating walker when agitated." 3. 10/4/12 10:15 pm Resident in family lounge just out of site of nurse's station. Heard something fall found resident face down on floor- overturned enclosed ambulating walker. The intervention was "to emergency room for evaluation-resident out of enclosed ambulating walker for the rest of night and all the next day." Report sent to the regional health department office on 10/5/12 states R7's injuries as "Resident had the skin above his right eye derma bonded, an x-ray of left elbow which was negative and a Computed tomography of the brain and spine which is also negative. 4. 10/11/12 9:00 am Resident scooted down to the foot rest of recliner. The suggested intervention is "taller enclosed ambulating walker ordered per Physical Therapy evaluation." 5. 12/24/12 at 6:15 PM -"Resident found in hall on right side in enclosed ambulating walker. Right temporal area has a approximate two inch laceration. Bleeding quickly stopped with direct pressure." with an intervention to "staff education to assist - out every 2 hours" 6. 1/1/13 at 10:55 am "Resident tipped his enclosed ambulating walker forward, falling forward onto his arm and face. He has a lip laceration from his teeth through the lower lip... He is awake and responding right brow has a contusion in the same spot as the contusion on 12/24/12. The intervention suggested was "close supervision while in enclosed ambulating walker x one week if no further falls." 7. 2/18/13 5:50 PM "Resident tipped (enclosed ambulating walker.)" The suggested intervention is "staff ed. staff lunch, walk, and toilet" E4, Licensed Nurse, 3/19/13 10:00 am clarified the written intervention that the" staff were educated to walk and toilet the resident (R7) before going to lunch." From the "Notification of Resident Incident" sent to the regional public health office "(Z1, physician for R7) was in the building and assessed the resident. Orders were received by Z1 to "send (R7) the emergency room for suturing." R7 received seven staples to the laceration on the right forehead. Interview with E1 on 3/21/13 verified that "even when the resident continued to fall after the second enclosed ambulating walker was initiated, the facility did not request the physical therapy department for an evaluation of the falls and/or enclosed ambulating walker safety. No interdisciplinary restraint reduction program for use of the enclosed ambulating walker was developed in the careplan." The facility's fall prevention program policy of 2/28/12 states that " Procedure: c. Ongoing communication between all members of the healthcare team is essential for implementation of a appropriate fall prevention plan.". E4, Licensed Practical Nurse, (Falls Coordinator) on 3/19/13 at 10:00 am verified that 13 out of the 26 resident incident reports starting from 9/24/12 through 12/22/12 did not get recorded on the current 1/29/13 careplan with the new interventions to address the individual falls. There are no prioritized measurable outcomes noted on the Fall Prevention/Intervention Careplan to monitor resident progress.