Every finding on record at Odd Fellow-Rebekah Home

Based on observation, interview and record review the facility failed to ensure the dignity of two (R1, R4) residents out of three residents reviewed for Resident Rights out of a sample list of seven residents.Findings include:1. R4's Electronic Medical Record (EMR) documents R4's medical diagnoses as Abnormalities of Gait and Mobility, Muscle Weakness, Spinal Stenosis, Dementia, Senile Degeneration of Brain and Palliative Care. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 is dependent on staff for bathing, dressing, personal hygiene and requires maximum assistance for toileting, bed mobility and transfers.On 8/7/26 at 1:48 PM, V22 Certified Nurse Aide (CNA) and V25 CNA transferred R4 from the wheelchair to the toilet using a mechanical stand lift. R4's pants were saturated with urine from the waistline to the back of R4's knees. R4's cushion in R4's wheelchair was urine soaked. V22 CNA attempted to remove R4's wheelchair cushion but it was stuck to the seat of the wheelchair with unknown food/liquids so much that the front of the wheelchair lifted off the floor two to three inches before the cushion would release from the food debris. On 8/7/26 at 2:00 PM, V22 CNA stated R4's wheelchair cushion being stuck to the wheelchair seat was 'gross!'. V22 CNA stated V22 could not identify what food/liquid it was that was sticking R4's wheelchair cushion to the wheelchair seat. On 8/7/26 at 2:10 PM, V22 CNA stated R4 was toileted right after breakfast about 9:00 AM. V22 CNA stated R4 had not been toileted since 9:00 AM due to V22 CNA was too busy assisting other residents.2. R1's Electronic Medical Record (EMR) documents R1's medical diagnoses as Alzheimer's Disease, Dementia, Bone Density Disorder, Pulmonary Hypertension, Psychosis, Glaucoma, History of Falls and Urinary Tract Infection (UTI).R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as totally dependent on assistance from staff for eating, oral hygiene, dressing, bathing, toileting, personal hygiene, bed mobility and transfers. R1 requires a total body mechanical lift for transfers. On 8/5/26 from 9:20 AM-1:10 PM, R1 sat in R1's wheelchair. Staff did not assist R1 with repositioning or toileting during this time. On 8/5/26 at 1:15 PM, V10 Certified Nurse Aide (CNA) and V20 Licensed Practical Nurse (LPN) removed R1's pants to assess R1's skin. R1 was wearing two disposable incontinence briefs and two cloth incontinence pads. Both of R1's incontinence briefs and one of the cloth incontinence pads were fully saturated with urine. R1's buttocks and upper thighs were very red and wet with urine.On 8/5/26 at 1:40 PM, V10 Certified Nurse Aide (CNA) stated staff should never use two incontinence briefs. V10 CNA stated another CNA was on R1's hallway earlier today but had to leave so V10 CNA took over R1's care at 9:30 AM. V10 CNA stated R1 has not been provided with incontinence care since prior to 9:30 AM due to V10 CNA has been trying to 'catch up' on all of the tasks that were left when the previous CNA left. V10 CNA stated V10 did not place two incontinence briefs on R1. On 8/12/26 at 2:15 PM, V2 Director of Nurses (DON) stated staff should provide toileting to dependent residents every two hours and as needed. V2 stated staff should not use more than one incontinence brief at one time due to it could cause a higher risk of skin breakdown and/or infections. V2 DON stated the facility does not have a policy for this, but the expectation is that the staff follow standards of practice. V2 DON confirmed the standard of practice is to provide toileting every two hours and not use more than one incontinence brief. The facility policy titled Long Term Care Ombudsman Program Resident Rights for People in Long Term Care Facilities revised November 2018 documents the facility must treat residents with dignity and respect and must care for residents in a manner that promotes their quality of life.

Based on observation, interview and record review the facility failed to report injuries of unknown origin to the State Agency for one (R4) resident and failed to report injuries of unknown origin to the Abuse Coordinator/Designee for one (R1) resident out of three residents reviewed for injuries of unknown origin in a sample list of seven residents.Findings include:1.R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 is dependent on staff for bathing, dressing, personal hygiene and requires maximum assistance for toileting, bed mobility and transfers.R4's Nurse Progress Note dated 6/29/26 at 1:17 PM documents R4 has a contusion over R4's Left and Right chest area. R4's Skin assessment dated [DATE] documents R4's Left Chest bruise as measuring 7.5 centimeters (cm) long by 4.0 cm wide and R4's Right Chest bruise as measuring 4.5 cm long by 1.3 cm wide. This same assessment documents R4's chest bruising as facility acquired and first identified on 6/29/26. 2. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as totally dependent on assistance from staff for eating, oral hygiene, dressing, bathing, toileting, personal hygiene, bed mobility and transfers. R1 requires a total body mechanical lift for transfers. R1's Nurse Progress Note dated 8/4/26 at 4:57 PM documents R1's skin assessment was completed showing a 3.0 centimeter (cm) long by 2.4 cm wide bruise noted under R1's Right eye.On 8/4/26 at 12:00 PM, R1's Right jawline and Right Cheek in front of R1's Right Ear both show separate quarter sized yellowed bruises. R1 has a very dark purple quarter sized bruise directly under R1's Right Eye. On 8/12/26 at 11:50 AM, V2 Director of Nurses (DON) stated R4's chest bruises were first identified on 6/29/26 when the staff reported them to V2. V2 DON stated the facility did not submit an investigative report to the State Agency due to V2 DON did not feel like R4 was abused. V2 DON stated the facility should have submitted an initial and final report to the State Agency. V2 DON stated V2 was made aware of R1's facial bruises (Right Cheek, Right Jaw and under Right Eye) on 8/4/26. V2 DON stated V2 is unsure what caused R1's facial bruises. V2 DON stated V2 does not believe R1 was abused but is unable to determine how R1's facial bruising occurred. V2 DON confirmed R1's yellow Right Cheek and Right Jaw bruises are older appearing than under R1's Right Eye that was a dark purple bruise based on the color of the bruises. V2 DON stated staff should have reported R1's facial bruises as soon as it was identified on 7/28/26. The facility policy titled Resident Care Policy and Procedure regarding abuse and neglect, involuntary seclusion, exploitation, misappropriation of resident property, injuries of unknown origin and social media revised January 29, 2026 documents injuries of unknown source, including, but not limited to, significant bruises, fractures, dislocations, lacerations, abrasions, contusions, lumps and/or severe swelling shall be reported immediately to the charge nurse, the Director of Nurses, and the Administrator. The Administrator shall provide the State Agency with initial notice of the incident of unknown origin immediately after the incident becomes known.

Based on interview and record review the facility failed to thoroughly investigate one (R4) resident injuries of unknown origin out of three residents reviewed for injuries of unknown origin in a sample list of seven residents. Findings include:R4's Electronic Medical Record (EMR) documents R4's medical diagnoses as Abnormalities of Gait and Mobility, Muscle Weakness, Spinal Stenosis, Dementia, Senile Degeneration of Brain and Palliative Care. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 is dependent on staff for bathing, dressing, personal hygiene and requires maximum assistance for toileting, bed mobility and transfers.R4's skin assessment dated [DATE] documents R4's Left Chest bruise as measuring 7.5 centimeters (cm) long by 4.0 cm wide and R4's Right Chest bruise as measuring 4.5 cm long by 1.3 cm wide. This same assessment documents R4's chest bruising as facility acquired and first identified on 6/29/26. The facility was unable to provide documentation of a thorough investigation of R4's chest bruises acquired on 6/29/26. On 8/7/26 at 12:45 PM, V18 Certified Nurse Aide (CNA) stated V18 assisted R4 with morning cares on 6/28/26. V18 CNA stated V18 assisted R4 out of R4's pajamas, assisted with R4's Activities of Daily Living (ADL) and then into clothes for the day. V18 CNA stated R4 did not have any bruises on R4's chest during V18's shift from 6:00 AM-2:00 PM on 6/28/26. V18 CNA stated V18 returned to work on 6/29/26 and noticed R4's large dark red bruise on R4's Left chest and a second large dark red bruise on R4's Right chest. V18 stated V18 notified V26 Licensed Practical Nurse (LPN) immediately. V18 CNA stated both of R4's Left and Right chest bruises were located between R4's collar bones and R4's breasts but closer to R4's breasts. V18 CNA stated R4's bruises would not be caused by the mechanical lift due to R4's bruising did not line up with the front of the lift bar. V18 stated R4 does get agitated but R4 does not hit or get combative. V18 CNA stated R4 was wearing a different night gown on 6/29 than on 6/28.On 8/7/26 at 1:30 PM, V23 Licensed Practical Nurse (LPN) stated V23 worked day shift on 6/29/26 and was told about R4's chest bruises. V23 LPN stated both of R4's chest bruises were large, dark red and did not have a particular identifiable shape. V23 LPN stated the staff reported to V23 that R4's bruises happened on night shift the evening of 6/28/26 and early morning of 6/29/26. V23 LPN stated V23 notified V2 Director of Nurses (DON) of R4's Left and Right chest bruises and stated there was no assignable cause. On 8/12/26 at 1:30 PM, V2 Director of Nurses (DON) stated R4 had a Left Chest bruise and a Right Chest bruise first noted on 6/29/26. V2 DON stated the facility is not able to provide documentation of a thorough investigation to determine the cause of R4's Chest bruises. V2 DON stated no other residents, or staff were interviewed to determine the cause of R4's chest bruising. V2 DON confirmed the investigation was missing key components and therefore was not complete. The facility policy titled Resident Care Policy and Procedure regarding abuse and neglect, involuntary seclusion, exploitation, misappropriation of resident property, injuries of unknown origin and social media revised January 29, 2026, documents after an initial report of suspected abuse or neglect is sent to the State Agency, the Administrator or designee shall investigate all alleged incidents of abuse or neglect. The investigation shall include, if possible, interviews with all parties involved and potential witnesses. If possible, at least two interviewers shall be present for each witness interview. When possible, the investigation shall include signed statements from those persons who saw or heard information pertinent to the incident. The Administrator shall keep copies of all notes of all interviews conducted by the Administrator or other facility interviewer during the investigation. The Administrator shall be responsible for supervising the investigation and reporting the results of the investigation to the Illinois Department of Public Health.

Based on observation, interview and record review the facility failed to implement fall interventions for one (R2) resident and failed to provide a safe total mechanical lift transfer for one (R1) resident out of three residents reviewed for Accidents in a sample list of seven residents.Findings include:1. R2's Electronic Medical Record (EMR) documents R2's medical diagnoses as Cardiac and Vascular Implant, Colostomy, Vascular Dementia, Transient Ischemic Attack (TIA), Unsteady on feet, Urine Retention, Cerebral Infarction, Abnormalities of Gait and Mobility, Muscle Weakness, Osteoporosis and Bilateral Primary Osteoarthritis of Knee. R2's Fall Investigation dated 7/12/26 documents R2 slid out of R2's wheelchair. R2's Care Plan intervention dated 7/12/26 documents staff are to remove R2's total body mechanical lift sling when R2 is up in the wheelchair.R2's Fall Investigation dated 8/2/26 documents R2 slid out of the wheelchair. This same report documents R2 was sitting on the lift sling in the wheelchair which contributed to the cause of the fall. On 8/5/26 at 10:27 AM, R2 stated that R2 fell on 8/2/26 and hurt R2's hip. R2 stated R2 slid out of R2's wheelchair due to the seat being slick. On 8/12/26 at 12:00 PM, V2 Director of Nurses (DON) stated the staff should follow R2's care plan to help to prevent falls. V2 DON stated R2 is supposed to have the total body mechanical lift sling removed when up in the wheelchair. V2 DON confirmed R2 was sitting on the sling which partially caused R2's fall out of the wheelchair on 8/2/26.2. R1's Electronic Medical Record (EMR) documents R1's medical diagnoses as Alzheimer's Disease, Dementia, Bone Density Disorder, Pulmonary Hypertension, Psychosis, Glaucoma, History of Falls and Urinary Tract Infection (UTI).R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as totally dependent on assistance from staff for eating, oral hygiene, dressing, bathing, toileting, personal hygiene, bed mobility and transfers. R1 requires a total body mechanical lift for transfers. R1's Fall Investigation dated 7/27/26 documents R1 had a witnessed fall from the total body mechanical lift while being transferred from the wheelchair to R1's bed. This same investigation documents (V4) Certified Nurse Aide (CNA) was standing behind (R1's) wheelchair. (V4) hooked up the front of the sling and (V22) CNA hooked up the middle. (V22) began to lift (R1) up. (V4) pulled the wheelchair out from underneath (R1). (R1's) Right leg dropped. (V4) grabbed (R1) by (R1's) leg and head. (R1) was falling out of the sling so (V4 and V22) lowered (R1) to the floor. This happened in between the beds in the room. (R1's) sling appeared to not be looped. This same investigation documents the facility determined the root cause of R1's fall on 7/27/26 as R1 was lowered to the floor related to mechanical lift sling. On 8/5/26 at 1:00 PM, V10 Certified Nurse Aide (CNA) and V20 Licensed Practical Nurse (LPN) transferred R1 from the wheelchair to R1's bed using a total body mechanical lift with a white sling with rainbow-colored straps. After attaching the total body mechanical lift straps, V10 CNA lifted R1 out of R1's wheelchair with V20 LPN standing behind R1. R1's total body mechanical lift strap did not cover R1's Right buttock and most of R1's Right outer thigh area. V10 CNA stated R1 is not supposed to be transferred like this due to the straps do not cover R1's entire buttock and hip area. On 8/7/26 at 11:50 AM, R1 was sitting on a white total body mechanical lift sling with rainbow-colored straps in R1's wheelchair.On 8/12/26 at 10:15 AM, R1 was sitting on a white total body mechanical lift sling with rainbow-colored straps in R1's wheelchair.On 8/5/26 at 3:10 PM, V4 Certified Nurse Aide (CNA) stated V4 and V22 CNAs transferred R1 from the wheelchair to the bed using a total body mechanical lift. V4 stated once the lift was positioned, V22 CNA began to use the lift to raise R1 above the height of the wheelchair. V4 CNA stated that is when the sling strap 'popped' off and R1 fell. V4 CNA stated R1's Right Buttock and Right Leg were not supported causing R1 to fall to the ground with V4 and V22 CNA's trying to break R1's fall. V4 CNA stated R1's sling was not attached properly causing R1 to fall. V4 CNA stated R1's sling was white with rainbow-colored straps with a cloth piece that is supposed to hold R1's legs together during the transfer. V4 CNA stated V4 and V22 CNAs could not find a nurse to assess R1 after R1's fall so V4 and V22 used the same lift and sling to transfer R1 from the floor to R1's bed. V4 CNA stated not making sure the lift sling was attached properly and transferring R1 after the fall without R1 being assessed by a nurse would increase the risk of harm for R1. On 8/12/26 at 1:25 PM, V2 Director of Nurses (DON) stated the total body mechanical lift slings should support the residents torso and limbs. V2 DON stated the staff should have adjusted R1's sling to ensure a safe transfer. V2 DON stated V2 was not able to find the manufacturers guidelines for the style of total body mechanical lift sling used to transfer R1 on 7/27/26 and 8/5/26. V2 DON stated V2 did not know where these slings came from and V2 did not order the white slings with the rainbow-colored straps. V2 DON stated due to the facility not having the manufacturers guidelines for that style of sling the facility has removed all that style of sling for safety precautions. The facility policy titled Fall Assessment and Management revised June 2024 documents after a fall, the resident will not be moved from their position until a licensed nurse determines it is safe to do so.

