Every finding on record at Luther Oaks

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled, stored, and not accessible to residents and unlicensed staff for five (R1, R3, R12, R13, R15) of five residents reviewed for medication storage in a sample list of 15.Findings include:1. R13's physician order dated 12/6/25 documents Morphine Sulfate (Concentrate) oral solution 100 milligram (mg)/5 milliliter (mL), give 0.25 mL by mouth or sublingual every one to two hours as needed for pain or air hunger.R15's physician order dated 4/20/23 documents Morphine Sulfate (Concentrate) oral solution 100 mg/5 mL, give 0.25 mL every two hours as needed for moderate to severe pain or shortness of breath.On 8/25/26 at 2:06 PM, observed V2 Director of Nursing (DON) get two full bottles of morphine for R13 and R15 out of the cabinet above V2's office desk. The cabinet has no lock on it. On 8/25/26 at 2:07 PM, V2 stated the two bottles of morphine for R13 and R15 have been kept in V2's office since 8/11/26. V2 stated the cabinet in V2's office where the morphine has been kept is not able to be locked. V2 stated V2's office door is not locked during the day while V2 is in the building.On 8/25/26 at 3:21 PM, V1 Administrator stated narcotic medications should be double locked at all times. 2. R1's physician order dated 11/18/25 documents Amoxicillin (antibiotic) oral capsule 250 mg, give 250 mg by mouth one time a day for prophylactic for dental procedures.R1's physician order dated 4/8/26 documents health shake one time a day four ounces (oz).R1's physician order dated 4/17/26 documents Ibuprofen (Non-steroidal anti-inflammatory) one 200 mg tablet by mouth three times a day for moderate pain.R1's physician order dated 11/14/25 documents Meclizine Hydrochloride (antihistamine/antinausea) oral tablet 25 mg, give one tablet by mouth three times a day for dizziness.R1's physician order dated 5/28/26 documents MiraLax (laxative) oral powder 17 grams (g) per scoop, give one scoop by mouth one time a day for constipation/stool burdens.R1's physician order dated 11/14/25 documents Potassium Chloride (mineral supplement) extended release (ER) 10 milliequivalent (mEq), give two tablets by mouth one time a day for supplement.R1's physician order dated 7/31/26 documents Pro-stat Advanced Wound Care (AWC) (supplement) three times a day for supplement, give 30 mL by mouth three times daily, mix with cranberry juice. R1's physician order dated 11/14/25 documents Torsemide (diuretic) oral tablet 20 mg, give one tablet by mouth one time a day for edema.On 8/20/26 at 8:09 AM, V3 Licensed Practical Nurse (LPN) placed R1's morning oral medication tablets, one Torsemide 20 mg tablet, two Potassium Chloride ER 10 mEq tablets, one Amoxicillin 250 mg tablet, one Meclizine 25 mg tablet, and one Ibuprofen 200 mg tablet, into a clear, plastic medicine cup. Then V3 poured the following medications into one clear, plastic drinking cup: health shake 3 oz, Miralax powder 17 grams, and Pro-stat AWC 30 mL. V3 did not label either the medicine cup or the drinking cup. The drinking cup was uncovered.On 8/20/26 at 8:10 AM, V3 took the medicine cup containing R1's medication tablets and R1's cup of liquid medications to R1's room to administer the medications to R1. R1 told V3 that R1 did not want to take the medications until after R1 had finished eating breakfast. V3 then left R1's room holding the medicine cup with the medication tablets and the drinking cup of liquid medications. V3 put the unlabeled medicine cup with medication tablets in the top drawer of the medication cart. V3 then put the unlabeled cup of liquid medications in the medication fridge.On 8/20/26 at 8:15 AM, R1 was finished eating breakfast and requested R1's medications be administered. V3 got the unlabeled cup of liquid medications out of the medication fridge. Then V3 got the unlabeled medicine cup with the medication tablets out of the top drawer of the medicine cart. Also observed within the top drawer of the medicine cart, sitting next to medicine cup, was a second medicine cup with numerous unknown medication tablets in it and an unlabeled vial of eye drops. This second cup was labeled with a last name only written in marker.On 8/20/26 at 8:16 AM, V3 stated the medicine cup in the top drawer labeled with a last name for R3. V3 stated V3 pulled R3's medications earlier in the day but R3 was not ready for them at that time, so V3 placed them in the top drawer of the medicine cart to be given when R3 was ready.On 8/20/26 at 8:56 AM, V3 LPN pulled the medicine cup containing multiple tablets and an unlabeled vial of eye drops from the top drawer of the medicine cart. The medicine cup was labeled with R3's last name only, written in marker. V3 then administered the medications and eye drops out of the medication cup to R3.On 8/20/26 at 8:59 AM, V3 stated if V3 had to leave the floor for an emergency, then V3 would have had to waste the medications in the medicine cups in the top drawer of the medicine cart because the oncoming nurse wouldn't have had any way of knowing what the medications in the cup were.On 8/21/26 at 11:46 AM, V6 Registered Nurse (RN)/part-time DON stated nurses should not place uncovered and unlabeled cups of supplement shakes and other liquid medications into the medication fridge. On 8/21/26 at 12:20 PM. V6 stated writing R3's last name in marker on a medicine cup is not sufficient labeling. V6 stated medications stored in insufficiently labeled medicine cups in the medicine cart should be destroyed. 3. On 8/20/26 at 8:34 AM, R1 had one container of Nystatin powder on R1's bedside table. The container was labeled with R12's name.R1's physician order dated 6/24/26 documents R1 has a current order for Nystatin powder apply one application topically every 12 hours as needed for rash.R12's physician order dated 11/24/25 documents the order for R12's Nystatin powder was discontinued on 1/9/26.On 8/21/26 at 11:46 AM, V6 stated other residents' medications should not be stored in other residents' rooms. 4. On 8/21/26 at 8:01 AM, V10 RN gathered R12's medications out of the medicine cart and placed the medications into a medicine cup. V10 then grabbed the cup and walked away from the cart, which was in the hallway, to administer medications to R12 in the dining room. V10 did not lock the cart before walking away from it. The cart remained unlocked and out of view of V10 while V10 was in the dining room.On 8/21/26 at 8:04 AM, V10 gathered R13's medications out of the medicine cart and placed the medications into a medicine cup. V10 then grabbed the cup and walked away from the cart, which was in the hallway, to administer medications to R13 in the dining room. V10 did not lock the cart before walking away from it. The cart remained unlocked and out of view of V10 while V10 was in the dining room.On 8/21/26 at 11:46 AM, V6 RN/part-time DON stated the medicine cart should be locked anytime the nurse steps away from it.The facility's Medication Storage in the Facility policy, effective May 2018, documents schedule two through four medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications or per state regulation.The facility's Medication Storage in the Facility policy, effective May 2018, documents refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications.The facility's Medication Storage in the Facility policy, effective May 2018, documents all medications dispensed by the pharmacy are stored in the container with the pharmacy label.The facility's Security of Medication Cart policy, last revised on 1/8/2020, documents the associate administering medications must secure the medication cart during the medication pass to prevent unauthorized entry. Medication carts should be securely locked when out of the medication administering associate's view.

Based on interviews and record review the facility failed to report allegations of abuse to the Illinois Department of Public Health and local authorities for one of 11 residents (R4) reviewed for abuse in the sample list of 15.Findings Include: 1.) R4's Face sheet documents R4's diagnoses to include Fracture of the Fourth Lumbar, Dementia, Muscle Weakness, Hypertension, Repeated Falls, Depression, Metabolic Encephalopathy.R4's Care Plan dated 3/18/2026 documents R4 has a focus of Activities of Daily Living (ADL) self-care performance deficit r/t (related to) generalized weakness. This care plan does not include a focus on risk or potential for abuse.R4's Minimum Data Set (MDS) dated [DATE] documents R4's Brief Interview for Mental Status (BIMS) score to be nine, indicating R4 is moderately cognitively impaired. This MDS also documents R4 requires partial/moderate assistance from staff for Activities of Daily Living (ADL).The facility's untitled document dated 8/14/26 documents, (R4)-Reported to DON (Director of Nursing) as (V2) walked by that (R4) was abused this morning.The facility's untitled document dated 7/17/2026 documents 10:20am (V22) Chaplain comes to (V2 Director of Nursing) DON office. States (R4) told (V22) that (R4) would like to file a grievance for abuse.The facility's document titled 7/17/26 (R4) Abuse Investigation documents, (R4) reported to DON as she walked by this morning that he (R4) was abused this morning. I asked him what he meant by that and he stated that they used a torture device to abuse him. He pointed to the full mechanical lift. I explained that we use that machine to help people who aren't able to safely stand and transfer. He stated that wasn't true, we only use it to punish people. He also stated that the girls were abusing his legs. When I asked exactly what they were doing he stated that they were putting his pants on. He then pointed to a scab on his hand that appeared to be several days old and said 'this is what they did today'.On 8-20-2026 at 2:45PM, V1 Administrator stated, The investigation process is to gather statements, talk with the resident, check for any medication changes, look at progress notes, would ask other residents both male and female about the staff member. V1 stated, (V1) was confused when asked for initial reports and final reports due to (V1) not being aware of the policy that any allegations of abuse was to be reported to the state (agency), (V1) misunderstood the process and procedures of how to investigate abuse and thought that only founded abuse was to be reported.On 8-21-2026 at 12:55PM, R4 stated (R4) did not remember the abuse allegations.On 8-21-2026 at 2:22PM, V2 Director of Nursing (DON) stated (V2) did not complete the grievance as (R4) requested on 7-17-26 because (V2) investigated the incident and did not believe it to be abuse. V2 stated (V2) talked to (R4) who often makes claims of abuse. V2 stated (V2) did not send the CNA (Certified Nursing Assistant) staff accused of abuse home or away from the facility. V2 stated According to the policy (V2) should have sent the CNAs accused of abuse on administrative leave. V2 stated This allegation of abuse was not reported to state agency because (V2) did not find the abuse allegation to be substantiated.On 8-22-2026 at 5:55 AM, V2 stated The provided abuse investigations were everything (V2) had regarding the allegations of abuse, (V2) did not do a full skin assessment, did not do any follow up charting or assessments as part of the investigation. V2 confirmed they did not report the allegations of abuse for R4 to the state agency or other officials because V2 did not consider it abuse.On 8-22-2026 at 7:04AM, V2 stated (V2) self-identified that (V2) was not investigating allegations of abuse properly so is unable to provide any abuse investigations before 7/17/2026. V2 DON stated, The facility was not keeping an abuse log.The facility's policy, Abuse and Neglect of a Resident last revised 7/11/2025 documents in part, 7. Internal Reporting: If a resident is alleging abuse or neglect (physical, sexual, verbal, emotional, mental, including injuries of unknown source and/or misappropriation of resident property), the team member receiving the complaint will immediately notify their direct supervisor and the Coordinator of Abuse and Prevention will maintain a log of all abuse and neglect allegations and investigations. 8. Internal Investigation of Allegations: The Abuse Prevention Coordinator or designee will coordinate the initial investigation of the neglect, abuse including injuries of unknown, and/or misappropriation of resident property allegation. This may include: Documented interview of the resident regarding alleged abuse. Documented interview of any witnesses to the alleged incident of abuse. Review of appropriate documentation including, but not limited to, chart review and the Preliminary Incident Investigation Form. If an internal investigation is warranted, then submit the preliminary abuse/neglect report to the state. If a team member(s) has been identified as the alleged abuse, that team member will be placed on administrative leave to protect the resident from the alleged perpetrator while the investigation proceeds. 9. External Reporting of Abuse Allegations: The resident's representative and the Department of Public Health shall be informed immediately. Immediately, and not to exceed, but not later than 2 hours after allegations is made, if the events that cause the allegation do not involve abuse and do not result in bodily injury, to the administrator of the facility and to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with state law. The Preliminary Incident Investigation report shall be sent to the Department of Public Health. Within five (5) working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation will be sent to the Department of Public Health.

