Every finding on record at Mt Zion Health & Rehab Center

Based on observation and interview, the facility failed to properly store medications in a locked medication cart that was accessible to the residents and visitors in the facility. This failure has the potential to affect all 68 residents residing in the facility on 7/31/2026.Findings Include:On 7/31/2026 at 10:36am, V1 Administrator provided a resident census documenting 68 residents residing in the facility on 7/31/2026.On 7/31/2026 at 10:07am, an unlocked medication cart was observed located in the facility library. The medication cart contained numerous loose unlabeled medications in the drawers.On 7/31/2026 at 12:39pm, R4 and V4 (R4's) Family Member were observed sitting in the facility library with the unlocked medication cart.On 7/31/2026 at 10:56am, V5 (R1's) Family Member, stated V5 visits every other day, and the unlocked medication cart has been located in the facility library for about three weeks. V5 stated V5 looked in the unlocked medication cart out of curiosity once and noted it to contain several unlabeled/loose medications.On 7/31/2026 at 11:07am, V1 Administrator stated staff, visitors, and residents all have access to the library where the printer and medication cart are stored at all times.On 7/31/2026 at 11:45am, R1 stated R1's family comes to visit R1 and the residents/visitors have access to the whole building, including the library. R1 stated there is a nursing medication cart in the library.On 7/31/2026 at 12:00pm, R2 stated R2 is the president of the resident council and that all residents always have access to the facility library. R2 stated R2 is unsure how long the unlocked medication cart has been located in the library.On 7/31/2026 at 12:29pm, R3 stated all residents have access to the facility including the library.On 7/31/2026 at 12:39pm, R4 stated R4 and R4's spouse sit in the library frequently and the unlocked medication cart has been in the library for an unknown amount of time. R4 stated all residents have access to the library at all times of the day and night.On 7/31/2026 at 12:45pm, V4 (R4's) spouse stated the medication cart has been in the library and that anyone can access the cart. V4 stated V4 and R4 often sit in the library and could have access to the medication cart.On 7/31/2026 at 12:53pm, V2 Director of Nursing confirmed there are numerous loose unknown medications in the drawers of the unlocked medication cart located in the facility library. V2 confirmed that the cart has been located in the library for at least two weeks plus, it has a broken lock that will not lock and staff/residents/visitors had access to the unknown medications. V2 stated that pharmacy was supposed to pick up the medication cart, and the medication cart should have been cleaned out, removing the loose medications prior to placing the cart in the facility library awaiting pick up.On 7/31/2026 at 1:00pm, V3 Activities Director stated all staff/residents/visitors have access to the library and that the door remains unlocked. V3 is unsure how long the medication cart has been in the library.R1's Electronic Health Record (EHR) documented that R1 was admitted to the facility on [DATE] and continues to reside at the facility. According to R1's EHR R1 has several diagnoses including: Anxiety Disorder, Presence of Cardiac Pacemaker, Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarction Without Residual Deficits, Hyperlipidemia, Hypothyroidism, Vitamin D Deficiency, Vitamin B12 Deficiency Anemia, and Depression.R1's Minimum Data Set (MDS) dated [DATE] documented that R1 is moderately cognitively impaired.R2's Electronic Health Record (EHR) documented that R2 was admitted to the facility on [DATE] and continues to reside at the facility. According to R2's EHR R2 has several diagnoses including: Type 2 Diabetes Mellitus, Insomnia, Sick Sinus Syndrome, Diverticulitis of Intestine, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Essential (Primary) Hypertension, Dependence on Renal Dialysis, Presence of Cardiac Pacemaker, Mild Intermittent Asthma, and Hyperlipidemia.R2's Minimum Data Set (MDS) dated [DATE] documented that R2 is cognitively intact.R3's Electronic Health Record (EHR) documented that R3 was admitted to the facility on [DATE] and continues to reside at the facility. According to R3's EHR R3 has several diagnoses including: Chronic Kidney Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hyperlipidemia, Major Depressive Disorder, and Primary Osteoarthritis.R3's Minimum Data Set (MDS) dated [DATE] documents that R3 is cognitively intact.R4's Electronic Health Record (EHR) documents that R4 was admitted to the facility on [DATE] and continues to reside at the facility. According to R4's EHR R4 has several diagnoses including: Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus with Diabetic Retinopathy, Chronic Kidney Disease, Anxiety Disorder, Insomnia, and Obesity.R4's Minimum Data Set (MDS) dated [DATE] documents that R4 is cognitively intact.The Medication Storage Policy dated 07 /01/23 documents PURPOSE: To provide guidance to facility nursing staff on the proper storage of medication.POLICY: The facility stores all drugs and biologicals in a safe, secure, and orderly manner and in accordance with state and federal regulations.POLICY INTERPRETATION AND IMPLEMENTATION: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only people authorized to prepare and administer medications may have access to locked medications.

Based on observation, interview, and record review, the facility failed to ensure medications were documented as administered after the resident received medications for ten (R2, R4, R6-R8, R11, R13-R16) of 16 residents reviewed for medication administration on a sample list of 16.The Facility's Charting and Documentation Policy dated 7/1/24 documents medications administered should be documented the date and time the medication was provided.The Facility's Medication Administration Procedure Policy dated 11/7/19 documents to chart the medications administered after resident has swallowed medications. On 7/13/26 at 10:20AM, V4 Licensed Practical Nurse (LPN) was observed preparing and administering medications for R2. R2's electronic medical record (EMR) documents R2 received these medications at 8:15AM. On 7/13/26 at 10:35AM, V4 LPN was observed preparing and administering medications for R4. R4's EMR documents R4 received these medications at 7:34AM. At 10:40AM on 7/13/26, V4 LPN stated she documented the morning medications as administered before actually giving them. She explained that after preparing the medications, she was headed to R4's room to administer them; however, staff had already taken the resident to activities. As a result, she waited until the resident returned before administering the medications. V4 further stated that her usual practice is to document medications as administered when she pulls them from the medication cart. V4 stated R6, R7, R8, R9, R11, R13, R14, R15, and R16 had not yet received their 8:00AM scheduled medications.The Facility's Medication Administration Audit Report dated 7/14/26 for the 7/13/26 medication pass documents R6's medications were signed as given at 8:23AM, R7's medications were signed as given at 7:26AM, R8's medications were signed as given at 7:38AM, R11's medications were signed as given at 8:11AM, R13's medications were signed as given at 7:11AM, R14's medications were signed as given at 8:18AM, R15's medications were signed as given at 7:42AM, and R16's medications were signed as given at 8:14AM. On 7/14/26 at 11:55 AMV2 Director of Nursing (DON) stated that V4 should not have marked off medications as given in the residents EMR until after medications were administered. V2 stated she was aware that medications were being given late but not aware the nurses were false documenting.

Based on interview and record review the facility failed to follow physician orders to obtain a laboratory test for one (R2) of three residents reviewed for accidents in the sample of three. Findings include:R2's Medical Record documents R2 was admitted to the facility on [DATE]. R2's Medical Record documents the following diagnoses: Maxillary Fracture, Left Lateral Orbital Fracture, Hyponatremia, Left-sided Hemiplegia/Hemiparalysis, Alzheimer's Disease, Insomnia, Subdural Hemorrhage, Metabolic Encephalopathy, Depression, and Insomnia. R2's Progress Note dated 3/31/2026 documents R2 was sent to a local hospital and was admitted for hyponatremia. R2's Discharge Instructions dated 4/3/26 document R2 returned to the facility on 4/3/2026.R2's Discharge Instructions dated 4/3/2026 included an order for a Basic Metabolic Panel (BMP) to be collected on April 10th, 2026. R2's Medical Record does not contain BMP results. On 5/26/2026 at 10:45 AM, V29 (Lab technician) stated R2's last BMP was collected in April 2025. On 5/27/2026 at 10:15 AM, V2 (DON) stated the process for lab (laboratory) draws is to enter the order into the medical chart. The order is sent to the lab company. The lab technician comes when the order is scheduled and collects the specimen. V2 (DON) stated it is expected for lab results to be communicated to the physician.On 5/27/2026 at 11:00 AM, V2 (DON) stated the reason R2 did not have a BMP drawn was because R2 refused blood draws. V2 (DON) stated V27 (Physician) was aware. No documentation is present in R2's Medical Record regarding R2 refusing labs or notification to the physician. On 5/27/2026 at 11:45 AM R2 stated R2 never refuses blood draws for labs. On 5/27/2026, a STAT BMP order was placed in R2's Physician Orders. On 5/27/26 at 12:10 PM V26 Registered Nurse confirmed R2 did not refuse the blood draw on 5/27/26. On 5/27/2026 at 1:55 PM V27 stated V27 was unaware that R2 had orders for a BMP (Basic Metabolic Panel) at the time of discharge and was unaware those orders were not processed or completed. The facility policy for Obtaining Blood Specimens dated 7/2/2023 documents laboratory results and notification of physician of results should be recorded in the resident's medical record. The policy documents to notify physician if unable to obtain lab specimen or of any abnormal findings.

Based on observation, interview and record review the facility failed to implement a fall care plan intervention for one of three residents (R2) reviewed for accidents in the sample list of three. Findings include:R2's Medical Record documents R2 was admitted to the facility on [DATE]. R2's Medical Record includes the following diagnoses: Maxillary Fracture, Left Lateral Orbital Fracture, Hyponatremia, Left-Sided Hemiplegia/Hemiparalysis, Alzheimer's Disease, Insomnia, Subdural Hemorrhage, Metabolic Encephalopathy, Depression, and Insomnia. R2's Fall Care Plan initiated 7/4/2025 documents R2 is at risk for falls related to medications, Alzheimer's Disease, Depression, and History of Falls. R2's Care Plan documents R2 transfers with a mechanical lift and includes an intervention for R2 to always have non-skid socks on.A facility reported incident documents on 3/31/2026 at 6:55 AM, R2 sustained an unwitnessed fall resulting in left orbital and left maxilla fractures. R2 was admitted to the hospital following the fall due to hyponatremia and received sutures to the left lateral eye with facial bruising.R2's Fall Risk assessment dated [DATE] documents R2 as at high risk for falls.On 5/26/2026 at 12:45 PM, V6 (Certified Nursing Aids, CNA) and V11 (CNA) used a mechanical lift to transfer R2 from the bed to the wheelchair. R2 did not have non-slip socks on. On 5/27/2026 at 10:00 AM, R2 was observed without non-skid socks on. On 5/28/2027 at 10:00 AM, R2 was observed without non-skid socks on.On 5/26/2026 at 10:20 AM, R2 stated R2 recently fell out of bed while sleeping. On 5/26/2026 at 11:00 AM, V6 (CNA) stated they do not place non-skid socks on R2 because R2 doesn't stand.The facility's Fall Policy dated 9/6/2023 documents if falling occurs despite initial interventions, staff will implement additional or different interventions, discontinue ineffective interventions, or indicate why the current approach remains relevant.

Based on observation, interviews, and record review, the facility failed to ensure appropriate supervision for a resident identified as a high fall risk and failed to implement care-planned fall interventions for one of three (R5) residents reviewed for accidents from a sample of five. This failure resulted in R5 sustaining a fall that resulted in a displaced fracture in the upper portion of R5's right leg. Findings:The facility's Fall Prevention Program/Protocol, dated 7/01/2023, documented that the purpose of the policy is to provide guidance to facility staff regarding the prevention and reduction of falls within the facility. The policy identifies the Director of Nursing and/or designee as responsible for ensuring that all staff are aware of the program's elements.This policy documented that the interpretation and implementation of the fall prevention program are based on prior evaluations and current data, and that staff are to identify and implement interventions specific to each resident's risk factors and causes in an effort to prevent falls and minimize complications.This policy outlined resident-centered approaches to fall prevention, including that the interdisciplinary team will implement an individualized fall prevention plan to address specific risk factors for residents identified as at risk based on fall assessment results or history of falls. The team is also responsible for identifying and implementing relevant interventions (e.g., hip protectors or treatment of osteoporosis, as applicable) to reduce the risk of serious injury.Additionally, the policy documented that early prevention and fall detection measures will be performed, including:Fall risk assessments completed upon admission, quarterly, and with any significant status change;Resident-specific fall interventions made accessible to all staff in a fall binder located at each nurse's station for quick reference; andResidents identified as high risk (scoring 10 or higher on the fall risk assessment) will have a visual identifier placed on the room door and on assistive or mobility devices to alert staff of the fall risk.R5's Minimum Data Set (MDS), dated [DATE], documented that R5 had moderate cognitive impairment. This MDS further documented that R5 required supervision or touching assistance from staff for chair-to-bed and bed-to-chair transfers, and that walking 10 feet was not attempted due to the resident's medical condition or safety concerns.R5's Care Plan, with an initiation date of 1/28/2026, identified the resident as being at risk for falls and injuries related to generalized weakness, pneumonia, dementia, and Chronic Obstructive Pulmonary Disease (COPD). This Care Plan documented that R5 sustained falls on 3/13/2026, 3/18/2026, 3/19/2026, 3/25/2026, and 4/11/2026.This Care Plan documented an intervention, dated 3/13/2026, to place a floor mat next to R5's bedside, and an intervention, dated 1/28/2026, to maintain R5's bed in the lowest position.R5's Fall Risk assessment dated [DATE] documented that R5 was at high risk for falls.R5's Electronic Health Record (EHR) contained a health status note dated 3/25/26 that documented writer was notified by the Social Services Director (SSD) that R5 was observed on the floor. Upon assessment, R5 was observed by writer laying on her right side next to her bed with her head at the head of bed. R5 was yelling out complaining of right hip pain rated at a 10/10. No bleeding or visible injuries noted.A state report form documented that on 3/25/26 at 5:30 p.m., R5 was observed on the floor in her bedroom. Staff had been in a short time prior, and resident was asleep in her bed. Shortly after the SSD heard a resident yell help while walking down the hallway and noticed R5 laying on her right side next to her bed with her head at the head of her bed. Bed was in low position, socks and house slippers on both feet, call light was clipped to R5 but not activated. R5's roommate stated R5 was sitting on the side of bed attempting to go to the bathroom and fell out of bed. This report documented that R5 had moderate cognitive impairment.On 4/27/2026 at 12:04 p.m., R6 (R5's roommate) stated she witnessed R5's fall on the day R5 was sent to the hospital with an injury. R6 stated R5 was sitting on the side of the bed, which R6 described as approximately knee height (about 2 feet off the ground), when R5 slipped off the side of the bed and fell.R6 stated that no fall mats were in place at the time of the fall and pointed to fall mats that were observed on the bed during this interview. R6 stated those mats were placed on the floor after R5 fell. R6 further stated that R5 had a history of frequent falls out of bed.On 4/27/2026 at 12:25 p.m., V9, Licensed Practical Nurse (LPN), stated she was the nurse caring for R5 on 3/25/2026 when R5 fell. V9 stated V3, Social Services Director (SSD), informed her that R5 was found lying on her back on the floor beside the bed, with the head positioned toward the head of the bed and feet toward the foot of the bed. V9 stated upon entering R5's room she found R5 on the floor and the bed was approximately knee height and that no fall mats were in place at the time of the fall.V9 stated that a CNA had taken R5 to the bathroom prior to the incident and that she was unsure why fall mats were not placed on the floor, noting that the Kardex indicated mats were to be in place. V9 stated that R5 was a known fall risk with a history of previous falls and that a call, don't fall sign was in place. V9 stated R5 was unable to explain how the fall occurred and was observed grabbing the right buttock and stating, ouch, ouch, please help me.On 4/27/2026 at 12:55 p.m., V3, Social Services Director (SSD), stated that R6 (R5's roommate) alerted staff that R5 had fallen and was on the floor complaining of hip pain. V3 stated she found R5 lying on her right side in a fetal position next to her bed, which was approximately at knee height.On 4/27/2026 at 1:22 p.m., V15, Licensed Practical Nurse (LPN), stated she responded to R5's room after hearing commotion in the hallway. V15 reported that she observed R5 lying on her right side on the floor next to the bed, with her back facing the bed, and complaining of right hip pain. V15 stated the bed was approximately knee height (about 3 feet off the floor) and confirmed that no floor mats were in place at the time of the fall.On 4/27/2026 at 2:02 p.m., V14, Certified Nurse Assistant (CNA), stated she had been in R5's room approximately 20 minutes prior to the fall and that a newly hired CNA, V16, whom she was training, was the last staff member to see R5 prior to the incident. V14 reported that shortly thereafter, she was alerted that R5 was on the floor and, upon entering the room, observed R5 lying on her right side. V14 stated that R5 reported she attempted to get up to close her door and fell while trying to stand. V14 confirmed that R5 was a known fall risk but was unsure whether required fall interventions, including fall mats, were in place at the time of the fall.On 4/27/2026 at 2:36 p.m., V16, CNA in training, stated she recalled a fall that occurred on her first day of training on 3/25/2026. V16 reported that she entered R5's room to assist the roommate (R6) and observed R5 sitting on the edge of the bed. V16 stated that R5 did not request assistance, and she was unsure why R5 was sitting on the side of the bed.V16 stated that approximately ten to fifteen minutes later, she and her trainer (V14) were informed that R5 was found on the floor next to the bed. V16 stated there was not a fall mat in place at that time.On 4/28/2026 at 11:05 a.m., V2, Director of Nursing (DON) stated V16, CNA should have responded to R5 sitting on the side of the bed and should have recognized that appropriate fall interventions were not in place. V2 further stated that V14, CNA should have remained with V16, as it was her first day of training and she was not yet familiar with the residents.X-ray results in R5's EHR, dated 03/25/26, document an acute, mildly displaced fracture of the right greater trochanter following the fall.

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This failure affects two residents (R1, R2) of four reviewed for abuse in the sample of four.Findings include:The facility Abuse Policy (1/9/2024) documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.R1's Medical Diagnosis list (4/9/2026) documents R1's diagnoses include: Generalized Anxiety Disorder, Major Depressive Disorder, and Parkinson's Disease (neurodegenerative disorder causing slow movement, muscle stiffness, and balance issues).R1's Resident Assessment (5/8/2025) documents R1 has moderately impaired cognition.The facility abuse investigation file (3/6/2026) documents R2 approached R1 in the facility hallway on 3/5/2026 and struck R1 in the arm twice. On 4/8/2026 at 1:35PM, V3 (Certified Nurse Aide) reported observing R2 strike R1 with a closed fist in R1's upper arm area on R1's right side and then hollered at R2 to not do that and then as V3 began walking towards R1 and R2, R2 hit R1 again with a closed fist in the lower right forearm area. V3 reported R2 was kind of aggressive towards staff when we went to provide care and would get overwhelmed with noise and would get agitated. V3 reported never seeing R2 hit someone like that before. V3 reported R2 had tried to hit some of the staff before. V3 reported providing care to R2 since R2's admission to the facility and reported R2 was not always having delirium and R2's agitation onset (on 3/5/2026) was sudden. V3 reported R1 just sat there and then R1 stated R1 was scared and cried a little bit but wasn't completely distraught. V3 reported once R2 left, and R1 had a snack, R1 was ok. V3 reported R2 stated R2 wanted to hit R1 and told the nurse that R2 would hit R1 or anyone else too and R2 was separated (from further potential resident contact) until the ambulance arrived to take R2 to the hospital for evaluation.