Based on observation, interview and record review the facility repeatedly failed to provide adequate pain relief for one (R2) resident after a fall out of three residents reviewed for Accidents in a sample list of seven residents.Findings include:R2's Electronic Medical Record (EMR) documents R2's medical diagnoses as Cardiac and Vascular Implant, Colostomy, Vascular Dementia, Transient Ischemic Attack (TIA), Unsteady on Feet, Urine Retention, Cerebral Infarction, Abnormalities of Gait and Mobility, Muscle Weakness, Osteoporosis and Bilateral Primary Osteoarthritis of Knee. R2's Fall Investigation dated 8/2/26 documents R2 slid out of the wheelchair. R2 complained of pain to R2's Left Hip after the fall.R2's Physician Order Sheet (POS) dated August 2026 documents a physician order starting 4/09/2024 to administer Acetaminophen Tablet 650 milligrams (mg) by mouth every (6) six hours as needed for pain.R2's Medication Administration Record (MAR) dated August 2026 documents R2 was administered as needed Acetaminophen (Tylenol) 650 mg on:-8/2/26 at 4:59 PM for a reported pain level of nine out of a possible ten points. -8/4/26 at 2:15 PM for a reported pain level of ten out of a possible ten points. -8/5/26 at 9:35 AM and again at 9:35 PM for a reported pain level of ten out of a possible ten points. -8/10/26 at 7:10 AM for a reported pain level of ten out of a possible ten points. R2's Progress Note dated 8/4/26 at 2:11 PM documents (R2) complained of pain to Left Hip stating 'its been hurting since I fell'. (R2) Rates pain 10/10. No bruising, shortening, or rotation noted. (V33) NP (Nurse Practitioner) notified. Acetaminophen (Tylenol) given. On 8/5/26 at 10:27 AM, R2 stated that R2 fell on 8/2/26 and hurt R2's hip. R2 was moaning out in pain saying it hurts, it hurts. R2 stated R2 slid out of R2's wheelchair due to the seat was slick. R2 stated the facility is not doing anything about R2's pain. R2 stated the facility should have gotten an X-Ray right after R2's fall on 8/2/26. R2 stated My hip is broken, and they (staff) won't do anything to relieve my pain.On 8/5/26 at 10:35 AM, R2's complaint of Left Hip pain was reported to V24 Licensed Practical Nurse (LPN)/wound nurse who stated R2's nurse was aware. V33 Nurse Practitioner (NP) has already been notified today (8/5/26) and the staff are waiting for the X-ray service to arrive and R2 has been provided with pain medication today.On 8/12/26 at 12:45 PM, V30 Licensed Practical Nurse (LPN) stated V30 administered Acetaminophen 650 mg to R2 due to R2 stated R2 was in pain. V30 LPN stated V30 was aware R2 fell on 8/2/26. V30 LPN stated R2 requested pain medicine for R2's Left Hip. V30 LPN stated V30 did notify V33 NP due to V30 thought that V33 NP already knew of R2's ongoing Left Hip pain. On 8/12/26 at 3:00 PM, V2 Director of Nurses (DON) stated R2 has been complaining of pain since R2's fall on 8/2/26 and is receiving Acetaminophen as needed. V2 DON stated V33 NP should have been contacted sooner but will be contacted today (8/12) to request something stronger for R2's ongoing pain and request an X-Ray of R2's Left Hip area. The facility policy titled Guidelines for Physician Notification of Change in Resident Condition revised April 2019 documents the facility standard is for staff to observe, document and communicate to the Physician changes in a resident's condition. This same policy documents a change in condition may include new or increased complaints of pain.

Based on observation, interview and record review the facility failed to wear the appropriate Personal Protective Equipment (PPE) when providing direct cares for one (R4) resident out of three residents reviewed for Injuries of Unknown Origin in a sample list of seven residents.Findings include: R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 is dependent on staff for bathing, dressing, personal hygiene and requires maximum assistance for toileting, bed mobility and transfers.On 8/7/26 at 1:40 PM, R4 has an orange sign posted on the outside of the room door that reads Enhanced Barrier Precaution (EBP) instructing staff to wear a mask and gown while providing direct cares. R4 has two large barrels inside R4's room for disposal of contaminated linens and garbage. On 8/7/26 at 1:45 PM, V25 and V22 Certified Nurse Aides (CNAs) transferred R4 from R4's wheelchair to the toilet using a mechanical stand lift. R4 stood in the mechanical lift with R4's buttocks pushing backwards. V22 CNA and V25 CNA did not wear gowns to assist R4 to the bathroom. R4's pants were saturated with urine from the waistline to the back of R4's knees. R4's cushion in R4's wheelchair was urine soaked. On 8/7/26 at 2:00 PM, V22 CNA stated that R4 is on Enhanced Barrier Precautions (EBP) due to a draining wound on R4's Coccyx. V22 CNA confirmed R4 has an EBP sign on R4's door instructing staff to wear gloves and a gown when providing direct care. V22 CNA stated both V22 CNA and V25 CNA should have been wearing gowns to assist R4 to the bathroom. On 8/7/26 at 2:05 PM, V25 CNA stated V25 saw the EBP sign on R4's door but did not think to wear a gown when providing cares for R4. V25 CNA stated if V25 had known R4 was going to be so saturated with urine and having an open draining wound, V25 would have 'definitely' worn a gown when providing direct cares for R4. On 8/7/26 at 3:30 PM, V27 Registered Nurse (RN)/Infection Preventionist (IP) stated R4 is on Enhanced Barrier Precautions (EBP) due to an open draining wound on R4's Coccyx. V27 RN/IP stated V27 is unsure if the facility has an EBP policy but stated staff should wash their hands, wear gloves and a gown when providing direct cares for a resident with an open wound who is also incontinent. V27 RN stated that R4 is not cognitively intact and does use R4's hands to 'pick' at R4's clothing, bed sheets, incontinence brief, etc. so staff should wear gloves and a gown. V27 RN/IP stated R1 has a 'big, orange sign on the door telling staff what to wear'. V27 RN/IP stated V27 will re-educate the staff.

Based on interview and record review the facility failed to ensure one resident (R2) was safely transferred out of three residents reviewed for transfers in a sample list of five residents.Findings Include:R2's Care Plan initiated 5/29/26 documents the following diagnoses: Encephalopathy, Seizures, Heart Disease, Dementia, Depression, Normal Pressure Hydrocephaly with Shunt, and history of a Cerebral Infarction. This Care plan included an intervention dated 5/27/25 Transfers: Sit-to-Stand transfer. Please use two staff members to assist with proper position related to my stroke history.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired and dependent on staff for Activities of Daily Living (ADLs).On 7/21/26 at 11:47AM, V3 (R2's) family member stated I have a camera set up in (R2's) room. Whenever anyone enters the room I get a message. On 7/3/26 at 4:43AM (V6) Certified Nurse's Aide (CNA) came into the room. (R2) is supposed to be lifted by two staff members and a sit-to stand lift. (V6) lifted (R2) under (R2's) shoulders and knees like a baby. (V6) could have dropped (R2) or hurt (R2). I reported this to (V1) Administrator and (V2) Director of Nursing. I showed them the pictures.On 7/21/26 at 12:00PM, V2 Director of Nursing stated I saw the pictures of (V6) lifting (R2) on 7/3/26. (V6) did not use the sit-to stand lift and should not have lifted (R2) alone. I have initiated the disciplinary process, and I am monitoring (V6) to ensure it does not happen again.On 7/21/26 at 12:15PM, V1 Administrator verified V1 had seen the photos (V3) has and is aware (V6) did not transfer (R2) appropriately and (V2) is disciplining (V6). V6 CNA was contacted but declined interview. The facility's Safe Resident Handling policy revised 3/18/18 states The Safe Resident Handling Program exists to ensure a safe working environment for resident handlers. The policy is to be reviewed & signed by all staff that perform or may perform resident handling. This policy will be reviewed annually with changes made accordingly. Initial screening will be performed on all residents to assess transfer & ambulating status. Resident transfer status will be reviewed via care-plan time frame and on an as needed basis. If therapy recommends a change in transfer status the recommendations will be reviewed by a nurse manager prior to changing the status in the care plan. The transfers will be designated into one of the following categories:0 = Independent1 = 1 person transfer with gait belt (< 25 lbs. of assistance from the caregiver)SSS = Sit to Stand with Standard SlingSSC = Sit to Stand with Carrier Sling - Friction Reducing Device (FRD) can be considered for bed mobilityM = Mechanical Lift Transfer ( Hoyer type) with two caregivers - requires Friction Reducing Device (FRD) for bed mobility Gait belt usage is mandatory for all resident handling with the exception of mechanical lift use, bed mobility & medical contraindications. The gait belt will be considered a part of the certified nursing assistant's uniform. Resident transfer status will be listed on the resident plan of care (POC). Should a resident fall to the floor, the resident will first be assessed by a nurse. If the resident is deemed medically appropriate to transfer from the floor, a full-size mechanical ( Hoyer type) lift will be used. If the resident is not medically appropriate to transfer from the floor, emergency medical technicians will be notified and said technicians will transfer the resident.

Based on interview and record review the facility failed to provide prompt complete catheter care to one resident (R2) of three residents reviewed for incontinence care in a sample list of five residents.Findings Include:R2's Care Plan initiated 5/29/26 documents the following diagnoses: Encephalopathy, Seizures, Heart Disease, Dementia, Depression, Normal Pressure Hydrocephaly with Shunt, and history of a Cerebral Infarction. This Care plan included an intervention dated 5/27/25 Transfers: Sit-to-Stand transfer. Please use two staff members to assist with proper position related to my stroke history.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired and dependent on staff for Activities of Daily Living (ADLs).On 7/21/26 qt 11:47AM, V3 (R2's) family member stated V3 came to see R2 and R3 on Sunday 7/19/26. R2 who has a urinary catheter had dried feces all over the catheter tubing and bag. V3 obtained a clean catheter bag and washed off the catheter tubing V3's self. V3 stated if (R2) was aware of how (R2) was left soiled (R2) would be appalled. V3 stated V3 took pictures and showed them to V1 Administrator and V2 Director of Nursing. On 7/21/26 at 12:00PM, V2 Director of Nursing stated I saw the pictures of (R2's) catheter bag on 7/19/26. This should not have happened. When I looked into it, I found the staff responsible for leaving (R2's) catheter this way was an agency Certified Nurse's Aide (CNA). I reported this to the agency, and we will no longer allow this CNA to work here.On 7/21/26 at 12:15PM, V1 Administrator verified V1 had seen the photos (V3) has and is aware an agency CNA failed to provide catheter care to (R2) and that CNA will no longer be utilized by the facility.The facility's policy Catheter Care/Incontinence Care revised 8/1/2005 states Catheter care is given every shift by the CNA trained in the procedure. Incontinent care will be given with each episode of incontinence.

Based on observation, interview, and record review the facility failed to ensure one resident (R1) was free from physical abuse from another resident (R2). This failure caused R1 to sustain a nasal fracture, a facial laceration requiring sutures to close, and bilateral hematomas to her eyes.Findings Include: R2's Care Plan, updated 6/16/26, includes the following diagnoses: Dementia, Hypertension (HTN), Hyperlipidemia, Pseudobulbar Affect, Seizure Disorder, and Aneurysm of the Aortic Arch.The Care Plan includes a problem initiated on 1/14/25 documenting that R2 has physical behavioral symptoms, including pulling others' hair, shoving or hitting others, and throwing items at others. The Care Plan also documents verbal behavioral symptoms, including yelling and growling at others. Additional behavioral symptoms include packing belongings, placing herself on the floor, urinating in inappropriate places, pacing, slamming or banging on doors, peeking around corners, and rummaging. The Care Plan further documents that R2 experiences delusions, including believing others are taking her money, and hallucinations, including seeing, talking to, or arguing with people who are not present.R1's Care Plan, updated 5/10/26, includes the following diagnoses: Alzheimer's Disease, Dementia, Osteoarthritis, Hypothyroidism, Chronic Kidney Disease, Hyperlipidemia, and Idiopathic Chronic Gout.The Care Plan includes a problem initiated on 8/21/25 documenting that R1 experiences episodes of impaired mood and behaviors. These behaviors include verbal symptoms such as yelling, screaming, swearing, and mocking; other symptoms such as hitting her chest and slamming her fists; physical symptoms including hitting and slapping others; and delusions, including the false belief that her daughter broke into her house and stole her belongings.The Facility Census dated 6/15/26 documents that both R1 and R2 resided in the facility's memory care unit.On 6/15/26 at 11:00 a.m., R1 was observed sitting at a table in a common area with other residents. R1 had purple-to-yellow bruising around both eyes and a new scar on her chin where sutures had recently been removed. When asked if she remembered how she sustained the bruising and chin wound, R1 stated, That's all over and it's just a lot of B.S. (expletive), and we can talk about something else.At the same time, R2 was observed sleeping quietly in her bed at the opposite end of the memory care unit.The facility's Final Report to the State Agency, dated 5/26/26, documents: (R2), who is alert and confused, ambulates and transfers independently, and has a BIMS (Brief Interview for Mental Status) score of 0, indicating severe cognitive impairment, was observed entering the doorway of the South Harmony Unit. R2 was slapping hands and arguing with (R1), who is alert and oriented to person only, ambulates and transfers independently, and has a BIMS score of 5. R1 was observed being pushed, causing her to lose her balance and fall to the floor. The interaction was observed by staff, and the residents were immediately separated. The resident who fell was immediately assessed and noted to have a laceration to her chin, bruising to her nose, and blood in her mouth. The Administrator, physicians, and Power of Attorney were notified. A new order was received to send R1 to the local hospital emergency department for evaluation and treatment. Emergency Medical Services (EMS) arrived and transported R1 to the emergency department, where she was diagnosed with a nasal fracture and received sutures to close the chin laceration. R1 returned to the facility with orders to remove the sutures in 7 to 10 days. No additional orders were received. The residents were kept separated, and no further incidents occurred.On 6/16/26 at 11:15 a.m., V8, Memory Care Plan Coordinator/LPN, verified that, prior to the altercation, unit staff were aware that both R1 and R2 had histories of physical altercations with other residents and that behavioral care plans were in place addressing these and other behaviors.On 6/16/26 at 11:30 a.m., V10, Memory Care Director, verified that when a resident has a known history of physical altercations, it is her expectation that staff take all reasonable measures to ensure those residents are kept a safe distance from other residents with similar histories whenever possible. V10 further verified that R1 and R2 were allowed to remain in close proximity to one another and that, as a result, R1 sustained injuries.The facility's Abuse and Neglect Policy, revised 1/29/26, states: All residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. This includes freedom from physical or chemical restraints not required to treat the resident's symptoms.The policy further defines abuse as: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse includes deprivation by an individual, including a caretaker, of goods or services necessary to attain or maintain physical, mental, or psychosocial well-being. Willful means the individual acted deliberately, not necessarily with the intent to inflict injury or harm.The policy defines physical abuse as: The infliction of injury on a resident that occurs other than by accidental means and requires (whether given) medical attention. Physical abuse may include, but is not limited to, hitting, slapping, kicking, hair pulling, and pinching.The policy further states: When an allegation of suspected abuse is received involving another resident as the alleged perpetrator, that resident's condition shall be immediately evaluated to determine the most appropriate therapy and placement, considering the safety of that resident as well as the safety of other residents and employees. If the incident involves suspected resident-to-resident abuse, the Administrator shall take all steps necessary to protect all residents in the facility from abuse until the allegation has been investigated.