Based on observation, interview, and record review, the facility repeatedly failed to maintain complete and accurate medical records for two of three (R1and R3) residents reviewed for falls on the sample list of three.Findings include: 1.) On 11/04/25 at 1:43 PM, V2 (Director of Nursing (DON)) provided an incident report dated 11/03/25 documenting that R3 had an unwitnessed fall on 11/03/25. In reviewing R3's Electronic Medical Record (EMR) there were no nurses' notes documenting R3's fall on 11/03/25. On 11/05/25 at 2:00 PM, V2 confirmed there were no nurses' notes in R3's EMR documenting R3's fall on 11/03/25. V2 stated documentation for R3 could be found in the daily skilled nursing notes under assessments. R3's skilled daily nursing notes dated 11/03/25 (Day and Night Shift) do not document R3's fall. On 11/05/25 at 9:50 am V16 (Physical Therapy Assistant (PTA)) stated, R3 fell transferring himself from his wheelchair to his recliner and R3 told V16 PTA that he had just slid off the front of the recliner. V16 PTA stated they placed a non-skid device in R3's recliner chair after R3's fall on 11/03/25. V16 PTA demonstrated, using a gait belt, and had R3 stand up from the recliner with a walker. V16 PTA confirmed the presence of non-skid device (twelve inches long by 15 inches wide) in the seat of R3's recliner. V16 PTA stated the non-skid device was added as an intervention after R3's fall on 11/03/25. On 11/05/25 at 2:00 PM, V2 DON stated that the non-skid device was not added to R3's Care Plan as an intervention. 2). R1's Fall, Final Investigation dated 10/22/25 signed by V2, Director of Nursing documents the following: Conclusion: The resident was attempting to reposition herself in bed when she inadvertently fell from the bed, causing the mattress to dislodge and fall with her. This unwitnessed fall resulted in a subarachnoid hemorrhage and fractures of the nasal bones. The resident's care plan has been revised to include additional safety interventions, specifically maintaining the bed in the lowest position and ensuring that floor mats are in place whenever the resident is resting in bed. There is no documentation by V2, Director of Nursing, in resident chart (R1's above investigation is not part of R1's clinical medical record) of the fall. On 11/05/25 at 12:49 V4, Registered Nurse (RN) stated I did not do vital signs or neuros (neurological checks) on (R1) because the (V2, DON) Director of Nursing was covering the unit while I (V4) was on a fifteen-minute break. V4, RN stated I returned to the unit and saw (R1) on the floor with blood all over the place. The DON (V2) and a CNA (V8) were with (R1) and the DON (V2) was holding a cloth on (R1's) nose. Within five minutes the fire department arrived. They told the DON (V2) not to move (R1) any further, after she had positioned her to a side lying position to hold the cloth on her (R1's) face. V4, RN also stated she charted what she saw herself, but did not document what occurred while V4 was on break. On 11/04/25 at 3:45 pm V2, Director of Nursing (DON) confirmed R1's documentation as follows: V2, DON stated The nurse (V4, Registered Nurse) was off the unit for a break at the time of (R1's) fall (10/22/25). When (V4, Registered Nurse) returned, she did the only documentation ( fall 10/22/25). I should have written the note, since I was the nurse at the time (while V4 was on a break). I see the CNA's (V8, Certified Nursing Assistant) statement on the investigation says (R1) was seated on the side of her bed. That is not accurate. (R1) was laying at the foot of her bed, before the fall. 3). R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview of Mental Status score of 12 out of a possible 15 indicating moderate cognitive impairment. Uses a walker and a wheelchair. There is no side rail/enabler documented on the MDS. R1's admission assessment dated [DATE] does not document R1 had a side rail/enabler. R1's Fall Risk Assessment on admission, dated 9/8/25 documents R1 is at a moderated risk for falls with a score of 40. R1's Current Care Plan documents the following: R1) has limited physical mobility r/t (related /to) left hip fracture. (R1) will demonstrate the appropriate use of enabler bars to increase mobility through the review date. Date Initiated: 09/09/2025. R1's Device Evaluation dated 10/27/25 upon readmission from the hospital to the facility does not document R1 uses an enabler side rail bars. On 11/04/25 at 9:55 am R1 was lying in a low bed. R1's low bed that did not have enabler side rails attached. R1 had a facial bruise under her left eye and stated the bruise was caused by a recent fall from her bed (10/22/25). R1 rubbed her fingers over the bridge of her nose and said she has a nasal fracture from the same fall. On 11/5/25 at 11:00 am V2, Director of Nursing (DON) reviewed R1's care plan above that was initiated on 09/09/25. V2 stated (R1) has never had enabler side rails for bed mobility. That is an error. I have her enabler assessment, as you can see, she does not have any enablers for bed mobility. (R1) therapies notes reflect the same (confirmed). The Care Plan Coordinator (V18) must have added the enabler intervention in error. On 11/5/25 at 11:05 am V18, Care Plan Coordinator/ Minimum Data Set Coordinator stated I (V18) had added the bed enabler rails to (R1's) care plan in error. (R1) did not have the enabler rails. That is a documentation error and I fixed the care plan. I work in another facility and the enablers are standard intervention for a resident that has been admitted post femur fracture. That is my guess, as to why I put that. The facility policy Medical Records dated 01/15/25 documents the following: POLICY STATEMENT:The organization must ensure that all members of the healthcare team have access to accurate and timely documentation regarding the resident's/client's overall physical, mental and psychosocial status. A medical record that is maintained in accordance with laws, regulations and professional standards of practice also verifies the organization's bills for items and services. In implementing this policy, the following shall apply.1. Each team member and agent must comply with the following requirements:A. Maintain sufficient documentation in the medical record to support the resident's/client's diagnosis, justify the items and services rendered to the resident/client, document the course of treatment and results, and promote the continuity of the resident's/client's care. The facility Falls Prevention and Post-Falls Management dated 9/06/24 documents the following: Documentation:When a resident falls, the following information should be recorded in the resident's medical record:1. The condition in which the resident was found (e.g., resident found lying on the floor betweenbed and chair).2. Assessment data, including vital signs and any obvious injuries.3. Interventions, first aid, or treatment administered.4. Notification of the physician and family, as indicated.5. Completion of a falls risk assessment.6. Appropriate interventions taken to prevent future falls.7. The signature and title of the person recording the data

Based on observation, interview, and record review the facility failed to provide a safe transfer for one of three residents (R2) reviewed for falls on the sample list of three. Findings include: R2's Minimum Data Set (MDS) dated [DATE] documents R2 has a Progressive Neurological Condition, Parkinson's disease with Dyskinesia, muscle weakness, abnormalities of gait/mobility, need for assistance with personal care and severe cognitive impairment. This MDS also documents that R2 requires partial to moderate assistance with getting to a standing position from sitting in a chair, wheelchair, or on the side of the bed. R2's Care Plan dated 5/22/25 with a revision on 9/03/25 documents R2 is at risk for falls related to generalized weakness and gait instability secondary to Parkinson's Disease. R2's Morse Fall Scale dated 8/20/25 documents R2 is at High Risk for Falling. On 11/04/25 at 1:43 PM, V2 (Director of Nursing (DON)) provided an incident report dated 10/29/25 documenting that R2 had a witnessed fall on 10/29/25. On 11/04/25 at 10:20 AM, V5 (Certified Nurse Assistant (CNA)) entered R2's room. R2 was seated in a recliner. R2 was difficult to understand and appeared to be confused at surveyor's introduction. V5 CNA proceeded to assist R2 with a transfer from R2's recliner to R2's wheelchair without the use of a gait belt. V5 CNA confirmed she did not use the gait belt to assist R2 in the transfer. V5 CNA stated usually V5 CNA will use the gait belt when R2 is anxious as she was with the transfer, and sometimes R2 does not need the gait belt for a safe transfer. On 11/05/25 at 9:32 AM, in a phone interview with V11 (Registered Nurse (RN)), V11 RN stated that all staff are expected to use a gait belt when transferring or walking with R2. On 11/05/2025 at 10:35 AM, V17 (Physical Therapist (PT)) stated R2 requires light touch assistance from staff when transferring and walking and that staff should always use a gait belt when transferring or walking R2. On 11/4/25 at 3:55 pm, V2 (Director of Nursing (DON)) and surveyor exited R1's room, R2 was being assisted into a wheelchair by a private sitter. V2, DON opened R2's door so the private sitter could push the wheelchair into R2's room. V2 confirmed the gait belt was rolled up and lying on the counter just inside R2's room. V2 confirmed I expect all staff to use the gait belt for resident transfers. R2 should have had a gait belt on, she has Parkinson's. The facility's Falls Prevention and Post-Falls Management Policy dated 10/11/22 with a revision on 9/06/24 documents the following: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and other members of the multidisciplinary team, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.