Deficiencies at this level require more than one Deficient Practice Statement.A. Based on interview and record review the facility failed to implement a Legionella surveillance program. This failure has the potential to affect all residents who reside in the facility. B. Based on interview and record review the facility failed to appropriately sanitize a glucometer following use for one resident (R48) of one resident screened for blood glucose monitoring in a sample list of 38 residents.A. The facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS-671) dated 01/05/2026 documents that 64 residents reside in the facility.The facility policy titled Infection Prevention & Control: Legionnaires' Disease (undated) states:Policy:The facility has formed a Water Management Program Committee to review Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) guidelines regarding Legionnaires' disease. The purpose of the water management program is to help identify areas or devices in the facility where Legionella may grow or spread, minimize exposure to individuals, increase awareness, assess Legionella exposure risk, and implement Legionella control measures so that risks of exposure may be minimized.Legionnaires' disease is a serious type of pneumonia caused by Legionella, a bacterium that exists in all water systems and can be potentially fatal. According to ASHRAE Standard [PHONE NUMBER], there are no parameters in place defining what constitutes a high level of Legionella in a water system. The committee is responsible for assessing the facility to identify risks for possible Legionella growth. Based on the results of the questionnaire provided by the CDC, it was determined that this facility should have a water management program in place. According to CDC parameters, this facility is a healthcare facility where patients stay overnight and where individuals with chronic and acute medical problems or weakened immune systems are housed and treated. The committee has developed and maintains an active water management program, with modifications implemented as needed.Legionella:Occurs naturally in freshwater environments such as lakes and streams; however, low levels in fresh water generally do not lead to diseaseExists in all water systemsUsually spreads through water droplets small enough to be inhaledTo pose a health risk, Legionella must first grow in number and then be aerosolized so that contaminated water droplets can be inhaledIs less commonly spread by aspiration of drinking water or iceOnly one possible case of person-to-person transmission has been reportedAccording to CMS, a very low percentage (19%) of outbreaks from 2000-2014 were associated with long-term care facilities42 CFR S483.80 states: The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.On 01/07/2026 at 11:00 AM, V6, Maintenance Director, when asked to provide documentation of the facility's water management (Legionella) plan and surveillance, stated, I (V6) check the water at the faucets every month and look for rust. V6 stated he was not aware of any testing or of high-risk areas for Legionella growth, was not aware of the CDC Legionella Questionnaire, and denied that any testing for Legionella was being conducted.On 01/07/2026 at 1:00 PM, V23, Corporate Maintenance Director, stated, (V6) has been given a test kit. We do have a policy and a checklist that (V6) should be completing. V6 provided a copy of the Legionella policy and the checklist. V23 verified that the policy was not being followed.B. On 01/07/2026 at 11:45 AM, V25, Licensed Practical Nurse (LPN), removed a glucometer from the medication cart, went to R48's room, and performed a blood glucose check. V25 then returned the contaminated glucometer to the medication cart.The package of bleach wipes on the medication cart documents that the required contact time with a surface to be sanitized is three minutes.V25 wiped the surface of the glucometer but did not maintain contact with the surface for the required time, instead wiping it for only a few seconds. V25 then replaced the glucometer in the medication cart drawer for use on other residents.When asked what the required contact time should have been for the wipe to remain in contact with the glucometer, V25 stated, I thought I just have to wipe it off.

Based on observation, interview, and record review the facility failed to provide nail care to a resident who was dependent on staff for assistance with (Activities of Daily Living (ADLs) for one resident (R54) of two reviewed for ADLs on a sample list of 38. Findings include:The facility's ADL Support Policy dated 07/01/2023 documents that the purpose of the policy is to provide staff with guidance on providing support with Activities of Daily Living (ADLs) to residents. The policy documents that residents will be provided with care, treatment, and services, as appropriate, to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.The policy outlines how care and services will be provided to residents who cannot perform ADLs independently, with the resident's consent and in accordance with the care plan. This includes appropriate support and assistance with hygiene, such as bathing, dressing, grooming, and oral care. A resident's ability to perform ADLs will be measured using clinical tools, including the Minimum Data Set (MDS). Functional decline or improvement will be evaluated with reference to the Assessment Reference Date. Interventions to improve or maintain a resident's functional abilities will be implemented in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice. The resident's response to interventions will be documented, monitored, evaluated, and revised as appropriate.R54's Minimum Data Set (MDS) dated [DATE] documents that R54 has severe cognitive impairment.R54's MDS dated [DATE] documents that R54 requires partial to moderate assistance with self-care to maintain personal hygiene, including combing hair, shaving, applying makeup, and washing and drying the face and hands.R54's care plan dated 03/11/2024 documents that R54 has a self-care deficit related to Alzheimer's disease, chronic obstructive pulmonary disease (COPD), asthma, and osteoarthritis. The care plan documents that R54 requires one-person physical assistance from staff to complete ADLs, including personal hygiene tasks.On 01/05/2026 at 3:12 PM, V18, R54's daughter and Power of Attorney, stated that R54's fingernails are often overgrown and dirty. V18 further stated that the facility has been made aware of this concern numerous times.On 01/07/2026 at 9:32 AM, R54 was observed in the activity room with dark brown debris under all fingernails. R54 was unable to recall when nail care was last performed.On 01/07/2026 at 9:38 AM, V15, Activity Director (AD), stated that nail care is typically performed weekly on Wednesdays in the Activity Department and that certified nursing assistants (CNAs) and nursing staff are responsible for daily nail care needs. V15 agreed that R54's nails required cleaning.On 01/07/2026 at 2:21 PM, V2, Director of Nursing (DON), stated that staff should observe residents during morning care and check nails daily. V2 agreed that nail care should be addressed when dirt is observed under a resident's fingernails.

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two (R6,R45) of four residents reviewed for abuse in the sample list of 38. Findings: The facility's Abuse Policy dated 07/01/2023, with a revision in 12/2025, documents that the purpose of the policy is to provide guidance and procedures to the facility and its staff to ensure residents remain free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment.The policy defines abuse as physical or mental injury or sexual assault inflicted upon a resident by means other than accidental. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment that results in physical harm, pain, or mental anguish to a resident. This definition also includes the deprivation, by an individual-including a caretaker-of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. The policy assumes that all instances of abuse of residents, including those in a coma, cause physical harm, pain, or mental anguish. The term willful, as used in the definition of abuse, means that the individual acted deliberately, not that the individual intended to inflict injury or harm.The policy defines physical abuse as the infliction of injury on a resident that occurs by means other than accidental and requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.An investigation report dated 12/29/2025 at 7:00 PM documents that R6 and R45 were involved in a resident-to-resident altercation. The report documents that R45 reported R6 pulled her hair. The report further documents that R6 and R45 were immediately separated and that an investigation was initiated.R6's Minimum Data Set (MDS) dated [DATE] documents that R6 has severe cognitive impairment.R6's care plan dated 12/26/2025 documents that R6 has the potential to be physically aggressive (grabbing, hitting, kicking, and punching) related to Alzheimer's disease or other related dementias, cognitive impairment, depression, and mental illness.On 01/07/2026 at 12:14 PM, R45 was observed sitting in her recliner in her room. During the observation, R45 stated she remembered the day R6 pulled her hair, while gesturing to the right side of her head. R45 added that she was not having a good day and did not want to discuss the incident further.R45's electronic medical record (EMR) contains a progress note dated 12/29/2025 at 7:00 PM documenting that R45 came to her door yelling that her roommate (R6) had pulled her hair so hard that she believed some of her hair was missing.On 01/07/2026 at 11:51 AM, V24, Licensed Practical Nurse (LPN), stated she was standing at the nurses' desk on 12/29/2025 when R45 was at her door yelling, She pulled my hair-my hair-I think she pulled out a plug. V24 stated she asked R6 about the incident, and R6 admitted to pulling R45's hair. V24 further stated that R6 had been fussing, speaking loudly, and was in a fussy mood throughout the evening. V24 reported learning that R45 was sitting in her recliner and that R6 was at the nightstand messing with things when R6 reached over and pulled R45's hair.On 01/05/2026 at 3:02 PM, V17 (R6's daughter) stated that R6 had exhibited some behaviors recently and that the facility moved R6 to another room because R6 pulled her roommate's hair.On 01/07/2026 at 1:29 PM, V21, Registered Nurse (RN), stated that R6 can be challenging to care for and requires a specific approach to avoid triggering or escalating behavioral issues.On 01/07/2026 at 2:21 PM, V2, Director of Nursing (DON), stated she was aware of the incident in which R6 pulled R45's hair and agreed that residents residing in the facility have the right to be free from abuse.

Based on interview and record review, the facility failed to report to the state an allegation of resident-to-resident abuse for two (R61, R66) out of four residents reviewed for abuse, on a sample list of 38. Findings:The facility's Abuse Policy dated 07/01/2023, with a revision on December 2025, documents that the purpose of the policy is to provide guidance and procedures to the facility and its staff to ensure residents remain free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment.The facility policy states that the Administrator and/or their designee serves as the Facility Abuse Coordinator and is responsible for ensuring compliance with abuse prevention and reporting requirements. All facility staff share responsibility for maintaining an environment in which residents remain free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services, and mistreatment. Staff are required to immediately report any allegation of abuse or any witnessed abuse to the Administrator, who acts as the Abuse Coordinator. Immediate reporting is essential to protect residents and ensure timely investigation and intervention.The policy further documents that, when alleged abuse is reported, the facility will complete accurate investigative reports. The facility will immediately report all allegations of abuse to the Administrator and timely report them to the appropriate authorities, including the Illinois Department of Public Health (IDPH), the Ombudsman, the local police department, the resident's Power of Attorney, and the medical doctor. The facility will immediately and thoroughly investigate all allegations of abuse, including but not limited to interviews with residents, staff, visitors, and vendors. The facility will timely submit all required abuse allegation reports (initial and final) to IDPH in accordance with state and federal regulations.R66's Minimum Data Set (MDS) dated [DATE] documents that R66 has moderate cognitive impairment. The MDS also documents that R66 has clear, intelligible speech; is able to make herself understood; and clearly comprehends others.On 01/05/2026 at 10:54 AM, Resident R66 stated that approximately three weeks earlier, while eating a meal in the dining room, another resident kicked her right leg under the table. R66 was unable to identify the other resident involved but reported that she immediately informed staff of the incident.No documentation related to this alleged incident was found in R66's electronic medical record (EMR).On 01/07/2026 at 11:05 AM, V4, Registered Nurse (RN), stated she was aware of the incident involving R66, in which another resident (R61) kicked R66 under the table. V4 reported that R61 has since passed away and described R61 as grouchy and disliking people around her. V4 stated that R66 was immediately moved to another table following the incident. V4 further stated she informed the former Administrator of the incident but was unsure what action, if any, was taken.On 01/07/2026 at 2:21 PM, V2, Director of Nursing (DON), stated she was not aware of the resident-to-resident abuse allegation until V1, Administrator, informed her during the morning meeting that day. V2 agreed that V4 should have documented the incident and that an investigation should have been initiated at the time the incident was reported.

Based on interview and record review the facility failed to coordinate hospice care with hospice provider for one resident (R70) of two residents reviewed for hospice in a sample list of 38.Findings Include: R75's care plan, updated on 12/27/2025, includes the following diagnoses: chronic atrial fibrillation, obsessive-compulsive disorder, anxiety disorder, lumbar osteomyelitis, and chronic pain syndrome.R75's Minimum Data Set (MDS) dated [DATE] documents that R75 is cognitively intact.R75's physician orders include an order dated 12/27/2025 for hospice care.R75's progress notes document that R75 has been receiving hospice care since 12/27/2025; however, R75's care plan was not updated until 01/06/2026 to include coordination of care with hospice.On 01/05/2026 at 12:00 PM, V2, Director of Nursing (DON), verified that R75 has been receiving hospice care since 12/27/2025 but stated that a care plan addressing coordination of hospice care with the provider was not in place. V2 further verified that it is the facility's expectation that when a resident is placed on hospice care, a care plan including resident-centered interventions is implemented.

Based on observation, Interview, and Record Review the facility failed to accurately assess one resident (R75) of one resident reviewed for smoking and failed to implement interventions to ensure (R75) is safe from hazards associated with smoking without staff knowledge or supervision in a sample list of 38 residents. Findings Include:R75's care plan, updated on 12/27/2025, includes the following diagnoses: chronic atrial fibrillation, obsessive-compulsive disorder, anxiety disorder, lumbar osteomyelitis, and chronic pain syndrome.R75's Minimum Data Set (MDS) dated [DATE] documents that R75 is cognitively intact.R75's progress note dated 11/16/2025 at 1:14 PM documents: CNA approached writer at this time reporting smoke coming from the resident's room. CNA reported the smoke smelled like cigarettes. Writer entered the room and observed the resident and a visitor. Writer could smell smoke but did not observe anyone actively smoking. Writer asked the resident about the smell of smoke and ashes on the bed. The resident stated he smoked a cigarette that the visitor brought him. The resident and visitor were educated on the dangers of smoking related to oxygen use in the facility and wound healing. The resident verbalized understanding, and the visitor exited the room. The on-call nurse manager was notified.R75's progress note dated 11/17/2025 at 8:01 AM, authored by Social Services, documents: Writer was informed over the weekend, on Sunday 11/16/25, that the resident had a visitor who brought him cigarettes. Families complained of smoke, and when nursing arrived at the resident's room, the visitor was flushing the cigarettes down the toilet. Writer spoke with the resident this morning and educated him on the risks of smoking in his room and that Mt. [NAME] Health and Rehab is a non-smoking facility. Writer provided the resident with the smoking policy and had the resident date and sign it. Writer also provided the resident with a smoking contract, which the resident initialed and signed.R75's progress note dated 01/01/2026 at 12:49 PM documents: Girlfriend present and stated that R75 wanted to go outside to have a cigarette. Writer explained that he could go outside with her, but this is a non-smoking facility. She stated, 'Okay.' Writer went outside for break and observed the two sitting outside smoking, with oxygen on and in his nose. Education was provided. They continued smoking. Upon returning inside, the girlfriend stated that R75 wanted to go home with his niece. She stated that she and the niece had discussed caring for him. Writer will speak with SSD on Monday.On 01/05/2026 at 9:30 AM, R75 was observed seated in his room. R75 stated, I will smoke if I feel like it. My woman will bring me cigarettes, and I will smoke them. I really don't care what any of them say.On 01/07/2026 at 1:00 PM, V1, Administrator, verified that the facility is a smoke-free facility and that smoking is not permitted in the building or on the grounds. V1 further verified that R75's care plan should have been updated to include specific interventions to protect R75 and other residents from hazards related to R75's smoking without the knowledge or observation of staff.R75's Safe Smoking assessment dated [DATE] documents that R75 does not smoke, has never smoked, and did not sign a smoking contract.The facility's Smoking Policy, revised 03/10/2025, states:PURPOSE: To provide guidance to staff and residents regarding safe smoking on facility property. POLICY: To provide a safe and healthy living environment with respect for the health, well-being and personal choice of each resident, staff member and visitor. The objective of this policy to communicate to each resident that they are responsible for following each rule and ongoing compliance with this smoking policy. POLICY INTERPRETATION AND IMPLEMENTATION: Smoking is only allowed in designated areas established by management. Residents who smoke will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. The facility shall complete Smoking Safety Assessments upon Admission, a quarterly basis, and as needed. (As applicable) Types of smoking include traditional cigarettes, self-rolled tobacco products, pipes, e-cigarettes, and vaping devices.Individuals who are noncompliant, exercise poor judgment, or show a lack of concern for the welfare of others shall be educated accordingly. Smoking privileges may be adjusted/suspended as listed under 'Consequences of Noncompliance at the end of this policy. The facility reserves the right to revoke smoking privileges at any time if there is a concern that hazardous behavior may occur.It is against facility policy for one resident to give away, sell, share, trade smoking materials, or light another resident's cigarette.Residents may not store their own smoking materials. Smoking materials for residents will be stored in a designated location within the facility. Primary contact of residents with supervised smoking sessions will be educated on the facility smoking policy and basic smoking/fire safety.All persons interested in retaining smoking privileges must follow the guidelines set forth in this policy.Smokers may be checked for smoking contraband if violation of smoking policy is suspected of not being followed.Smokers may be checked for smoking contraband upon exiting designated smoking areas and any contraband found will be confiscated.Smokers may be checked by nursing staff for smoking contraband upon admission and when returning from out on pass.

Based on observation, interview, and record review, the facility failed to administer enteral feeding as ordered for one (R9) reviewed of one resident reviewed for tube feedings in a sample list of 38. Findings Include:R9's undated care plan documents that R9 was admitted to the facility on [DATE] with the following diagnoses: chronic atrial fibrillation; essential hypertension; gout; dysphagia, oropharyngeal phase; nondisplaced Type II dens fracture, subsequent encounter for fracture with routine healing; maxillary fracture, unspecified side, subsequent encounter for fracture with routine healing; gastroesophageal reflux disease without esophagitis; multiple fractures of the ribs, left side, subsequent encounter for fracture with routine healing; unspecified displaced fracture of the fourth cervical vertebra, subsequent encounter for fracture with routine healing; dysphagia, oral phase; hypothyroidism; pleural plaque with presence of asbestos; pulmonary fibrosis, unspecified; and encounter for attention to gastrostomy.R9's physician orders dated 11/12/2025 document an order to infuse Jevity 1.5 via enteral pump at 70 mL per hour for 20 hours, for a total of 1,400 mL, providing 2,100 total calories, 900 mL of free fluid, and an unspecified total grams of protein per day via G-tube. The order further documents to disconnect the pump at 8:00 AM and restart at 12:00 PM.R9's Medication Administration Record (MAR) for the month of December documents twice-daily nursing entries with various recorded amounts that do not total 2,300 mL of fluid per day.On 01/05/2026 at 11:30 AM, R9 was observed in the room attached to a tube feeding pump. The pump displayed 1,546 mL of feed infused, with 775 mL of flush infused. R9 stated that the pump was supposed to be shut off at 8:00 AM and that it had been beeping for some time. R9 further stated that when staff came to the room, they indicated the beeping was due to no water being placed in the flush bag; water was added, but the pump was left on and continued infusing.On 01/05/2026 at 11:39 AM, V2, Director of Nursing (DON), stated she spoke with the staff nurse, who was going to enter a note explaining why the pump was still infusing. V2 stated the pump should be shut off after 1,400 mL of tube feeding had infused.On 01/06/2026 at 12:45 PM, V2 acknowledged errors and stated there was no excuse. V2 further stated that a new order for bolus feedings was entered that day.The facility policy dated 07/03/2023, titled Enteral Feedings, documents that the nurse is responsible for confirming that enteral nutrition is completed as ordered and accurately documented.