Based on observation, interview and record review the facility failed to implement a baseline careplan for one (R2) resident, failed to implement fall interventions for three (R2, R3, R4) residents, failed to ensure the safety of one (R3) resident and failed to complete comprehensive fall investigations for three (R2, R3, R4) residents out of three residents reviewed for Accidents in a sample list of ten residents. R3 obtained five sutures to her forehead and a Subdural Hematoma due to an unwitnessed fall at the facility. R3 was transported to the emergency room to undergo diagnostic testing, laboratory work and full assessments from hospital staff. R3 experienced pain due to falling off her bed that was in high position. Findings include:1.R3's Electronic Medical Record (EMR) documents that R3 was admitted to the facility on [DATE].R3's EMR documents medical diagnoses of morbid obesity, chronic congestive heart failure, atrial fibrillation, chronic obstructive pulmonary disease (COPD), restless leg syndrome, and traumatic subdural hemorrhage without loss of consciousness.R3's Physician Order Sheet (POS), dated March 2026, documents a physician order beginning 1/13/2026 to administer Warfarin Sodium (anticoagulant) 2 milligrams (mg) daily Saturday through Thursday and 1 mg every Friday. This same POS documents that R3 is to wear oxygen at 2 liters per nasal cannula continuously.R3's Minimum Data Set (MDS), dated [DATE], documents R3 as moderately cognitively impaired. This same MDS documents R3 as dependent for toileting, dressing, and transfers, and requiring maximum assistance for bathing, personal hygiene, and bed mobility.R3's Fall Risk Evaluation, dated 2/17/26, documents R3 as a high fall risk.R3's Nurse Progress Note, dated:3/10/26 at 10:45 AM, documents R3 was observed on the ground next to her bed with the bed in a high position. This same note documents V7 Licensed Practical Nurse (LPN) was completing medication administration when V7 LPN saw R3 lying on the floor next to her bed on her stomach, unclothed, and with blood on the floor. This same note documents R3 stated she did not know how she got there but did not roll out of bed. This same note documents R3 had a hematoma with a laceration on the right side of her forehead above the brow bone, and scattered bruising noted more prominently on her right arm after her fall.3/10/26 at 5:45 PM, documents R3 was admitted to the hospital with diagnoses of fall and urinary tract infection (UTI). This same note documents R3 received five sutures to the forehead laceration. This same note documents R3's X-ray reads possible fractures of the ninth and tenth ribs, and the physician notes document actual fractures.3/17/26 at 2:01 PM, documents staff removed five sutures from the right side of R3's forehead.R3's Hospital Record, dated 3/10/26, documents R3 had an unwitnessed fall with unknown down time on 3/10/26, resulting in a right forehead abrasion, a 4 centimeter (cm) long by 2 millimeter (mm) deep laceration to her right forehead, right elbow and right lateral ankle abrasions, right leg and right elbow skin tears, and bruising to bilateral forearms. This same record documents R3's computerized tomography (CT) scan of her head was initially read as nothing acute and then was updated at 1521 to demonstrate a 3 millimeter (mm) right parietal subdural hematoma, which did appear acute.R3's Chest X-ray, dated 3/10/26, documents possible ninth and tenth rib fractures.R3's Fall Investigation, dated 3/10/26, does not document whether R3 was wearing her physician-ordered oxygen. R3's fall investigation does not document how R3's bed was in a high position, when R3 was last observed, or what fall interventions were in place.R3's Final Report to the State Agency, dated 3/17/26, documents R3 had an unwitnessed fall on 3/10/26 resulting in five sutures to the right forehead and a subdural hematoma caused by the fall. This same report documents R3's bed was found in a high position.On 4/23/26 at 9:35 AM, R3 was placed in her room by V7 Licensed Practical Nurse (LPN). R3 stated she remembers falling on 3/10/26. R3 stated, Boy! That hurt! I had a headache for days. My bed was as high as the clouds. That is why it hurt so bad.On 4/23/26 at 9:47 AM, V7 Licensed Practical Nurse (LPN) stated she was R3's nurse on 3/10/26. V7 LPN stated she got report at 6:00 AM, prepared for the day, and then started down the hall to begin passing medications. V7 LPN stated she entered R3's room to administer medications to R3's roommate. V7 LPN stated R3's curtain was pulled around her bed, but she heard R3 faintly say, Help me. V7 LPN stated when she pulled R3's curtain back, she could see that R3 was lying on her stomach, not wearing any clothes, and the bed sheet was lying on the floor. V7 LPN stated R3's call light was attached to her side rail and out of her reach. V7 LPN stated R3's room was dark. V7 LPN stated R3 had a pool of blood around her head. V7 LPN stated R3's bed was at chest-level height. V7 LPN stated R3 stated she was trying to sit herself up but clearly didn't make it. V7 LPN stated R3 had been there a long time based on R3's appearance and the look of her injury.On 4/23/26 at 10:00 AM, V24 Certified Nurse Aide (CNA) stated when V24 entered R3's room, R3 was not wearing any clothes. V24 CNA stated R3 was lying with her head underneath the bed and her feet facing toward the room door. V24 CNA stated R3 was lying in a lot of blood. V24 CNA stated R3's bed was in the highest position it could go.On 4/23/26 at 10:20 AM, V23 Agency Certified Nurse Aide (CNA) stated she arrived at work at 6:00 AM on 3/10/26 and was assigned to R3's hallway. V23 CNA stated she received a verbal report from V25 CNA, who stated everyone is fine. V23 CNA stated she prepared for her shift and started getting other residents up first. V23 CNA stated she had not entered R3's room until V7 Licensed Practical Nurse (LPN) asked her to help assist R3 after she fell. V23 CNA stated when she entered R3's room, R3 had dried blood on her forehead and was lying in a puddle of blood on the floor with her bed in the highest position it could go. V23 CNA stated R3's bed should not have been in such a high position because it is dangerous for the residents. V23 CNA stated it appeared that R3 had not been checked on for a long time. 2. R4's Care Plan, initiated 2/9/26, documents medical diagnoses of repeated falls, glaucoma, dementia, Parkinson's disease, abnormalities of gait and mobility, and abnormal posture. This same Care Plan documents fall interventions, dated 3/2/26, instructing staff to use anti-rollback brakes on R4's wheelchair.R4's Minimum Data Set (MDS), dated [DATE], documents R4 as severely cognitively impaired. This same MDS documents R4 as requiring maximum assistance for toileting and moderate assistance for dressing, bed mobility, and transfers.R4's Fall Risk Evaluation, dated 2/27/26, documents R4 as a high fall risk.R4's Nurse Progress Note, dated 3/30/26 at 2:22 PM, documents R4 attempted to stand and ambulate herself when she slid out of her wheelchair and onto the floor.R4's Fall Investigation for the 3/30/26 fall documents R4's anti-lock brakes needed reassessment. This same fall investigation does not document when R4's wheelchair had been assessed for safety or whether it was functioning properly.On 4/22/26 at 11:40 AM, V16 Agency Licensed Practical Nurse (LPN) stated she was R4's nurse and was not aware of any fall interventions for R4. V16 agency LPN demonstrated she was not able to open R4's care plan to access R4's fall interventions. V17 Restorative Nurse/Fall Nurse showed V16 how to access resident fall interventions in the resident care plan. V16 agency LPN stated, Oh thank you. Now I know how to do that. That is good to know.On 4/24/26 at 10:05 AM, V28 Environmental Services Director stated the facility has a computer system staff use to input work orders. V28 stated the system is reliant on what staff enter as the problem. V28 stated staff may enter wheelchair brakes, but that does not tell V28 what is wrong with the brakes. V28 stated the facility does not have a tracking system showing what was fixed on any given piece of equipment. V28 stated the system only allows staff to enter whether the work order was completed, not the actual work that was done. V28 stated there is really no way to tell what was done to any piece of equipment. V28 Environmental Services Director stated R4's anti-rollback brakes needed readjustment because R4's wheelchair was sliding back. V28 stated R4's anti-lock brakes were assessed on 3/31/26 and found to be not functioning properly. V28 stated R4's anti-lock brakes were readjusted on 3/31/26.On 4/24/26 at 10:35 AM, V29 Maintenance Assistant confirmed he worked on R4's anti-lock brakes. V29 stated the work order documents the work order was completed. V29 stated he does not remember whether the anti-lock brakes were loose or out of alignment, but that there was something wrong with them for me to work on them. V29 stated he adjusted R4's brakes and completed the work order. V29 confirmed he fixed R4's anti-lock brakes on 4/1/26.On 4/24/26 at 9:25 AM, V11 Licensed Practical Nurse (LPN) stated V26 Activity Aide was sitting with R4 when she fell on 3/30/26. V11 stated R4 stood up and then went to sit down when her wheelchair rolled back, causing R4 to fall to the floor. V11 LPN stated R4 was not injured. V11 stated R4's anti-rollback brakes did not work. V11 stated the intervention put into place was a non-skid mat to be placed in R4's chair because R4 slid out of her wheelchair as she was trying to sit back down. V11 stated the anti-rollback brakes were already an intervention but did not work.On 4/24/26 at 9:35 AM, V26 Activity Aide stated she had been sitting with R4 on 3/30/26 in the activity room when R4 fell. V26 stated she left R4's side to assist another resident when R4 stood and fell. V26 stated R4's wheelchair had anti-lock brakes in place, but they were broken because the wheelchair rolled back when R4 went to sit back down. 3. R2's undated Face Sheet documents R2 was admitted to the facility on [DATE] with medical diagnoses of dementia, abnormal posture, unsteady gait, traumatic subdural hemorrhage, and neurocognitive disorder with Lewy bodies.R2's Minimum Data Set (MDS), dated [DATE], documents R2 as moderately cognitively impaired. This same MDS documents R2 as requiring supervision with transfers.R2's Fall Risk Assessment, dated 3/6/2026, documents R2 as a high fall risk.R2's Electronic Medical Record (EMR) does not document a Baseline Care Plan.R2's Fall Investigation, dated 3/12/26, documents R2 had a witnessed fall after walking independently in the hallway and tripping over a total body mechanical lift, hitting her face/left cheek on the lift. This same investigation documents R2 voiced pain in her right hip/pelvic area with external rotation of the right leg when lying flat on her back. This same report documents R2 was sent to the emergency room. This same report documents V19 Assistant Dietary Manager saw R2 ambulating independently in the hallway, said Hi to R2, and then R2 fell, landing on the leg of the lift. This same report documents the root cause of R2's fall was that R2 turned around and lost balance.On 4/22/26 at 12:08 PM, V18 Certified Nurse Aide (CNA) stated she would look in the Kardex to find safety interventions for a resident. V18 CNA demonstrated she could not gain entry to a facility computer. V18 CNA stated she does not ever use the computers on the halls to chart or see safety interventions. V18 CNA stated she completes all charting after her shift is done in the break room. V18 CNA stated if there were a new safety/fall intervention put in place for any resident, she would not know what it was until after her shift was completed.On 4/24/26 at 12:00 PM, V2 Director of Nurses (DON) stated the fall investigations for R2, R3, and R4 were all incomplete because the investigations lacked key pieces of information pertaining to the residents' falls. V2 DON stated R2's fall investigation should have included information about when R2's needs were last met because she was wandering the halls; R3's fall investigation should have included information about when R3's needs were last met and who placed R3's bed in a high position; and R4's fall investigation should have included who last visualized R4 and whether the fall interventions were in place. V2 DON stated fall interventions should be in place. V2 DON stated R2 did not have a baseline care plan in place for any areas of focused care. V2 DON stated the facility is to complete a baseline care plan for all areas of concern for the resident and then complete a thorough care plan at a later date. V2 DON stated staff would not know what the fall interventions were for R2 if the care plan were not in place. V2 DON stated there should have been an intervention put into place after R2's fall on 3/11/26 and again after her fall on 3/12/26. V2 DON stated R2's falls had different causes, but the care plan should have been in place. V2 DON stated staff are to offer/provide incontinence care every two hours on the even hours. V2 DON stated there is no documentation and/or staff able to report that R3 was visualized between 4:00 AM and 6:55 AM when she was found on the floor. V2 DON stated staff are allowed to raise resident beds during care, but then they should lower them back down to their care-planned height. V2 DON stated R3 was not care planned to be in a low bed, but that her bed position should have been the standard height, about knee height, from the floor. V2 DON stated the facility is not able to provide any documentation or staff reports of R3 ever raising the bed herself, so V2 DON assumes staff left R3's bed in a high position. V2 DON stated R4 was on rounds every 15 minutes, but the facility does not have any documentation the frequent visual checks were completed. V2 DON stated there is an alert system that rings to V2's phone and then V1 Administrator's phone if the call light has been activated too long, but there is no documentation showing staff visually checked the resident. V2 DON stated due to R4's fall on 3/30/26, the facility will now complete monthly visual checks on all resident wheelchairs to ensure they are working properly. V2 DON stated R4's non-skid mat in her wheelchair should be placed on top of and underneath her wheelchair cushion. V2 DON stated the facility did not directly cause the resident falls, but staff should ensure all fall interventions are in place.On 4/24/26 at 2:10 PM, V30 Nurse Practitioner (NP) stated the facility does need to document the conditions of falls and condition changes more thoroughly. V30 NP stated R4 would not have been able to pull the privacy curtain by herself. V30 NP stated basic nursing training includes checking on residents at least every two hours. V30 NP stated she has not reviewed the fall investigations directly but was informed by the facility of resident falls. V30 NP stated the facility did not directly cause injuries, but fall interventions should have been in place and functional, and residents should have been checked on at least every two hours.The facility Fall Assessment and Management policy, revised June 2024, documents the potential for falls will be care planned based on the results of the fall assessment. All staff providing care for the resident shall have access to the resident care plan.

Based on interview and record review, the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for one (R6) of three residents reviewed in a sample of nine. Findings include:On 4/22/2026 at 11:26 AM R6 states sometimes it can take staff 20-30 minutes to answer call lights. R6 states since admission he has had three or four incontinent episodes due to having to wait for assistance with toileting. R6 states he has now been wearing incontinent briefs due to not knowing how quickly staff will be available to assist him to the restroom. R6 states he did not wear incontinent briefs prior to being admitted to the facility.On 4/23/2026 at 9:54 AM R6 states he had an episode of bowel incontinence this morning. R6 states he is now wearing incontinent briefs all day long. R6 states if he does have an incontinent episode that staff will assist him with perineal care right away.On 4/22/2026 at 1:52 PM V15 Registered Nurse states R6 is continent if he can reach the restroom on time. V15 states R6 requires assistance of one staff member to transfer onto toilet using a walker and wheelchair. V15 states she believes R6 was continent while at home.R6's Bladder Incontinence assessment dated [DATE] documents R6 is continent of bladder.R6's bowel and bladder task documentation in his electronic health record (EHR) shows one episode of bowel incontinence and three episodes of bladder incontinence between the dates of 4/17/2026 and 4/23/2026.R6's admission progress note dated 4/17/2026 at 3:30 PM documents Abdomen flat, non-tender. Bowel sounds present x4. Denies indigestion, nausea, vomiting, diarrhea, constipation or bowel incontinence. Resident continent of bladder. Urine clear yellow. Denies urinary complaints.Grievance Complaint Report dated 12/8/2026 documents a grievance from Resident Council that call lights are on for an extended period of time before help can be given. Certified Nursing Assistants (CNA) come in, turn call light off, say they will return but never do.Grievance Complaint Report dated 1/27/2026 documents a grievance from Resident Council that Call lights are not being answered timely. Residents complained about not getting enough help.On 4/24/2026 at 10:23 AM V2 Director of Nursing states he would expect staff to answer call lights within five minutes or less, however answering in less than ten minutes during times of higher activity levels is appropriate.The Illinois Long-Term Care Ombudsman Program booklet titled Residents' Rights for People in Long-Term Care Facilities, revised on 11/2018, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

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 (R4, R6) of three residents reviewed for abuse in the sample list of 7. This failure resulted in R4 sustaining a fracture to her right wrist.Findings include:R4's health status note dated 12/27/25 documents that R4 allegedly had a physical altercation with another resident that resulted in R4 falling to the ground and sent to the emergency room for evaluation.R4's event note dated 12/28/25 documents that R4 was pushed by another resident (R6).R4's progress notes dated 12/28/25 documents R4 returned to the facility form the emergency room with a soft cast to her right hand due to a fracture.On 2/19/26 at 11:50 a.m., V4, Licensed Practical Nurse (LPN) stated that on the night of 12/27/25 she was passing pills when V15 Certified Nurse Assistant (CNA) told her that R4 was on the floor because another resident (R6) pushed R4. V4 stated she went to check on R4 and observed her on the floor by the nurse station close to the fireplace. V4 attempted to assess R4 but R4 refused and demanded to be sent to the hospital. V4 stated she sent R4 to the hospital for evaluation per physician's order and notified R4's family. V4 stated she notified V1 about the incident between R4 and R6. V4 stated R4 provoked R6 that may have led to pushing. V4 stated that R4 returned to the facility the next morning with a soft cast to her right hand.R4's Care Plan dated 8/14/25 documents that R4 exhibits verbal behaviors such as yelling and threatening others. R6's Care Plan dated 4/15/24 documents that R6 experiences episodes of impaired moods/behaviors. This Care Plan documents that R6 has physical behaviors such as hitting others, swinging purse at others, throwing things, attempting to break windows, and flashing others. On 2/19/26 at 10:53 a.m., R4 was observed sitting in a chair in the common area with a platform walker positioned in front of her. R4 had a wrist brace applied to her right hand. R4 stated that her hand was broken because she interfered in a fight, stating, I got the worst of it. R4 stated she does not remember when the fight occurred. R4 stated she was pushed but was unable to identify who pushed her.On 2/20/2026 at 11:28 a.m., V15, CNA stated she was present when the incident occurred between R4 and R6 on 12/27/25. V15 stated she did not witness how the alleged altercation started but when she turned around, she witnessed R6 push R4 causing R4 to fall to the ground. V15 stated they separated both residents and reported the incident to the nurse. V15 stated she wrote a statement regarding the incident on 12/27/25 and gave it the nurse.R4's Electronic Medical Record (EMR) documents an X-ray result dated 12/28/25, which showed that R4 sustained a shattered and displaced wrist fracture (distal radius) as a result of her fall.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement care plan interventions for a resident who required her bed to be maintained in the lowest position when in bed. This failure resulted in a fall for one (R3) of three residents reviewed for accidents. R3 sustained soft tissue swelling around the left eye and a 2-centimeter (cm) laceration above left eyebrow, requiring emergency room treatment and wound closure with adhesive glue. Findings Include:The facility's Fall Assessment and Management Policy dated 11/30/2012 with a revision on 6/2024 documents that it is the policy of the facility 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, assess and ultimately reduce injury. Factors related to the risk will be addressed and care planned.This policy documents that based on the results of the Fall Risk Assessment, the potential for falls will be carefully addressed through individualized planning. The interdisciplinary care plan will be person-centered, reflecting the resident's unique needs, preferences, and identified risk factors. All staff members responsible for providing care will have access to the care plan and/or Kardex to ensure consistency and continuity in implementing fall prevention strategies.This policy documents that interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall. Some examples may be: Falls related to gait/balance deficit.Falls related to confusion.Falls related to position problems.Falls related to toileting needs.Falls related to syncopal episodes.Falls related to environmental hazards.Falls related to sensory/perceptual problems.Falls related to poor judgement or knowledge deficit. R3's Minimum Data Set (MDS) dated [DATE], documents R3 has Unspecified Dementia with agitation. This MDS also documents that R3 requires substantial/maximal assistance from staff when getting from a lying to sitting on side of bed and a sitting to lying position.R3's Electronic Medical Record (EMR) contains a fall assessment dated [DATE] documents that R2 is at high risk for falling.R3's care plan dated 05/15/2025 documents that R3 is at risk for falls due to unsteady gait, poor balance, and generalized weakness. Interventions implemented to address this risk include maintaining R3's bed in the lowest position.R3's incident investigation report dated 1/11/26 documents that R3 requires staff assistance with transfers and was observed on the floor of her room. This report documents that R3 had been sitting on the edge of the bed preparing to get up for the day when R3 scooted forward off the bed as aide was preparing to assist R3 into the wheelchair. R3 landed in a sitting position on the floor and as her Torso went forward, she bumped her head on the floor.On 02/19/2026 at 10:38 a.m., R3 was observed seated in her wheelchair adjacent to the nurses' station, leaning noticeably to one side while sleeping.On 2/19/26 at 1:19 p.m., V7, Certified Nurse Assistant (CNA), stated she was caring for R3 on the day of R3's fall from her bed on 1/11/26. V7 stated she entered R3's room and raised the bed from its lowest position to assist with dressing and preparing the resident to get up for the day. V7 stated she helped R3 to a sitting position on the edge of the bed, then laid R3 back down to retrieve clothing from the bedside table. V7 stated that while her back was turned to gather the clothing, she heard a sound and realized R3 had fallen. V7 stated the resident appeared to have slid off the bed, landing on her buttocks and then falling forward, striking her head on the floor. V7 confirmed R3's bed was in its normal position, approximately two feet from the floor. On 1/19/26 at 11:40 a.m., V6, Licensed Practical Nurse (LPN), stated she was the nurse caring for R3 on the day of the fall, 01/11/2026. V6 stated V7, CNA, came and got her when the incident occurred. V6 stated that V7 reported that R3 was sitting on the edge of the bed when V7 turned to retrieve the mechanical lift device to transfer R3 to her wheelchair and when V7 turned back toward R3, she observed that R3 had slid off the bed, falling forward and striking her head. V6 stated she assessed R3 and noted a cut on R3's left eyebrow. V6 stated she sent R3 to the emergency room for evaluation and R3 later returned with the eyebrow repaired using adhesive glue. V6 stated R3 can sometimes be combative, particularly during transfers, and other CNAs commented to V6 that the fall was not surprising, as R3 frequently attempts to scoot off the bed. V6 confirmed that R3's bed was not in the low position when she entered the resident's room, although it is typically kept in the lowest position when the resident is in bed.On 02/20/2026 at 12:37 a.m., V2, Director of Nursing (DON), stated he would need to review R3's Care Plan; however, he stated that if the Care Plan indicated R3 required a low bed, then the CNA caring for R3 should have maintained the bed in the lowest position until she was prepared to provide care that morning. V2 stated the CNA should not have turned away from R3 while the R3 was in bed and not in a low position.R3's emergency room notes dated 01/11/2026 document that the resident's fall resulted in treatment for soft tissue swelling around the left eye and a 2-centimeter laceration above the left eyebrow.