Based on observation, interview and record review the facility failed to have an infection control surveillance program in place and failed to prevent cross contamination when administering medications. These failures have the potential to affect all 16 residents who reside in the facility. Findings include: The Long Term Care Facility Application for Medicare and Medicaid dated 7/30/24 documents sixteen long term care residents reside in the facility. The facility provided Infection Prevention and Control Program dated 7/20/23 documents that the goal of the infection control program is to ensure a structured and coordinated approach for the surveillance, investigation, prevention and control of healthcare infections and other infectious diseases. 1.) On 7/30/24 at 12:30PM V5 IP (Infection Preventionist) provided an incomplete infection control log for July 2024 and said that it was the only resident log of infections that she had for surveillance at this time. On 7/31/24 at 8:49AM, V5 Infection Preventionist (IP) said that logging/surveillance of infections just began in July 2024. I wasn't keeping logs or resident or employee illnesses or following McGreers (protocol for antibiotic use) before July. 41970 2.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively intact. R1's Care Plan dated 7/22/24 documents R1 has impaired cognitive function/Dementia or impaired thought processes due to diagnosis of Dementia. On 7/31/24 at 8:08 AM V15 Registered Nurse (RN) handed R1 his morning medication. During the transfer of R1's medications, R1's pre-cut half pill of Metoprolol Tartrate (beta-blocker)12.5 milligrams (mg) dropped on the dining room table. V15 RN picked up R1's contaminated Metoprolol Tartrate with her bare hands and placed it back in R1's palm of his hand. R1 then swallowed the Metoprolol Tartrate. V15 Registered Nurse (RN) then administered R1's Flonase Allergy Relief Nasal Suspension 50 micrograms (MCG) (Fluticasone Propionate (Nasal)) to both of R1's nares without wearing gloves. R1 had clear drainage from both nares just prior to V15 RN administering nasal spray. V15 RN did not wash her hands in between picking up R1's medication and administering nasal spray. On 7/31/24 at 8:45 AM V15 Registered Nurse (RN) stated V15 should have worn gloves when picking up R1's Metoprolol Tartrate off of the dining room table and when administering R1's Flonase nasal spray. V15 RN stated also V15 should have washed hands after picking up R1's contaminated medication and before administering his Flonase. ON 7/31/24 at 12:00 PM V2 Director of Nurses (DON) stated V15 Registered Nurse (RN) should have used appropriate hand hygiene when administering medications. The facility policy titled Handwashing/Hand Hygiene revised 4/25/2023 documents staff are to use an alcohol-based hand rub or alternatively, soap and water for the following situations: before preparing and handling medications. This same policy documents all team members shall follow the hand washing /hand hygiene procedures to help prevent the spread of infections to residents, visitors, and other staff members.

Based on observation, interview and record review the facility failed to store dishes in a sanitary manner, clean food preparation areas with appropriate chemicals, ensure staff's hair was secure to prevent food contamination, and ensure ice cream lids were in place to prevent cross contamination. These failures have the potential to affect all 16 residents who reside in the facility. Findings include: The Long Term Care Facility application for Medicare and Medicaid dated 7/30/24 documents 16 long term care residents reside in the facility. The facility policy Manual Cleaning and Sanitizing date revised 6/1/2021 documents Equipment, utensils, and tableware will be washed and sanitized in a method which complies with the Federal Food Code and any state or local ordinances. Sanitize the equipment surface. Make sure the sanitizer comes in contact with each surface. The concentration of the sanitizer must meet the requirements. Scrape or remove food from the equipment surfaces. Wash the equipment surfaces. Use a cleaning solution prepared with an approved cleaner. Wash the equipment with the correct cleaning tool, such as nylon brush or pad, or a cloth towel. Sanitize the equipment surface. Make sure sanitizer comes in contact with each surface. The concentration of the sanitizer must meet requirements. All other surface clean and sanitize by hand with an approved chemical. Allow surfaces to air dry. On 7/30/24 at 9:35 AM, the kitchen staff were preparing food while not wearing hair nets in the kitchen. V8 Dietary Aide said that she was unsure where hairnets were located. On 7/30/24 at 9:45 AM, food crumbs and debris were covering the food tray that contained soup bowls. Food particles and debris were also observed on the soup table which had soup warming to be served at lunch. Two large Ice cream containers were in the freezer with no lids on the containers. On 7/31/24 at 11:13 AM, V11 Dietary Manager tested her sanitation bucket with test strips. The test results were 3.0 out of 5.5 on the PH scale, indicating not enough sanitizer in solution. V11 stated that the strips should be green to show proper amount of sanitation being used. The test strips were orange. On 7/31/24 at 11:12 AM, V17 [NAME] cleaned the food prep area with degreaser solution and stated she did not know where the sanitation solution was. V11 confirmed after testing the bucket of solution that V17 did not follow the facilities cleaning policy.

Based on observation, interview, and record review the facility failed to employ a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 16 residents residing in the facility. Findings include: The Long-Term Care Facility Application for Medicare and Medicaid dated 7/30/24 documents 16 residents reside in the facility. Throughout the survey from 7/30/24-8/1/24, the facility failed to keep the kitchen clean and free of debris in preparation and storage areas, failed to sanitize food preparation areas according to facility's sanitation policy, and failed to cover and contain ice cream canisters in the freezer. Kitchen staff also failed to contain hair while in the kitchen and food preparation areas. On 7/30/24 at 11:00 AM, V11 (Dietary Manager in Training) stated she enrolled in Certified Dietary Manager courses in April 2024, but has not had time to start the modules yet. On 7/30/24 at 11:30 AM V1 (Administrator) confirmed that V11 has not started Certified Dietary Manager training.

Based on observation, interview, and record review the facility failed to identify behaviors and implement non-pharmacological interventions prior to the use of psychotropic medications for one (R6) of five residents reviewed for psychotropic medications on the sample list of 24 residents. Findings include: Facility Policy Psychotropic Medication Management System dated 10/26/2022 documents Behavior Management focuses on person-centered, non-pharmacological approaches to care to meet the individual needs of each resident. While there may be isolated situations where pharmacological intervention is required first, these situations do not negate the obligation of the community to develop and implement non-pharmacological approaches. Behavior monitoring is initiated on all residents who exhibited behaviors in the past and all residents who are taking any psychotropic medications of any classification whether scheduled or as needed basis. Behavior monitoring involves identifying behaviors, the number of behavior episodes, success of interventions (whether pharmacologic or non-pharmacologic intervention), the number of PRN psychotropic used, and any side effects from the psychotropic medication. R6's Physicians Order Sheet (POS) dated 7/30/24 documents an order for Seroquel (anti-psychotic) Oral Tablet 25 milligrams (MG) give one tablet by mouth, two times a day, every Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday for agitation. This POS also documents an order for 25 milligrams of Seroquel (anti-psychotic) every Sunday for agitation. On 7/30/24 at 10:55 AM and on 7/31/24 at 12:32 PM, R6 was sitting in community areas in the facility. R6 was pleasant and interacting with staff and other residents. R6 did not display any type of behavior. On 7/31/24 at 12:32 PM, V18 (Certified Nursing Assistant) stated she has worked at this facility for a year and has never seen R6 have any behaviors. V18 stated she cares for R6 on a regular basis. On 7/31/24 at 12:42 PM, V15 (Registered Nurse) stated R6 hasn't had any behaviors recently, sometimes R6 gets confused looking for her husband and kids, but other than that V15 stated she has never observed or heard of any behaviors from R6. V15 stated she has worked here since January. On 7/31/24 at 1:45 PM V18 provided incontinent care to R6. R6 was cooperative and followed commands without incident. R6's medical record did not contain documentation of behavior tracking or the use of non-pharmacological interventions. R6's psychotropic care plan dated 7/31/24 does not document targeted behaviors or non-pharmacological interventions. R6's Psychiatry note dated 4/28/24 documents to administer Seroquel (anti-psychotic) 25 mg twice a day for a diagnosis of Dementia. On 8/1/24 at 9:10 AM, V10 (Family member) stated R6 has never had any mental health issues. V10 stated R6 was independent and fully functioning until 2019 when she had some falls at home. After R6's falls with her Parkinson's and dementia R6 has slowly declined. On 8/1/24 at 11:10 AM, V2 (Director of Nursing) stated R6 was originally put on Seroquel in July 2022 for delusional disorder. R6 was on Hospice at this time. In January 2023 R6 was discharged from Hospice. V2 said that the physician gave a diagnosis of Schizoaffective Disorder in May 2023 because R6 was crying, angry, falling and exit seeking. V2 Director of Nursing (DON) confirmed these behaviors are also expected with a dementia diagnosis. V2 stated that R6 has had no documented behaviors since 2022.

Based on interview and record review the facility failed to provide an individual discharge plan for R18 who was discharged on [DATE] to Independent Living . R18 is one of one resident reviewed for discharge planning in sample of 24. Findings include: The Physician Orders Sheet dated July 2024 documents R18 has the following diagnoses: Urinary tract infection and Infection and inflammatory reaction due to Indwelling Urethral Catheter, Subsequent Encounter. R18's Minimum Data Set (MDS) assessment documents his Brief Interview for Mental Status (BIMS) dated 6/12/24 as being cognitively impaired. R18 requires assistance with his activities of daily living. R18 will try to do things for his care and is not able to complete and will required assistance. R18's care plan dated 6/5/24 does not have any information for discharge planning. V19 Social Service Designee stated in interview 7/31/24 at 3:30 PM I was gone on vacation and did not know they were planning on discharging (R18). No, I did not do any discharge planning for him in the care plan. Facility policy Discharge Planning and Summary dated 4/25/2024 state as their Policy Statement: A post-discharge plan and discharge summary is developed to assist the resident with transition.