Based on observations, interview and record review the facility failed to ensure resident right to be free from staff to resident (R1) misappropriation of a credit card. R1 is one of three residents reviewed for abuse/misappropriation on the sample list 31. R1 experienced psychosocial harm, including emotional distress and tearfulness, as a direct result of the misappropriation of her credit card.Findings include:R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating R1 has no cognitive impairment.R1's Local Police Report, dated 11/24/25, documents that V6, Certified Nursing Assistant (CNA), was arrested by the local police department after using R1's credit card for purchases totaling $1,350.01, as verified by V16, local police detective. The same police report documents that V6, CNA, was charged with Aggravated Identity Theft Against a Person [AGE] years of age or Older or a Person with a Disability.On 12/09/25 at 1:05 p.m., R1 became tearful while discussing the details of the theft of her credit card. R1 stated she was the victim of theft by V6, a former Certified Nursing Assistant at the facility, who stole R1's bank card and charged over $1,000. R1 stated that V6, CNA, had been arrested. R1 also stated that the police were aware that V6, CNA, had sent R1 messages apologizing for stealing her credit card.On 12/10/25 at 10:15 a.m., V3, Regional Nurse Consultant, stated that the facility did not have an Administrator at the time R1 lost her bank card. It was confirmed through the police department and the police investigation that over $1,000 was charged on R1's bank card by V6, CNA.On 12/10/25 at 11:30 a.m., V16, Detective with the local police department, stated, My investigation regarding R1's bank card was complete. We had enough evidence, including camera footage, to arrest V6, CNA, for the theft.On 12/11/25 at 10:29 a.m., V24, Licensed Practical Nurse (LPN), stated, I heard about R1's bank card being stolen. I heard police were here. I don't know anything about the previous Administrator (V14) doing an investigation. Nobody talked to me about that. I do know R1 was very upset and became tearful when talking about this.The facility's Abuse Policy, revised 12/2025, documents the following:PURPOSETo provide guidance and procedures to the facility and staff to ensure residents remain free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment.RESPONSIBILITYThe Administrator and/or designee is the facility's Abuse Coordinator. It is the responsibility of all facility staff to ensure that all residents remain free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. All staff are responsible for reporting any allegation or witnessed abuse immediately to the Administrator (Abuse Coordinator).

Based on interview and record review the facility failed to safely transport a resident resulting in two falls from the wheelchair. The facility also failed to document fall investigations for two falls. These failures affected one of three residents (R9) reviewed for falls on the sample list of 31. Findings Include:The facility's Accidents and Incidents Policy dated 7/1/23 documents that all accidents or incidents involving a resident will be documented in risk management, and the nursing team will complete an investigation that includes identification of the root cause and implementation of new interventions.R9's undated Medical Diagnoses List documents that R9 was diagnosed with Alzheimer's disease, adult failure to thrive, rhabdomyolysis, and unspecified abnormalities of gait and mobility.R9's Fall Risk assessment dated [DATE] documents that R9 was at high risk for falls due to being consistently disoriented, having one to two falls in the last three months, being chair-bound and/or requiring assistance, taking one to two high-risk medications, and having one to two high-risk medical diagnoses.R9's Care Plan dated 9/29/25 documents that R9 was at risk for falls and injuries related to adult failure to thrive, protein-calorie malnutrition, and Alzheimer's disease. R9 experienced three falls in September 2025 (9/11/25, 9/20/25, and 9/24/25). On 9/20/25, R9 fell, and a new intervention was added to the care plan directing staff to ensure the resident was positioned correctly in her wheelchair when being transported.R9's Progress Note dated 9/20/25 documents that shortly after 5:00 PM, staff member V45, Certified Nursing Assistant (CNA), attempted to transport R9 to the dining room. During transport, R9 fell forward out of her wheelchair.On 12/16/25 at 12:52 PM, V45, CNA, confirmed she transported R9 to the dining room when R9 fell from the wheelchair. V45 could not recall specific details but stated that R9's posture was curved forward and that she leaned forward constantly while seated. V45 also confirmed that R9 would attempt to stand during transport.R9's Progress Note dated 9/24/25 documents that R9 was in the hallway and was very restless, leaning forward in her wheelchair. V37, Certified Nursing Assistant (CNA), turned R9's wheelchair to take her to the dining room when R9 leaned forward and fell to the floor. R9 sustained a hematoma to the right side of her forehead.On 12/16/25 at 12:57 PM, V37, CNA, confirmed R9 was a very high fall risk and leaned forward in her wheelchair frequently. V37 stated that R9 often attempted to stand on her own. V37 stated that on 9/24/25, she began transporting R9 to the dining room while R9 was anxious and leaning forward in her wheelchair. As V37 began to push the wheelchair, R9 leaned forward again, placed her foot down in an attempt to stand, and fell forward out of the wheelchair.On 12/16/25 at 2:35 PM, V2, Director of Nursing, confirmed that neither staff member should have pushed R9's wheelchair forward if R9 was leaning forward or attempting to stand, which resulted in R9 falling and sustaining a hematoma to her forehead. V2 confirmed that R9 was known to have a forward-leaning posture and was a very high fall risk, frequently leaning forward in her wheelchair and attempting to stand independently. V2 confirmed that staff should ensure R9's safety during transport. V2 also confirmed that the facility did not complete fall investigations for two of R9's falls occurring on 9/11/25 and 9/20/25.

Based on interview and record review, the facility failed to transcribe a physician ordered medication (Coumadin) to prevent blood clot formation, for a resident post-surgical procedure, and an underlying high-risk diagnoses for blood clot formation. This failure resulted in a significant medication error. This failure affected one of 20 residents (R4) reviewed for medications on the sample list of 31. Findings include:R4's Current Diagnoses List documents the following diagnoses, which significantly increase the likelihood of blood clot development: Unspecified Encounter of Shaft of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Pain Due to Internal Orthopedic Prosthetic Devices, Implants, and Grafts, Subsequent Encounter; Atrial Fibrillation; Cardiomyopathy, Unspecified; Nonrheumatic Mitral Valve Disorder; Occlusion and Stenosis of Carotid Artery, Unspecified; and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina.R4's hospital discharge records document that R4 was discharged from the hospital to the facility on [DATE] following Left Femur Fracture ORIF (Open Reduction and Internal Fixation), a surgical procedure required to repair a severe fracture using plates, screws, rods, and pins. ORIF of the left femur requires anticoagulation (blood thinner) therapy to prevent deep vein thrombosis (blood clots that can form in deep veins and travel to the lungs, causing a life-threatening pulmonary embolism).The same hospital discharge record documents that R4's medications were to be continued at the skilled nursing facility. R4's medication orders included Coumadin (anticoagulant/blood thinner) as follows: Coumadin 1 mg (one tablet) by mouth four times weekly on Tuesday, Thursday, Saturday, and Sunday, and Coumadin 2 mg (two tablets) by mouth on Monday, Wednesday, and Friday.The hospital discharge record further documents: Last time this medication (Coumadin) was given: November 10, 2025, at 4:47 p.m. and Take your blood thinner exactly as ordered. Do not skip doses or stop taking this drug without talking to your doctor.R4's Health Status Note on admission, dated 11/11/25 at 12:28 p.m., documents: Hospital discharge summary received and faxed to pharmacy for review.The facility pharmacy packing slip documents that R4's Coumadin 1 mg tablets (26-count) were delivered to the facility on [DATE] at 2:22 a.m. and were available for administration.R4's pharmacy requisition sheet dated 11/11/25 includes a pharmacy label documenting: Coumadin 1 mg by mouth four times weekly on Tuesday, Thursday, Saturday, and Sunday, and Coumadin 2 mg by mouth on Monday, Wednesday, and Friday.R4's Physician Order Sheet (POS) dated 11/01/25-11/30/25 does not document the initial Coumadin order upon admission on [DATE]. As a result, the electronic Medication Administration Record (MAR) did not populate the Coumadin order for administration by facility nursing staff.R4's Minimum Data Set (MDS), dated [DATE], does not document that R4 was receiving anticoagulant medication.The facility's Quality Assurance (QA) Report, dated 11/25/25 and signed by V2, Director of Nursing, documents the following:Type: Medication IncidentIncident Location: Upon admission [DATE])Prior Caregiver: V19, Licensed Practical Nurse (LPN)Witness: V29, Licensed Practical NursePhysician Notified: V4, Medical Director, 11/25/25 at 11:00 a.m.Resident Representative Notified: V42, family member/POA, 11/25/25 at 11:00 a.m.Staff Responsible for Error: V19, LPNType of Error: Missed dosesMedication: CoumadinDose Ordered: 1 mg / 2 mgRoute: PO (by mouth)Problem Statement: Second nurse did not check R4's admission orders.Why: Multiple nurses did not check or follow up on medications and discharge orders.Investigative Statement:V19, LPN, stated she thought she entered the order into the electronic medical record but later recalled the Coumadin order was confusing and that she forgot to follow up to clarify it. V19 acknowledged the Coumadin order was not entered upon admission on [DATE], resulting in 14 missed days of therapy before the error was identified on 11/25/25.The QA report also documents an additional transcription error involving the Coumadin dose and frequency, which could have resulted in further medication errors had V4, Medical Director, not discontinued the order on 11/25/25. The report incorrectly listed the higher dose on opposite days from the hospital discharge and pharmacy instructions. No Coumadin was administered from 11/11/25 through 11/24/25.R4's physician visit note, signed by V4, Medical Director, documents that R4 was seen in person on 11/25/25. V4 initiated aggressive bridged anticoagulation therapy, including injectable anticoagulant and increased oral Coumadin dosing. New orders included Lovenox 40 mg subcutaneously twice daily and Coumadin 5 mg by mouth, along with daily PT/INR laboratory monitoring to assess therapeutic anticoagulation levels.On 12/10/25 at 3:20 p.m., V19, LPN, stated she completed R4's admission on [DATE] and missed the Coumadin order due to confusion regarding the dosing schedule. V19 acknowledged several doses were missed. She stated V4 initiated Lovenox and Coumadin when the error was discovered and ordered daily PT/INR monitoring until therapeutic levels were achieved. V19 stated nursing staff were re-educated on admission order transcription and verification by two nurses.On 12/11/25 at 10:29 a.m., V24, LPN, stated she cared for R4 and was unaware Coumadin had been ordered. V24 stated she was rounding with V4, MD, who expressed concern that R4 had not received anticoagulation therapy. V4 ordered immediate Coumadin, Lovenox, and INR testing, which V24 administered on 11/25/25.On 12/12/25 at 11:05 a.m., V41, Pharmacist, stated the Coumadin prescription matched the hospital discharge orders. The pharmacy filled the prescription promptly, and the medication was available at the facility. V41 stated Coumadin should not be stopped abruptly, especially in a patient post-ORIF surgery with atrial fibrillation, as doing so significantly increases the risk of blood clots and serious harm.On 12/15/25 at 9:55 a.m., V4, Medical Director, confirmed he was notified on 11/25/25 that R4 missed 14 doses of Coumadin. V4 stated the missed anticoagulation therapy posed a significant risk due to R4's cardiac diagnoses, atrial fibrillation, and recent ORIF surgery of the left femur. V4 stated, There was a potential for a lot of damage.

Based on interview and record review the facility failed to investigate two resident (R1 and R12) allegations of misappropriation. R1 and R12 are two of four residents reviewed for abuse/misappropriation on the sample list of 31.Findings include:1.) R1's Minimum Data Set (MDS), dated [DATE], documents R1's Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating R1 has no cognitive impairment.On 12/09/25 at 1:05 p.m., R1 became tearful while discussing the details of the theft of her credit card. R1 stated the missing credit card was investigated by the local police department, who arrested V6, Certified Nursing Assistant (CNA), after their investigation found that V6 had charged over $1,000 to the card. R1 stated that V3, Regional Nurse Consultant, spoke with her but never spoke with her roommate, R13. R1 stated that R13 knew all about R1's stolen credit card and also knew about R12's missing ring around the same time.R13's MDS, dated [DATE], documents R13's BIMS score as 15 out of a possible 15.On 12/09/25 at 1:30 p.m., R13 confirmed she was with R1 at the time they believe the credit card was stolen by V6, CNA. R13 stated no one at the facility ever interviewed her regarding R1's credit card. R13 also stated she had knowledge of R12's missing ring, which R12 had received from her family and which went missing just before Thanksgiving. R13 stated no one asked her about that incident either.On 12/10/25 at 10:15 a.m., V3, Regional Nurse Consultant, stated the facility did not have an Administrator at the time R1's bank card went missing. It was later confirmed through the police department and their investigation that the card had been stolen and charges were made on the account. V3 stated she was responsible for the investigation but did not conduct it because she was busy managing nine other buildings at that time.2.) R12's Minimum Data Set (MDS), dated [DATE], documents R12's BIMS score of 5 out of a possible 15, indicating severe cognitive impairment.On 12/09/25 at 1:35 p.m., R12 was confused about the details but was insistent that a ring her grandchildren had given her for her birthday was missing.On 12/09/25 at 3:10 p.m., V2, Director of Nursing (DON), stated, Regarding R12, I recall V35, R12's family member, reported to staff that R12's ring was missing sometime before Thanksgiving. I heard about it in a morning meeting. I think V14, Interim Administrator, was there, but I can't be sure. I did not report or investigate R12's missing ring because everybody seemed to already know. I did not call the police at that time. I thought the Social Service Director (V17) had reported and investigated it. She was in the meeting and generally helps with investigations like that.On 12/10/25 at 10:05 a.m., V1, new Administrator/Abuse Prevention Coordinator, stated, I did not find documentation of any investigation regarding R12's missing ring. It does not appear to have been reported to IDPH (Illinois Department of Public Health) or investigated.The facility's initial misappropriation of property report to IDPH was dated 12/10/25 at 10:00 a.m. (during this survey). R12's ring had been missing since at least 11/21/25, per V35, R12's Power of Attorney/family member, who first reported the missing ring.On 12/11/25 at 11:30 a.m., V25, Certified Nursing Assistant (CNA), stated she searched for R12's ring after taking R12 to the dining room a few days before Thanksgiving. Another resident, R30, asked R12 if she had found her lost ring. V25 stated the ring was a silver band with a large purple amethyst stone and that R12's family had brought it in for her birthday. V25 stated she saw the ring several times. V25 reported the missing ring to V26, Licensed Practical Nurse (LPN), who directed V25 to write a note and slide it under V17's (Social Service Director) door. V25 stated she wrote the note and slid it under the door. V25 further stated no one ever followed up with her regarding R12's ring.On 12/10/25 at 10:25 a.m., V5, Dietary Manager, stated that V14, Interim Administrator/Abuse Prevention Coordinator, was present at a morning meeting. V14 asked housekeeping staff and CNAs to look for R12's ring.On 12/11/25 at 12:05 p.m., V17, Social Service Director, acknowledged she was aware of R12's missing ring but did not conduct an investigation because she was not directed to do so by V14, Interim Administrator.On 12/12/25 at 3:10 p.m., V35, R12's family member, stated, R12's ring has an amethyst stone at the center with small diamond stones surrounding it. It was given to her by her grandchildren for her birthday on 11/15/25. It was last seen when I visited on 11/21/25. The day before Thanksgiving (11/26/25), the ring was missing. I reported this to a CNA at the time, but I don't remember which one. She told me she would look for it. I didn't hear anything else from the facility until yesterday. I spoke with the current Administrator, V1, who said she would conduct an investigation. I'm not sure how the issue was missed previously. I thought they were still looking for it. The ring has been missing for weeks. The police department has since been called and reassured me they will conduct a thorough investigation. I sent a picture of the ring to the current Administrator and the local police department. I'm still hopeful the ring will turn up.On 12/16/25 at 11:00 a.m., V1, Administrator, stated, Had R1's misappropriation been thoroughly investigated by the previous Administrator (V14), R1's roommate (R13) and others who had knowledge of additional misappropriation events, R12's missing ring may have been identified sooner. We now know that several people were aware of this. V1 showed the surveyor a large amethyst ring surrounded by diamonds. V1 stated that through her investigation, the ring was found in a medication cart after she interviewed several individuals.Facility PolicyThe facility's Abuse Policy, revised 12/2025, documents the following:PURPOSETo provide guidance and procedures to the facility and staff to ensure residents remain free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment.RESPONSIBILITYThe Administrator and/or designee is the facility's Abuse Coordinator. It is the responsibility of all facility staff to ensure that residents remain free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. All staff are responsible for reporting any allegation or witnessed abuse immediately to the Administrator (Abuse Coordinator).The same policy further documents: The facility immediately and thoroughly investigates all allegations of abuse, including but not limited to interviews of residents, staff, visitors, and vendors.