Based on interview and record review, the facility failed to report to the state an allegation of resident-to-resident abuse for two (R4, R6) out of three residents reviewed for abuse, on a sample list of seven.Findings include:The facility's abuse prohibition policy with revision date of 1/29/2026 documents if the incident involves alleged abuse, the incident will immediately be reported to the Administrator and the Administrator shall provide the Illinois Department of Public Health with initial notice of the alleged abuse via OHCR Portal or by emailing or telefaxing to the Department a copy of a report of the incident completed immediately after the incident becomes known. Administrator shall report alleged violations of abuse or if there is resulting serious bodily injury, immediately, but no later than two hours after the allegation was made. R4's health status note dated 12/27/25 documents that R4 allegedly had a physical altercation with another resident and resulted that resulted in R4 falling to the ground and being sent to the emergency room for evaluation. R4's Electronic Medical Record (EMR) contains an event note dated 12/28/25 that documents R4 was pushed by another resident. R4's progress notes dated 12/28/25 documents R4 returned to the facility with a soft cast to her right hand due to a wrist fracture following the incident.R4's health status note dated 12/28/25 at documents that V4 notified V1 Administrator about the incident. On 2/19/26 at 11:50 a.m., V4 Licensed Practical Nurse (LPN) stated she called V1 Administrator and reported the incident. On 2/20/25 at 3:00 p.m., V1 Administrator stated he did not notify the State Agency about the incident involving R4 and R6. V1 Administrator stated that he should report all allegation of abuse incidents.

Based on interview and record review the facility failed to investigate allegations of resident-to-resident physical abuse for two (R4, R6) out of three residents reviewed for abuse, on a sample list of seven. Findings include:The facility's abuse prohibition policy with revision date 1/29/2026 documents after an initial report of suspected abuse or neglect is sent to IDPH, the Administrator or designee shall investigate all alleged incidents of abuse. R4's health status note dated 12/2/25 documents that R4 allegedly had a physical altercation with another resident and resulted for R4's to fall that required sending her to the emergency room.R4's progress note dated 12/28/25 documents R4 returned to the facility with a soft cast to her right hand due to a fracture following the incident. R4's event note dated 12/28/25 documents that R4 as pushed by another resident.R4's health status note dated 12/28/25 documents V4 Licensed Practical Nurse (LPN) notified V1 Administrator following the incident between R4 and R6.V4, LPN stated she called V1, Administrator to report the incident on the day it occurred.On 2/20/26 at 3:00 p.m., V1, Administrator stated he did not investigate the incident. V1 Administrator stated he should investigate all alleged abuse that is reported to him.

Based on interview and record review, the facility failed to acquire, obtain, provide, and dispense prescribed medications for one resident (R3) of three reviewed for medications on a sample list of three. Findings include: R3's Census Detail dated 11/25/25 documents that R3 was originally admitted to the facility on [DATE].R3's Medical Diagnoses List dated 11/25/25 documents that R3's medical diagnoses include symptomatic epilepsy with complex partial seizures, other seizures, hyperlipidemia, depression, history of cerebral infarction (stroke), Parkinson's disease, and hydrocephalus with a cerebrospinal fluid drainage device.R3's Physician Order Sheet (POS) dated 11/25/25 documents that R3 was prescribed Levetiracetam liquid in a strength of 100 milligrams (mg) per milliliter and was to receive 10 milliliters for a total of 1,000 mg twice daily for seizures. This same POS documents that R3 was prescribed Carbidopa-Levodopa 25-100 mg four times daily for Parkinson's disease. This same POS documents that R3 was prescribed Fluoxetine 10 mg daily for depression. This same POS also documents that R3 was prescribed Atorvastatin 40 mg daily for hyperlipidemia.R3's Medication Administration Record (MAR) for September 2025 documents that R3's Levetiracetam anti-seizure medication was not administered for either of the two doses on 9/18/25, with a special code of 7, indicating to see the nurses' progress notes for that date.R3's Nurses' Progress Notes dated 9/18/25 document that R3's anti-seizure medication Levetiracetam was on order.R3's MAR for September 2025 documents that R3's Atorvastatin (hyperlipidemia medication) was not administered on 9/14/25 with a special code of 7, indicating to see the nurses' progress notes. This same MAR documents that R3's Fluoxetine (antidepressant medication) was not administered on 9/14/25 with the same special code 7. This same MAR further documents that R3's Carbidopa-Levodopa (Parkinson's medication) was not administered for two doses on 9/29/25 with the special code 7.R3's Nurses' Progress Notes dated 9/14/25 document that R3's Atorvastatin and Fluoxetine were not available, were not in the medication storage room, and were not in the medication cart. R3's Nurses' Progress Notes dated 9/29/25-one entered at 12:03 p.m. and a second entered at 3:53 p.m.-document that R3's Carbidopa-Levodopa was on order.R3's MAR for October 2025 documents that R3's Levetiracetam anti-seizure medication was not administered for either of two doses on 10/3/25 and for the morning dose on 10/21/25, with a special code of 7, indicating to see the nurses' progress notes for those dates.R3's Nurses' Progress Notes dated 10/3/25 document that R3's anti-seizure medication Levetiracetam was not available for either of the two doses on 10/3/25. R3's Nurses' Progress Notes dated 10/21/25 document that R3's anti-seizure medication Levetiracetam was on order.On 11/25/25 at 2:48 p.m., V2, Director of Nursing, stated that the reordering process is supposed to work as follows: when any medication supply reaches 3 to 5 doses remaining, the nurse on duty is supposed to click a button in the computer for that medication, which automatically sends a note to the pharmacy to reorder the medication.On 11/26/25 at 9:48 a.m., V2, Director of Nursing, stated that there is a back-up procedure if a resident runs out of a needed medication. The nurse can call the regular pharmacy provider, which has an on-call service available 24 hours per day; however, the on-call service might be located in California. V2 further stated that the on-call service would call area pharmacies to locate one able to fill the needed medication. V2 additionally stated that if a resident is out of a medication, they typically only need one or two doses before the regular pharmacy delivery arrives, making it difficult to find a pharmacy willing to fill an order for one or two pills, especially if the facility is not a regular customer. V2 concluded by stating that the special on-call delivery might still take up to 12 hours, at which point it would be just as effective to wait for the regular daily pharmacy delivery.

Based on observation, interview, and record review, the facility failed to ensure that a resident was free from a significant medication error involving an anti-seizure medication. This failure affected one resident (R2) out of three reviewed for anti-seizure medications on the sample list of three.Findings include: R2's Census Detail dated 11/25/25 documented that R2 was admitted to the facility on [DATE].R2's Medical Diagnoses List dated 11/25/25 documented that R2's medical diagnoses included epilepsy.R2's Physician Prescription Facsimile from the neurologist (V6), dated 9/22/2025, documented an order for R2 to take two tablets of Keppra 250 milligrams (mg) by mouth twice a day, totaling 500 mg twice daily.R2's Physician Order Sheet entry dated 6/12/2024 documented an order for R2 to receive Levetiracetam oral tablets, 250 mg, to be given by mouth twice a day.On 11/25/2025 at 11:45 a.m., V3, Licensed Practical Nurse, stated she gave R2 one tablet of Keppra 250 mg that morning during her medication administration pass. V3 verified the order in R2's Medication Administration Record (MAR) as one tablet of Keppra 250 mg by mouth twice a day.On 11/25/2025 at 11:55 a.m., a bubble pack of Keppra 500 mg was observed for R2, documenting that one 500 mg tablet was to be given by mouth twice a day. The bubble pack was retrieved from the medication cart by V3. Handwritten on the medication bubble pack was 1/2 tab. V3 stated that 1/2 tab indicated one-half of a tablet was to be given at each dose, equaling a 250 mg dose twice daily.On 11/25/2025 at 12:15 p.m., R2's MAR documented that R2 had been administered Keppra 250 mg by mouth twice a day from 9/1/2025 through the morning dose on 11/25/2025.On 11/25/25 at 2:48 p.m., V2, Director of Nursing, confirmed that the most recent physician order from the neurologist (V6) was for Keppra 250 mg with instructions to administer two 250 mg tablets twice daily, for a total of 500 mg twice daily. V2 stated the facsimile did not have a signature from facility nursing staff and the document must have been uploaded into R2's electronic medical record prior to the nurses transcribing the new order onto R2's Physician Order Sheet. V2 confirmed that the current dose should be 500 mg twice daily.

Based on observation, interview, and record review, the facility failed to provide appropriate urinary incontinence care for resident cleanliness. This failure affects ten residents (R2, R3, R5, R10, R52, R57, R77, R92, R94, R111) out of twenty-five residing on the facility [NAME] Hall on the sample list of 45. Findings include: On 11/18/25 from 9:30 AM until 4:15 PM, and 11/19/25 from 8:45 AM until 4:15 PM, there was a consistent, distinct, and moderately offensive urine odor in the facility's [NAME] Hallway. The urine odor was more pronounced in the resident rooms of R5, R57, R111, R52, R2, R77, R3, R92 and R94. Rooms of R111, R52, R2, R77, and R3 were noted to have hand-held plastic urinals. On 11/21/25 at 9:15 AM, the [NAME] Hall had noted urine odor in the hallway and pronounced around rooms of R92, R94, R3, R5 and R57. On 11/18/25 at 3:55 PM, during an unsolicited interview, R10 stated the facility staff do not wipe her clean when they change her incontinence undergarment, simply remove the wet one and place a new dry one. R10 further stated then she notices she smells like urine and puts her at risk for skin breakdown. R10's Brief Interview for Mental Status and Narrative Score document R10 received a 14 out of a possible 15, rating R10 as cognitively intact. R10's Care Plan dated as beginning 7/19/24 documents R10 is at risk for skin impairment, requires staff assistance for toileting hygiene, and barrier skin protection cream after incontinence episodes. On 11/19/25 at 11:45 AM, V7, Registered Nurse, stated she had to monitor the agency staff working in the facility because she had found the agency staff would change residents' incontinence undergarments but leave the absorbent pad on the bed soaking wet. V7 continued stating the urine odor would permeate from the resident rooms into the hallways. V7 stated she had addressed the issue with the agency staff because that practice is not acceptable. The facility's Form 802 Resident Matrix dated 11/18/25 documents R2, R3, R5, R10, R52, R57, R77, R92, R94, R111 reside on the [NAME] Hall

Based on observation, interview, and record review, the facility failed to keep residents' nurse call lights within reach of residents requiring staff assistance. This failure affects two residents (R5 and R57) out of nine reviewed for dignity and activities of daily living on the sample list of 45. Findings include: On 11/19/25 at 1:20 PM, R5 and R57, roommates, were both lying in their respective beds. Each of the resident's nurse call light activation devices were coiled in a circle and laying on the floor between the bed and wall behind the room divider curtain. On 11/19/25 at 1:20 PM, R5 only opened her eyes and stared when greeted verbally. R5 made no verbal response of her own. R57 stated if she needed some attention from the staff she would use the call light but didn't know where the call light was. R57 indicated the call light cord might be across the room by the dresser but she didn't have it. On 11/19/25 at 1:35 PM, V10, Restorative Registered Nurse, stated R5 probably would have the physical ability to use a call light but cognitively would not recognize what to do with the call light. V10 continued to state R57 would not be able to use a call light and was surprised when informed R57 had made statements indicating she would use the call light if she had it in reach. V10 concluded by stating she would make sure the two call lights got placed where the residents could use it if they needed staff assistance. R5's Brief Interview for Mental Status and Narrative Summary Score dated 8/6/25 documents R5 was rated as severely cognitively impaired. R57's Brief Interview for Mental Status and Narrative Summary Score dated 9/23/25 documents R57 was rated as severely cognitively impaired.

Based on observation, interview and record review the facility failed to obtain a physician order for and assess a physical restraint placed on one (R62) resident out of two residents reviewed for restraints in a sample list of 45 residents. Findings include: R62's Minimum Data Set (MDS) dated [DATE] documents R62 as severely cognitively impaired. This same MDS documents R62 requires moderate assistance with toileting, bed mobility and transfers, maximum assistance with bathing and dressing and R62 is dependent on staff for assistance with personal hygiene. R62's Care plan intervention dated 12/5/24 documents R62 may use a self-release belt while up in wheelchair and release during rounds, Activities of Daily Living (ADLS), and during supervised activities. R62's Electronic Medical Record (EMR) does not document a physician order nor an assessment for the use of a physical restraint. R62's Physician Order Sheet (POS) dated November 2025 documents a physician order starting 12/5/24 to apply a self-release belt when up in wheelchair due to unsteadiness and weakness. To be removed with rounds, Activities of Daily Living (ADL) and supervised activities and as needed. This same POS does not document a physician order to apply a non-self releasing seat belt for R62. R62's restraint consent dated 6/9/25 documents verbal consent from R62's POS for a soft belt restraint. R62's Physical Device Evaluation dated 9/22/25 documents R62 may use a self-release belt when up in wheelchair. To be released with rounds, Activities of Daily Living (ADL), meals, and as needed (PRN). On 11/18/25 at 12:30 PM R62 was sitting by the nurses station in her wheelchair. R62 was sitting on a cushion with pommel. R62 had a cloth style lap belt with long straps around her mid section that were tied to the bottom of the back of the wheelchair. R62's lap belt is not self-releasing. On 11/19/25 at 2:45 PM R62 was sitting by the nurses station in her wheelchair. R46 was sitting on a cushion with pommel. R62 had a cloth style lap belt with long straps around her mid section that were tied to the bottom of the back of the wheelchair. On 11/20/25 at 8:40 AM V18 Registered Nurse (RN) asked R62 to remove her seatbelt. R62 was not able to remove her seatbelt independently. R62 stated 'I hate this thing' as she was pulling on the front of the lap belt. On 11/20/25 at 8:45 AM V18 Registered Nurse (RN) stated she is R62's 'regular' nurse. V18 RN stated R62 used to wear a seat belt that had a 'latch' in the front which R62 could remove by herself. V18 RN stated the facility changed to a soft seat belt that R62 cannot remove by herself. V18 RN stated R62 was falling 'every day or so' so she has to wear the seatbelt to keep her from falling. On 11/21/25 at 8:45 AM V2 Director of Nurses (DON) stated R62 has fallen multiple times and the facility has added a new intervention with each fall. V2 DON stated R62 used to wear the self releasing style of seat belt but was releasing the belt 'so many times' which resulted in falls the facility and R62's family decided to use the non-self releasing style of seat belt. V2 DON stated R62 is not able to release this new style of belt. V2 DON stated the change was made in June 2025. V2 DON confirmed the facility did not have a physician order or assessment for the physical restraint used on R62. V2 DON stated the facility errors have been 'fixed and now everything is in place' for a non-self releasing style of seat belt for R62. The facility policy titled Restraint Program Policy and Procedure revised November 10, 2015 documents prior to the use of any restraint, each resident is assessed for potential alternatives by using the restraint Pre-Restraining and Quarterly Evaluation assessment. Documentation of alternatives are then listed in the resident's plan of care. If a restraint is necessary, Physician and Power of Attorney (POA) are notified and a Restraint Consent is completed. A quarterly review of restraint use is done using the Pre-Restraint and Quarterly Evaluation to identify the least restrictive methods. Care Plans are adjusted as needed to reflect the resident's current status. Reduction attempts are documented.