Based on interview and record review the facility failed to have an antibiotic stewardship program in place for two (R9, R12) of six residents reviewed for antibiotic stewardship on the total sample of 24 residents. Findings include: The facility provided Antimicrobial Stewardship Policy retrieval date 7/31/24 documents that antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by residents. Improving antibiotic prescribing and use is critical to effectively treat infections, protect residents from harms caused by unnecessary antibiotic use and combat antibiotic resistance. Facility Communities recognize McGreer's evidence-based assessment as the standard for infection definition and as a protocol for antibiotic usage. The Medical Director oversees the adherence to antibiotic prescription. The Infection Preventionist monitors antibiotic use and adherence use protocol and works with the medical director and /or infectious disease doctor to review antibiotic resistance patterns in the community, if present. 1.) R9's physician order dated 7/6/24 documents Sulfa/Trimethoprim (antibiotic) 800/160 milligrams for seven days for a wound infection. R9's physician order dated 6/22/24 documents Methenamine (antibiotic) 1 gram twice daily for urinary symptoms. On 8/1/24 at 8:39AM, V5 Infection Preventionist (IP) said that R9's Sulfa/Trimethoprim antibiotic was for a wound infection, We wouldn't have gotten a culture for that and the Methenamine is a prophylactic antibiotic for urinary tract infections, we don't have cultures for those either. 2.) R12's physician order dated 5/22/24 documents Nitrofurantoin (antibiotic) 100 milligrams to be given twice daily for urinary symptoms. On 8/1/24 at 8:45AM, V5 IP said that R12 is on Nitrofurantoin prophylactic. We don't have a culture and sensitivity when they are on antibiotics prophylactically. I wish that (the doctors) wouldn't put them on them, but my doctors don't agree. No antibiotic stewardship documentation including cultures, sensitivities, resident symptoms, McGreers documentation or communication between V5 IP and the physician prescribers could be located at this survey. On 7/31/24 at 8:49AM, V5 IP said that she wasn't keeping antibiotic logs including types of infections, antibiotic usage, cultures and sensitivities or McGreers criteria for cultures before July (2024).

Based on observation, interview and record review the facility failed to provide hygienic oxygen masks and tubing and failed to label and contain the oxygen masks and tubing for two (R13, R7) of two residents reviewed for respiratory care from a total sample list of 24. Findings include: 1.) R13's physician orders dated 5/4/23 document Albuterol Sulfate (bronchodilator) 2.5 milligram per 3 milliliters to be inhaled orally via nebulizer every six hours as needed for wheezing, shortness of breath and coughing. On 7/30/24 at 10:56AM, R13's nebulizer mask was laying on the bedside table, unbagged, without a date or time when to be changed and the mask appeared wet. On 7/31/24 at 10:37AM, R13's nebulizer mask remained on the table, unbagged, without a date or time when to be changed and dust was on it. On 7/31/24 at 11:22AM. V2 Director of Nursing said that the facility did not have a policy regarding the maintenance and care of respiratory equipment; however nebulizer masks and oxygen tubing should be rinsed, labeled and bagged to ensure cleanliness. 41970 2.) R7's Physician Order Sheet (POS) dated July 2024 documents a physician order starting 10/20/2023 to administer Albuterol Sulfate Inhalation Nebulization Solution (2.5 milligram (MG)/3 milliliter (ML) 0.083% (Albuterol Sulfate) every four hours as needed wheezing and shortness of breath. This same POS documents R7's medical diagnoses of Chronic Obstructive Pulmonary Disease (COPD). R7's Medication Administration Record (MAR) dated July 2024 documents R7 was administered Albuterol Nebulizer on 7/23/24. On 7/30/24 at 10:26 AM R7's Nebulizer tubing and mask were not dated and not bagged while laying on top of R7's bedside dresser. R7's Nebulizer mask showed multiple debris on the inside of the mask.

Based on observation, interview and record review the facility failed to provide shaving care for two residents (R12, R13) dependent on staff assistance of 16 residents reviewed for shaving care from a total sample list of 24 residents. Findings include: The facility provided General Nursing and Personal Care Policy dated 10/26/16 documents that each resident shall have proper daily personal attention including skin, nails, hair and oral hygiene. A resident who is unable to perform Activities of Daily Living will receive the support needed to maintain nutrition, grooming and personal hygiene. 1. R12's care plan dated 4/17/24 documents that R12 requires extensive assistance with activities of daily living due to confusion, disease processes, and impaired balance. On 7/30/24 at 10:34 AM, R12 was not shaved and had beard hair growing approximately one half inch in length. 2. R13's care plan dated 9/20/23 documents that R13 requires assistance with activities of daily living due to dementia. On 7/30/24 at 10:32AM, R13 was not shaved and had beard growth approximately one half inch in length. On 7/30/24 at 10:34AM, V4 Registered Nurse said that all residents should be shaved daily. On 7/30/24 at 10:59AM, V6 Certified Nursing Assistant said that it isn't possible for the staff to get everyone shaved with the heavy care needs on this hall.

Based on observation, interview and record review the facility failed to honor resident food preferences for one of one residents (R5) reviewed for food preferences in a sample list of 24 residents. Findings include: R5's undated Face Sheet documents medical diagnoses of Alzheimer's Disease, Failure to Thrive and Gastroesophageal Reflux Disease (GERD). R5's Minimum Data Set (MDS) dated [DATE] documents R5 as severely cognitively impaired. This same MDS documents R5 requires supervision with eating. R5's Physician Order Sheet (POS) dated July 2024 documents a physician order starting 5/10/24 with no end date for a Mechanical soft textured diet. NO green beans, broccoli or cauliflower. R5's Nurse Progress Note dated 7/30/24 at 2:22 PM documents (R5) had choking episode at lunchtime. (V13) Hospice Certified Nurse Aide (CNA) present with her at the time and had been assisting with meal supervision. (R5) able to cough and clear her throat. The facility dietary inservice form dated 7/10/24, 7/11/24, 7/23/24 and 7/24/24 documents (Staff) need to follow diet list provided in the pantry book, food preferences are on it. On 7/30/24 at 12:30 PM R5 was sitting at the dining room table being assisted by V13 Hospice Certified Nurse Aide (CNA). V13 Hospice CNA was trying and unable to cut through a large four inch long piece of broccoli with R5's fork. V13 Hospice CNA was able to cut off an end piece of broccoli with R5's knife and assisted R5 in eating the broccoli. R5 immediately began coughing. R5 was coughing for approximately ten minutes. R5 did not finish her lunch meal. R5 was assisted to the resident lounge area while coughing and spitting up pieces of broccoli. On 7/30/24 at 12:33 PM V13 stated There aren't any diet tickets so I just trust the staff to serve the right tray. I don't know of any book with diets. On 7/30/24 at 12:55 PM V12 Dietary Aide stated the dietary staff keep a book in the kitchen which is updated with every resident's diet. V12 stated V12 looks at the book when a resident first admits to the facility to see what their diet is but never looks at it after that. On 7/30/24 at 12:58 PM V13 Restorative Certified Nurse Aide (CNA) stated V13 served R5 her lunch meal on 7/30/24. V13 stated There is a diet book with all of the resident diets written in it. We (staff) are supposed to check the book. I did not check the book and unfortunately did not see that part in that book where it said (R5) should not receive broccoli. On 7/30/24 at 1:10 PM V14 Dietician stated the staff were inserviced on serving the residents accurate diets two weeks ago. V14 Dietician stated V12 Dietary Aide was present for the inservice. V14 Dietician stated the person plating the meal should check the resident diet book every meal to make sure there haven't been any updates. V14 stated R5's Physician order that states R5 should not have any broccoli is a resident preference, not any allergy. V14 Dietician stated broccoli is included in a mechanical soft textured diet but should be fork tender.

Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical and verbal abuse by another resident. This failure affects three residents (R4, R16, R271) of three residents reviewed for abuse in a sample list of 24 residents. Findings include: The facility policy titled 'Abuse and Neglect of a Resident' revised 6/16/2023 documents the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment such as: pushing, slapping, hitting, shoving, shaking, striking with or without an object, pinching, kicking, burning, physical punishment, confinement, or unlawful use of restraints, corporal punishment. R16's Minimum Data Set (MDS) dated [DATE] documents R16 as severely cognitively impaired. This same MDS documents R16 requires maximum assistance for transfers. R16's Final Incident Report to the State Agency dated 4/22/24 documents (V19) Social Worker was notified by (V5) Assistant Director of Nursing (ADON) about report from (V15 Registered Nurse (RN). (R16) was in the living room area when she called out for help. (V21) Certified Nurse Aide (CNA) went to assist. (R16) was calling out because (R4) was squeezing (R16's) hand and pulled her hair. This same report documents R16 was comforted while R4 was placed on continual observation until R4 deescalated. Both (R4, R16) remained on close observation for the next 24 hours. Redness noted on (R16's) Right Thumb. The redness was gone within a few hours. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 propels self in wheelchair independently. R4's Nurse Progress Note dated: --4/18/24 at 8:16 AM documents (R4) has been verbally aggressive towards staff and other residents this morning, difficult to redirect despite multiple attempts. --4/18/24 at 8:50 AM (R4's) behaviors escalating, directed unprovoked towards other residents and staff. Staff provided continual observations and remained with her until calmed. --4/18/24 at 10:30 AM (R16) seated in recliner in television room when (R4) approached her, grabbing (R16's) Right Hand and pulling her hair. Noted a red spot to (R16's) Right thumb area. V20 Housekeeper's witness statement for R4 to R16 physical abuse investigation dated 4/18/24 documents on 4/17/24 Shortly after lunch, (R4) was in a bad mood and started to verbally assault those around her. (R4's) main target was (R271). (R4) started to pound on (R271's) table, grabbing (R271's) things and yelling at (R271). (R4) ended up grabbing a fork and full ketchup bottle and threw it at (R271). I managed to catch it before any of it hit (R271). This same witness statement documents on 4/18/24 During breakfast, (R4) was again verbally assaulting those around her. (R4's) main targets being (R16 and R271). As (R271) was coming back to breakfast, (R4) attempted to trip her and kicked (R271's) walker to which I wheeled (R4) to her room. V22 Certified Nurse Aide (CNA) witness statement for R4 to R16 physical abuse investigation dated 4/18/24 documents I heard (R16) screaming. I was over by the coffee maker with (V21) CNA. I said (R4) get away from (R16). I turned the corner and saw (R4's) hand on (R16's) hand and hanging on to (R16's) hair. I said back up and lean in between the two (R4, R16) residents. Once (R4) backed up, I fully stepped in between (R4, R16). (V21) CNA was behind me. V21 Certified Nurse Aide (CNA) witness statement for R4 to R16 physical abuse investigation dated 4/18/24 documents On 4/18/24 at around 8:55 AM, when I heard (R16) yell. (V22) Certified Nurse Aide (CNA) ran to (R16). I saw (R4) grabbing (R16's) hand and also grabbed (R16's) hair. I was able to separate both (R4, R16) residents and stayed with them until V19 Social Service Director (SSD) came. On 7/30/24 at 11:00 AM R4 was self propelling in her wheelchair in hallway next to R16 sitting in her wheelchair. On 7/31/24 at 8:15 AM R4 was sitting in the wheelchair in the hallway several feet away from R16 sitting in her wheelchair in the resident lounge. On 8/1/24 at 11:25 AM R4 was sitting in the hallway next to the resident lounge area within a few feet of R16 sitting in her wheelchair. On 7/31/24 at 1:25 PM R16 stated That lady (R4) pulled my hair. That really hurt. On 7/31/24 at 3:30 PM V19 Social Service Director (SSD)/Abuse Coordinator stated staff should report allegations of any kind of abuse to V19 or V2 Director of Nurses (DON) in V19's absence. V19 stated I was notified of (R4's) interaction with ((R271)) on 4/18/24. No one let me know anything happened on 4/17/24. The staff should have reported that to me so I could have investigated that incident. (R4) threw a fork and ketchup bottle at (R271). (R4) was placed on closer supervision for the first day but I don't know what happened after that. On 8/1/24 at 8:45 AM V2 Director of Nurses (DON) stated R4 has had previous behaviors when staff needed to intervene providing interventions to help de-escalate R4 to baseline behaviors. V2 DON stated R4 was being monitored during breakfast by staff assisting other residents in the dining room. V2 DON confirmed R4 did grab R16's Right Wrist and pull R16's hair. V2 DON stated the incident between R4 and R16 on 4/18/24 did occur but she was not informed of R4's earlier behaviors on 4/17/24 nor 4/18/24 until after the incident between R4 and R16.

Based on interview and record review the facility failed to complete a level two Pre-Admission Screening and Resident Review (PASARR) after a mental health diagnosis was added to R6's electronic medical record. This failure effects one (R6) of five residents reviewed for PASARR in a sample list of 24 residents. Findings include: On 7/31/24 at 9:40 AM, V2 (Director of Nursing) stated the facility does not have a policy for PASARRs, they just follow the regulation as a guideline. R6's Level 1 PASARR completed on 7/24/19 documents that a level two is not recommended. R6's Electronic Medical Diagnosis report dated 7/30/2024 documents a diagnosis of Schizophrenia added May 20, 2023. On 8/1/24 at 10:15 AM, V2 said that no other PASARRs have been completed since 7/24/19 when R6 was admitted . V2 then said that a PASARR should be completed any time there is change in psychiatric diagnosis and that a PASARR should have been completed when the Schizophrenia Effective Disorder was added in May 2023 as a new diagnosis.

Based on observation, interview, and record review the facility failed to assess and track behaviors before giving a diagnosis of Schizophrenia for the administration of antipsychotic medications for one (R6) of five residents reviewed for diagnosis without assessment in sample list of 24 residents. Findings include: The Facility Policy Psychotropic Medication Management System dated 10/26/2022 documents Behavior Management focuses on person-centered, non-pharmacological approaches to care to meet the individual needs of each resident. While there may be isolated situations where pharmacological intervention is required first, these situations do not negate the obligation of the community to develop and implement non-pharmacological approaches. Behavior monitoring is initiated on all residents who exhibited behaviors in the past and all residents who are taking any psychotropic medications of any classification whether scheduled or as needed basis. Behavior monitoring involves identifying behaviors, the number of behavior episodes, success of interventions (whether pharmacological or non-pharmacological intervention), the number of PRN psychotropic used, and any side effects from the psychotropic medication. R6's Diagnosis report dated 7/30/24 documents a diagnosis of Schizophrenia was added to the electronic chart on 5/30/23. On 7/30/24 at 1:38 PM, V2 Director of Nursing stated the physician gave R6 a diagnosis of Schizophrenia on May 20, 2023. On 7/30/24 at 10:55 AM, R6 was sitting in activities in a manual wheelchair with a word find puzzle in front of her. R6 was pleasant and answered questions appropriately and with soft speech. On 7/31/24 at 12:28 PM, R6 was sitting in a wheelchair at the dining room table having an appropriate conversation with the staff and residents. At that time, no behaviors or hallucinations were observed. On 7/31/24 at 12:32 PM, V18 (Certified Nursing Assistant) stated she has worked at this facility for a year and has never seen R6 have any behaviors or hallucinations. V18 stated she cares for R6 on a regular basis. On 7/31/24 at 12:42 PM, V15 (Registered Nurse) stated R6 hasn't had any behaviors recently, sometimes R6 gets confused and looks for her husband and kids, but other than that V15 stated she has never observed or heard of any behaviors or hallucinations. V15 stated she has worked here since January. On 8/1/24 at 9:10 AM, V10 Family member stated R6 has never had any mental health issues. V10 stated R6 was independent and fully functioning until 2019 when she had some falls at home. V10 stated after R6's falls with her Parkinson's and Dementia R6 has slowly declined. V10 stated she was not aware that this diagnosis had been added to R6's chart. On 8/1/24 at 10:20 AM, V2 stated R6 was originally put on Seroquel (antipsychotic) in July 2022 for delusional disorder. R6 was on Hospice at this time. In January 2023, R6 was discharged from Hospice. V2 stated the physician gave the diagnosis of Schizoaffective Disorder in May 2023 because R6 was crying, angry, falling, and exit seeking. V2 confirmed these behaviors are also expected with her Dementia diagnosis. V2 stated R6 has had no documented behaviors since 2022.

Based on interview and record review the facility failed to provide a safe transfer for one (R1) of three residents reviewed for falls on the sample list of five. Findings include: R1's care plan dated 9/12/22 documents R1 has a self-care deficit related to Dementia, Confusion, and limited range of motion. This care plan documents R1 requires two assist with a full mechanical lift for transfers. R1's Fall Note dated 2/12/2024 at 6:45 AM documents V11 Certified Nurse's Assistant called V3 Registered Nurse to R1's room. This note states V11 stated V11 had to lower R1 to the floor during transfer. This note documents upon V3's arrival noted R1 was laying on her back next to the bed with her head on a pillow. On 2/17/24 at 12:15 AM, V11 stated upon coming to work on 2/12/24 she was asked to get R1 up out of bed. V11 stated it was her first time on the hall and assumed that R1 was a one assist because she did not see a mechanical lift sling. V11 stated V11 assisted R1 by herself and did not utilize a gait belt. V11 stated after R1 stood up and pivoted R1 to sit in the wheelchair, R1 began to sit down missing the wheelchair. V11 stated R1 had to be lowered to the floor. On 2/17/24 at 11:51 AM, V2 Director of Nursing stated upon investigation the incident it was determined that V11 transferred R1 without using the mechanical lift and R1 is a two person assist with the mechanical lift.