Based on interview and record review the facility failed to report misappropriation of an amethyst stone ring to Illinois Department of Public Health (IDPH), in a timely manner. This failure affected one of four residents (R12) reviewed for abuse/misappropriation on the sample list of 31.Findings include:R1's Minimum Data Set (MDS), dated [DATE], documents R1's Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating R1 has no cognitive impairment.On 12/09/25 at 1:05 p.m., R1 became tearful while discussing the details of the theft of her credit card, which was investigated by the local police department. R1 then stated that her roommate, R13, could provide details about R12, who had a missing ring that occurred around the same time R1's credit card was stolen.On 12/09/25 at 1:30 p.m., R13 propelled her wheelchair into her shared room with R1. R13 stated, R12's family bought her a ring for her birthday just before Thanksgiving. She told the facility, and they looked for it but never found it. V18, Certified Nursing Assistant (CNA), knows all about it. R12 is still talking about it. She mentioned how important the ring was to her, and she is heartsick that it came up stolen.R12's MDS, dated [DATE], documents that R12's BIMS score at the time of the assessment was 5 out of a possible 15, indicating severe cognitive impairment.On 12/09/25 at 1:35 p.m., R12 stated, Someone stole the ring my grandchildren saved up to buy me for my birthday. I couldn't believe it. It happened a week or so ago. Staff searched for it but never found it. The police called here today and said they found two rings (could not confirm this). I don't know if I am missing two rings. I am waiting for a ride to go confirm which one is mine. I did not have two rings missing-at least I don't think I did. I am hopeful that one of the two the police found is mine.On 12/09/25 at 1:58 p.m., V18, Certified Nursing Assistant, stated, I heard about R12's ring missing last week. R12 told me when I gave her a shower. She was so upset. The Director of Nursing (V2) asked me if I had ever seen R12 wearing a ring. I could not say yes or no. I did look around her room and never saw it. I was told the Administrator at the time, V14 (Interim Administrator), already knew about R12's missing ring. I don't take care of her that often, so I really could not say if she had a ring. I can say she probably did, since it upset her so much when she talked to me.On 12/09/25 at 3:10 p.m., V2, Director of Nursing (DON), stated, Regarding R12, I recall V35, R12's family member, reported to staff that R12's ring was missing sometime before Thanksgiving. I heard about it in a morning meeting. I think V14, Interim Administrator, was there, but I can't be sure. I did not report or investigate R12's missing ring because everybody seemed to already know. I did not call the police at that time. I thought the Social Service Director (V17) had reported and investigated it. She was in the meeting and generally helps with investigations like that.On 12/10/25 at 10:05 a.m., V1, New Administrator/Abuse Prevention Coordinator, stated, I did not find documentation of any investigation regarding R12's missing ring. It does not appear to have been reported to IDPH or investigated. V1 provided the facility's initial misappropriation of property report to IDPH dated 12/10/25 at 10:00 a.m. The report documents that V35, R12's Power of Attorney/family member, reported R12's missing ring, which was last seen in November.On 12/11/25 at 11:30 a.m., V25, Certified Nursing Assistant (CNA), stated, I was R12's CNA the day her ring was discovered missing. I had taken her to the dining room, and another resident, R30, asked R12 if her ring was ever found. I was told it had been missing a few days before Thanksgiving. I was here on her birthday when she got the ring, so I know she had it. I told V26, Licensed Practical Nurse (LPN), about it. We did not have an Administrator at the time, as far as I know. I knew I was supposed to report it. V26 told me to write a report and slide it under V17's (Social Service Director) door. I wrote a statement, and V26 slid it under the door. I then went to R12's room and checked under the sheets, under her bed, on the floor, and through her dirty clothes. I did a thorough search and did not find anything. I reported all of that to V26. The ring was a silver band with a large purple amethyst stone. Her family brought it in for her birthday. I saw it several times. Nobody ever contacted me for additional details beyond my report. I received a call yesterday about it, but the ring went missing last week or the week before.On 12/10/25 at 10:25 a.m., V5, Dietary Manager, stated that V14 was the Interim Administrator and was present at a morning meeting. V14 asked housekeeping staff and CNAs to look for R12's ring. Within minutes, V25 was in R12's room looking for the ring.On 12/11/25 at 12:05 p.m., V17, Social Service Director, stated, I do recall a note about R12's ring missing. The note was not signed, or I could not read who wrote it. I did not think anything of it. I did not put it on the IDPH reportable log or the grievance log. I did call V35, R12's family member, but she didn't answer and her voicemail was full. I forgot about it. I did not report it to V14 because I did not think of this as abuse. It was just a missing ring.On 12/12/25 at 3:10 p.m., V35, R12's family member, returned the call and stated, R12's ring has an amethyst stone at the center with small diamond stones around it. It was given to her by her grandchildren for her birthday on 11/15/25. It was last seen when I visited on 11/21/25. The day before Thanksgiving, the ring was missing. I reported this to a CNA at the time, but I don't remember which one. She told me she would look for it. I didn't hear anything else from the facility until yesterday. I spoke with the current Administrator, V1, who said she would conduct an investigation. I'm not sure how the issue was missed previously. I thought they were still looking for it. The ring has been missing for weeks. The police department has since called and reassured me they will conduct a thorough investigation. I sent a picture of the ring to the current Administrator and the police department. I'm still hopeful the ring will turn up.The facility's Abuse Policy, revised 12/2025, documents the following:PURPOSETo provide guidance and procedures to the facility and staff to ensure residents remain free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment.RESPONSIBILITYThe Administrator and/or designee is the facility's Abuse Coordinator. It is the responsibility of all facility staff to ensure that all residents remain free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. All staff are responsible for reporting any allegation or witnessed abuse immediately to the Administrator (Abuse Coordinator).The same policy further documents: The facility will report all allegations of abuse immediately to the Administrator and timely to the appropriate authorities, including IDPH, the Ombudsman, the local police department, the Power of Attorney (POA), and the Medical Director (MD).

Based on observation, interview and record review the facility failed to maintain residents dignity by failing to provide toileting in a timely manner. This failure affected one of five residents (R1) reviewed for dignity/incontinence care on the sample list of 3. Findings include:R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating R1 has no cognitive impairment.The same MDS documents that R1 is always continent of bowel and bladder, and that R1 requires substantial/maximal assistance to transfer on and off the toilet.On 12/09/25 at 1:05 p.m., R1 stated, As far as staff, they have never provided rough care. On the other hand, there was an incident last week that really upset me. A CNA (later identified as V37, Certified Nursing Assistant), I don't know her name, brought my breakfast in and rudely dropped my tray on the bedside table. She was upset because I asked her if she would take me to the bathroom before I ate. She said, 'p** (urinate) your diaper, I am not your CNA, I don't have time.'R1 further stated, I don't believe this was abuse. I do believe this was humiliating and very disrespectful (R1 became tearful). R1 continued, My roommate (R13) can tell you this really upset me. I did not tell anyone else until after I ate breakfast. I was sitting in my own urine for what felt like an hour. After breakfast, another CNA came in and walked me to the bathroom. That girl (V37, CNA) has not been in my room since. I don't know if she was having a bad day or what the issue was. If it happens again, I will go straight to the nurse and report it.On 12/09/25 at 1:30 p.m., R13 stated, I do know there was a CNA (later identified as V37) that told R1 she would not take her to the bathroom before breakfast and said R1 should p** (urinate) in her diaper. Of course, this is a horrible thing to say. It made R1 very upset. It would make anyone upset. R1 was humiliated and tried to hold it until staff had time to take her.On 12/09/25 at 1:58 p.m., V18, Certified Nursing Assistant, stated, R1 was upset that a CNA had left her in a wet incontinence brief. I would be upset too. She told me about it after the fact. I think the CNA (V37) told her she was not R1's CNA, so she didn't take her to the bathroom because she was on trays (delivering meals) that day. It does not matter which residents we are assigned; we all know to take a resident when they ask. Yes, that is a dignity issue-being left to urinate in their brief. I did not hear that she was told to p** (urinate) herself.On 12/11/25 at 10:29 a.m., V24, Licensed Practical Nurse (LPN), stated, I was here and had heard about V37, CNA, telling R1 she couldn't take her to the bathroom. I did not hear that V37 told her to p** in her diaper. Absolutely, I would think that telling her to p** in her pants would be abuse. No one should tell any resident that. I did report this to the supervisor on duty. I did not see this as abuse. I did ask R1 if she felt abused, and she said she was just embarrassed that she peed on herself. I can't remember who the supervisor was that was working. R1 was tearful at the time. She was taken to the bathroom after somebody heard her crying. R1 was incontinent of urine that morning; she is never incontinent. V37 should have stopped passing breakfast trays and taken R1 immediately to the bathroom. V37 was not R1's CNA and was passing breakfast trays. She said she told R1's CNA (unidentified) that R1 needed to go to the bathroom. I was here and told the supervisor when I received R1's complaint. I think this was a significant dignity issue. The CNAs were educated to stop and take residents to the bathroom when they ask. They can't hold it very long and should not have to. I have not had any other issues with V37 or other CNAs toileting residents when they ask. V37 needed a refresher (repeat education).On 12/11/25 at 11:50 a.m., V25, CNA, walked R1 to the bathroom and provided peri-care assistance. R1 voided continent of urine. R1's incontinence brief was dry, confirming R1 is continent of urine when toileted promptly.On 12/12/25 at 9:45 a.m., V37, Certified Nursing Assistant, stated, I brought R1 her breakfast tray, but I never told her to use the bathroom in her brief. I know she is usually taken to the bathroom. She did say something about needing to go to the bathroom and me getting her up. V6 (previous CNA) doesn't work here anymore. I think V6 was R1's CNA that day. I may have told R1 I would get her CNA. I just did not have time to do R1's morning care. Her CNA was supposed to get her up, dressed, and complete her morning care, which includes taking the resident to the bathroom. R1 was still in bed when she asked me to get her up to go to the bathroom. I did not take her. I was on hall trays (serving meals). I remember that. I thought I told V6, but I don't remember for sure. I was busy.The facility's Resident Rights Policy, dated 07/02/23, documents the following:PURPOSE:To provide guidance to facility staff on resident rights.POLICY:Employees shall treat all residents with kindness, respect, and dignity.POLICY INTERPRETATION AND IMPLEMENTATION:Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existenceb. be treated with respect, kindness, and dignity

Based on interview and record review the facility failed to implement physician's orders for one of three residents (R9) reviewed for following plans of care on the sample list of 31.Findings Include:R9's Hospice admission Orders dated [DATE] document that R9 was admitted to hospice care. To protect R9's skin, staff were instructed to use incontinence pads instead of incontinence briefs.On [DATE] at 1:21 PM, V29, Licensed Practical Nurse (LPN), stated she was not aware that staff were supposed to use incontinence pads instead of incontinence briefs for R9.On [DATE] at 12:52 PM, V45, Certified Nursing Assistant (CNA), stated she was not aware that staff were supposed to use incontinence pads instead of incontinence briefs for R9.On [DATE] at 12:57 PM, V37, Certified Nursing Assistant (CNA), stated she was never told that R9 was to use incontinence pads instead of incontinence briefs and that she and other staff continued to use incontinence briefs until R9's death on [DATE].On [DATE] at 2:35 PM, V2, Director of Nursing, stated she did not know for sure whether the hospice order for staff to use incontinence pads instead of incontinence briefs was communicated to nursing or CNA staff. V2 confirmed this information should have been communicated to staff and that staff should have been following the physician's order to use incontinence pads instead of incontinence briefs.

Based on observation, interview, and record review the facility failed to safely transport a resident in a wheelchair for one of three residents (R1) reviewed for accidents in a sample list of three residents. This failure resulted in R1 sustaining a nasal bone fracture when R1 fell out of the wheelchair on to R1's face.Findings Include: R1's Care Plan updated 10/10/25 includes the following diagnoses: Osteoporosis, Anxiety Disorder, Left Hemiparesis, Major Depression, Delusional Disorder, History of Right Shoulder Replacement, Parkinson's Disease, Type II Diabetes, and History of Cerebral Infarction. R1's Fall Risk assessment dated [DATE] documents R1 is at high risk for falls. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact.R1's CAT (Computerized Axial Tomography) scan dated 8/16/25 at 12:07PM documents Bilateral Nasal Bone Fracture. Soft Tissue Hematoma noted overlying the inferior aspect of the frontal bone.On 10/14/24 at 1:30PM R1 was seated in her room in her wheelchair. Both foot pedals were in place on R1's wheelchair. When asked if R1 recalled falling out of her wheelchair about a month ago R1 stated I sure do. I broke my nose I thought it would never stop bleeding. After that I had two big black eyes. I fell flat on my face. It hurt a lot, and I was pretty anxious. I had a stroke, and I am partly paralyzed on my left leg. Before I fell, sometimes they would put on one of my foot pedals. When I fell, I didn't have on either one of the pedals. My weak foot (Left) got caught on the front wheel and I went out of the chair on my face. Therapy (staff) put on both foot pedals when I got back from the hospital.On 10/14/25 at 1:40PM V8 Dietary Aide stated When (R1) fell and broke her nose we had just finished the meal, and I took (R1) in her wheelchair to her room. Neither of the footrests were in place. (R1's) bad leg got caught in the front wheel of the wheelchair and she went to the floor on her face. Her nose was bleeding bad, so I got the nurse right away.On 10/14/25 at 1:56PM V7, Physical Therapy Assistant stated I think when (R1) fell her footrests were in her closet. We assessed (R1) after the fall and put the footrests in place.On 10/14/25 at 2:10PM V7, Acting Director of Nursing verified it would be her expectation when staff is transporting a resident in a wheelchair the foot pedals should be in place. The facility did not provide a policy for use of foot pedals during transfer.