Based on interview and record review the facility failed to develop post fall interventions and treatment for a resident on anticoagulant therapy with head injury (R171), failed to implement careplan interventions for a resident (R171) post fall, failed to complete fall risk assessments and failed to thoroughly investigate falls for a resident (R67). These failure affects two (R171, R67) out of five residents reviewed for falls in a sample list of 75 residents. These failures resulted in R171, who was receiving anticoagulants, falling and sustaining a subdural hematoma. Findings include: The facility policy titled Fall Assessment and Management Policy revised June 2024 documents the facility will 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, assess and ultimately reduce injury risk. A licensed nurse will document for 72 hours after the incident regarding the resident's status and note any changes in the resident's condition. 1.) R171's undated Face Sheet documents R171's medical diagnoses as Dementia, Unsteadiness on Feet, Abnormalities of Gait and Mobility, Long Term Use of Anticoagulants, Osteoporosis without current Pathological Fracture and History of Venous Thrombosis and Embolism. R171's Minimum Data Set (MDS) dated [DATE] documents R171 as severely cognitively impaired. This same MDS documents R171 as requiring maximum assistance with toileting and moderate assistance with bathing, dressing, personal hygiene and bed mobility. R171's Physician Order Sheet (POS) dated September 2024 documents a physician order starting 3/19/24 for Aspirin 81 milligrams (mg) daily for Chronic Atherosclerosis Disease. This same POS documents Rivaroxaban 10 mg daily starting 7/3/24 for blood clot prevention. R171's Careplan intervention dated 2/23/24 documents (R171) may transfer and ambulate with one assist, assistive device and gait belt. R171's Fall Risk assessment dated [DATE] documents R171 as a high fall risk. This same careplan documents a fall intervention dated 9/15/24 to place R171 on a restorative ambulation program. R171's medical record documents R171 fell on ,d+[DATE] at 12:45 PM resulting in a left eye laceration. There was no documentation that the physician was notified of this fall. There were no policies regarding residents on anticoagulant therapy urgent treatment post head injury needs. R171 fell on [DATE] at 7:00 PM, R171 complained of hip pain, R171 was sent to the emergency room (ER) for hip pain. ER documented closed head injury. R171's Electronic Medical Record (EMR) does not document R171's restorative evaluation or program notes. This same EMR does not document R171 as being in the restorative ambulation program nor receiving any assistance for the restorative ambulation program. R171's Nurse Progress Note dated 9/20/24 at 3:14 PM documents (R171) was observed on the floor in the hallway. (R171) was on her left side. A reopened laceration to her Left Temple was noted. On assessment (R171) was not able to move her left leg due to excruciating pain. (R171) stated I'm going to pass out! Ambulance was called. Emergency Medical Technicians (EMT'S) left with the resident at 3:04 PM. R171's emergency room Progress Notes dated 9/20/24 document R171 was seen in the emergency room after having an unwitnessed fall at facility on 9/20/24. This same progress note documents (R171) has fallen twice in the last week. Today, after falling (R171) became increasingly altered. (R171) is oriented x0 and obtunded. (R171) is obviously unwell. (R171) does not follow commands and is having some occasional sonorous respirations. Spontaneous eye opening, no verbal or motor response. (R171's) head is laid over to the Left, does not track to the Right. R171's Computerized Tomography (CT) of her brain without contrast dated 9/20/24 documents Findings: Large Left Frontal and Temporal mixed density Subdural Hematoma measuring 3.2 centimeters (cm) in maximum diameter. The majority of this hemorrhage appears acute. Considerable mass effect on the underlying brain parenchyma resulting in 1.8 cm of rightward midline shift. Left Frontal Scalp soft tissue swelling. R171's Death Certificate documents R171's date of death as 9/21/24 with a Primary Cause of Death as Subdural Hematoma with an approximate interval between onset and death as one day. On 10/8/24 at 9:05 AM, V36 CNA stated R171 was severely cognitively impaired and had very poor safety awareness. V36 stated I don't know that (R171) was ever on a restorative ambulation program. It never came up in our charting. I worked with (R171) all the time and no one ever said anything about that. (R171) was impulsive and quick. (R171) would be laying down one minute and up the next. (R171) was very unsteady when she walked and needed one person to help her. (R171) was on 15 minute monitoring for months. I had last checked on (R171) 15-20 minutes prior to her falling on 9/20/24. It was awful. I found her in the hallway outside her room. (R171) was bleeding. I sat there with her. (R171) bled all over my pants. I'll never forget that. I felt so bad for (R171) but I don't know what else we could have done besides putting her on a one to one. (R171) needed constant supervision and we (facility) just couldn't keep up with her. At this time V36 CNA also stated, the fifteen minute rounders means the call lights are activated every 15 minutes in the resident's room. V36 CNA stated the rounder lights can be deactivated in the resident room or at the nurses station. V36 stated when the 15 minute rounders go off the staff are supposed to visually see the resident to make sure they are safe. On 10/8/24 at 10:50 AM, V7 Assistant Director of Nurses (ADON)/Restorative Nurse stated restorative programming is completed by the floor CNA assigned to the resident in a program. V7 stated V7 was on leave from 8/2/24-9/29/24 and V42 Restorative CNA was on leave from 9/19/24-10/9/24. V7 stated V7 is not able to find any documentation that R171 was ever evaluated or started on the restorative ambulation program. V7 stated It shouldn't matter if I was gone or not. (R171's) careplan intervention was added for her 9/15/24 fall and was never done. (R171) could have benefited from that program. It may have not prevented her fall on 9/20/24 but we really don't know because (R171) never received the services. On 10/8/24 at 12:30 PM, V2 Director of Nurses (DON) stated the facility has a system that activates a call light in the residents room every 15 minutes for any resident placed on 15 minute rounders. V2 stated there is a button at the nurses station and also in the resident rooms to deactivate the 15 minute rounders. V2 stated the staff are supposed to visualize the resident every 15 minutes and then deactivate the call system. V2 stated the call system will automatically come back on every 15 minutes. V2 DON stated Normally, I am able to pull a report of what exact time the 15 minute reminder was activated and deactivated but our system is down today and I am not able to provide any documentation that (R171) was being checked on every 15 minutes. V2 DON stated the facility does not have a policy on restorative programming or 15 minute rounders/call light policy. On 10/8/24 at 3:00 PM, V22 Physician/Medical Director stated R171 should have been sent to the emergency room after her 9/15/24 12:45 PM fall due to being severely cognitively impaired, having a fall with a head injury and on anticoagulants (ASA, Rivaroxaban). V22 stated after R171's falls on 9/15, she should have been on 'very close' monitoring. V22 stated (R171) did not have a strength deficit. I don't know why they (facility) would have placed her on a restorative ambulation program. (R171) was too ambitious with movements. Along with her cognitive impairments, (R171) could not foresee any dangers due to her poor cognition. (R171) relied solely on the staff to ensure her safety. I don't normally recommend the personal alarms or one to one's (continual observation) but (R171) would have been a great candidate due to her poor awareness of instability. (R171's) falls were missed opportunities resulting in her major injuries. 31642 2.) R67's diagnoses sheet dated 7/9/24 documents the following diagnoses: Muscle Weakness (Generalized) Repeated Falls, Spinal Stenosis, Cervical Region, Non-Surgical Orthopedic/Musculoskeletal, Spinal Stenosis, Lumbar Region Without Neurogenic, Claudication, Radiculopathy, Cervical Region, Non-Surgical Orthopedic/Musculoskeletal, Muscle Wasting Andatrophy, Not Otherwise Classified, Unspecified Site, Personal History Of Transient Ischemic Attack, and Cerebral Infarction Without Residual Effect Deficits. R67's Unwitnessed Fall investigation dated 8/25/24 at 5:14 pm documents the following (the same as the corresponding nurses note): Resident told CNA this morning while getting him up that he was just on the floor and 2 (two) girls came in and picked him up and put him back into bed. Resident was assessed no injury's were noted, no pain on range of motion, neuros (neurological assessment) were started because self reported fall. There are no documented interviews by V2, Director of Nursing, of R67, any other residents that may have had knowledge of the fall, or any CNA's or Nurses working that morning. There is no post-fall 8/25/24 risk assessment as policy directs. R67's Unwitnessed Fall investigation dated 9/21/24 at 3:37 am documents the following (the same as the corresponding nurses note):Resident was yelling, help me. When nurse walked into resident's room resident was observed sitting on knees next to bed. Resident's top half of body was still in bed and the lower half of body hanging out of the bed. Nurse notified CNA (unidentified) to help assist resident back into bed per 2 (two) assist ( unidentified). CNA assisted resident to be cleaned up. Urine was observed on the floor. Resident Description: Resident stated he was trying to roll to his other side. There are no documented interviews by V2, Director of Nursing, of R67, any other residents that may have had knowledge of the fall, or any CNA's or Nurses working that morning. There is no post- fall 9/21/24 risk assessment as policy directs. R67's Unwitnessed Fall investigation dated 9/22/24 at 11:20 am documents the following (the same as the corresponding nurses note): Patient found sitting on floor on knees next to bed facing head of bed. CNA stated pt. head was caught on bedside rail. Resident Description: Patient stated he was unsure how he got on floor. There are no documented interviews by V2, Director of Nursing, of R67, any other residents that may have had knowledge of the fall, or any CNA's or Nurses working that morning. On 10/8/24 at 11:25 am, V2, Director of Nursing (DON) reviewed R67's fall investigations 8/25/24, 9/21/24 and 9/22/24 and stated he did not interview anyone, does not know the last time that R67 was seen by staff and only has the details he obtained from R67's nurses notes that document R67 slid out of bed on each of those falls. V2, DON stated he is working on a better electronic medical record system to complete a more thorough fall investigation. At this time I have not implemented a new system to ensure the investigations are completed thoroughly. V2, DON also stated he does not have fall risk assessment for R67's falls on 8/25/24 or 9/21/24. He expects the nurses to complete them when a fall occurs.

Based on interview and record review the facility failed to maintain a resident's nutritional status and prevent significant weight loss by failing to implement nutritional supplements recommended by the dietician, and failing to notify the physician and dietician when significant weight loss continued. This failure resulted in R36 continuing to lose a significant amount of weight over one months time. This failure affected one of two residents (R36) reviewed for nutrition on the sample list of 75. Findings Include: The facility's Weight Management Policy and Procedure dated 2023 documents all residents will be monitored for significant weight changes to assure maintenance of acceptable parameters of body weight. Any resident with a significant weight change will be referred to the dietitian for assessment of the resident's condition. The dietician will implement any necessary clinical interventions or make recommendations regarding diet and supplementation to the physician. The physician will be notified of any significant weight change and be made aware of any recommendations made by the dietitian. R36's Medical Diagnoses sheet dated October 2024 documents R36 is diagnosed with Protein Calorie Malnutrition and Muscle Wasting and Atrophy. R36's Physician Order Sheet dated October 2024 documents R36 is prescribed a regular diet with thin liquids. R36's Care Plan dated 8/9/24 documents R36 is at risk for altered nutrition. Interventions include to provide supplements as ordered, monitor intakes, report weight changes to physician, and refer to dietician as needed. R36's Weights Record document on 8/9/24 R36's weight upon admission was 130.6 pounds. On 8/28/24 R36's weight was 120.1 pounds. R36's Dietician assessment dated [DATE] documents R36 was admitted on [DATE] and weighed 129.3 pounds on 8/12/24. The same assessment documented R36 had a weight loss of 12 pounds or nine percent of her weight over the last thirty days according to (pre-admission) hospital and facility records. A recommendation was made for R36 to begin to receive 60 cubic centimeters of a liquid nutritional supplement three times per day in order to prevent further weight loss. There is no documentation in R36's medical record that the recommended nutritional supplement was implemented or that the physician was ever notified of R36's continued weight loss of 9.2 pounds. On 10/4/24 at 12:57 PM, V2 Director of Nurses (DON) confirmed R36's recommended nutritional supplements were not implemented and R36 continued to lose weight. R36 had a significant weight loss of 10.5 pounds (7.69%) from admission on 8/9/24 to 8/28/24. V2 DON confirmed the facility should have notified the physician of and then implemented the nutritional supplement recommendation and monitored R36's weight closely. Staff should have notified the physician of R36's continued weight loss which ended up being significant. On 10/4/24 at 1:49 PM, V32 Registered Dietician confirmed she assessed R36 on 8/13/24 for nutritional risk and significant weight loss prior to admission. In order to assist in further weight loss, V32 recommended R36 be given a nutritional supplement three times a day. V32 confirmed her recommendation should have been sent to the physician and added to R36's plan of care. V32 confirmed if the nutritional supplement would have been implemented, potentially R36's weight loss could have been lessened.