Based on observation, interview, and record review, the facility failed to provide appropriate supervision for a dependent resident to prevent a fall, thoroughly investigate a fall, implement post fall interventions, and report a fall timely to the physician and resident representative for three of four residents (R1, R2, R3) reviewed for falls on the sample list of 18. This failure resulted in R1 falling in the bathroom after being left unattended and sustaining a head laceration requiring two staples. Findings include: 1.R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. This same MDS documents R1 is independent with cares and uses both a walker and wheelchair. R1's MDS in progress dated 1/24/24 indicates R1 requires maximum assistance of one person for toileting, upper and lower body dressing and moderate assistance for chair/bed to chair transfer. R1's undated Face Sheet documents diagnoses of Other Frontotemporal Neurocognitive Disorder, Need for Assistance with Personal Care, History of Falling, Unsteadiness On Feet. R1's Fall Risk Assessment, dated 10/20/23, documents R1 is at risk for falls. R1's Nursing Progress Notes dated 1/3/24 at 4:14 pm document R1 was observed on the bathroom floor next to the toilet. R1 was unable to provide details leading up to the fall. Upon assessment, bleeding was noted to the back of R1's head. Pressure was applied; however, the bleeding was unable to be controlled. R1 was transported to the hospital. R1's ED (Emergency Department) Report dated 1/3/24 documents, R1 had a fall while on the toilet and hit (R1's) head resulting in complaints of pain and a laceration to the back of the head. R1's laceration was repaired and R1 was returned to the nursing facility. R1's Nursing Progress Notes dated 1/3/24 at 10:55 pm documents R1 returned to the facility with two staples in the back of the R1's head with a scant amount of bleeding. On 1/29/24 at 10:30 am, V7 Certified Nursing Assistant (CNA) stated V7 got R1 up from bed for dinner and took R1 to the restroom. V7 explained V7 left R1 alone on toilet to go check on another resident and upon returning to R1's room, noted R1 on the floor. V7 stated R1 had attempted to stand up and pull up R1's own pants. V7 stated R1 has always used the call light to alert staff when R1 needs help but failed to use the call light at this time. V7 stated V7 immediately called the nurse in to access R1 and R1 was sent to the hospital. On 1/29/24 at 1:50 PM, V3 Assistant Director of Nurses (ADON), stated R1 fell on [DATE] at 3:30 PM while in the bathroom alone. V3 stated residents should not be left alone in the bathroom. R1's Nurse Progress Note, dated 12/1/23 at 6:37 AM, documents, R1 was calling out and was observed on floor in front of R1's bed, sitting on a pile of blankets and sheets. The progress notes reflect, On coming nurse RN (Registered Nurse) to contact POA (Power of Attorney), On call physician and PCP (Primary Care Provider. There is no further documentation indicating that notifications were completed. On 1/29/24 at 1:50 pm, V3 ADON (Assistant Director of Nursing) stated, in the presence of V1 Administrator and V2 DON (Director of Nursing), family notification is to be documented in the medical chart either in a progress note or in the fall investigation. V3 confirmed there is no progress note stating the family had been notified, only that the night nurse endorsed this task to the dayshift nurse. 2. The facility's Incident by Incident Type Log dated 1/29/24 documents R2 had a fall on 12/9/23. R2's Unwitnessed Fall Report dated 12/9/23 documents the CNA (Certified Nursing Assistant) reported that R2 was on the floor. This report did not contain an investigation identifying the root cause of the fall; however, it does document a post fall intervention of frequent checks to be implemented. R2's Care Plan dated 5/25/23 documents R2 is at high risk for falls related to Confusion, Gait/balance problems, Incontinence, and Psychoactive drug use. This Care Plan does not document the new intervention of frequent checks from R2's 12/9/23 fall. On 1/29/24 at 1:50 PM, V1 Administrator, V2 DON (Director of Nursing) and V3 ADON (Assistant Director of Nursing) all stated that the care plan should be updated to reflect new interventions as listed on the Fall Report. V3 acknowledges that the care plan did not contain the intervention of frequent checks of R2 from the 12/9/23 fall. 34201 3. R3's Fall Risk assessment dated [DATE] documents R3 is a moderate fall risk. R3's MDS (Minimum Data Set) dated 9/19/23 documents R3 has severe cognitive impairments and requires extensive assistance of one staff for transfers. R3's Unwitnessed Fall Report dated 11/3/23 documents CNA (Certified Nursing Assistant) found R3 sitting on R3's buttocks, on the floor next to the bed, leaning against the bed. R3's call light was on. R3 stated R3 pressed the call light after sliding off the bed and explained R3 was trying to get to the bathroom. R3's bed was very wet from being incontinent and (R3) was trying to get to the bathroom. The facility did not provide a fall investigation with documented root cause of the fall or what new interventions were implemented. R3's Care Plan dated 10/11/23 documents, R3 is at risk for falls due to gait/balance problems and incontinence with interventions including: anticipate and meet needs, be sure call light is within reach and encourage R3 to use it for assistance as needed. Respond promptly to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure R3's bed is in lowest position and floor mats are in place. Ensure R3 is sitting in the wheelchair properly. Offer earlier times to get up in the morning if R3 is awake. Staff to get R3 ready for the day at the end of midnight shift due to R3's pattern of wanting to get up earlier and attempting to do so without assistance. Staff to offer snack, drink, and activity while waiting for breakfast. Staff to provide frequent checks to ensure proper alignment in bed. Reposition as needed and use smaller blankets on bed to prevent R3 from getting tangled up in covers. This care plan does not document any new fall interventions since 8/1/23. On 1/29/23 at 12:15 pm, V1 Administrator stated the facility normally investigates falls, especially if there is injury, but did not do one with R3's 11/3/23 fall. V1 also verified that since there was no fall investigation, there were no new post fall interventions implemented. The facility's Fall Prevention and Post Fall Management Policy dated 8/8/23 documents the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and other members of the multidisciplinary team, will seek to identify and document resident risk factors for falls and establish a resident centered falls prevention plan based on relevant assessment information. The staff will seek to identify environmental factors that may contribute to falling, implement a resident centered fall prevention plan to reduce the specific risks factor(s) of falls for each resident at risk or with a history of falls, and implement relevant interventions to try to minimize serious consequences of falling. Resident responses to interventions will be monitored and if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change the current interventions. Continue to collect and evaluate information until the cause of the falling is identified or it is determined that the cause cannot be found. When a fall occurs, the following information should be recorded in the resident's medical record: the condition in which the resident was found, assessment of the data including vital signs and any obvious injury, interventions or treatment administered, notification of the family and physician, and appropriate interventions taken to prevent future falls.

Based on interview and record review, the facility failed to notify physician and resident representative of a change in medical condition for one of four residents (R4) reviewed for notification of changes in condition on the sample list of four. Findings Include: R4's Treatment Encounter Notes by V12 PTA (Physical Therapy Assistant)/Therapy Director documents: 12/27/23 - R4 refused PT (Physical Therapy) this morning due to not feeling up to it but agreed to do it in the afternoon/evening. R4 reports feeling weak. R4 also reports moderate left leg pain during gait (knee to ankle on anterior aspect). R4 was observed to pick left foot up from ground and shake it out during gait. Increased assistance required for transfers. Nurse reports R4 was very weak and did not feel well yesterday. 12/29/23 - R4 requires frequent sitting rest breaks on this date due to complaints of pain in left lower leg. 1/1/24 - R4 is having some difficulty tolerating weight bearing on left lower extremity. R4 reports pain in the left ankle and mid gastric areas. R4 has no reports of pain while sitting. R4 is unable to ambulate longer distances due to discomfort. Supervising Nurse notified. 1/3/24 - R4 is unable to tolerate ambulating longer distances due to reports of pain in the left ankle and gastric areas. R4 ambulated approximately 90 feet then reports pain and has difficulty tolerating weight bearing on the left leg. R4 was able to ambulate an additional 20 feet then asks to sit. Attempted to ambulate again but R4 was unable to tolerate weight bearing. 1/5/14 - R4 ambulated 50-90 feet then complained of pain in the left lower extremity. R4 becomes unsteady as a result of discomfort and has to sit down. R4 is unable to ambulate longer distances as a result. R4 denies pain while sitting. Discussed R4's complaints with supervising nurse. R4's Medical Record does not document the above change in R4's medical condition or that V13 Physician or V14 (family) were notified of this change in condition until 1/6/24. R4's Progress Note dated 1/6/24 by V4 RN (Registered Nurse) documents R4 been complaining of pain on weight-bearing to left lower extremity. Physical therapy reports R4's endurance has decreased due to pain. Noted R4 began complaining of pain approximately one week ago per therapist's report. No redness, edema, warmth, or signs of injury on assessment by this nurse. V14 notified of concerns. Staff encouraged fluids, rest, and nutritional options with no notable relief. V13 Physician here on 1/5/24 and assessed. Orders received for x-rays to left lower extremity as well as Ultrasound/Doppler. V14 in agreement with orders. On 1/25/24 at 3:37 pm, V14 (R4's family) stated V14 isn't sure when R4 got hurt and started having pain specifically because V14 was not notified about it until the beginning of January 2024 but was told at that time that R4 had been hurting for a while. On 1/19/24 at 10:30 am, V4 confirmed R4 had been complaining of pain to the left lower extremity for approximately one week prior to V13 and V14 being notified. V4 stated the facility was providing conservative treatments to R4 such as rest, hydration and proper positioning but when that was not affective, that is when V4 notified V13. The facility's Change in Resident's Condition or Status Policy dated 12/8/23 documents this organization promptly notifies the resident, his or her attending physician/healthcare provider, and the resident's representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician/healthcare provider when there has been a (an): accident or incident involving the resident, discovery of injuries of an unknown source and/or a significant change in the resident's physical/emotional/mental condition.

Based on interview and record review the facility failed to administer Pneumococcal Conjugate Vaccine (PCV) 13, PCV 15, PCV 20 and/or Pneumococcal Polysaccharide Vaccine (PPSV) 23 to four (R1, R3, R4, R8) residents out of five residents reviewed for vaccinations in a sample list of 16 residents. Findings include: 1.) R1's undated Face Sheet documents R1's admitted [DATE]. R1's Electronic Medical Record (EMR) documents R1's medical diagnoses of Vascular Dementia, Diabetes Mellitus, Severe Protein-Calorie Malnutrition and Peripheral Vascular Disease (PVD). This same EMR does not document R1's refusal nor administration of Pneumococcal Conjugate Vaccine (PCV) 13, PCV 15, PCV 20 and/or Pneumococcal Polysaccharide Vaccine (PPSV) 23. 2.) R3's undated Face Sheet documents R3's admitted [DATE]. R3's Electronic Medical Record (EMR) documents medical diagnoses of Alzheimer's Disease, Stage 3 Chronic Kidney Disease, Protein Calorie Malnutrition and Asthma. This same EMR documents R1 had received PPSV 23 on 7/8/2014. This same EMR does not document any further administrations nor refusals of PCV 13, PCV 15, PCV 20 and/or PPSV 23. 3.) R4's undated Face Sheet documents R4's admitted [DATE]. R4's Electronic Medical Record (EMR) documents R4's medical diagnoses of Alzheimer's Disease, Allergic Rhinitis, Protein Calorie Malnutrition and Atrial Fibrillation. This same EMR documents R1 had received PPSV 23 on 9/1/2017. This same EMR does not document any further administrations nor refusals of PCV 13, PCV 15, PCV 20 and/or PPSV 23. 4.) R8's undated Face Sheet documents R8's admitted [DATE]. R8's Electronic Medical Record (EMR) documents R8's medical diagnoses. This same EMR documents R8 had received PPSV 23 on 10/4/2014 and PCV 13 on 11/3/2015. This same EMR does not document any further administrations nor refusals of PCV 13, PCV 15, PCV 20 and/or PPSV 23. On 8/2/23 at 12:30 PM V2 Director of Nurses stated the facility is not able to provide any further documentation on resident Pneumococcal Vaccinations. V2 stated the program was monitored by another employee who has since left. V2 stated, We (facility) are working on getting this all together for the future. I have already spoken with pharmacy to get doses on hand. I have already begun to get this program organized. It is too bad it wasn't already but I am working on it. The undated facility policy titled 'Pneumococcal Vaccine Program Policy and Procedure' documents it is the policy of this facility that each resident will be offered immunization(s) against Pneumococcal disease in accordance with current standards of practice and the Advisory Committee on Immunization Practices (ACIP) recommendations, unless contraindicated or already immunized. For residents [AGE] years or older: 1 dose of PCV 20 or 1 dose of PCV 15 followed by a dose of PPSV 23 greater than or equal to one year later. A physician's order for the Pneumococcal vaccination must be obtained for PCV 20, PCV 15 and/or PPSV 23. Residents and/or representatives will be provided with education on the benefits and potential risks of receiving the Pneumococcal vaccine. Documentation will include education provided and resident/resident representative decision to accept or refuse vaccination. If the resident did not receive the influenza vaccine and the reason of medical contraindication and /or refusal after education provided.