Based on record review and interview, the facility failed to implement interventions to prevent the development of pressure wounds and to promote healing of facility acquired pressure wounds, failed to develop and implement a plan including pressure relieving interventions to prevent further skin injury, and failed to follow physician orders to implement nutritional supplements for wound healing for one (R2) resident of three residents reviewed for pressure wounds on the sample list of 10 residents. These failures resulted in R2 developing an unstageable deep tissue Injury to the left heel, a stage four pressure wound to the sacrum, and a stage three pressure wound to the right buttock. R2's sacral pressure wound was initially identified as an unstageable pressure wound and deteriorated to a stage four wound with [CONDITION(S)] requiring Intravenous antibiotics and hospitalization . These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remained out of compliance at a severity level two. The facility is in the process of re-educating all staff on proper pressure sore prevention and management, obtaining consultation from a wound specialist, and reviewing the orders for all residents with pressure sores. Findings include: R2's undated Face Sheet documents an admitted [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Pressure Risk Assessment, dated [DATE], documents a score of 13, indicating moderate risk for skin breakdown. R2's Wound Assessment, dated [DATE], documents a Suspected Deep Tissue Injury (SDTI) to Right Heel as being initially noted on [DATE]. R2's Electronic Medical Record (EMR) does not document any other Pressure Ulcers on admission ([DATE]). R2's Initial Wound Evaluation and Management Summary Report, dated [DATE], documents Site 1 Right Heel Deep Tissue Injury (DTI) partial thickness. This same Report also documents a Physician recommendation of heel protectors while in bed. R2's [DATE] Physician Order Sheet (POS) does not document a Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 13 out of 15 possible points, which indicates R2 was cognitively intact. This same MDS documents R2 as requiring extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. R2's Care plan documents interventions, dated [DATE], for daily skin checks; [DATE] encourage to wear off loading heel protectors; and [DATE] encourage to turn side to side while in bed to relieve pressure. R2's Care Plan did not include interventions to relieve pressure upon admission. R2's Wound Evaluation and Management Reports document the following: *[DATE] Site 1 Unstageable Right Heel had deteriorated. Site 2 Initial evaluation of Unstageable Deep Tissue Injury (DTI) of Left Heel Partial Thickness. Recommended heel protector in bed. Site 3 Initial evaluation of Unstageable Sacrum Full Thickness. Site 4 Initial evaluation of Right Buttock Full Thickness Pressure Ulcer. Recommended turn side to side and front to back every one to two hours if able; limit sitting to 60 minutes, wedge to bed for off-loading, low air loss mattress. *[DATE] Site 1 Unstageable Due to Necrosis Right Heel Full Thickness Pressure Ulcer as deteriorated. Site 2 Unstageable DTI of Left Heel Partial Thickness Pressure Ulcer documented as no change. Site 3 Stage 4 Sacrum Pressure Ulcer Full Thickness documented as deteriorated. Site 4 Stage 3 Right Buttock Full Thickness documented as no change. Recommended heel protectors, turn side to side and front to back every one to two hours if able; limit sitting to 60 minutes, wedge to bed for off-loading, low air loss mattress. *[DATE] documents Site 1 Stage 4 Right Heel Pressure Ulcer had no change. Site 2 Unstageable Left Heel DTI documented as no change. Site 3 Stage 4 Sacral Pressure Ulcer documented as deteriorated due to larger. Site 4 Stage 3 Right Buttock Full Thickness Pressure Ulcer documented as improved. Recommended heel protectors, turn side to side and front to back every one to two hours if able; limit sitting to 60 minutes, wedge to bed for off-loading, low air loss mattress. *[DATE] documents Site 1 Stage 4 Right Heel Pressure Ulcer as improved. Site 2 Unstageable Left Heel DTI as no change. Site 3 Stage 4 Sacral Pressure Ulcer Full Thickness deteriorated. Recommended heel protectors. Additional wound detail: palpable sacrum bone, clinically positive for [CONDITION(S)], wound culture obtained. Discussed with patient and wife that given stable condition can treat [CONDITION(S)] in-house, but if they prefer, it is reasonable to transfer to emergency room for further evaluation. Site 4 Stage 3 Right Buttock Pressure Ulcer documented as improved by decreased surface area. R2's Dietician Assessment, dated [DATE], documents Plan: Current height 69 inches, weight 147.7 pounds, Basal Metabolic Index (BMI) 21.8 underweight for advanced age, but weight within Ideal Body Weight (IBW) range. Given wound and variable intakes, suggest 60 ml nutritional supplement twice per day. Also suggest Physician consider appetite stimulant. R2's Registered Dietician Progress Note, dated [DATE], documents, New pressure wounds per wound report. Left Heel (DTI), Right Buttock and Sacrum (Stage 3). Continues with DTI to Right Heel. Mostly good intakes noted. Previous RD recommendation to start 60 ml (supplement). R2's Physician Order Sheet (POS), dated [DATE], does not document a Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's EMR does not document any Registered Dietician (V18) recommendations or Physician (V13) ordered nutritional supplements or liquid protein. R2's Nurse Progress Note, dated [DATE] at 3:00 PM, documents, (V15) Wound Physician here to see (R2). Wounds to sacrum, right buttock, left and right heel assessed. Sacral wound continues to worsen. Wound culture obtained. Wife (V5) present. Discussed with (V15) concern for [CONDITION(S)] and need for Intravenous (IV) antibiotic treatment. (V5) Wife requesting (R2) be admitted to hospital. R2's Hospital records document an admitted [DATE], and Hospital course: [AGE] year-old male who recently had a fracture and was sent to rehabilitation presented to emergency room with Sacral Decubitus with [CONDITION(S)] and pain in Right Heel wound. admitted with infected Sacral Decubitus Unstageable and Right Heel wound. status post [MEDICAL RECORD OR PHYSICIAN ORDER] . This same record documents Skin findings: [CONDITION(S)] and lesion present. There is a large approximately 10.0 centimeters (cm) x 6.0 cm decubitus ulcer with [CONDITION(S)] and [CONDITION(S)]. There is visible muscle tissue. Unstageable at this time. R2's Computerized Tomography (CT) of Pelvis with Intravenous Contrast results, dated [DATE], document Impression: There are findings worrisome Prostate [CONDITION(S)] involving the proximal Coccyx and potentially the distal aspect of the fifth Sacral body as described. R2's Sacral Tissue Culture with Gram Stain Final Result dated [DATE] documents Culture Result growth of Escherichia Coli. On [DATE] at 10:15 AM, V5 (R2 wife) stated, That facility was negligent in my husband's (R2) care. They (staff) did not stay on top of (R2) care. (R2) did not enter there with any wounds and they (facility) caused (R2) to get one that killed (R2). (R2) had [CONDITION(S)] and a broken (R2) leg. (R2) was supposed to come back home after the therapy. Because they (facility) didn't care for (R2) and turn and position (R2) every two hours like they should have, (R2) got a horrible bed sore on (R2) bottom. It got so bad (R2) had to be hospitalized . The hospital put a wound vac on the bed sore because it was so big and awful. I was there from 10:00 AM to 8:00 PM every day. They (facility) let (R2) sit in the wheelchair for hours and hours without moving (R2) at all or even checking on (R2). The doctor (V15) told us (R2, V5) that the wound was worse and there was nothing more (V15) could do. But they (facility and V15) didn't send (R2) to the hospital for another week. (R2) had to have Intravenous antibiotics twice a day and the wound vacuum. It was just awful. After (R2) was released from the hospital, we went to another facility. (R2) was in the hospital for a month. R2's Death Certificate, dated [DATE], documents [CONDITION(S)] of Sacral Decubitus Ulcer as a significant contributing condition of R2's death on [DATE]. On [DATE] at 3:05 PM, V11, Licensed Practical Nurse (LPN)/Wound Nurse, stated, (R2) admitted to facility with the Deep Tissue Injury (DTI) to right heel. That wound became a Stage 4 Pressure Ulcer while (R2) lived at facility. The other wounds, Left Heel, Sacrum and Right Buttock Pressure Ulcers were all acquired and worsened at facility. (R2) didn't like to get out of bed, but didn't mind once (R2) was sitting up. It seemed to be the transfer process that (R2) didn't like. Once (R2) was settled, then (R2) would be ok for awhile. If the staff would encourage him, then he would do whatever you asked. I (V11) worked Wednesday [DATE]. I (V11) was off work ,d+[DATE]-,d+[DATE] and returned to work on Monday [DATE]. That is when I was notified of these three new wounds. That is when the careplan was updated to include wound prevention interventions and heel protectors were applied. We (facility) did not put any interventions in place to try to prevent that wound from getting worse or any new wounds from forming. We (facility) should have initiated a repositioning schedule, heel protectors, daily skin checks and a low air loss mattress from the beginning. The interventions should have been put into place from the admitted on because (R2) admitted with a significant size DTI on Right Heel. That wound nurse no longer works at this facility. (V15) Wound Physician obtained a wound culture of (R2) sacral wound on [DATE], but that was the same day (R2) went to the hospital for that wound. It was pretty bad. The staff couldn't have been repositioning him (R2) for it to have gotten to that point. Any resident with such significant Pressure Ulcers should be repositioned every one to two hours. On [DATE] at 3:10 PM, V1, Administrator, stated, Any resident who admits with a Pressure Ulcer should have Care Plan interventions that address the particular wound. (R2) admitted with a significant Pressure Ulcer to Right Heel and there was no Care Plan in place to direct the care for the staff. There is no documentation of (R2) refusing cares or being non-compliant. (V1) was shocked to see how little was documented. (R2) was a nice gentleman that did like to have things done a certain way. Occasionally (R2) did refuse certain things but that is not documented anywhere. We (facility) really messed this one up. We (facility) should have done a much better job for (R2). (V1) know we (facility) didn't do what we were supposed to do. That is obvious. On [DATE] at 9:45 AM, V14, Nurse Practitioner, stated, (R2) and wife (V5) were both very sweet. (R2) did admit with a Pressure Ulcer on Right Heel and obtained three new Pressure Ulcers during the stay. The staff should be turning and repositioning any resident who is at risk or who is known to have Pressure Ulcers. That is a basic standard of care. (R2) required a great deal of assistance to turn and position. (R2) was set in his ways but would do what was asked most of the time. (V5) did share with (V14) that (R2) was being left to sit up in the wheelchair for 'hours on end'. V14 Nurse Practitioner stated, (R2) was quite debilitated due to history of Tophus Gout, [CONDITION(S)] and recent surgery after Femur fracture. (R2) had a lot of pain with movement due to the Gout. (R2) was able to move minimally independently but mostly required a lot of assistance from staff. (R2) was tall and thin 'skin and bones'. I did receive a fax from this facility on [DATE] relaying the Registered Dietician (V18) recommendations of 60 milliliters (ml) of nutritional supplement and appetite stimulant. I responded by writing 'agree' with (V18, RD) recommendations on [DATE], and faxed response back to facility on [DATE]. (R2) told me on [DATE] that (R2) did not want the appetite stimulant. I wasn't aware that the facility was not giving the nutritional supplement as ordered. Nutritional supplements will help prevent or heal Pressure Ulcers due to the extra protein content. The lack of Physician ordered, and Registered Dietician recommended, nutritional supplements, definitely played a part in the deterioration of (R2) wounds. On [DATE] at 10:15 AM, V16, Corporate Registered Dietician (RD), stated (V18, Registered Dietician) is not available for interview. V16, RD, confirmed V18 did review R2's medical chart on [DATE], and wrote recommendations for 60 milliliters (ml) nutritional supplement and appetite stimulant. V16, RD, stated, The recommendations made by the RD (V18) should have been sent to the Physician. Once the Physician approves the recommendation, it is sent back to the facility and entered into the Physician orders. The facility should then carry out those Physician orders. The Registered Dietician is a nutrition specialist so I am sure if nutritional supplements are ordered, they are necessary and important for many facets including wound prevention and healing. Nutritional supplements provide a supportive role in nutrition and are extremely important in wound healing. On [DATE] at 11:45 AM, V20, Physical Therapy Assistant (PTA), stated, (R2) was cooperative with the therapy department. He (R2) was set in his ways but would eventually cooperate with what we (staff) needed him to do. (R2) was completely independent in the community, so this was a big change for him. Having to go from walking on your own, to only using a wheelchair with others to help you, and then being admitted to a nursing home, then the nutritional problems, then the wounds, (R2) had to make a lot of adjustments. It was a big transition. That is why (V5, R2's wife) was so adamant about (R2) returning home. I (V20) am sure she (V5) never expected it to get that bad. (R2) was very anxious to go back home. (R2) was using a full mechanical lift and then graduated to a partial mechanical lift with maximum assistance of two staff for transfers. (R2) could move a small amount in the wheelchair, but not what I would call repositioning. That would require staff involvement. On [DATE] at 1:40 PM, V17, Orthopedic Surgeon, stated, (R2) had previously fractured the Left Femur for which I performed that surgery in August of 2020. (R2) did very well with that procedure and returned home to the community. I again performed this surgery after (R2) fell and fractured the same Femur in the same area. This was a more complex surgery due to the fact that (R2) had previously had the device implanted but there would be no reason for further concern post-surgery. The surgery went well, and (R2) was supposed to receive therapy services and then return home again. (R2) was to be toe touch weight bearing on the Left side. There was no contraindications as to (R2) not being able to turn and position. (R2)'s medical history would offer no reason for (R2) to gain three Pressure Ulcers to Sacrum or lower extremities. There is no medical reason for (R2) to have Pressure Ulcers if the staff are turning and positioning (R2) as required. There would be no reason NOT to move the Left leg to off load pressure. (R2) could turn back to side and side to back in bed, move from a supine to sitting position, move from a sitting to standing position and back with no restrictions. (R2)'s only restriction was toe touch weight bearing on (R2) Left leg. On [DATE] at 3:00 PM, V15, Wound Physician, stated, (R2) liked to do things his own way. educated (R2) on wound healing and prevention. (R2) had just had surgery so his mobility was lessened. I recommended the heel protectors but they were never in place. (R2) was very stiff, and the staff did not provide the care they should have. Between the stiffness, the recent fracture, and the lack of care provided by the staff, the wounds were expedited. If (R2) were receiving the care as it was ordered, (R2) might have held off the wounds for six months or so, but (R2) wounds were definitely expedited by the lack of turning and positioning from staff. It only takes six to seven hours for a Pressure Ulcer to form, so it makes sense that the staff just left him (R2) lay in bed or sit in the wheelchair for long time periods causing the wounds to be expedited. On [DATE] at 3:35 PM, V2, Director of Nursing, stated, (R2's) Registered Dietician (V18) recommendations were never entered into the Physician orders, and they were never scanned into Electronic Medical Record (EMR). They could have gotten lost or thrown away. All know is they are not in (R2's) EMR so (R2) never got them. An Immediate Jeopardy situation was identified on [DATE]. V1, Administrator, was notified of the Immediate jeopardy on [DATE] at 10:44 AM. The Immediate Jeopardy was identified to have begun on [DATE] when the facility failed to provide interventions to address a worsening pressure ulcer and new wounds were identified. On [DATE], the surveyor confirmed through interview, record review and observation, the facility took the following actions to remove the Immediate Jeopardy: **All licensed nurses and CNA staff have been educated on: identifying wounds, pressure ulcer prevention including interventions and verifying that interventions are in place, reporting wounds, notification to the physician and POA, developing care plan interventions and documenting interventions as well as documenting resident response to interventions. - Confirmed by V2 RN Director of Nursing and V11 LPN/Wound Nurse/Assistant Director of Nursing on [DATE]. **Immediate Change to Facility Systems: The facility has policies and procedures based on current standards of practice. As part of the re-education, the facility is educating nursing staff regarding wound management guidelines. The facility has reviewed Braden scores for all residents within the facility and verified that all residents at risk have care plan interventions in place for pressure ulcer prevention. Facility has also reviewed pressure relief interventions for all newly admitted residents who admitted with pressure sores or those that are at risk for pressure ulcers. Facility has audited that physician notification and orders are in place. Facility has audited resident treatment administration records to assure current orders are in place. Facility has completed head to toe assessments on all residents in the facility. Facility wound nurse will monitor wounds weekly and as needed. - Confirmed by V1 Administrator on [DATE]. **Monitoring: The Administrator or designee will monitor all resident's that are at risk for pressure ulcers to verify that pressure relief interventions are in place three times a week for four weeks The findings of the audit tools will be reviewed in the QA meeting. -ongoing confirmed by V1 Administrator on [DATE].

Based on record review and interview, the facility failed to monitor a resident using a laptop cushion device while being propelled by staff, which resulted in a fall with minor injury for one (R3) out of three residents reviewed for falls. Findings include: R3's undated Face Sheet documents an admitted [DATE], and medical diagnoses of Muscle Weakness, Unsteady on Feet, Abnormalities of Gait and Mobility, Left Hand Contracture, History of Falling, and Dementia Without Behavioral Disturbances. Minimum Data Set (MDS), dated [DATE], documents R3's cognitive decision making skills as moderately impaired. This same MDS documents R3 as requiring one person extensive assistance for bed mobility, dressing, eating, toileting and personal hygiene and two person extensive assistance required for transfers. R3's Fall Scale Assessment, dated 12/19/21, documents a fall score of 60, indicating R3 is a high fall risk. R3's Physician Order Sheet (POS), dated January 1-31, 2022, documents a Physician order initiated 3/29/21 for may have (laptop cushion) while in wheelchair for safety, release at least every two hours and as needed for muscle weakness and unsteadiness and impulsiveness with safety. R3's Contracture Risk Evaluation, dated 11/10/21, documents R3 as having moderate to severe hand contractures due to previous [CONDITION(S)] ([CONDITION(S)]). R3's Care Plan intervention, dated 3/25/21, instructs staff to provide with correct positioning with proper body alignment while restrained. R3's Nurse Progress Note, dated 12/19/21 at 12:18 PM, documents (R3) had a fall at 11:45 am. Initial assessment (R3) is nonresponsive to verbal or physical stimuli. Moderate amount of blood noted to right side of forehead. Pressure applied with gauze. (R3) starts to yell that (R3) is in pain. (R3) is more verbal a this time, but does not follow commands & will not open her eyes. R3's Hospital Record, dated 12/19/21, documents the reason for visit as fall and [CONDITION(S)]. This same record documents R3's Right Forehead laceration was treated with tissue adhesive and R3 was returned to facility on 12/19/21 without being admitted to the hospital. On 1/7/22 at 12:15 PM, V33 Certified Nurse Aide (CNA) stated, I (V33) was pushing (R3) in (R3) wheelchair down the hall on the way to the dining room for lunch. I (V33) saw (R3) leaning forward. (V33) couldn't get around to the front of (R3) wheelchair fast enough to push (R3) back. (V33) didn't try to stop the wheelchair or pull (R3) back into the wheelchair from behind. (R3) leans forward like that all the time. (R3) always was leaning over that (laptop cushion). On 1/18/22 at 3:00 PM, V2, Director of Nursing, stated V33, Certified Nurse Aide (CNA), was pushing R3 down the hall en route to lunch. (R3) was leaning forward in (R3's) wheelchair. (R3) leaned forward a lot. (V33) should have gently reached for (R3) from behind and pulled (R3) back to prevent the fall. If (V33) were paying attention, (R3) probably wouldn't have fallen. (V33) should have made sure (R3) (laptop cushion) was in the proper place and obviously (V33) didn't. On 1/18/22 at 3:10 PM, V43, Dietary Aide, stated, (V43) witnessed (R3) fall. (R3) was leaning really far forward and (R3) (laptop cushion) was only half way on. It was so loose, (V43) am surprised (R3) didn't fall before (R3) did. The Certified Nurse Aide (CNA), should have been paying attention. (V43) don't think (V33) made (R3) fall on purpose but if (V33) would have been paying attention to (R3) (laptop cushion) (R3) might not have fallen at all.