Based on observation, interview and record review the facility failed to administer physician prescribed medications to one (R321) resident out of five residents reviewed for significant medication errors in a sample list of 75 residents. R321 experienced Gastrointestinal (GI) upset, malaise and was hospitalized as a result of R321 missing multiple doses of medications for blood glucose control and Gastroesophageal Reflux Disease (GERD). Findings include: R321's undated Face Sheet documents R321's medical diagnoses as Encephalopathy, Ischemic Cardiomyopathy, Heart Disease, Muscle Wasting and Atrophy, Acute Kidney Failure, Esophageal Obstruction, Diabetes Mellitus Type II, Other Specified Disease of the Pancreas, Pneumonia, Pleural Effusion, Peritoneal Abscess, Pneumonitis due to Inhalation of Food and Vomit, Chronic Diastolic Congestive Heart Failure, Cardiac Vascular Implant and Graft, Gastroesophageal Reflux Disease (GERD), Implanted Cardiac Defibrillator, Colostomy Status, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant side and Transischemic Attack (TIA). R321's Physician Order Sheet (POS) dated October 2024 documents a physician order starting 9/24/24 and discontinued 10/3/24 to administer Dapagliflozin Propanediol (Farxiga) Oral Tablet 5 milligrams (mg) daily for Diabetes Mellitus. This same POS documents a physician order for Lansoprazole Suspension 3 milligrams (mg)/milliliter (ml) starting 9/24/24 with no end date listed. Give 10 ml via Gastrostomy Tube (G-Tube) in the morning for 30 days. R321's Minimum Data Set (MDS) dated [DATE] documents R321 as cognitively intact. This same MDS documents R321 requires moderate assistance with toileting, maximum assistance with dressing, personal hygiene, bed mobility and is dependent on staff for transfers. R321's Care Plan intervention dated 6/18/24 instructs staff to administer Gastrointestinal (GI) medications/laxatives/stool softeners as ordered. Assess for symptoms such as pain, bloating reflux, abnormal bowel function, nausea/vomiting, discomfort/pain upon defecation, blood in stool, black stools, hard/dry stools, mucous, signs of hemorrhoids. This same care plan instructs staff to administer diabetic medication/insulin as ordered. R321's Medication Administration Record (MAR) dated September 2024 documents R321 was administered Farxiga 5 milligrams (mg) on 9/24-9/27, 9/29 and 9/30. This same MAR documents R321's Farxiga was not administered on 9/28/24. This same MAR documents R321's Lansoprazole 3 milligrams (mg)/milliliter (ml) was not administered on 9/24, 9/27, 9/28 and 9/29. This same MAR documents R321's Lansoprazole was administered on 9/25, 9/26 and 9/30. R321's Medication Administration Record (MAR) dated October 2024 documents R321 was administered Farxiga 5 milligrams (mg) on 10/1/24 and not on 10/2/24. This same MAR documents R321 was not administered Lansoprazole 3 milligrams (mg)/milliliter (ml) give 10 ml 10/1/24-10/3/24. R321' Nurse Progress Note dated: -10/2/24 at 8:00 AM documents Late Entry: 10/4/24 at 7:34 AM (R321's) Lansoprazole and Farxiga not administered by nurse. Lansoprazole had not been sent yet because of waiting on pharmacy to complete insurance authorization. Farxiga was in process of being re-ordered and was sent on the night of 10/2/2024. (R321) unsure exactly what meds he didn't take. (V22) Physician notified and no new orders given for Farxiga. Instructed to consult Gastrointestinal Physician regarding Lansoprazole which was changed to Omeprazole by mouth. -10/2/24 at 1:18 PM documents Faxed (V22) Physician and made aware that Farxiga 5 mg was not given this am, and also noted that his insurance will not cover his Lansoprazole oral suspension 3 mg/ml, that his cost out of pocket is plus $600. Spoke with pharmacy, included this information with fax to (V22) Physician, awaiting any new order, Farxiga will be sent out this evening. -10/2/24 at 5:16 PM documents Received fax from pharmacy at this time, (R321) insurance prefers the brand name Dapagliflozin (Farxiga) they will be sending the Brand name Farxiga moving forward. -10/3/24 at 1:45 PM documents New order for Omeprazole 20 mg by mouth daily. -10/3/24 at 11:54 PM documents (R321) complained of malaise and stomach ache. First attempt via automatic blood pressure (BP) wrist cuff 87/39, second attempt manual BP 87/38. (R321) stated, I just feel blah. (V22) Physician paged via telephone. Nurse waiting for return call. -10/4/24 at 1:04 AM documents (R321) continued to complain of stomach pain and malaise. Ambulance notified via telephone for transfer to emergency room for evaluation and treatment. On 10/2/24 at 8:15 AM V8 Licensed Practical Nurse (LPN) searched through the medication cart and medication storage room looking for R321's Lansoprazole and Farxiga. V8 LPN did not find those two medications. On 10/2/24 at 8:28 AM, R321 was laying in his bed with head of bed flat. R321's enteral feeding was running. R321's skin was pale. R321's voice was soft and raspy. R321's hand was rubbing his abdomen area. R321 stated I don't feel good. I feel blah. My stomach hurts. as V8 Licensed Practical Nurse (LPN) was assessing R321. On 10/2/24 at 8:20 AM V8 Licensed Practical Nurse (LPN) stated R321 does not have any Lansoprazole or Farxiga. V8 LPN stated (R321) is the only resident who gets Lansoprazole in suspension form. The other nurses couldn't borrow it from someone because no one else has that order. (R321's) Farxiga and Lansoprazole has been signed out. I will have to investigate with pharmacy. On 10/2/24 at 4:00 PM, V8 Licensed Practical Nurse (LPN) stated I spoke with pharmacy. (R321's) Lansoprazole was waiting on insurance and so the pharmacy never did even send it. (R321's) Farxiga was never re-ordered when he came back from the hospital on 9/23/24. I don't know why other nurses have been signing those two medications out because they weren't here to give. On 10/3/24 at 2:00 PM, V2 Director of Nurses (DON) stated R321 had missed doses of his Lansoprazole and Farxiga. V2 DON stated V2 called the pharmacy and verified the number of doses sent to the facility and when. V2 DON stated through V2's investigation, R321 did miss multiple doses of his Farxiga and Lansoprazole. V2 DON state nurses should only sign off that a medications been given if the resident actually got the medication. V2 DON stated if a resident misses a dose of any medications, there should be documentation as to why and that the proper people should be notified with multiple missed doses. V2 DON stated V2 was not certain why R321's Farxiga and Lansoprazole were signed out as given when they were not. V2 DON stated V2 would investigate this further and educate staff on medication administration and documentation. V2 DON stated the facility does not have a medication error rate policy but would assume that it is a standard of care to investigate and document why a resident would miss multiple doses of medications including notifications and any effect on the resident. V2 DON stated the facility does not have a policy for medication errors. V2 stated the expectation is for the nurses to self-report to V2 who would then do an investigation. V2 DON stated I was not aware (R321) not receiving his medications until yesterday (10/2/24). On 10/4/24 at 2:55 PM, V33 Pharmacy Technician Data Entry Specialist stated R321's Farxiga was delivered to the facility on [DATE]. V33 stated that would be a 14 day supply (14 doses). V33 stated R321's Farxiga should have lasted until 8/30/24. V33 stated R321 would have missed nine consecutive doses from 9/24/24-10/2/24. V33 stated Farxiga was not sent any other times. V33 stated R321's Lansoprazole required authorization from his insurance company which was never obtained. V33 stated R321's Lansoprazole was never sent to the facility. V33 stated R321 would have missed eight consecutive doses from 9/25/24-10/2/24. On 10/4/24 at 3:10 PM, V34 Pharmacist stated Lansoprazole and Pantoprazole have similar effects on the body. V34 stated If someone like (R321) with severe Gastrointestinal (GI) disease did not get these medications it could certainly contribute to GI distress and put him at a higher risk of having GI complications. (R321's) hospitalization in part could be caused by him not receiving his prescribed medications. V34 Pharmacist stated R321 should have his blood glucose monitored regularly due to R321 is receiving enteral feedings as his main nutritional source. On 10/8/24 at 3:00 PM, V22 Physician/Medical Director stated R321 has a long standing history of Gastrointestinal Disease. V22 stated R321 was recently hospitalized for GI issues. V22 stated R321 needs his Lansoprazole for his Gastroesophageal Reflux Disorder (GERD) or he will become symptomatic. V22 stated symptoms may include GI upset, malaise, nausea, vomiting or a feeling of fullness. V22 stated it is important for R321 to receive his prescription medications including the Lansoprazole to avoid being re-hospitalized . V22 stated R321 has a medical diagnosis of Diabetes Mellitus Type II and also requires his medication (Farxiga) to help to lower his blood glucose levels. V22 stated R321 missing so many doses of his Lansoprazole and Farxiga with no notification to V22 is unacceptable. V22 stated R321 was re-hospitalized on [DATE] due to GERD symptoms. V22 stated the facility failing to administer R321's prescribed medications attributed to the fact that R321 has been hospitalized twice in the recent past for the same symptoms related to his Diabetes and GERD.

Based on observation. interview, and record review the facility failed to implement interventions to prevent a pressure ulcer and failed to assess and treat a facility acquired pressure ulcer for a resident. These failures affect one resident (R265) of three residents reviewed for pressure ulcers in a sample list of 58 residents. These failures caused R265 to develop two facility acquired unstageable pressure areas and an additional stage II pressure area. Findings include: R265's Care Plan initiated 12/1/23 includes the following diagnoses: Status Post Spinal Surgery, Diabetes with Neuropathy, Spinal Stenosis, Congestive Heart Failure, Generalized Anxiety Disorder, Depression. R265's Braden Skin Risk assessment dated [DATE] documented R265 is at risk for skin breakdown. R265's Wound Assessments dated 12/1/23 document R265 was admitted [DATE] with a surgical wound to upper midback, Reddened area to Right hip, Excoriated/reddened area to coccyx, and a reddened area to right iliac crest. R265's Care Plan initiated 12/1/23 documents (R265) at risk for impaired skin integrity due to impaired mobility, Diabetes Mellitus, poor appetite and recent surgery. Provide (R265) with a pressure reduction mattress. May use a pressure reduction cushion if uses a wheelchair. Remind/assist (R265) to shift weight/reposition at least every two hours. Ensure pressure reduction on any areas that might be impaired with education/assistance. R265's Physician's orders include admission orders dated 12/1/23 for Physical and Occupational therapy. On 12/4/23 at 1:34 AM, R265 was being lifted with a sling type mechanical lift by V30 Certified Nurse's Aide (CNA) and V31 CNA and transferred to a bariatric wheelchair. There was no pressure relieving cushion in the chair and no pressure relieving mattress on R265's bed. R265 stated this is the first time I've been up since I came in Friday (12/1/23). V30 stated, They just brought out the wheelchair from downstairs for (R265). (R265) will have therapy for the first time today. R265's Treatment Administration Record (TAR) has an order dated 12/1/23 to assess skin daily and document I for intact and W for wound every night shift for skin integrity. R265's TAR for 12/1/23 through 12/6/23, documents I indicating R265's skin was intact. On 12/6/23 at 9:50 AM, V30 and V33 CNAs were providing incontinence care and catheter care for R265. When R265 was turned to her left side to be cleaned a three centimeter (cm) by four cm, dark purple edematous, unstageable deep tissue injury was visible to R265's right buttock near the gluteal cleft. A two cm by three cm dark purple edematous, unstageable deep tissue injury was visible to R265's left buttock near the gluteal cleft. And an eight cm by one half cm, Stage II pressure area was noted in the crease under R265's right buttock along where the catheter tubing had been laying. R265 stated My butt really hurts. The nurses haven't looked at it and I don't get any dressing or anything. I'd like them to do something for it. It's been sore for at least a couple days. V33 stated The wound nurse hasn't been in since (R265) got here. She'll be here today so we've just been keeping it clean. There was no documentation of assessment, physician's notification, or treatment order in place for these areas. On 12/6/23 at 2:00 PM V32, Wound Nurse stated I was not aware of the deep tissue injuries or the pressure area under (R265's) right buttock. I have assessed them now and there are two unstageable Deep tissue Injuries on (R265's) buttocks and a new pressure area under R265's right buttock on her thigh. I will notify the doctor and get a treatment order. The facility's policy Wound and Ulcer Policy and Procedure revised 1/10/18 states It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. This policy also documents Moderate risk protocol Daily skin check completed by direct care staff. The 'skin observation report' may be used to communicate skin observation to the nurse.

Based on observation, interview, and record review the facility failed to provide a safe transfer and implement care plan interventions for three (R87, R265, R39) of eight residents reviewed for Accidents in a sample list of 58 residents. These failures resulted in R39 sustaining an upper arm (Right Humeral) fracture and pelvic (Inferior Pubic Ramus) fractures and R87 sustaining pelvic (Superior and Inferior Pubis Rami) fractures. R39 and R87 required emergency services and hospitalization . Findings include: 1.) R87's Medical Diagnoses List documents R87's medical diagnoses of Dementia, Disorders of Bone Density and Structure, Hyperosmolality and Hypernatremia, Kidney Failure and Closed Fracture of Pubis. R87's Minimum Data Set (MDS) dated [DATE] documents R87 as severely cognitively impaired. This same MDS documents R87 uses a walker for mobility and requires supervision with transfers and walking. R87's Fall Risk Evaluation dated 7/25/23 documents R87 as a high fall risk. R87's Fall Investigation dated 8/6/23 documents (R87) was ambulating without walker and assistance also had plain socks on. (R87) complained of pain on the inside of Left groin area. Pain when Range of Motion (ROM) performed. Placed in a standing position. This same fall investigation documents R87's shoes were in path of (R87). R87's Final Incident Report to State Agency dated 8/14/23 documents (R87) was observed on the floor in her room on 8/6/23. It was determined that (R87) had Superior and Inferior Pubic Rami Fractures. Facility investigation of the fall determined that (R87) had been in her room wearing only regular socks when she states 'I saw a bug fly to the floor so I got up to kill it and slipped to my bottom.' R87's Care Plan intervention dated 4/18/23 instructs staff to have R87 wear appropriate shoes and monitor for unsteady gait, poor balance, poor posture, dizziness and fatigue. R87's Nurse Progress Note dated: --8/6/23 at 11:40 PM documents (R87) yelled and (V26) Certified Nurse Aide (CNA) observed (R87) sitting on buttocks in the middle of the her floor. Observed (R87) sitting on buttocks in her room. (R87) stated that she went to kill a bug and sat down on the floor. (R87) stated that she had pain on the inside a little to the left of her groin area. (R87) ambulated a little slower than usual. (R87) laid down in bed . Physician (MD) are aware. MD will assess (R87) when he comes in. --8/7/23 at 9:10 AM documents (R87) having pain left hip area. Physician (MD) gave new order for X-Ray. Portable x-ray ordered due to Dementia diagnosis. Portable x-ray ordered three views to left hip due to post fall, pain and immobility. --8/7/23 at 11:25 AM documents Facility Interdisciplinary Team (IDT) Review: (R87) Female resident who is alert and oriented X two. (R87) needs supervised to limited assistance with Activities of Daily Living (ADLs). (R87) was observed sitting on her buttocks on her room floor on 8/6/23 at 11:40 PM. Assessed: vital signs within normal limits, neurological checks initiated, pain with Range of Motion (ROM) performed, placed in a standing position. (R87) ambulating without her walker and had regular socks on feet. (R87) stated, was getting up to kill a bug that flew off her bed onto the floor and slid to the floor on her buttocks. --8/7/23 at 4:11 PM documents (R87) continues to have pain. Spoke with Physician (MD) office to have (R87) sent to emergency room (ER) for evaluation and treatment since results have still not been read. MD gave order for ER for evaluation and treatment. --8/7/23 at 8:08 PM documents Hospital called and stated (R87) has Superior and Inferior Left Pubic Fractures. --8/8/23 at 1:41 PM documents (R87) complains of Pelvic pain. (R87) Refusing to get out of chair and stand due to pain. (R87) Stated she would just go to the bathroom in her depends because the pain of standing was so bad she was going to have a heart attack. --8/9/23 at 4:18 PM documents Resident returned from appointment with (V27) Orthopedic Surgeon regarding Pubic Rami Fractures. (R87) is to be up walking with walker as much as possible. Fractures should heal on their own. R87's Orthopedic Surgeon (V27) Progress Note dated 8/9/23 documents (R87) does have a Pubic Rami Fracture but will heal on its own and not need surgery. (R87) can walk on her own with a walker as allowed and tolerated. On 12/5/23 at 9:55 AM R87 walked independently to R87's room door. (V7) Activity Director walked over to R87, invited R87 to join in on activity. (V7) stated to R87 'Come on over and join us'. R87 then walked back into R87's room and returned in two minutes with seat cushion and purse. R87 then walked independently with shuffling gait from room the activity area across the hall. V7 did not encourage R87 to use walker when ambulating. On 12/5/23 at 10:05 AM (V7) stated (R87) walks by herself all the time back and forth from her room to the dining/activity area. I guess I should have encouraged (R87) to use her walker but I never see her use it so I guess I thought she didn't need it anymore. On 12/5/23 at 10:10 AM V8 Dementia Unit Director stated R87 is a high fall risk and should be using her walker when ambulating. V8 stated (R87) did fall a few months ago and got a fracture. (R87) can walk independently but we (staff) should all encourage her to use her walker. (V7) Activity Director should have encouraged (R87) to use her walker when walking to the activity. On 12/6/23 at 9:45 AM V9 Assistant Director of Nurses (ADON)/Fall Nurse stated (R87) fell because the staff weren't watching her. We (facility) know (R87) gets up and down all the time. After (R87) fell , they (staff) should have used the total body mechanical lift to get her back up but instead they just got her up and let her start walking independently again. They (staff) even documented that (R87's) gait was slower than usual. (R87) was complaining of pain at the time of the fall. (V18) Licensed Practical Nurse (LPN) and (V26) Certified Nurse Aide (CNA) should not have gotten her up. (V18) should have just called the ambulance from there. On 12/6/23 at 1:05 PM V19 Medical Director stated the facility did not follow R87's careplan to help prevent R87's fall. V19 stated (R87) has a very short term memory. (R87) does not remember anything you tell her for any length of time. That is why (R87) lives in a Dementia unit. The facility staff should have made sure (R87) was being monitored more closely. V19 stated R87 fell because staff did not ensure R87's safety. V19 stated (R87) fell at this facility which resulted in her fractures. I do not recall (V18) reporting pain for (R87). Normally, I would just have the resident sent directly to the emergency room for X-Rays. Especially with a Dementia resident who is not cognitively able to accurately report exact source of pain. I would have just sent (R87) to the emergency room . Whether (R87) obtained the fractures because of the fall or because the staff got her up right after the fall without the use of the total body mechanical lift is a mute point. Either way, (R87) obtained the fractures due to the facility not following their own policies and careplan guidelines. 2.) R39's Medical Diagnosis list documents R39's medical diagnoses as Alzheimer's Disease, Dementia, Parkinson's Disease, Epilepsy with Complex Partial Seizures, Anxiety Disorder, Unsteady on Feet, Right Pubis Fracture, Muscle Weakness and Lack of Coordination. R39's Minimum Data Set (MDS) dated [DATE] documents R39 as severely cognitively impaired. This same MDS documents R39 requires extensive assistance of one person for transfers, bed mobility, toileting, personal hygiene and limited assistance of one person for walking in room. R39's Care Plan intervention dated 11/5/18 instructs staff to identify factors that increase R39's risk for falls such as obstacles, unmet needs or medications, keep pathways clear and to eliminate factors that may increase my risk for fall/injury. This same careplan documents an intervention dated 4/26/19 that instructs staff to ensure R39 wears non-skid socks. R39's Fall Risk Evaluation dated 10/5/23 documents R39 as a high fall risk. R39's Nurse Progress Note dated: --11/9/23 at 6:03 PM documents (R39) was observed on the floor. (R39) stated she was getting her walker that was in between the bathroom and her room. --11/9/23 at 6:05 PM documents (R39) started to complain of her head hurting and her right side hurting. Physician (MD) was notified and gave orders to send out to emergency room to treat and evaluate at 5:00 PM. R39's Fall Investigation dated 11/9/23 documents R39 obtained a bruise on Right Hip and Head Trauma on Right side of back head. This same fall investigation documents staff applied an ice pack to R39's head, R39 stated 'I hit my head' and '(R39) was trying to go to the bathroom to get her walker. R39's Final Incident Report to State Agency dated 11/17/23 documents R39 fell at facility on 11/9/23 at 11:45 AM. This same report documents R39 was sent to the emergency room where she was admitted with Right Humeral Fracture and Inferior Pubic Ramus Fracture. This same report documents R39's statement 'I was trying to get my walker. I left it in the bathroom. I hit my head.' R39's Hospital Record dated 11/9/23 documents R39 sustained a Right Humeral Fracture and Inferior Pubis Rami Fracture from unwitnessed fall at facility on 11/9/23. On 12/5/23 at 2:00 PM V9 Assistant Director of Nurses (ADON)/Fall Nurse stated R39 fell on [DATE] obtaining a Left Humeral Fracture and Inferior Pubis Rami Fracture due to fall at facility. V9 stated the staff had been in R39's room [ROOM NUMBER] minutes prior to fall to attempt to get R39 out of bed. V9 stated R39 refused to get out of bed so the staff left R39 in her room alone and forgot to put the walker back within her reach. V9 ADON/Fall Nurse stated (R39) probably would not have fallen that time if the staff had put her walker next to her. But since (R39) had to get her own walker out of the bathroom, (R39) was apparently unsteady and fell . (R39) ended up getting fractures that could have been prevented if our staff would have just left (R39) her walker. On 12/6/23 at 1:00 PM V19 Medical Director stated Dementia residents are known for being forgetful. The staff is there to help give verbal reminders to help keep the residents safe. I remember being told about this fall for (R39). (R39) is more apt to use her walker if it is within her sight and reach. (R39) has very poor safety awareness and is not able to make safe decisions for herself. Unfortunately for (R39) the facility did cause the fall which was the cause of the fractures. This fall was preventable. Maybe others might not be, but this fall for (R39) could have been prevented. The facility policy titled 'Safe Resident Handling Program' revised 3/18/18 documents if a resident falls to the floor, the resident will be first assessed by a nurse. If the resident is deemed medically appropriate to transfer from the floor, a full size mechanical lift will be used. If the resident is not medically appropriate to transfer from the floor, emergency medical technicians will be notified and said technicians will transfer the resident. 37813 3. R265's Care Plan initiated 12/1/23 includes the following diagnoses: Status Post Spinal Surgery, Diabetes with Neuropathy, Spinal Stenosis, Congestive Heart Failure, Generalized Anxiety Disorder, Depression. On 12/4/23 at 1:34 AM, R265 was being lifted with a mechanical lift by V30, Certified Nurse's Aide (CNA) and V31 CNA and transferred to a bariatric wheelchair. R265 was lying on the bed with a split leg sling positioned under her. V30 placed the lift hook in the blue loop on R265's left upper body. V31 then attached the left upper loop. V30 and V31 attached the leg loops to the mechanical lift but did not cross the loops. R265 was then raised in the lift. V30 rolled the lift from under the bed but did not spread the legs to provide a safe base of support prior to rolling the lift several feet across the room to the wheelchair. When the lift was in front of the wheelchair V30 spread the legs of the lift to place R265 in the wheelchair. V30 stated I know the leg supports are supposed to be crossed before you lift, but (R265) doesn't like us to do that. I suppose I should have opened the legs before rolling (R265) to the wheel chair to keep the lift from tipping. On 12/5/23 at 11:00 AM, V2 Director of Nurse's stated To keep the resident from slipping out of the sling while transferring, the straps on the split sling should be crossed between the residents legs and the legs (mechanical lift legs) should be in the open position to prevent tipping during transfer.