Based on observation, interview and record review, the facility failed to ensure a resident did not develop a pressure ulcer, failed to complete an initial or weekly wound assessments and failed to refer resident to the dietician for an evaluation of nutritional interventions to promote healing for one of three residents (R3) reviewed for pressure ulcers on the sample list of six. This failure resulted in R3 acquiring an unstageable pressure ulcer to the right heel on 1/11/23 and not receiving nutritional interventions to promote healing until 3/21/23. Findings Include: The facility's Skin Integrity-Pressure Ulcers/Pressure Injury Policy dated 12/4/2017 documents any resident who is admitted without a pressure ulcer/pressure injury will not develop a pressure ulcer/pressure injury unless clinically unavoidable and a resident who has a pressure ulcer/pressure injury will receive care, services to promote healing, prevent infection (to the extent possible), and prevention of additional pressure ulcers/pressure injury. A pressure ulcer/Injury refers to the localized damage to the skin and/or the underlying soft tissue usually over a bony prominence or related to a medical device or other device. Avoidable means the resident developed a pressure ulcer/injury and that the facility did not do one of more of the following: evaluate the resident's clinical condition and pressure ulcer/pressure injury risk factors; define and implement interventions that are consistent with the resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Unstageable encompasses three different scenarios: having a non-removable dressing in place that cannot be removed, slough and/or eschar, known but not stageable due to coverage of the wound bed by slough and/or eschar, or suspected deep tissue injury in evolution. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. To prevent a pressure ulcer/pressure injury, the facility will identify whether the resident is at risk for developing or has a pressure ulcer/pressure injury upon admission and thereafter; evaluate resident specific risk factors for changes in the resident's condition that may impact the development and/or healing of a pressure ulcer/pressure injury, implement/monitor/modify interventions to attempt to stabilize, reduce or remove the underlying risk factors. Using the Skin Risk Breakdown Assessment Tool which includes categories for sensory perception, moisture, activity, mobility, nutrition and friction, make consideration of those individual scores that place a resident at risk and refer to the prevention guidelines for interventions. R3's MDS (Minimum Data Set) dated 1/2/23 documents R3 requires extensive assist of two staff for bed mobility and transfers and is at risk for pressure ulcers. R3's Skin Breakdown Risk assessment dated [DATE] documents R3 is at high risk for skin breakdown. R3's Care Plan dated 12/29/22 documents R3 is at risk for potential pressure ulcer development related to urinary incontinence and immobility with interventions to educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, monitor/document/report PRN (as needed) any changes in skin status; appearance, color, wound healing, sign/symptoms of infection, wound size (length, width, and depth) and stage of wound, and thoroughly cleanse and dry peri area with each incontinent episode. R3's Nursing Progress Notes document the following: 12/29/22 - R3 was admitted to the facility status post hospitalization for a fractured right hip. There is no documentation of any pressure ulcers upon admission, only of a surgical wound to the right hip. 1/11/23 - R3 noted to have a wound to the right heel, which was measured and logged in the wound documentation. Dry dressing applied. R3 tolerated well. Complaints of pain to area when touched. There is no documentation in R3's medical record that the RD (Registered Dietician) was notified of R3 having a wound until 3/28/23. R3's 3/28/23 Nutritional Assessment by V13 RD documents R3 is receiving a magic cup daily, has a fractured hip and blister to the right heel and is experiencing right foot pain. R3's laboratory results dated [DATE] document an albumin level of 2.7, normal is 3.5 - 5.0 and a total protein level of 4.9, normal is 6.3-8.3. R3's Only Wound Evaluations/Assessments in R3's Medical Record are as follows: 1/11/23 - R3 has a wound measuring 0.56 cm (centimeters) by 0.97 cm but does not document the size, stage or characteristics of the wound. 1/15/23 - R3 has a blister to the right heel, in house acquired, of unknown age measuring 5 cm by 4.43 cm but does not document the stage or characteristics of the wound. 1/28/23 - R3 has a blister to the right heel, in house acquired, of unknown age, measuring 3.21 cm by 3.79 cm. 3/26/23 - R3 has a blister to the right heel, in house acquired, of unknown age, measuring 2.1 cm by 3.57 cm. 4/1/23 - R3 has a blister to the right heel, in house acquired, measuring 3.95 cm by 2.37 cm. R3's Wound Care Telemedicine Initial Evaluation Notes dated 2/10/23 by V14 Wound Physician documents R3 has an unstageable, full thickness, pressure ulcer to the right heel measuring 5 cm by 4 cm covered in 50% thick adherent devitalized necrotic tissue and 50% dermis with moderate serous drainage. R3's Wound Care Telemedicine Follow Up Evaluations document the following: 3/3/23 - unstageable, full thickness, pressure ulcer to the right heel measuring 5 cm by 4 cm, covered 100% by a thick adherent devitalized necrotic tissue with light serous drainage. No change to the wound. 4/14/23 - unstageable, full thickness, pressure ulcer to the right heel measuring 5 cm by 3 cm, covered 100% with thick adherent devitalized necrotic tissue with no exudate. No change to the wound. R3's April 2023 Physician Orders documents an order to Cleanse the right heel wound with normal saline and pat dry. Then apply betadine and wrap with gauze three times per week. These orders also document an order dated 3/21/23 for a Magic Cup {Nutritional Supplement} QD (daily), which was then increased to BID (twice a day) on 4/12/23. R3's March 2023 MAR (Medication Administration Record) documents R3 did not receive the ordered magic cup on the 21st, 24th, 25th and 26th. R3's April 2023 MAR does not document R3 received the magic cup BID {with breakfast and supper} as ordered from the 12th - 16th. On 4/17/23 at 9:05 am, R3 was brought breakfast and did not receive the ordered magic cup. On 4/17/23 at 10:30 am, V4 RN (Registered Nurse) confirmed R3 was supposed to get a magic cup as a nutritional supplement but did not get it at times due to the supplier being out of them. V4 stated the magic cups are served with meals and come out of the kitchen. On 4/17/23 at 10:38 am, V12 Dietary Aide confirmed the facility was out of magic cups for a while but currently has them. V12 stated V12 is not sure why R3 did not receive it today with breakfast. On 4/13/23 at 1:45 pm, R3 was lying in bed, on a regular mattress. V4 RN (Registered Nurse) removed the dressing to R3's right heel to reveal an approximate. 4 cm x 3 cm hard black eschar area to the right heel. V4 completed the dressing change as ordered. On 4/17/23 at 1:13 pm, V13 RD stated normally V13 is notified of wounds by V2 DON (Director of Nursing) or the nursing staff and if a resident has a wound, I (V13) normally throw the kitchen sink at them; reviewing their intakes, weight history, any current supplements, if they are taking them or not, and if the wound isn't healing, what else needs changed. Just try to find the breakdown. V13 stated V13 will write a progress note and/or complete a nutritional assessment for the resident when V13 is notified of skin breakdown, and with no assessment completed until 3/28/23, V13 guesses V13 wasn't notified until 3/28/23 but will have to check V13's records. V13 stated V13 isn't sure what V13 would have recommended at the time for R3 when R3 developed the pressure ulcer to the right heel., V13 stated, I (V13) would have done something, probably liquid protein. V13 also stated V13 hates to say R3 not receiving the supplement when the wound first developed, or as ordered since it was started, is contributing to the wound not healing because nutrition is just one corner stone of the healing process but with R3's albumin level and total protein level being low and the fact R3 has an unstageable pressure ulcer and significant weight loss, R3 needs something more than what (R3) is getting. On 4/17/23 at 1:46 pm, V2 DON stated, when a resident develops a new pressure ulcer, the nurses should measure the wound, call family, and the physician to get order for treatment or a wound consult visit. The floor nurses should also call the RD or email the RD for possible interventions. V2 also stated the facility at times will put residents into a specialty mattress if the wound is a recurring problem or if it isn't getting better with the current treatments but hasn't investigated doing that for R3. On 4/17/23 at 2:22 pm, V2 DON stated the Wound Evaluations of R3's pressure ulcer that were provided are the only ones the facility has completed. V2 explained V2 would like the evaluations to be done weekly but that is a work in progress. On 4/18/23 at 10:01 am, V14 Wound Physician stated V14 has seen R3 via Telemedicine visits only and the facility staff are providing the measurements and condition of the wound to V14. V14 stated V14 is being told the pressure ulcer isn't draining anymore and that is what V14 was managing is the drainage aspect, so in that case, the pressure ulcer is now stable. Nutritional interventions such as Vitamin C, multivitamins, and/or extra protein would help to heal the wound. On 4/18/23 at 11:29 am, V13 RD stated after looking back on V13's notes, V13 had not been informed of the pressure ulcer when it first developed, it wasn't until R3 also had a weight loss that V13 was notified. I have already spoken with V2 and V3 ADON (Assistant Director of Nursing) and we are coming up with a new way for V13 to be notified so that this doesn't happen again in the future. V13 explained, supplements absolutely aid in healing of the wound and had I (V13) been notified of the wound upon development, I (V13) would have at least put (R3) on a multivitamin and possibly liquid protein also but you have to look at the whole picture. At that point, I (V13) believe (R3) was eating well because (R3's) weight was stable. (R3) had just broken (R3's) hip prior to the development so that is part of looking at the whole picture of what is going on with someone. Hopefully we {facility} will start to see some improvement in the wound now with these additional supplements. On 4/18/23 at 1:50 pm, V2 DON in the presence of V1 Executive Director and V3 ADON stated looking back on R3's situation and with R3 just having a fractured hip and not being mobile, R3 would have been a candidate for a special pressure relieving mattress and that R3 should have had one. V2 confirmed there were no pressure relieving interventions in place upon admission to prevent R3 from developing a pressure ulcer.