Based on interview and record review, the facility failed to provide emergency medical equipment, airway management, and rescue breathing for R1 during a respiratory medical emergency for one of three residents (R1) reviewed for basic life support. These failures have the potential to affect ten (10) additional residents (R4-R13) who have chosen to be a Full Code. R1 subsequently died of Acute Cardiopulmonary Arrest. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity level two. The facility is in the process of implementation and monitoring of education provided to all licensed nurses and CNA's (Certified Nursing Assistant's) on the crash cart (emergency response equipment/supply cart) checklist and completing those checks daily, educating on life saving equipment and airway management during a life threatening respiratory medical emergency, and ensuring all licensed nursing staff have a valid CPR (Cardiopulmonary Resuscitation) Certificate. Findings include: R1's POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Report to Illinois Department of Public Health, dated [DATE], by V2, DON (Director of Nursing), documents R1 was in the dining room, but had not eaten, when a CNA noted R1 had an ashen tint to R1's skin. This CNA notified the nurse. The nurse entered the dining room and completed an assessment on R1, and removed R1 from the dining room and took R1 to R1's room to further assess. During the assessment, R1 became unresponsive and subsequently CPR was initiated and 911 was called, due to R1 being a full code (full CPR during a life threatening emergency). EMS (Emergency Medical Service) arrived on scene and took over CPR for facility staff. Physician and POA (Power of Attorney) notified. Final Report to Follow. On [DATE] at 9:52 am, V1, Administrator, stated R1's incident is still being investigated, but R1 passed away. On [DATE] at 11:12 am, V5, RN (Registered Nurse), stated V5 gave R1, R1's medications that morning, and R1 was fine at that time. Then at lunch time, R1 was being brought down the hall in R1's wheelchair by V4, LPN (Licensed Practical Nurse), and an unidentified CNA. R1 had been in the Dining Room. R1 was pale, leaning to the right side, and drooling from R1's mouth. V5 stated, You could hear (R1's) lungs were full by the way (R1) was breathing. V5 explained V5 wanted R1 in R1's room to further assess R1, so the unidentified CNA and V5 transferred R1 from the wheelchair to the bed using a mechanical lift, while V4, LPN, went to check R1's code status. V5 stated during the transfer into bed, R1 went into cardiac arrest and stopped breathing. V5 explained, We immediately laid (R1) into bed and I (V5) got into bed with (R1) and started {chest} compressions. V5 stated V5 was yelling out orders for the crash cart and back board. The backboard was brought into the room so R1 was rolled onto R1's side, the backboard was placed under R1, then chest compressions resumed. V5 explained the staff were only doing compressions, no rescue breaths, because V4, LPN, was checking the crash cart, and V4 couldn't find an ambu bag (manual emergency resuscitation device). V5 stated another nurse, later identified as V3, Restorative Nurse, entered the room and took over doing compressions for a bit, while V5 continued shouting orders to call 911. V5 stated V5 then took back over doing compressions until EMS arrived. V5 explained V5 had checked R1's mouth and there was no food in R1's mouth or around R1's face, but R1 had a lot of saliva in R1's mouth and was drooling a lot. On [DATE] at 11:28 am, V3, Restorative Nurse, stated V3 was coming down the hall and someone told V3 staff were in R1's room due to a code situation. V3 explained V3 went into R1's room to help until EMS arrived, and when V3 walked in, V5, RN, was already doing chest compressions on R1. V3 stated V3 offered to give V5 a break with the CPR and took over for a bit, then V5 started again until EMS arrived. V3 stated chest compressions were being given, R1 had drool coming from R1's mouth, and V3 never saw rescue breaths being delivered. V3 stated during the time that CPR was ongoing at the facility, R1 never regained a heart beat or respirations. On [DATE] at 12:04 pm, V4, LPN, stated V4 was sitting at the desk when V9, CNA, said R1 wasn't being R1's normal self, so V4 went to check on R1. V4 explained, R1 didn't look okay, he was leaning to one side, and wouldn't respond to me when I (V4) talked to (R1). V4 stated at that time, V4 did not check for a pulse or respirations, My main priority was getting (R1) out of the Dining Room and to (R1's) room to be assessed. V4 stated V4 did check R1's mouth since R1 was in the Dining Room with R1's food tray in front of R1, but that didn't have any food in R1's mouth. V4 stated on the way to R1's room, with R1 in the wheelchair, V4 passed R1's nurse, V5, who followed to R1's room. V4 stated once in R1's room, V4 left to check R1's medical record for R1's code status, and by the time V4 finished that, things were getting hectic, so V4 grabbed the crash cart on the way to R1's room. V4 explained upon entering R1's room, chest compressions had already been initiated. V4 explained V4 had to leave the room again to get oxygen, but once back in the room, realized the 02 (Oxygen) connectors were not in the crash cart, so V4 had to leave R1's room again to get the needed supplies. V4 stated once back to R1's room, V4 took over doing chest compressions for about 15 seconds until EMS arrived. V4 stated no rescue breaths were being delivered, only chest compressions. V4 stated, The contents of the {crash} cart had been emptied onto the floor and people were grabbing what they needed, but I (V4) did not see an ambu bag. On [DATE] at 12:28 pm, V3, Restorative Nurse, stated V3 knows rescue breathing is an important part of CPR, but there was no ambu bag in the cart or in (R1's) room to my knowledge. I (V3) was just focused on the {chest} compressions. On [DATE] at 12:32 pm, V5 confirmed the contents of the crash cart were emptied, everything was everywhere. V5 stated, V5 did not see an ambu bag, but V5 was on the bed with R1 and V4 was the nurse looking for it, and no mouth to mouth was provided due to the large amount of secretions coming from R1's mouth, and there not being a suction machine on the cart to clear the secretions. V5 explained, We did the best we could with the supplies we had. On [DATE] at 1:02 pm, V9, CNA, stated V9 was in the Dining Room with R1 and V10, R1's wife. V9 stated R1 was talking to V10, and then V10 left the facility so V9 gave R1, R1's lunch tray and asked R1 if R1 was going to eat. V9 explained V9 attempted to give R1 a bite of food, but R1 pushed V9's hand and the tray away, and said R1 didn't want anything. V9 then left to gather drinks for other residents and came back a couple seconds later to find R1 leaning to the side in R1's wheelchair with R1's arm dangling over the side. V9 stated R1's eyes looked different, they were half open. V9 explained at that time, R1's color was normal, and R1 hadn't had any changes in R1's breathing, but knew that something wasn't right, so V9 went and got the nurse. On [DATE] at 2:58 pm, V2, DON, stated when a resident goes unresponsive from cardiac arrest, nurses are expected to initiate CPR & call 911. V2 explained CPR consists of opening the airway, performing rescue breathing, and chest compressions. V2 stated R1 should have been suctioned due to the secretions, but the suction machine was not on the cart. V2 also stated R1 should have received rescue breaths via an ambu bag, On [DATE] at 3:12 pm, V12, Physician, explained R1 has a history of cardiac disease ,and with R1 drooling that much, R1 could have been choking on (R1's) saliva, it can happen so fast, they {facility} should have suctioned (R1) to ensure an open airway. V12 also stated rescue breathing should have been attempted with an ambu bag if R1 wasn't or couldn't be intubated. R1's Death Certificate documents R1's cause of death on [DATE] as Acute Cardiopulmonary Arrest. On [DATE] at 10:35 am, V1, Administrator, stated the crash cart should be checked at least a couple times a week, and after each use by the night shift nurse to ensure all the equipment is available and restocked for the next medical emergency. The facility did not provide any documentation of the crash cart being checked and restocked. The facility provided an undated list of all residents with Full Code Status, which included R4, R5, R6, R7, R8, R9, R10, R11, R12, and R13. The facility undated and untitled CPR Policy documents staff must provide basic life support, including CPR, to a resident who requires emergency care prior to emergency medical services arriving, consistent with resident's advance directives (POLST Form). The facility undated Crash Cart Checklist documents Emergency Care Items that are to be in the Crash Cart, which consists of an Ambu Bag, Suction Machine, Oxygen Tank, Oxygen Key, Pocket Mask, Suction Tubing, Suction Catheters, as well as other emergency care equipment items. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was identified to have begun on [DATE] when the facility failed to provide lifesaving equipment, airway management, and rescue breathing for R1 during a respiratory medical emergency. V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 9:30 a.m. On [DATE] between 9:30 am - 2:45 pm, the surveyor confirmed through interview, observation, and record review, the facility took the following actions to remove the Immediate Jeopardy: 1.) V2, DON, verified and provided inservice (education) sheets, dated [DATE], that V22, Resident Care Coordinator, V23, ADON (Assistant Director of Nursing), and V3, Restorative Nurse completed inservice/education on [DATE] for all licensed nurses and CNA's {in person and via the telephone} on the crash cart checklist and the need for the crash cart checklist to be completed daily. 2.) V2, DON, verified and provided inservice sheets, dated [DATE], that V22, Resident Care Coordinator, V23, ADON, and V3, Restorative Nurse completed inservice/education on [DATE] for all licensed nurses and CNA's {in person and via the telephone} on the use of life saving equipment and airway management for residents during a life-threatening respiratory medical emergency. 3.) V2, DON, verified all licensed staff, that did not have a valid CPR Certification, completed a CPR certification class performed by V24, RN, on [DATE], and provided the sign in sheet for the class. 4.) V2, DON, verified V2 is monitoring the CPR certification status of all nursing staff by maintaining a log and copies of CPR cards in a 3-ring binder, which was completed on [DATE]. V2 will update the binder as staff status changes and this binder will be reviewed in the QA (Quality Assurance) meeting. 5.) V1, Administrator, verified and provided an audit sheet, dated [DATE]-[DATE], documenting V2, DON, is checking at least three times a week to ensure the crash cart is supplied and functional, and staff nurses are completing the crash cart check list daily.

Based on interview and record review, the facility failed to provide and properly maintain essential lifesaving medical equipment during a respiratory medical emergency for R1. R1 did not have the benefit of essential lifesaving equipment including an oral suctioning device and mechanical ventilation device for responding medical staff to use during a respiratory medical crisis. As a result, R1 was not provided airway management and rescue breathing. R1 subsequently died of Acute Cardiopulmonary Arrest. R1 is one of three residents (R1) reviewed for basic life support. This failure has the potential to affect ten (10) additional residents (R4-R13) who have chosen to be a Full Code. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity level two. The facility is in the process of implementation and monitoring of education provided to all licensed nurses and CNA's (Certified Nursing Assistant's) on the crash cart (portable emergency response equipment/supply cart) checklist and completing those checks daily, educating on life saving equipment and airway management during a life threatening respiratory medical emergency, and ensuring all licensed nursing staff have a valid CPR (Cardiopulmonary Resuscitation) Certificate. Findings include: R1's POLST (Physician Orders for Lift Sustaining Treatment), dated [DATE], documents R1 is a Full Code, which means R1 has elected to receive full life sustaining measures in the event of a medical emergency, including but not limited to CPR. The facility Report to Illinois Department of Public Health, dated [DATE], by V2, DON, (Director of Nursing) documents R1 was in the dining room, but had not eaten when a CNA (Certified Nursing Assistant) noted R1 had an ashen tint to R1's skin. This CNA notified the nurse. The nurse entered the dining room and completed an assessment on R1, and removed R1 from the dining room and took R1 to R1's room to further assess. During the assessment, R1 became unresponsive and subsequently CPR (Cardiopulmonary Resuscitation) was initiated and 911 was called, due to R1 being a full code. On [DATE] at 11:12 am, V5, RN (Registered Nurse), stated on [DATE] around lunch time, R1 was being brought down the hall in R1's wheelchair by V4, LPN (Licensed Practical Nurse), and an unidentified CNA. R1 was pale, leaning to the right side, and drooling from R1's mouth. V5 stated, You could hear (R1's) lungs were full by the way (R1) was breathing. V5 stated V5 and an unidentified CNA (Certified Nursing Assistant) were in the process of transferring R1 from the wheelchair to the bed, via a mechanical lift, when R1 went into cardiac arrest. V5 stated V5 sent staff to check R1's code status and gather medical supplies. V5 stated V4, LPN (Licensed Practical Nurse), brought the crash cart (emergency response equipment/supply cart) to R1's room, but was not able to find an ambu bag on the cart. On [DATE] at 12:04 pm, V4, LPN, stated on [DATE], V4 was sitting at the desk when V9, CNA, said R1 wasn't being R1's normal self, so V4 went to check on R1. V4 explained R1 didn't look okay, he was leaning to one side, and wouldn't respond to me when I (V4) talked to (R1). V4 stated V4 propelled R1 to R1's room in the wheelchair, and once to R1's room, V4 left R1 with V5, RN, and V4 went to check R1's code status and grabbed the crash cart. V4 explained upon entering R1's room, chest compressions had already been initiated. V4 explained V4 had to leave the room to get oxygen, but once back in the room, realized the 02 (Oxygen) connectors were not in the crash cart, so V4 had to leave R1's room again to get the needed supplies. V4 stated no rescue breaths were being delivered, only chest compressions. V4 stated, The contents of the {crash} cart had been emptied onto the floor and people were grabbing what they needed, but I (V4) did not see an ambu bag. V4 explained V4 is an agency nurse, so V4 has only been in the crash cart once or twice, and that was just to check where it was and that it was stocked, but never needed anything out of it. V4 stated V4 does not recall ever seeing an ambu bag in the cart. On [DATE] at 12:28 pm, V3, Restorative Nurse, stated V3 knows rescue breathing is an important part of CPR but there was no ambu bag in the cart or in (R1's) room to my knowledge. I (V3) was just focused on the {chest} compressions. On [DATE] at 12:32 pm, V5 confirmed the contents of the crash cart where emptied, everything was everywhere. V5 stated, V5 did not see an ambu bag, but V5 was on the bed with R1, and V4 was the nurse looking for it, and no mouth to mouth was provided due to the large amount of secretions coming from R1's mouth, and there not being a suction machine on the cart to clear the secretions. V5 explained, We did the best we could with the supplies we had. On [DATE] at 2:58 pm, V2, DON, confirmed the crash cart should be stocked with a suction machine and materials, oxygen tank and ambu bag. V2 stated V2 was aware there was not a suction machine on the crash cart at the time of R1's code, but was not aware the cart didn't contain an ambu bag. On [DATE] at 10:35 am, V1, Administrator, stated the crash cart should be checked at least a couple times a week, and after each use by the night shift nurse to ensure all the equipment is available, working and restocked for the next medical emergency. The facility did not provide any documentation of the crash cart being checked and restocked. The facility provided an undated list of all residents with a Full Code status, who could potential require the contents of the crash cart in case of a medical emergency, which includes R4, R5, R6, R7, R8, R9, R10, R11, R12, and R13. The facility undated Crash Cart Checklist documents Emergency Care Items that are to be in the Crash Cart, which consists of an Ambu Bag, Suction Machine, Oxygen Tank, Oxygen Key, Pocket Mask, Suction Tubing, Suction Catheters, as well as other emergency care equipment items. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was identified to have begun on [DATE] when the facility failed to provide lifesaving equipment, airway management, and rescue breathing for R1 during a respiratory medical emergency. V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 9:30 a.m. On [DATE] between 9:30 am - 2:45 pm, the surveyor confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1.) V2, DON, verified and provided inservice (education) sheets, dated [DATE], that V22, Resident Care Coordinator, V23, ADON (Assistant Director of Nursing), and V3, Restorative Nurse completed inservice/education on [DATE] for all licensed nurses and CNA's {in person and via the telephone} on the crash cart checklist and the need for the crash cart checklist to be completed daily. The crash cart is now supplied with airway management equipment including emergency suctioning devices and an emergency mechanical ventilation device. 2.) V2, DON, verified and provided inservice sheets, dated [DATE], that V22, Resident Care Coordinator, V23, ADON, and V3, Restorative Nurse, completed inservice/education on [DATE] for all licensed nurses and CNA's {in person and via the telephone} on the use of life saving equipment and airway management for residents during a life-threatening respiratory medical emergency. 3.) V2, DON, verified all licensed staff, that did not have a valid CPR Certification, completed a CPR certification class performed by V24, RN, on [DATE], and provided the sign in sheet for the class. 4.) V2, DON, verified V2 is monitoring the CPR certification status of all nursing staff by maintaining a log and copies of CPR cards in a 3-ring binder, which was completed on [DATE]. V2 will update the binder as staff status changes, and this binder will be reviewed in the QA (Quality Assurance) meeting. 5.) V1, Administrator, verified and provided an audit sheet, dated [DATE]-[DATE], documenting V2, DON, is checking at least three times a week to ensure the crash cart is supplied and functional, and staff nurses are completing the crash cart check list daily.

Based on interview and record review, the facility failed to properly supervise a resident seated on the edge of the bed to prevent a fall. This failure resulted in R1 falling to the ground and sustaining an eyebrow laceration requiring sutures. R1 is one of three residents reviewed for falls in the sample of three. Findings include: R1's Medical Diagnosis sheet (8/6/2021) documents diagnoses including: [CONDITION(S)] (paralysis of one side of the body), Intracerebral Hemorrhage (stroke), Muscle Wasting and Atrophy, Difficulty in Walking, Unsteadiness on Feet, [CONDITION(S)] of Knee, and Abnormalities of Gait and Mobility. R1's Care Plan (8/4/2021) documents R1 has right side weakness due to a Stroke, is at risk for falls, and is unaware of safety needs. R1's 5/31/2021 MDS (Minimum Data Set) documents R1 requires extensive staff assistance for bed mobility, including weight bearing support. R1's 7/27/2021 MDS documents R1 requires full staff performance for bed mobility. Both the 5/31/2021 and 7/27/2021 MDS document R1 has fully intact cognition. R1's Progress Notes (7/9/2021, 7/12/2021) document R1 fell from the bed on 7/9/2021 at 7:15AM while receiving cares from facility staff (unnamed in the notes). The same record documents R1 fell to the ground hitting R1's head causing a laceration above the right eyebrow, and R1 complained of pain all over and required evaluation and treatment at the hospital. R1's Hospital Report (7/9/2021) documents R1 fell from the bed, received a two centimeter laceration to the right eyebrow requiring sutures, and had headaches associated with the fall. The facility Incident Report (7/9/2021) documents V5 (Certified Nurse Aide) was the staff member providing cares to R1 during the fall on 7/9/2021. The same record documents V5 was getting supplies ready to provide cares for R1, left R1's room to retrieve towels, and returned to R1's room while R1 was actively rolling from the bed to the floor. On 8/4/2021 at 11:04AM, R1 reported R1 was seated on the edge of the bed when facility staff (V5) left his room and R1 fell to the ground on 7/9/2021. On 8/4/2021 at 1:13PM, V9 (R1's family) reported R1 is not able to roll out of bed. On 8/4/2021 at 3:20PM, V10 (Certified Nurse Aide) reported being one of R1's direct care providers and reported R1 does not roll in bed and has not fallen from the bed. On 8/4/2021 at 3:24PM, V11 (Certified Nurse Aide) reported being one of R1's direct care providers. V11 stated, (I) have never known (R1) to roll (in bed) and (R1) uses (R1's) call light (if R1 needs something). On 8/4/2021 at 3:14PM, V12 (Certified Nurse Aide) reported being one of R1's direct care providers. V12 stated V12 doesn't think (R1) has ever been able to roll (R1's) self out of bed. V12 reported R1 had a concave mattress in place when R1's fall occurred on 7/9/2021. On 8/5/2021 at 9:25AM, V13 (Certified Nurse Aide) reported R1 is not able to roll to his side by himself while in bed and is not able to roll out of bed. V13 stated, (R1) rolling out of bed, I would never see that happening (to him). V13 reported hearing R1 was left sitting on the side of the bed while V5 left the room to retrieve towels and R1 fell to the ground before V5 returned to R1's room. V13 reported R1 is unable to be seated on the edge of the bed and remain upright by himself without staff assistance. On 8/5/2021 at 1:00PM, R1 again reported R1 was seated on the side of the bed when V5 left R1's room and R1 fell to the ground on 7/9/2021. When asked if R1 could sit upright independently, R1 stated Not for very long.