Based on interview and record review the facility failed to provide assistance with ambulation and ensure appropriate placement of non-skid strips to prevent a fall for one of three residents (R5) reviewed for falls on the sample list of six. This failure resulted in R5 falling face first onto the floor, sustaining a laceration to the head which required emergency medical assistance and sustaining a fracture to the nasal bone. Findings include: R5's emergency room records dated 1/24/23 at 12:23 PM, documents R5 was seen in the emergency room due to a fall from the standing position and hitting face on the concrete. This record documents R5 has a comminuted (broken into more than two pieces) mildly displaced fracture of the left nasal bone. These records documents R5 received 10 sutures to the forehead laceration. R5's Careplan dated 3/02/21 documents R5's safety awareness is compromised due to a diagnosis of Alzheimer's disease. This care plan includes an intervention to monitor for unsteady gait, poor balance, poor posture, dizziness, and fatigue. R5's Nurse's Note dated 1/24/2023 at 8:30 AM written by V10 Licensed Practical Nurse documents, (R5) observed falling to floor by CNA (V11, Certified Nurse's Assistant). Resident has no (complaints of) pain at this time. (R5) at baseline A&O x 1(alert and oriented to person). No pain with (passive range of motion). Resident able to (move all extremities). Resident VS (vitals signs) stable. No injuries noted. Resident did not hit head. On 3/27/23 at 10:12 AM, V11 stated, R5 didn't feel well that day. V11 stated that morning (1/24/23) after breakfast she toileted R5 and she missed the bed and slid to the floor. On 3/23/23 at 11:21 AM, V10 stated on 1/24/23 at 8:30 AM, R5 had been at breakfast, she is ambulatory without a walker and walked back to room and attempted to get into the bed and slid off the side. V10 stated the intervention put into place was to assist R5 out of bed and with ambulation. That was the intervention I put into place because she was really unsteady and acting tired. The next fall happened at 11:25 AM. R5's Nurse's note dated 1/24/2023 at 12:09 PM written by V10 documents, (R5) observed by CNA (V11) falling to floor from standing position. (R5) noted to have open area on forehead that was bleeding, and bloody nose. Area was cleansed with NS (normal saline) and pressure dressing applied, nose bleed was controlled. This note also documents R5 was sent to the emergency room for an evaluation. On 3/27/23 at 10:12 AM, V11 stated after the first fall on 1/24/23 the new intervention was to assist her with transfers and ambulation. V11 stated she went in there to get her up and she stood up fine. V11 stated when V11 was turning to walk out of the room R5 fell straight on her face. V11 stated she turned to walk with me and she fell straight down. V11 stated she fell right in front of her bed. On 3/27/23 at 1:19 PM, V3 Assistant Director of Nursing stated she investigated R5's fall. When asked about the root cause of the fall, V3 stated when she reenacted the fall by sitting on the edge of the bed. V3 noticed that her left foot was on the nonskid strip that was on the floor but her right foot was not. V3 stated the strips in front of the bed needed to be longer so that both of R5's feet would touch the non skid strips. V3 stated she also found out that V11 had went in to get R5 to take her to lunch. V3 stated V11 told her that the fall happened when she turned to leave and told R5 that it was time for dinner. V3 stated V11 told me that her back was to her when she fell . V3 stated she fell face first onto the floor.

Based on interview and record review, the facility failed to effectively supervise R1 to prevent a traumatic fall. This failure resulted in R1 falling to the ground on R1's head and sustaining head lacerations, contusions, and a brain bleed requiring emergency hospitalization and treatment. R1 is one of three residents reviewed for falls in the sample of three. Findings include: R1's Face Sheet (12/15/2022) documents R1 admitted to the facility from the hospital on 10/31/2022. The same record documents R1's diagnoses included: Cognitive Impairment, Unsteadiness on Feet, Abnormal Gait and Mobility, and Muscle Weakness. R1's admission Fall Risk Assessment (10/31/2022) documents R1 is at High Risk for Falling. R1's subsequent Fall Risk Assessments (11/1/2022, 11/8/2022, 11/13/2022) all document R1 remained at High Risk For Falling. R1's admission Minimum Data Set assessment (11/6/2022) documents R1 utilizes a wheelchair for mobility and has impaired balance during transitions and walking. The same record documents R1 is not steady moving from the seated to standing position or during walking and is only able to stabilize with staff assistance. The facility Occurrence Report (undated) documents R1 sustained a fall on 11/1/2022, one day after R1's admission, and additional falls on 11/7/2022 and 11/10/2022. The facility fall investigation (undated) documents on 11/10/2022 facility staff placed R1 in R1's wheelchair in the hallway near the nurse's station due to poor safety awareness and continual attempts to stand up. The same record documents R1 can no longer balance on R1's feet and R1 attempted to stand up and fell to the ground. The facility Post Fall Investigation (11/11/2022) documents prior to R1's 11/10/2022 fall Resident (R1) was sitting in w/c (wheelchair) up at nurse's station for visual observation. The same record documents Resident alone or unattended (at the time of the fall) and the resident stated get up just prior to the fall. On 12/15/2022 at 2:59PM, V4 (Physical Therapy Assistant) reported R1 had been restless on the day of R1's above fall and had frequently attempted to stand up from R1's wheelchair. V4 reported being in the nearby therapy room at the time of R1's fall and only being able to see R1's head through the therapy room window separating the therapy room from the hallway where R1 was seated in a wheelchair prior to the fall. V4 recalled looking through the window and seeing R1's head rise and then fall abruptly. V4 reported exiting the therapy room into the hallway where R1 was on the ground and being the first staff present to assist R1 after the fall, with no other staff around. V4 reported the nurse on duty, V5, was not at the adjacent nurses's station at the time of R1's fall to the ground and R1 was confused and moaning after the fall. V4 reported being unaware if any facility staff had been assigned to supervise R1 at the time of the fall. On 12/15/2022 at 2:30 PM, V3 (Certified Nurse Aide) reported being in an office nearby the nurse's station and hearing R1 fall to the ground, and when V3 went into the hallway to check on R1, V4 was the only staff present. On 12/16/2022 at 10:40 AM, V3 reported R1 had not verbalized anything prior to R1's fall on 11/10/2022. V3 reported R1's fall may have been preventable had facility staff been present with R1 at the time of R1's fall. On 12/15/2022 at 3:23 PM, V5 (Registered Nurse) reported R1 had been placed at the nurse station on 11/10/2022 for increased supervision due to attempting to get out of her chair. V5 reported returning from a lunch break, and when V5 entered the nursing unit, R1 had already fallen and facility staff were assisting R1. V5 reported not being sure if any facility staff were supervising R1 at the time of the fall. R1's 11/10/2022 Progress Notes document R1 fell from R1's wheelchair in front of the nurse's station and fell on to R1's left side. The same record documents R1 was crying in pain when moved and a gash and hematoma (bruise) were forming to R1's temple. R1's Emergency Department report (11/11/2022) documents R1 sustained a brain bleed falling from R1's wheelchair to the floor in the facility on 11/10/2022. The same record documents R1 required further evaluation at a higher care level and was transferred to the trauma service at another hospital. On 12/16/2022 at 12:39 PM, V6 (R1's medical provider) reported R1 was redirectable at the time of R1's fall and stated I can see that (the facility should have provided R1 maximum supervision instead of leaving R1 unsupervised in R1's wheelchair in the hallway on 11/10/2022).

Based on interview and record review the facility failed to provide supervision for one of three residents (R2) reviewed for falls in the sample of three by leaving R2 on the toilet unsupervised. This failure resulted in R2 falling and received a life-threatening head injury, large subdural hematoma, which caused R2's death. This failure resulted in an Immediately Jeopardy. The Immediate Jeopardy began on [DATE] when (R2) was found on R2's bed after being left unsupervised on the toilet. The Immediate Jeopardy was identified on [DATE]. V1 Administrator, was notified of the Immediate Jeopardy on [DATE] at 11:55 AM. The surveyor confirmed by interview and record review the Immediate Jeopardy was removed on [DATE], but non-compliance remains at a severity level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training. Findings include: The Physician Order Sheet (POS) dated [DATE] documents the following diagnoses for R2: [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], [CONDITION(S)], Other Abnormalities of gait and mobility, Unsteadiness on feet and generalized Muscle Weakness. The same POS documents R2 receives the blood thinner medication [MEDICATION(S)] ([MEDICATION(S)]) tablet 2.5 milligrams 1 tablet by mouth two times a day for A-fib ([CONDITION(S)]). The MDS (Minimum Data Set) assessment dated [DATE] documents R2 is cognitively impaired and requires staff assistance of one with all tasks of daily living. The same MDS documents R2 is not steady during transition and walking and must have staff with her to stabilize while toileting. The MDS documents R2 requires the use of wheelchair or a walker. R2's admission fall assessment dated [DATE] documents R2 is at high risk for falls. The post fall assessments dated [DATE], [DATE] and [DATE] also document R2 is high risk for falls. R2's fall investigation report dated [DATE] at 10:15 PM, documents R2 was walking back from the bathroom with V10 CNA (Certified Nurse Aide) and R2's legs became weak and V10 walking with her lowered R2 to the floor. R2's Progress Notes dated [DATE] at 10:15 PM, written V9 RN (Registered Nurse) documents CNA (V10) was walking to bathroom and (R2's) legs became weak and (V10) lowered her to the floor into sitting position. No pain or injury noted mechanical lifted. Bed was placed in low position, instructed to ring for assistance and not to get up by self. The Fall Investigation Report dated [DATE] documents Interventions decided by the IDT (Interdisciplinary team) were to use wheelchair for long distances. R2's facility report titled Falls Details Report--Occ# 87 dated [DATE] documents NO under the section titled Independent for toileting. R2's facility Fall Investigation Report dated [DATE] at 6:00 PM, documents R2 was found on the floor in front of R2's bed lying on her right side and with the walker on top of her legs. The Fall Investigation Report documents V11, CNA was the staff member who found R2. The Investigation Report documents R2 stated I was just getting up to go back to bathroom. Progress notes for R2 dated [DATE] at 6:00 PM, written by V9 at 8:29 PM document R2 was laying on right side in front of bed when (V11) entered, with walker over (R2's) legs. No pain with Range of Motion (ROM) no injury noted at this time. Mechanical lift to bed, neuro (neurological) checks started, bed in low position with every 15 minutes rounders continuing. Progress notes dated [DATE] at 1:59 PM, document Intervention decided by the IDT team was 15 minute rounds to be done for (R2). The facility report titled Fall Details Report--Occ # 37 dated [DATE] documents NO under the section titled Independent for toileting. The facility's report titled Report to Illinois Department of Public Health dated [DATE] reports (R2) was found laying across her bed, no clothes on and the walker turned over on [DATE] at 6 PM. It was noted (R2) had a yellowing bruise to the right side of her face from (R2's) fall that occurred prior to admission. On [DATE] at 6:40 AM the facility staff noted a purple bruise to R2's right forehead, eye and cheek. The Physician and POA (Power of Attorney) were both notified and an order for (R2) to be sent to Emergency Department was written. R2's care plan dated [DATE] has the interventions in place from the two falls on [DATE] and [DATE] and it continues to state to Ensure correct footwear is on and to ensure (R2's) room is free of obstacles and monitor (R2) for unsteady gait, poor balance, poor posture, dizziness and fatigue. Instruct and remind (R2) to use assistive devices to promote safety. On [DATE] at 4:50 PM, V3 CNA stated (on [DATE] at 6:00 PM) V3 was getting ready to go to R2's room to get R2 ready for bed. V3 stated V8 unknown CNA came out of R2's room and told V3 that R2 was on the toilet with clothes on. V3 stated that is when she went into R2's room and found R2 on the bed, undressed and lying across her bed sideways with R2 responding to V3's questions and the walker turned over on the floor. V3 stated she cleaned R2 up and positioned her correctly in the bed and notified the nurse about the condition she found R2 in. V9 Registered Nurse documents in the progress notes for R2 on [DATE] at 4:30 AM, found laying across bed after taking self back to bed from bathroom (on [DATE] at 6:00 PM), right bruising of eye and forehead continues. Ice pack applied and reinstructed not to get up without help. c/o (complain of) foley (indwelling urinary catheter) and having to pee, showed foley and urine in bag to resident at this time again. Continue to monitor for changes in condition. Neuro checks continue at this time. R2's Progress note dated [DATE] at 6:40 AM, documented by V11, RN states CNAs were getting resident out of bed to get dressed for am et (and) noted bruising to right forehead, eye, et cheek. CNA's alerted RN et (and) RN immediately assessed resident et noted a 10.5 cm (centimeter) X 12 bruise to right forehead, right eye, et right cheek. Right eyelid with purple bruising et swelling. Neurochecks initiated et remain @ (at) resident's baseline. VSS (vital signs stable). Resident stated she fell last night. Resident verbalizing to staff et able to answer questions et denies pain other than to right side of face. Resident transferred to toilet per staff et then assisted into w/c (wheelchair) et brought to nurse's station for close monitoring. Will contact MD (Medical Doctor). R2's Progress Note dated [DATE] at 6:55 AM, documents R2 was assessed by the nurse and V7, Physician was at the facility and saw R2 and immediately told the nurse to send R2 to the emergency room for evaluation. R2's Computed Tomography report dated [DATE] at 9:09 AM, documents Large right subdural hematoma, acute, measuring up to 2.2 centimeters in thickness. Continues to document Moderate bilateral frontal subarachnoid hemorrhages. Hospital Records dated [DATE] document R2 was transferred to another hospital. R2's Hospital Discharge Summary dated [DATE] at 4:52 PM, documents R2 was admitted to the hospital on [DATE] and expired on [DATE]. The Discharge Summary Documents R2's cause of death as Cardiorespiratory Arrest, Acute Subdural Hematoma and that R2's Admission Diagnoses were Mechanical fall and Acute Subdural Hematoma. The Discharge Summary documents R2's Final Diagnosis and diagnosis during hospitalization as Mechanical fall with large right hemisphere acute subdural with subfalcine herniation to the left and right uncal herniation, while on anticoagulant for history of [CONDITION(S)] [CONDITION(S)]. On [DATE] at 3:24 PM V11, RN stated The CNA's called me to (R2's) room and they said her face was black and blue. V11 stated (R2) was oriented to name and place and she told me she fell and (V3) picked her up. V11 stated (V7), Physician was here and gave an order to send her to ER (Hospital emergency room ) immediately, so I did. On [DATE] at 3:05 PM, V2 Director of Nurses stated, Yes I was the one who did the interview with the staff for the investigation of R2's fall on [DATE]. V2 stated V2 believed V3's report that an unknown CNA (V8) left R2 on the toilet. V2 stated that at the time of the fall, R2 would not have been safe by herself. V2 stated I would not expect (R2) to be able to get from the toilet to her bed on her own. On [DATE] at 10 AM, V7 Physician stated Yes the fall subdural hematoma is the reason the resident (R2) died . I cannot say if (R2) was strong enough to walk back from the toilet to the bed because I had not seen her for a long time, that is one of the reasons I was there at the facility when I gave the order to send to (the) emergency room . On [DATE] at 12:26 PM, V12 and V13 Physical Therapy Assistants stated (R2) was not strong enough to walk by herself. When we walk with her, she is unsteady, and we always make sure our hands are on her gait belt. (R2) also has the issue of leaning over and complaining (R2's) catheter is hurting. The facility's Fall Policy revision date ,d+[DATE] states: It is the policy of this facility 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, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. The Immediate Jeopardy that began on [DATE] was removed on [DATE]. The surveyor confirmed through observation, interview, and record review on [DATE], that the facility took the following actions to remove the immediacy: 1.) Morse Fall Scale assessments were completed on all residents immediately. As a result of the fall assessments, the facility identified all residents needing fall interventions. Interventions were in place based on total score and residents' specifics. Completed by Director of Nursing and Minimum Data Set Coordinator on [DATE]. 2.) Staff updated all care plans to reflect these needs for each resident. Completed by Director of Nursing and Minimum Data Set Coordinator on [DATE]. 3.) V14 Regional Director of Operations in-serviced V1 Administrator, V2 Director of Nurses and Department Heads on the Facility Fall Management Program policy on [DATE]. 4.) All policies and procedures regarding the fall management program have been reviewed and revised by V1 Administrator and V2 Director of Nurses on [DATE]. 5.) Staff have been in-serviced by V14 Regional Director of Operations, V2 Director of Nurses and V1 Administrator on identified residents needing supervision and current care needs on [DATE]. 6.) Staff have been in-serviced by V14 Regional Director of Operations, V2 Director of Nurses and V1 Administrator on policy revisions regarding staff response to resident's requests for assistance on [DATE]. 7.) Staff have been in-serviced by V14 Regional Director of Operations, V2 Director of Nurses and V1 Administrator on effective interventions that have been implemented to prevent falls on [DATE]. 8.) Staff have been in-serviced by V14 Regional Director of Operations, V2 Director of Nurses and V1 Administrator on the procedure for assessing, identifying, and providing appropriate supervision for all newly admitted residents to ensure supervision is provided and to ensure the resident's room is free from accident hazards as necessary on [DATE]. 9.) V2 Director of Nursing is monitoring newly admitted residents to ensure fall assessment, supervision and interventions are provided. Completed on [DATE] and is ongoing.