Based on interview and record review, the facility failed to complete thorough post fall investigations for two residents (R1, R4). The facility also failed ensure a resident was supervised and using the appropriate transfer devices to prevent a fall for one of three residents (R1) reviewed for falls on the sample of six. This failure resulted in R1 falling while standing unassisted in the bathroom, sustaining a head laceration requiring four staples. Findings include: The facility's Fall Reduction Policy dated last revised on 1/5/2021 with next review dated 1/5/2022 documents that this policy is intended to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks and monitoring effectiveness and modifying interventions when necessary. The policy states that all residents will be assessed on admission, following a fall, quarterly per guidelines or if the Interdisciplinary Team (IDT) recognizes a change in condition and that all residents are assessed on admission using the Admission Nursing Evaluation and following Minimum Data Set (MDS) protocol thereafter. The policy states residents identified as being at risk for falls will have individualized care plan intervention. IDT Falls Committee will meet on an ongoing basis to review fall analysis. This policy documents procedure following a fall is outlined in the Incident Reports policy which includes completion of Incident Report, documentation in IDT notes, 72-hour monitoring, Fall Risk Evaluation Tool, and review and update of Plan of Care. The facility's Incident Reports - Clinical Department policy dated 9/3/2009 documents an incident is any happening which is not consistent with the routine operation of the facility or the care of a particular resident. It may be an accident or a situation which might result in an accident. The nurse should complete an incident report after each incident for example falls. The policy states this facility shall notify the Department of Public health of any accident or incident, which has, or likely to have a significant effect on the health, safety, or welfare of our resident and in implementing this policy the following shall apply to ensure appropriate follow-up care in the event of an accident/incident. The residents power of attorney for health care, physician, and supervisor should be notified. After the residents cared for, the incident report and incident management investigation tool should be completed in its entirety by the nurse. Any recommended intervention should be carried out to prevent event from reoccurring. A complete report will be filed on the approved incident form. No incident report or copies are to be placed in the medical record. Incident reports are to be reviewed by the director of health care services or designee and the administrator as appropriate. Incidents resulting in injury should be forwarded to corporate director of risk management for example falls resulting in serious injury/illness or death. The policy states a descriptive summary of each incident or accident shall be recorded in the progress notes or nurses notes for each resident involved and the facility shall maintain a file of all written reports of incidents or accidents involving residents. The facilities Incident Reports - Clinical Department policy does not include the facility is to complete 72-hour monitoring, Fall Risk Evaluation Tool, and review and update of Plan of Care as the facility's Fall Reduction Protocol documents the Incident Reports - Clinical Department policy will outline. 1. R1's Minimum Data Set (MDS) dated [DATE] documents R1's balance during transitions and walking as, not steady, only able to stabilize with staff assistance. R1's Incident Report dated 1/1/23 at 2:36pm documents R1 had a witnessed fall on 1/1/23 at 9:35am. This report documents V21, Certified Nursing Assistant (CNA) called V4, Registered Nurse (RN) to R1's room. R1 was laying on R1's back on the floor in R1's bathroom with bright red blood on the back of R1's head, which was actively bleeding. V21 stated V21 was providing care, turned for a brief moment and R1 lost R1's balance and fell straight back. There is no documentation into an investigation of details of what care was being provided, where R1 was and what R1 was doing just before R1 fell , or why/where V21, CNA turned away from R1. R1 told V21 immediately after the fall, I (R1) can't see. Within a few seconds R1 was able to see the CNA. This report documents R1 was unable to provide further details. This report documents V4, RN and V21 attempted to sit R1 up after assessing R1. R1 cried out in pain to the lower back. This report documents predisposing physiological factor of gait imbalance and that R1 was ambulating without assist. There is no documentation that a gait belt was in place while R1 was standing in R1's bathroom. This report documents R1's Care Plan was reviewed and implemented a new intervention post fall to have Physical Therapy evaluate and treat. There is no documentation of the root cause of this fall. R1's medical records do not document 72-hour post fall monitoring as per the facility's policy. R1's Neurological check documentation is incomplete. R1's Hospital Records dated 1/1/23 document R1's Computed Tomography of the Head or Brain without Contrast results dated 1/1/23 document no acute Intracranial abnormality and a right posterior parietal scalp hematoma. These records document R1's X-ray of the left hip with pelvis results dated 1/1/23 at 2:43pm documenting there is no fracture or acute abnormality. This report documents degenerative changes of the lower lumbar spine. There is no documentation of additional lumbar spine radiology tests on 1/1/23. R1's Hospital Records dated 1/9/23 document R1 arrived at the local emergency room with complaints of increased confusion ongoing since 1/1/23 after sustaining a fall and that R1 had been seen at another local emergency roiagnom on [DATE] where R1 was diagnosed with a Urinary Tract Infection (UTI) and staples were placed in R1's head. R1 has chronic pain but R1's lower back pain has increased. These records document R1's initial Computed Tomography (CT) scan was abnormal in which R1 was evaluated by neurosurgery at the bedside. These records document R1 was also found to have L1 (Lumbar Vertebrae) compression fracture. These records document CT of Abdomen and Pelvis with Contrast Results dated 1/9/23 at 3:13pm documenting, there is a slight concave compression of the L1 inferior endplate with slight increased density of this segment. Consider MRI (Magnetic Resonance Imaging) if indicated for a questionable subtle acute compression fracture of the L1 vertebral body. These records also document CT of the Brain without Contrast results including Low-density/chronic left subdural fluid collection/hemorrhage and that this report flagged for provider attention. These records document Assessment/Plan including L1 Compression Fracture and a Left Convexity Subdural Hygroma VS Subdural Hematoma. R1's Neurosurgery Consultation dated 1/9/23 documents R1 has a Mild Compression Fracture of unknown Chronicity and a small left convexity Subdural Hygroma verses Chronic Subdural Hematoma. This consultation documents R1 is not a candidate for kyphoplasty at this given time and no neurosurgical intervention indicated at this time. The handwritten report notes dated 1/10/23 from the local hospital document the facility received information that R1 had a L1 compression fracture in addition to a Urinary Tract Infection. On 4/17/23 at 11:15am, V4, Registered Nurse (RN) stated V4 was notified that R1 was on the floor. R1 was on R1's back with a wound to right side of R1's head that was bleeding. V4 stated V21, CNA said V21 was within arm's reach of R1 and saw R1 falling and was not able to reach R1. V21 stated V21 was by R1's recliner and R1 was at the sink in the bathroom. V4 stated R1 requires a stand by assist while standing and ambulating and that V21 was aware as V4 notified V21 on 1/1/23 before the fall. V4 stated V21 was also aware that V21 was to stay with/right beside R1 when R1 was standing. V4 stated R1 hit R1's head pretty hard. V4 stated R1 complained of (R1's) back hurting, tried to sit (R1) up a little but (R1) was in excruciating pain to R1's back. V4 stated R1 was crying out in pain to R1's back so they did not move R1 and called 911 to transport R1 to the hospital. V4 stated R1 has a history of chronic back pain, but never the level of severity R1 had after falling on 1/1/23. On 4/20/23 at 1:40pm, V2, Director of Nursing (DON) stated the fall investigations are completed by the floor nurses. V2 stated the Interdisciplinary team (IDT) meetings discuss and decide appropriate interventions related to each fall. V2 stated, if needed V3, Assistant Director of Nursing (ADON) and V2 look in to the fall more and get additional information if needed and update care plan. V2 stated the IDT works on the root cause of the fall together and there is a page in the electronic charting for incidents where that is documented. I do not recall what the root cause of R1's fall was on 1/1/23. The box that is empty on the fall report is where that information should be regarding the root cause. I think V3 talked to V21, CNA. V2 thinks V21 told V2 that V21 turned around to grab some type of linen and that V21 was right next to R1. V2 stated R1 was standing at R1's sink with R1's walker but did not have a gait belt on and should have. V2 was unsure if R1 was wearing R1's shoes. V2 stated V21, CNA was terminated, due to the fall as well as issues with other staff. 2. R4's Fall Risk assessment dated [DATE] documents R4 is a high risk for falling. R4's Progress Notes dated as follows document: 2/6/23 at 4:57pm - Diagnosis: Right elbow fracture, post fall 2-1-23. Alert to self only, confused. Right arm in splint with ace wrap. 2/14/23 at 4:28pm - Description of event: R4 noted to be sitting on the floor in front of recliner with back leaning against recliner. Staff states R4 had been transferred to the recliner 5 minutes prior to watch television. Current Evaluation: R4 denies pain at this time. Assessment for Injury: No acute injury. New interventions put in place: (blank) R4's Incident report documents on 2/14/23 at 4:10pm, R4 was found sitting on the floor in front of recliner with R4's back leaning against the recliner. Staff stated R4 had been transferred to R4's recliner 5 minutes prior to watch television. This report documents R4 was unable to give a statement, R4 was assessed for injury and assisted in to the wheelchair. This report documents there were no witnesses found. This report documents added to care plan to provide (R4) with activities that serve as distractions to help prevent R4 from falling. There is no documentation of witness statements from staff as to when R4 had been toileted, if R4 was incontinent at the time of the fall or if R4's call light was in reach. There is no documentation as to if R4 was wearing proper footwear. There is no documentation as to the root cause of R4's fall on 2/14/23. R4's medical records do not document a fall risk assessment post R4's fall on 2/14/23. On 4/20/23 at 1:40pm, V2, DON stated V2 did not believe the facility documented which staff were responsible for R4 at the time of R4's fall on 2/14/23. V2 stated V2 does not believe any witness statements were received from staff. V2 stated R4 kept stating R4 had to urinate, even with the urinary catheter being in place, even though it was draining okay, of which none of that information is documented in the investigation. V2 stated the facility policies are needing reviewed and that there have been a lot of corporate changes and that is who reviews/updates policies.