Based on observation, interview, and record review, the facility failed to assess underlying behaviors leading to falls, and failed to develop and initiate individualized, resident centered fall prevention interventions for two residents (R1 and R3). R1 and R3 are two of three residents reviewed for falls with injury in a sample list of three residents. This failure resulted in a fall for R1 causing a broken left hip with resulting pain. This failure also resulted in a head injury from a fall and a laceration requiring five stitches for R3. Findings Include: 1. R1's Care Plan, reviewed 7/14/20, includes the following Diagnoses: [REDACTED]. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is severely cognitively impaired and R1's balance is not steady. Only able to stabilize with human assistance. R1's Care Plan, documented as reviewed 7/14/20, states: I am at risk for falls related to Confusion , Poor communication/comprehension, Psychoactive drug use and increased weakness. Date Initiated: 09/16/2015. R1's Progress Note, dated 1/25/20, documents that R1 sustained a fall with a right [MEDICAL CONDITION]. On 3/4/20 R1's Care Plan documents a problem: (R1 has) a behavior problem yells out statements: help me; Where is my family; her husbands name. Though some generic interventions are documented on R1's care plan, a resident specific plan of interventions when this behavior occurs is not documented. On 5/12/20 at 3:45 PM, V3, Licensed Practical Nurse (LPN) documented in R1's progress note, Resident yelling out help me, help me I have to go to the bathroom. Where's my husband, I want to go home. R1's occurrence report by V9, Licensed Practical Nurse (LPN), dated 5/12/20 at 5:01 PM, documents (R1) observed on floor in room (R1) assessed. Complains of left hip pain with external rotation of leg. Medical Doctor and Power of Attorney notified. New order received send to ER (emergency room ) for evaluation and treatment. R1's hospital discharge Summary, dated 5/18/20, documents, [MEDICAL CONDITION] noted 5/12/20. On 8/24/20 at 12:50PM, V5, Licensed Practical Nurse (LPN), documented a progress note, (R1) continues asking and yelling for her: husband, (Daughter) where is my father, get out of here, you idiot. This behavior of calling for family members is documented in progress notes by various staff members 8/18/20, 8/21/20. There are frequent progress notes by various staff dating back over a year documenting R1's behavior of searching for husband and daughter and thinking she needs to go home. These behaviors frequently are documented mid-afternoon to evening. On 8/25/20 at 11:15AM, R1 was sitting alone in her room and appeared to be watching television. The curtain was half closed, and R1 could not be visualized without entering the room. At 1:48PM, R1 was wheeling down South Hall. There were no staff in the area monitoring R1. On 8/26/20 at 2:46PM, V8, Certified Nurse's Aide (CNA), stated, (R1) was my resident the night she fell (5/12/20). (R1) was in her room and we heard the alarm. We rushed in and (R1) had fallen into her closet. (R1) seemed to have a lot of pain. The nurse took over from there. (R1) always calls about for her husband or daughter. She will not calm down until she sees or talks to them. She had been yelling for her husband before she fell . I guess she gets up to try to find him. (R1) pretty persistently asks for him. On 8/26/20 at 3:07PM, V4, Registered Nurse (RN), Care Plan Coordinator, stated, I know (R1) does have some behaviors. I'm not sure what the behaviors are. I think we tried a lap buddy and (R1) was able to take it off easily and so we switched to a seat belt. On 3/24/20 at 3:15PM, V3, Restorative Nurse, documented that the thought of discontinuing lap buddy and starting with alarmed seat belt for safety was to try and decrease agitation episodes. On 8/26/20 at 3:15PM,when asked if the interdisciplinary team had discussed a behavioral program concentrated on R1's behavior of frequently calling out for her family, V3 stated, I don't take care of the behavioral programs. I'm not sure who does. 2. R3's [DIAGNOSES REDACTED]. R3's Minimum Data Set, dated dated [DATE], documents R3 as severely cognitively impaired. R3's Care Plan, dated April 4, 2020, documents dementia interventions including monitor, reminisce, and use task sequencing with R3. R3's Behavior Documentation Record of June 2020, documents R3 yelling/screaming on 26 separate occasions, with only documented interventions as one to one or offering food. R3's Progress Note, dated June 5, 2020, documents, (R3) crashing her wheel chair into medication cart, removing med cups, throwing all over floor. Non-pharmacological intervention of one to one, explained to resident she may end up causing injuries to self or others with this action, writer able to redirect resident. R3's Fall Documentation of June 9, 2020, 6:00 PM, documents that V6, Certified Nursing Assistant, witnessed R3 throw herself out of wheelchair in hallway. Fall resulted in a skin tear and bump on head. R3's Behavior Documentation Record of July 2020 documents 13 occasions of R3 yelling/screaming, with only behavioral interventions as one to one, offering food or toileting. R3's Fall Documentation Record of July 7, 2020, 10:30 AM, documents R3 fell trying to get out of bed. R3's Care Plan, dated August 2020, documents dementia interventions including monitor, reminisce and use task sequencing with R3. R3's Behavior Documentation Record of August 2020, documents 11 occasions of R3 yelling/screaming with the only behavioral intervention as one to one, offering food or toileting. R3's Fall Documentation of August 3, 2020 at 7:00 AM, documents R3 fell in room. Resulted in a [MEDICAL CONDITION] and 6 stitches. R3's Fall Documentation of August 23, 2020 at 6:12 PM, documents R3 fell in room out of bed. On 8/27/2020 at 9:18 AM, V2 stated that the Restorative Nurse documents on all falls and recommends interventions for implementation. On 8/27/2020 at 9:21 AM, V3, Restorative Nurse, was asked what type of dementia training V3 had been given that would relate to R3's falls, I'm not sure. On 8/27/20 at 10:10 AM, V6, Certified Nursing Assistant, was asked about V3's falls and behaviors. V6 stated, (R3)screams a lot in her room and wants us in there a lot. She tries to get out of bed and won't use her call light. When asked about R3's cognition, V6 confirmed that R3 is confused. When asked about what R3 does when her alarms go off, (R3) yells. If we don't come in when (R3) wants us, (R3) tries to get out of bed. On 8/27/20 at 9:48 AM, V2 was asked about R'3s fall interventions with respect to R3's behaviors. V2 confirmed that no specific interventions were made related to R3's behaviors. V2 confirmed that R3 is in a room that is not close to the nurse station, We don't have one across from the station currently available. V2 stated (R3) falls because she is confused and thinks that she can transfer herself. It would help if someone were with her all of the time, but we don't do one to one care. The facility's policy Fall Assessment and Management, revised 4/2019, states, It is the policy to assess each resident's fall risk on admission, quarterly,and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor and assess and ultimately reduce injury risk. Factors related to falls will be addressed and care planned. This policy also states F. Interventions will be based on fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall. Some examples may be: Falls related to gait or balance deficit, Falls related to confusion, Falls related to sensory/perceptual problems, Falls related to poor judgement or knowledge deficit.

Based on interview and record review, the facility failed to develop and implement targeted resident specific interventions to address increased agitation and fall prevention for one resident (R1) reviewed for falls in a sample list of three residents. R1 experienced expected situational agitation and sustained a fall resulting in a right [MEDICAL CONDITION] and subsequent surgical Right Hip Replacement. Findings Include: R1's face sheet, printed 2/11/20, includes the following Diagnoses: [REDACTED]. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is severely cognitively impaired and requires extensive assistance of two or more staff members to transfer/toilet. This MDS also documents R1's balance is not steady only able to (be) stabilized with staff assistance. R1's fall risk assessments, dated 11/6/19, 1/6/20, and 1/25/20, document R1 is at high risk for falls and has had prior falls. These assessments document that R1's gait is impaired (difficulty rising from chair, keeps head down when walking, grasps furniture, person or aid when ambulating). The assessments document that R1 overestimates or forgets limits with regard to ambulating safely. None of these assessments document R1's situational agitation and/or it's potential to contribute to falls. R1's Physical Therapy Assessment, dated 1/6/20, documents, Due to physical impairments and associated functional deficits, (R1) is at risk for falls. R1's Progress Note, dated 1/25/20 at 5:20PM, by V12, Registered Nurse (RN), documents, Observed (R1) standing from wheel chair, sensor alarm sounding, writer on phone, other nurse (V15, Licensed Practical Nurse) at other desk started running. (R1) going to floor, unable to reach in time to prevent. Went to floor on back, hit back of head on floor, noted wasn't extending Right leg straight, (R1) continues to complain of pain Right groin. Later documentation by V12 on 1/25/20 documents that R1 was sent to the emergency room per ambulance. R1's hospital discharge summary by V18, Medical Doctor, dated 2/5/20, documents, Acute impacted Right Femoral Neck Fracture Hip Surgery 1/28/20. R1's 1-28-20 Care Plan documents an entry initiated 9/16/15 stating, (R1) at risk for falls Related To Confusion , Poor communication/comprehension, Psychoactive drug use and increased weakness. R1's fall interventions are documented to include: be sure (R1's) call light is within reach and encourage (R1) to use it for assistance as needed, (R1) encouraged to wear shoes for all transfers and ambulation, (R1) needs a safe environment with even floors free from spills and/or clutter; adequate, glare free light; a working and reachable call light; handrails on walls, personal items within reach, ensure (R1) is wearing non-skid shoes when ambulating, monitor for potential side effects of [MEDICAL CONDITION] drugs, non skid strips in front of bed and chair, remind (R1) to use call light and not get up alone, staff to be conscious of when (R1) chooses to get up and go to (R1's) bathroom to do (R1's) morning face washing routine. There are four interventions related specifically to safety considerations to be implemented by R1's spouse and family when alone with R1. R1's 1-28-20 Care Plan does not address R1's situational agitation and/or it's potential to contribute to falls. On 2/10/20 at 1:05PM, V15, Licensed Practical Nurse (LPN), stated, After (R1's) (Visitor) left at around 3:30PM on 1/25/20, (R1) was calling out like (R1) always does. (R1) always asks where is my family and tells us (R1) needs to go home. (R1) had tried to get up unassisted several times before (R1) fell . When a resident needs constant attention, we sit them in wheelchairs outside their rooms in the hall. There were two CNAs on the hall but when (R1) fell both CNA's were busy in resident rooms. (V12) and I were at the desk. (V12) was on the phone. I heard (R1's) chair alarm, but by the time I got to (R1) had fallen. On 2/11/20 at 9:45AM, V14, Certified Nurse's Aide (CNA), stated, (V13) and I assigned to South hall on 1/25/20. I was in a resident room feeding when (R1) fell . (R1) was on the floor by the time I came out. (R1) gets real angry when (visitor) leaves. Then (R1) will try to get out of the wheelchair. (R1) used to work word search puzzles and that would keep (R1's) mind occupied but because of (R1's) dementia (R1) gets even more angry when (R1) can't find a word. We have to keep a constant eye on (R1). On 2/11/20 at 10:48AM, V12, Registered Nurse (RN), stated, I was talking on the phone V15, Licensed Practical Nurse (LPN) was at the other desk charting. (R1) was in a wheelchair sitting outside (R1's) room. The two CNAs who were assigned to the hall were in resident rooms giving care. (R1) has a habit of becoming upset when (visitor) leaves. (R1) will ask where is my family. I need to go home with my family. Then she will get up and try to walk unassisted. R1 had tried to get up several times after (visitor) left. We redirect (R1) and try to distract (R1). We used to give (R1) word search puzzles, but that only gets (R1) more upset now when (R1) can't find a word. We had several residents in the hall who needed to be supervised. I guess we could have put (R1) closer to the desk so we might have prevented (R1) from falling. On 2/11/20 at 1:30PM, V13, Certified Nurse's Aide (CNA), stated, I remember the evening (R1) fell (1/25/20). I was in a room giving a bed bath. It was Saturday. We were really busy that weekend. We had several residents with the stomach flu. By the time I came out in the hall (R1) had already fallen. (R1) gets anxious when (visitor) leaves and tries to get out of wheelchair to go home and find family. (R1) had tried to get up a few times that day before (R1) fell . When (R1) does that we just remind (R1) that her (visitor) will come back. On 2/11/20 at 1:30 PM, (V3) Restorative Nurse stated, Yes we are all aware that (R1) gets very agitated when her husband leaves. (R1) wants to go with him and will try to get up. (R1) constantly asks where is my family? I need to get home with my family. (R1) has a care plan for falls. When asked where this behavior is documented on R1's care plans, V3 stated We just all know her. On 2/11/20 at 2:00PM, V17, Physical Therapy Assistant, stated, We did evaluate (R1) on 1/6/20 after (R1) returned from an extended hospital stay. We worked with (R1) to help regain strength. (R1) was not safe for independent ambulation and basically has no safety awareness. I would expect that when (R1) is agitated especially after (Visitor) leaves, the staff would try to distract (R1) with puzzles, books, and try to talk (R1) down. On 2/11/20 at 1:15PM, V5, Medical Director, and R1's primary care provider stated, I would say that the fall (R1) experienced (1/25/20) is likely the mechanism which caused (R1's) [MEDICAL CONDITION].

Based on record review and interview, the facility failed to safely transport a resident (R23) in a wheelchair when entering a doorway. This failure resulted in R23 sustaining a laceration, requiring emergency treatment with 12 staples. R23 is one of two residents reviewed for accidents in the sample of 20. Findings include: The Physician order [REDACTED]. R23's Minimum Data Set ((MDS) dated [DATE] documents R23 as being severely cognitively impaired. This same MDS documents R23 as a one person assist with locomotion and using a wheelchair for all mobility purposes. Progress Notes for R23 dated 1/5/18 at 8:00 pm document the following: (R23) being pushed in wheelchair by a (V24, Certified Nursing Assistant) CNA shortly before 8:00 pm and resident crossed legs when entering doorway and leg caught on doorway resulting in laceration to posterior aspect of right leg. Pressure dressing applied by writer, (Medical Doctor) notified and ordered resident be sent to emergency room for evaluation and (treatment). Pain medication administered. Progress Note is electronically signed by V25, Licensed Practical Nurse. A facility document titled Occurrence Report and dated 1/5/18 documents the laceration to R23's right leg measuring 3 centimeters by 3 centimeters by 1.5 centimeters deep. The report documents that R23's leg was scraped on the wheelchair foot pedal. The report documents staff educated to be aware of all extremities of resident when going through doorways. This report is signed by V2, Director of Nursing. Hospital emergency room record document R23 arriving on 1/5/18 at 9:23 pm with a laceration to the right lower extremity and repair of laceration with staples. R23's leg was also x-rayed due to R23 complaining of pain. The x-ray was negative for fracture. R23 was discharged back to the facility. Progress Notes for R23 dated 1/6/18 at 1:33 am document R23 arriving at the facility from the hospital with 12 staples to the posterior right leg and staples are to be removed in 7 days. On 3/7/18 at 1:10 pm V2 Director of Nursing stated that V24 was a new CNA and was just learning. V2 stated V24 should have made sure the resident's (R23) extremities were protected. V2 stated (R23) has a large wheelchair and has dementia. (R23) flails (R23's) arms and legs. V24 should have known this. On 3/9/18 at 11:15 am, V21 Primary Care Physician for R23 stated that the laceration to R23's leg was caused from V24 not transporting R23 in a safe manner. V21 stated When you are transporting a resident with dementia, regardless of their moving extremities, you have to know the placement of those extremities before entering a narrow doorway.

Based on record review and interview, the facility failed to provide close supervision for R24, given a known history and tendency to unsafely self transfer and ambulate. R24 is one of seven residents reviewed for falls in the sample of 15. This failure resulted in R24 sustaining a hematoma to the head and a brain hemorrhage. Findings include: The Physician order [REDACTED]. The Resident Assessment Instrument (RAI) dated 6/2/15 for R24 documents the following: R24 has total dependence on staff and needs the assistance of two persons for all transfers and for toileting. R24 requires the use of assistance for ambulation on and off the unit. R24 uses a wheel chair for mobility purposes. The RAI documents that R24 has total dependence on staff for eating with the assist of one person. R24 is not able to stabilize herself without staff assistance when moving from seated to standing positions, turning around while standing and surface to surface transfers. R24's Fall Risk Assessments dated 5/15 and 5/15 document R24 as being at High Risk for Falls. Facility Nursing Notes dated 4/27/15 document that R24 is not able to be left unattended. (R24) keeps trying to ambulate and transfer self. On 5/5/15 Nursing Notes document notification to R24's son that R24's behaviors have increased and the facility is not able to provide one on one care, alternative placement may be needed. Nursing Notes dated 5/18/15 document behaviors continue, R24 is in need of one on one care and alternative placement may be necessary. On 5/23/15, Nursing Notes document that R24 continues to attempt to get up from the wheelchair and ambulate without assistance. On 6/10/15 Nursing Notes document that R24 has been up all night and had to be brought out to the nursing desk for supervision due to R24 trying to get up per self. Facility Occurrence Reports document the following: On 4/27/15, R24 was noted on floor in room. R24 lost balance and fell . On 5/15/15, R24 was sitting in wheelchair and had an unwitnessed fall, sustaining a laceration to the left arm. Alarm sounding. R24 is unable to communicate what happened. R24 was sent to the emergency room for treatment and evaluation of left forearm laceration and was returned to the facility the same day. On 6/24/15 R24 was in a chair in the dining room and got up and fell , hitting (R24's) forehead on the ground. No alarm sounding. A facility resident (unidentified) stated (R4) got up from the table to walk away and lost balance and fell striking head very hard on the floor. The report documents (R24) is often restless and agitated and frequently attempts to stand up and ambulate without assistance. (R24) is unsteady during ambulation and needs assistance .(R24) is unable to communicate with staff the reason she is attempting to stand up. R24 was sent to the hospital for evaluation and treatment of [REDACTED]. E2, Director of Nursing documents in the follow up procedures of the facility Occurrence Report dated 6/24/15 the following: (R24) at one time was able to walk independently. Now (R24) cannot walk a straight line, is continually stumbling over her own feet and running into walls and surroundings. (R24) cannot carry on a conversation, speaking in incomplete sentences and rambling forms of communication has never used any form of walking aid and cannot comprehend how to use a cane or walker has began to show times of combativeness with care and overall change in personality. Son, Power of Attorney is aware and is not able to give much assistance with one on one care or sitting due to busy work schedule. (R24) requiring one on one supervision with such poor safety awareness. A Hospital report tilled Radiology Report/Computed Tomography of R24's brain dated 6/24/15 documents: R24 has a left forehead injury status [REDACTED]. Subcutaneous hematoma overlying the lateral left frontal bone. R24 was admitted to the hospital for observation and returned to the facility on [DATE]. On 1/22/16 at 11:45 am, E2 Director of Nursing stated the facility had been trying to find different placement for R24 because of R24's need of one on one care/supervision even prior to the 6/24/15 fall. E2 stated R24's son could not help with providing one on one with R24 due to his work schedule. E2 stated she had thought about putting R24 in the second dining timeframe because there was more staff for assistance and R24 needed more supervision, but had not done it until after R24 fell on [DATE]. On 1/22/16 at 12:55 pm Z2, Primary Care Physician and Medical Director stated that R24 had declined mentally and physically in the last several months due to Dementia and Alzheimers. Z2 stated R24 needed closer supervision and if second dining had more staff, then that's where R24 should have been. Z2 acknowledged that R24's lack of supervision may have contributed to the fall and in turn caused the trauma to her forehead, resulting in a brain hemorrhage. A facility Discharge Summary Report dated 7/1/15 documents that R24 was discharged and transferred to a different facility due to R24 requiring one on one care.

Based on interview and record review the facility failed to provide sufficient staff to assist with resident transfer and ambulation for one of six residents (R20) reviewed for falls in a sample of 15. This failure resulted in R20 sustaining a fall with fracture to the left ankle. Findings include: R20's Endurance/Functional Ability assessment dated [DATE] states, "Recommend two assist for walking and transferring resident in room with walker..." R20's Care Plan interventions dated 2/17/14 stated, "Restorative to assess resident ambulation..." R20's Care Plan interventions dated 2/18/14 states, "Two assist for transfers and walking resident with wheeled walker in room and bathroom." An incident summary dated 4/08/14 states, "...Resident ambulating with walker from bathroom to bed, standby assistance with gait belt around resident waist provided by (R20's) CNA (Certified Nurse Aide)." The incident summary documents, "Resident stated to CNA that her leg was giving out." The incident report documents R20 was lowered to the floor at which time R20's left ankle was "twisted." The incident summary documents an X-ray was performed and indicated R20 had a fracture to the left ankle. R20's X-ray report dated 4/08/14 confirms R20 sustained, "Non displaced fracture of distal fibula with soft tissue swelling." On 12/16/14 at 10:45a.m. E6 (Restorative Nurse) verified R20 was assessed for ambulation assistance needs on 2/18/14. E6 stated, "Because of obstacles in (R20's) room and because of (R20's) behaviors I assessed (R20) needed the assistance of two (staff) for walking and transferring," while in R20's room. On 12/16/14 at 12:00p.m. E2 (Director of Nurses) verified R20 fell sustaining a fractured left ankle 4/08/14 while walking in R20's room with the assistance of only one CNA.

Based on interview, observation and record review, the facility failed to assess, analyze the circumstances of falls and develop effective interventions to prevent further falls and failed to attempt alternative interventions and provide adequate supervision for 4 (R14, R12, R7, R3) of 7 sampled residents reviewed for falls. This failure resulted in R14 falling on [DATE] and fracturing her left humerus. Findings include: 1. MDS dated [DATE] identifies R14 as being interviewable and requiring minimal assist of one staff for all mobility except corridor ambulation and locomotion. R14's balance is assessed as "unsteady but able to stand and balance without assistance." According to the J1800 section of the MDS of [DATE], R14 has had no falls since admission and/or prior to admission to the facility although the Incident/Accident log indicates R14 had documented falls on [DATE] and [DATE] sustaining injuries from both falls. The care plan dated [DATE] identifies R14 to be at risk for injuries due to multiple falls. Interventions include assuring call lights within reach at all times, pressure alarm in bed and chair ([DATE]), assist with all transfers, ambulation and toileting, keep her bed in lowest chair, instruct her repeatedly not to attempt to get up without assist among others. The last two interventions added include ([DATE]) reminding staff that R14 can be anxious and impatient and [DATE] monitor for any changes. According to incident reports, R14 sustained a 4cm x 4cm hematoma occipital head and 4cm x 3cm skin tear right wrist on [DATE] when the alarm sounded and staff was unable to reach her before she fell to the floor. Interventions added at that time include Physical Therapy for balance training, and re-orient her to call light, reminding her to ask for help as needed for times she needs to get out of chair. R14 had no additional falls until [DATE]. According to the INCIDENT/ACCIDENT LOG, R14 had an unwitnessed fall to the floor on [DATE] at 5:15am. The report states the alarm was sounding and R14 was "observed on the floor face down with left arm under her chest. Head was facing closet/dresser." Half bed rails were up. The fall report indicates she was attempting to ambulate to the bathroom "because she had urgency." The report describes her gait as "unsteady" and states "She shuffles her feet and walks briskly." R14 sustained a laceration to the area above her left eyebrow, large skin tear right below the left knee extensive serous drainage noted, and complaints of left arm pain with a suspected fracture. She was transported to the emergency room where she received 5 sutures left eyebrow, hematoma around left eyebrow, and fractured humerus with arm sling placed. The radiology report dated [DATE] states "Comminuted mildly impacted fx (fractured) nec of humerus and avulsion greater tuberosity." R14 returned to the facility. The fall report indicates recommendations included re-educating her to the importance of using her call light and waiting on staff to come and assist, re-educate that when she hears the alarm to sit back down and wait for staff to come, keep the call light within reach and asked maintenance man to apply gripper pads to floor next to bed among others. The care plan shows no additional interventions added to it after after this fall with injury and no documentation toward the effectiveness of the alarm when staff are unable to reach in time is not reflected in the report and/or care plan. In addition, there is nothing in the falls prevention plan regarding R14's toileting needs. On [DATE] at 7am, R14 was found on the floor again. The nurses notes states "res found sitting on the floor in front of her recliner & next to her bed. Res stated she was trying to get up and go to the bathroom and lost her balance." The report indicates no apparent injury noted and left arm sling in place. The witness statement says "saw resident sitting on her recliner, heard alarm going off, went & checked on to the res. Res sitting on the floor." There is no explanation as to why staff was unable to respond to the alarm before R14 fell . New recommendations include adding grippy socks to resident when she prefers to be sock footed. Keep call light pinned to her recliner chair and on the right side so she can reach it, and asked nursing to add longer strips of grippers in front of the recliner chair in an attempt to give her tractions for future" but again fails to include R14's toileting needs since this is the second fall trying to take herself to the toilet. The conclusion on the report indicates that R14 did not turn on call light to ask for help and attempted to get up on own without assistance losing her balance and falling to the floor. There is no indication at this point that indicates R14 appropriately uses her call light and/or that the alarm sounding deters her from continuing to get up unassisted or that the facility identified that R14 was taking herself to the toilet when she fell all three times. There is no reference to scheduling toileting in an effort to meet this need in falls prevention. Restorative notes dated [DATE] indicates staff met with R14's family member regarding falls and subsequent fractured left humerus with daughter and asked to move R14 to a room closer to the nurses station so staff could monitor her on a more closer basis. The report indicates the family refused citing concerns with R14's increased confusion as the reason. However, there is no evidence the facility came up with an alternative plan to moving R14 closer to the nurses station. This was confirmed in interview with the Restorative Nurse on [DATE] at 10:30am. On [DATE] at 12pm, the facility provided a Restorative Program Care Plan dated [DATE] that included a toileting program that identified R14's need as "assist to toilet to maintain continence of urine and safety with toileting/transfers." The physician (Z1) saw R14 on [DATE]. The note indicated that R14 would continue with a sling and re-xray in a month. On [DATE], therapy saw R14 and implemented treatment three times per week. Safety awareness was marked as "poor" with pain level ,[DATE] with 5 being the worse. An Occurrence report dated [DATE], states R14 was again found on the floor at 2:10pm. The report indicates that the Certified Nurses Aide (CNA) heard the alarm, ran into her room to find R14 on the floor already. The nurses notes indicate that it "appeared her feet got tangled in blanket that she was covered up with prior to the fall" and that R14 stated she was trying to use the bathroom. The alarm was sounding . The conclusion of the report states "alert but confused resident who has fallen recently with bone in arm fractures and currently wearing sling, stated that she got up to toilet self, got her foot tangled in her blanket across her lap, causing her to lose her balance and fall. Resident did not turn on call light, CNA in hallway two doors down heard her alarm, ran to her room but resident was already on floor." R14 complained of pain to the same arm and a mobile x-ray was ordered. Recommendations made as a result of the fall include "educate resident at all times to use her call light and be patient, to given CNA time to get to her and help her to bathroom, move resident to a room closer to nurses station" were made. There is no evidence that the facility identified whether R14 could effectively use the call light given her cognitive impairment and no evidence that alternative safety devices were considered in an effort to keep her from falling. There is also no evidence that a room change closer to the nurses station was done and that the facility provided added supervision to respond to the alarm. The mobile x-ray shows R14's fracture worse after the fall on [DATE]. The report identifies a "Subacute moderately displaced fracture of the humerus surgical neck with extension of the fracture into the greater tuberosity." The physician and family was notified with the family requesting comfort care care only. No treatment was provided except pain management. On [DATE], R14 had Roxanol .25ml and Ativan 0.5mg ordered every two hours. On [DATE], the physician's assistant saw R14 and wrote in her note "pt fell this week et re-injured L (left) humerus. She has had (increase) in pain et was placed on Roxinol which has helped (decrease) pain. Pt is declining in functional status since 1st fall which resulted in initial fx (fracture) of humerus." The note continues to state "body language denotes pain with movement", general appearance is documented as "uncomfortable" and assessment plan states had "refracture and family declined eval at (hospital).. she is in obvious pain and is not eating or drinking." R14 expired later that day on [DATE]. Discharge summary brief note that lead to discharge states "Very pleasant confused resident on O2 at times. Very independent failed to ask for help or forgot at times." On [DATE] at 2pm, interview with the physician's nurse, Z2, indicated that R11 returned to the facility following the first fall with a splint and the Doctor saw her on [DATE]. Z2 indicated that the third fall resulted in a displaced fracture of the humerus and increased pain. The physician's nurse indicated that Z1, Physician, discussed the re-injured fractured humerus with the family following the fall on [DATE] but they declined treatment and opted to keep R14 comfortable. Observation of R14's room on [DATE] shows that it is at the end of the hall farthest from the nurses station. On [DATE] at 9:34am, E13 Registered Nurse (RN) was asked if R14 used her call light and responded "No, never." E13 stated R14 was confused and you could "remind her and remind her" to call for assistance and not get up but she didn't get it. E13 stated R14 had a "very quick gait, as soon as she was up, she was in the bathroom." E13 stated R14's alarm sounded at least every shift and stated the alarm did not deter her from getting up. E13 described R14's gait as unsteady as well as standing balance. On [DATE] at 2:34pm, E15 CNA was asked if R14 used her call light appropriately and stated "very seldom." E15 also stated R14 was very quick once she was up and that the alarm did not deter her from getting up once it sounded. E15 stated R14's gait and balance as unsteady. On [DATE] at 3:40pm, E11, MDS/Care Plan Coordinator stated the facility tried different interventions following the falls including moving her closer to the nurses station which the family refused. E11 stated R14 was placed in a geriatric chair following the second fall because "she was leaning so bad" and because of "her poor little arm." No new MDS was done even though R14 did exhibit a significant decline. E11 stated they also placed her at the nurses station and did 1:1's at times because of her falls. E11 stated after her second fracture ([DATE]), on [DATE], they did 1:1's frequently. E11 also said scheduled toileting was implemented as a restorative program and agreed that it was not incorporated into the falls program. The facility's policy entitled FALL ASSESSMENT, RISK IDENTIFICATION AND MANAGEMENT POLICY indicates that the facility is to assess each resident's fall risk on admission, post fall - immediately after fall and careplan. Interventions toward management falls will be based on resident assessment and the circumstances surrounding the risk for injury or actual injury or fall and may include gait/balance deficits, confusion, toileting needs, poor judgement or knowledge deficit among others. Restraints may be used only in compliance with facility policy and procedure. 2. According to the MDS dated [DATE], R12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicates R12 required extensive assist of one staff for all aspects of mobility and balance deficits which the coding indicates "Not steady, only able to stabilize with human assistance." The care plan dated [DATE] identifies R12 as being at risk for falls due to Parkinson's, generalized weakness, spinal stenosis and "gait shuffled and unsteady" with a history of falls. R12 is also receiving restorative services for transfer and ambulation. The care plan for transfer describes R12's balance as "unsteady during surface to surface transfers." Restorative Notes dated [DATE] stated under MOBILITY/GAIT/BALANCE that husband states had approximately 12 falls in last 6 months period prior to admission. Needs assist for transfers, bed mobility and walking with WW (wheeled walker). Gait is unsteady. W/C (wheelchair) primary mode of locomotion of/off unit and needs assist of staff to propel W/C." In additional notes, the restorative evaluation indicates hospital history/physical notes loss of balance, continued weakness with neurology consult. An Occurrence Report dated [DATE] states R12 fell at 7:50am while in the bathroom with staff. The report states "CNA state that she, herself, was standing in the doorway of the BR watching res (resident) brush her teeth, as she normally does, with residents wig in her hand. Resident finished brushing her teeth, put the tooth brush down and began to pivot towards the doorway when she lost her balance and started to fall. Resident tried to grab a hold of sink to catch herself but couldn't. Resident then fell to the floor hitting her head on the wall and landing on her buttock." R12 complained of low back pain following the incident. The Conclusion section of the report indicates "CNA attempted to reach out and stop her from falling with resident also trying to grab onto sink to kept from falling." Following the incident, R12 complained of back pain and x-rays were done with no findings. The report indicates pain medication was given throughout the entire day with a new order for stronger pain medication obtained from the physician. The facility concluded that the cause of the fall was that R12 was turning to pivot around causing her to lose her balance therefore causing fall. However, there is no reference to the CNA standing on the other side of the wheelchair out given that R12 had balance deficits identified already. In addition, there is also no reference to R12's wheelchair being between the resident and the CNA which prohibited the CNA from being able to break R12's fall and/or steady her when she went to pivot that day or if R12 had a gait belt on at the time of the fall. The care plan fails to include whether or not a gait belt is to be utilized when R12 is transferred and ambulated. According to the restorative note dated [DATE], R12 was placed on a sit to stand mechanical lift on [DATE]. On [DATE], therapy inservice notes indicate that the resident would benefit from a ,[DATE] person transfer with w/w + gait belt and a recommendation to discontinue the sit to stand was given. The noted states staff "must use gait belt @ (at) all x's (times) (secondary) to pt (patient) fear + prior history of falls." The restorative notes dated [DATE] states R12 had a "fear of falling. Needs assist for transfers, bed mobility and walking with WW. Unsteady during transfers and walking and only able to stabilize with human assist." There is nothing in her report regarding R12's safety awareness ability. The report indicates that R12 is now able to bear weight thru bilateral lower extremities with assist. R12 exhibited a decline in overall condition following her fall on [DATE]. Interview with E13, RN, who was working at the time R12 fell and completed the report, could not recall if R12 had a gait belt on at the time of the fall or not and described her standing balance as "unsteady." E3, Corporate Nurse, stated on [DATE] at 3:40pm that the CNA normally allowed R12 to stand at the sink and brush her teeth and that it was a normal routine for R12. E11, Care Plan Coordinator stated on [DATE] at 3:40pm that R12's wheelchair was between the CNA and resident at an angle but not directly behind her. E11 stated R12 lost her balance and fell to the side. The CNA wasn't expecting it and was unable to catch her. E11 and E13 both stated R12 pivoted toward the doorway but didn't fall in that direction. Both were asked if R12 had a gait belt on and stated they didn't know but E11 stated they probably should have had one on her. The CNA was unable to steady or break R12's fall when she started to lose her balance. On [DATE] at 1:33pm, E5 and E16 CNA's went into R12 room. E16 told R12 that she was going to walk her to the toilet and as she was walking behind R12's wheelchair, R12 began to stand up immediately. E16 told R12 to wait until she got a gait belt on her and turned the alarm off. R12 was then assisted by both CNA's to stand and with the wheeled walker, took very slow deliberate steps toward the bathroom. Both CNA's used the gait belt to steady R12's balance as she walked. On [DATE] at 11:30am, R12's husband stated that R12 walked into the facility with a wheeled walker and then had the fall. He stated R12 had declined since that fall in mobility and is currently taking therapy and getting better. On [DATE] at 1pm, the Certified Restorative Nurse was asked about R12's safety awareness and responded "I would say she is spontaneous." 2. Review of R7's record indicates R7 was admitted to the facility on [DATE] with the following diagnoses, in part, Alzheimer's with Depressive Features, Aphasia, Transient Ischemic Attacks, Myocardial Infarction, Atrial Fibrillation, [DIAGNOSES REDACTED], Urinary Tract Infections, History of Uterine Cancer and Hyponatremia. Review of R7's quarterly minimum (MDS) data set [DATE] indicates that R7 usually understands and is usually understood. She rated a "4 out of 15" on cognition. R7 has disorganized thinking, inattention and wanders 1 to 3 days out of 7 days. Review of "Occurrence Report Log" R7 as noted to have thirteen falls between [DATE] and [DATE]. R7 received a minor injury of a hematoma to left eyebrow during fall on [DATE]. All of R7s other falls were without serious injury. Review of "Follow-up Report to Occurrences" indicated that the facility made the following recommendations: [DATE] - call family for one to one care and inform staff to watch closely; [DATE] - Nurse Practitioner to evaluate on [DATE] and give as needed medications intramuscularly; [DATE] - continue one to one staff or sitter and added new medication at bedtime; [DATE] - continue one to one sitter, check alarms and occupy R7 by playing "Rummy" card game; [DATE] - to continue previous interventions, in addition try to get R7 to lay down, or offer food and/or fluid; [DATE] - Activity Director and activity personnel to keep R7 occupied with playing cards; [DATE] - monitor closely when sitters not utilized and continue to keep R7 occupied; [DATE] - staff to be aware of where about's, add new medication of Xanax and keep family aware of need for sitters; [DATE] - educate family to tell nursing staff when the family leaves R7 alone in the facility; [DATE] - reorient R7 to her surroundings, instruct to use call light and staff to monitor R7; [DATE] - staff to continue to monitor, provide hydration, nutrition and toileting, reorient; [DATE] - staff to continue to monitor where about's and for pain, provide hydration and nutrition; and [DATE] - continue to monitor, treat for pain, encourage good nutrition and hydration, and certified nursing assistants are to ensure R7's pressure alarm is in place and working. Review of R7's nurses notes indicate despite multiple interventions R7 had another fall without injury on [DATE]. Interview with E10 (Social Service Director-SSD) at 1:10 p.m. on [DATE] indicates that R7's family does not want to use restraints that would agitate R7 more. Interview with E10 (SSD) and E9 (Certified Occupational Therapy Assistant -COTA) at 1:20 p.m. on [DATE] indicates that they do not believe that R7 would benefit from any other positional device. E9 (COTA) and E10 (SSD) confirmed that the facility had not completed a formal wheelchair evaluation prior to this date. 3. R3's Minimum Data Set (MDS), dated [DATE] and [DATE], documented severely cognitively impaired, extensive assistance with one person physical assistance with transfer and mobility and a history of falls. R3's Care Plan, initially dated [DATE], documented R3 was at risk for falls due to decreased standing balance unsteady gait, hearing and vision deficits and history of falls. It was also noted R3 fell , in part, on [DATE], [DATE], [DATE], [DATE] and [DATE]. R3's Occurrence Report Conclusions documented: On [DATE], R3 was observed sitting in front of her wheel chair on the floor with alarm sounding. Interventions to re-orient R3 to wheel chair, sound alarm makes and to ask for help before attempting to get out of wheelchair. R3's MDS documented she was severely cognitive impaired. On [DATE], R3, due to small statue and weakness of R3, R3 was unable to hold herself up as R3 was sliding from chair. Interventions, in part, to remind resident to sit up straight and tall in wheel chair and to use place a assistive seating device in her chair. On [DATE], R3 was found on the floor after sliding out of bed. Interventions to re-orient R3 to room and surrounds and to use her call light when she needs help getting up. It was also noted R3 due to her cognition would most likely not remember to use the call light. On [DATE], R3 slide out of her reclining chair. Interventions, in part, were to reorient R3 to her call light and re-instruct her to utilize call light when needing assistance to transfer. On [DATE], R3 was found lying on the floor after sliding off her chair. Interventions, in part, were to re-orient R3 to her room, soundings, call light and knowing to always ask for help when she needs to get up. R3's Care Plan did not document R3's [DATE] fall or interventions to prevent further falls. R3's Care Plan documented, [DATE], "Assist R3 with all transfers. Pressure alarm in bed and chair. Keep bed in low positron." R3's Occurrence Reports did not consistently document the status of the pressure alarm, either bed or chair or the effectiveness of the alarm(s) as an effective intervention to prevent falls. Only R3's [DATE] Occurrence Report documented the the status of her alarm, sounding or not, with her fall.