These failures require more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to provide safety and supervision to prevent falls by failing to implement post fall interventions. This failure resulted in R1 subsequently falling on two additional occurrences and sustaining head trauma and a [CONDITION(S)] requiring surgical intervention. This failure affects one of four residents (R1) reviewed for accidents on the total sample list of six. B. Based on interview, and record review, the facility failed to supervise and contain a potentially hazardous chemical for one of four residents (R5) reviewed for accidents on the total sample list of six. Findings include: a. R1's fall risk assessments completed on 12/14/21, 1/12/22, 1/27/22, and 2/1/22 document a risk score of 65, indicating R1 is at high risk for falls. R1's medical record documents on 1/27/2022 at 8:51 PM, Resident was sitting in the day room and fell out of recliner and hit her head. R1's post fall occurrence reports documents, on 1/27/22 at 8:45 PM, resident was sitting in day room eating a snack then stood up and fell forward. Injuries: Bruising to the left side of the forehead measuring 7 centimeters by 5 centimeters, bruise is purple in color. R1's post fall investigation form documents, resident had been toileted at 8:00 PM layed down and tried to get out of bed on her own, resident was brought to the day room for snacks. R1's Fall Investigation Analysis form documents, What type of assistance was the resident receiving at the time of the fall: resident alone or unattended. What appears to be the root cause of this fall: Unaware of safety needs due to cognitive impairment. Describe interventions to prevent future falls: Keep resident in visual observation when up in wheelchair. R1's medical record documents on 1/31/22 at 10:15 AM, Heard noise, noted resident sitting on floor in hall near nurses station, leaning against an office door. Noted raised area to back of head, no bruising or open areas seen at this time. Alert with normal confusion, stating help me up, continues to try standing up after assisting her into the wheelchair. R1's post fall occurrence report documents, on 1/31/22 at 10:15 AM, heard noise, saw resident sitting on buttocks by wheelchair, back of head against office door. Injuries: head trauma, center side of back of head. Care prior to fall, visually observed on 1/31/22 at 10:10 AM. R1's post fall investigation form documents,Where did fall occur: Hallway, Fall Summary: found on floor (unwitnessed). Other: Had been trying to stand up all morning. Possible contributing factors to help identify root cause: yelling out trying to get up by self out of chair. R1's Fall Investigation Analysis form documents, What type of assistance was the resident receiving at the time of the fall: Resident alone or unattended. What appears to be the root cause of this fall: Advancing disease process. Describe intervention to prevent future falls: Provide one on one interaction, socialization. R1's medical record documents on 2/6/2022 at 3:36 PM, Resident observed on floor of corridor. Resident assisted to bed. Resident was resting in bed and began to complain of pain to left leg. Received order to send to emergency room for evaluation/treatment. R1's post fall occurrence report documents, on 2/6/22 at 3:15 PM, Nurse observed resident on floor laying on back with wheelchair beside resident. Resident stands up by pulling self up with rails in hallway, redirected to sit down, resident is non compliant. Care prior to fall: Visually observed on 2/6/22 at 3:10 PM. R1's Post Fall Investigation form documents, Where did fall occur: Hallway, Fall Summary: found on floor (unwitnessed). R1's Fall Investigation Analysis form documents, What type of assistance was the resident receiving at the time of the fall: Resident alone or unattended. What appears to be the root cause of the fall: Unaware of safety needs due to cognitive impairment. Describe intervention to prevent further falls: Transferred to hospital for evaluation and treatment. R1's Hospital History and Physical reports document, service date/time: 2/7/22 at 8:21 AM, Chief Complaint: Unwitnessed fall at nursing home. History of present illness: presented to the emergency room yesterday afternoon (2/6/22) after having an unwitnessed fall at nursing home. The patient is a long term nursing home resident and has chronic dementia with pseudobulbar affect. In the emergency department she was evaluated and determined to have a left femoral neck fracture and multiple contusions. She was admitted for further care, nursing staff reports that overnight the patient was yelling, screaming and in significant pain with bed position changes. Physical exam: Skin: Bruising to face. Assessment/Plan: 1) fall at nursing home, 2) Left Femoral Neck Fracture 2/6/22, 3) scalp hematoma. Xrays of the left hip and pelvis confirm left femoral neck fracture. CT of the brain shows a large subgaleal scalp hematoma. Xray of hips dated 2/6/22 documents: indications: multiple falls, pain. Impression: Left [CONDITION(S)]. Xray of femur bilateral 2/6/22 documents: Findings: oblique fracture of intertrochanteric portion of the femur with medial angulation of the distal fracture fragment. Impression: Left [CONDITION(S)]. R1's Hospital discharge paperwork documents:1) fall at nursing home, 2) left femoral neck fracture 2/6/22 status post hemiarthroplasty 2/7/22, 3) scalp hematoma. R1's care plan initiated on 6/17/2021 documents, I am at risk for falls related to unsteady gait, poor balance, weakness. I am here from the hospital. I fell and have had a broken hip repaired. I hope to rehab and then will remain long term here. Interventions: date initiated: 1/28/22, Keep resident in visual observation when up in wheelchair. On 2/23/22 at 12:19 PM, V6 LPN stated I was working when R1 fell on [DATE]. I was on the hallway in another patients room, the other nurse who was working the floor (V8 Licensed Practical Nurse) was coming back to the floor from break and noticed R1 on the floor by the water fountain around the nurses station. V8 assessed her and then had staff get me. It was an unwitnessed fall, R1 was not in visual observation of staff and no staff members saw her fall, we were in rooms getting other residents up for the meal, R1 was not being visually observed at the time of her fall. On 2/23/22 at 1:50 PM V3 Assistant Director of Nursing stated, I do post fall investigations. On 1-27-22 R1 was found sitting in day room eating a snack and stood up and fell , poor safety needs due to impaired cognition. Intervention: staff were to keep R1 in visual observation while up in wheelchair. On 1-31-22 was found sitting on buttocks, by office door, anxious getting up an down, advancing dementia. Staff were to provide one to one calming activities with resident and social interaction when anxious. This fall was unwitnessed. R1 had a raised area to back of head. On 2-6-22 staff found R1 on the floor on back with wheelchair bedside her. R1 has returned from the hospital and is not doing well, R1 is on comfort care. Keeping R1 in visual observation could be she is down the hallway from the nurses station but staff should be able to see her. On 2/23/22 at 11:00 AM, R1 was lying in bed in R1's room, R1 had fading yellow, purple, maroon discolorations surrounding the entire left eye area and left forehead area. R1 did not respond to verbal stimuli, R1's eyes remained closed. The facility's policy, with a revision date of April 2019, titled Resident Care Policy and Procedure: Fall assessment and Management Policy documents, Policy: It is the policy of the facility to assess resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. Procedure: I: Fall risk and planning assessment: F: Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or the actual injury or fall. II: Resident fall: C- Care planning after a fall: 1- A licensed nurse will consult with the resident's care givers and other interdisciplinary team members in regards to future interventions and resident specific risk factors. b. R5's medical record documents on 2/14/2022 at 7:01 PM, Certified Nursing Assistant reported to nurse witnessing (R5) put acetone bottle to her lips. CNA states she is unsure if resident took drink or not. Nurse evaluated, no [CONDITION(S)] in mouth, no behavior to suggest resident might have taken drink (no signs and symptoms of upset stomach, no acetone smell apparent on resident or resident breath.) Physician contacted and stated to contact poison control and follow their directions for care. Poison control contacted, states that acetone may have intoxicating effects and cause Gastrointestinal Upset if consumed, but is unlikely to cause injury. Poison control suggests to monitor patient and contact Physician if any concerns arise. Monitoring closely. On 2/23//22 at 1:25 PM, V9 Certified Nursing Assistant, stated I was standing away from (R5), (R5) was at the nurses station, I noticed (R5) had a cap to something in her hand. I then seen (R5) tipping a bottle up to her mouth, I immediately ran to (R5) and took the bottle and cap away and went and got V6 (Licensed Practical Nurse) immediately. V6 then assessed her. Acetone (finger nail polish remover) is something that is not to be left at any time on the unit, it is always locked up. I had not seen the bottle lying out anywhere on the unit that day, I do not know where (R5) obtained it from. On 2/23/22 at 12:50 PM, V6 LPN stated I was down the hallway in another residents room and the CNA (V9) came and got me and told me that (R5) was at the nurses station holding a bottle of acetone (nail polish remover) up to her mouth. (V9) had taken the bottle away immediately and placed the lid back on the bottle. We do not know were (R5) got the bottle from, there was new activity aide working on the unit that day and I don't know if she was not aware and accidentally left it out or what, we had not seen it sitting out earlier. Normally activities keep it locked up on the unit. I immediately did an assessment on (R5). (R5) did not have any acetone smell around or in her mouth, (R5) was not spitting anything out of her mouth, (R5) was not grabbing at her throat. I immediately notified the physician who had me contact poison control. We continued to monitor (R5) closely all evening and (R5) never exhibited any symptoms of ingestion of the acetone. On 2/23/22 at 11:50 AM, V2 Director of Nursing stated, I was not aware of the acetone incident until yesterday (2/22/22). Acetone containing products (any chemically hazardous products) should be used and put away (locked up) immediately, it is not to be left out for residents to find.

Based on record review and interview the facility failed to provide timely assessment, monitoring, and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R2 developing a stage 4 wound to sacrum. Findings include: The facility policy titled 'Wound and Ulcer Policy and Procedure', revised 1/10/18, documents the following: When a resident is found to have a wound, the licensed nurse will complete the following: document assessment of the wound in the medical record, initiate the treatment protocol for the appropriate stage of ulcer, care interventions for staff involved in the residents care are communicated via the resident care plan and assessment of progress toward healing is completed weekly. R2's undated Face Sheet documents admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 12 out of 15 total possible points, indicating cognitive ability is intact. This same MDS documents R2 requires extensive two person assist for bed mobility, personal hygiene and transfers. R2's Shower and Skin Observation Reports, dated 8/13/21, 8/17/21, 9/25/21, 9/28/21 and 9/29/21, documents showers/bed baths were given on these dates. R2's medical record does not have any other documentation of showers/bed baths being given. R2's Skin Observation task documents a new reddened area on 9/8/21. R2's Nurse Progress Notes in Electronic Medical Records (EMR) do not document a new reddened area on 9/8/21. R2's EMR does not document assessment or monitoring of R2's new reddened area on coccyx. On 10/4/21 at 11:30 AM, V15, Certified Nurse Aide (CNA), stated took care of R2 on 9/8/21 and noticed a reddened area on (R2's) bottom right where the bone is. V15 stated R2 stated area was painful. V15 stated, I (V15) can't remember who the nurse was that day but I (V15) did notify the nurse of (R2's) red painful bottom. (R2) had a red bottom that entire afternoon. The redness never went away. Every time I (V15) provided incontinence care for (R2), it (R2's sacral area) was dark red. R2's Care Plan intervention, dated 5/18/21, documents protect my skin from scrapes, bumps, pressure and tight fitting clothes. This same Care Plan does not include R2's stage 4 Pressure Injury on Sacrum. There was no documentation between 9/8/21 and 9/16/21 of R2's coccyx wound. R2's Initial Wound Evaluation and Management Summary, dated 9/28/21, documents a Stage 4 Full Thickness Pressure Wound on R2's Sacrum with 20% of R2's Stage 4 Sacral Pressure Wound being tendon and bone. On 10/1/21 at 11:45 AM, V2, Director of Nursing, confirmed R2 received a Stage 4 Pressure Injury to Sacrum at facility. V2 stated, The nurses were signing off in the Treatment Administration Record (TAR) that R2's skin checks were being completed. I (V2) don't know how we (facility) didn't notice an open pressure ulcer on (R2's) coccyx until it measured 6.0 centimeter (cm) x 10.0 cm x 0.2 cm Stage 4 Pressure Wound, if we (facility) were actually doing the skin checks. The first time the wound was documented was on 9/16/21, after it had already progressed to a stage 4. V2 stated R2 was living on another hall, and then tested positive for COVID-19 so was moved to the designated COVID-19 hall. (R2's) wound was noted the same day (R2) moved to the new hall. I (V2) have already talked with those nurses. I (V2) was NOT happy about this. We (facility) should be doing better than this for our residents. On 10/1/21 at 1:00 PM, V11, Licensed Practical Nurse (LPN)/Wound Nurse, stated V11 was notified of R2's large open area to coccyx on 9/16/21. V11 stated V11 was not aware R2 had any pressure areas prior to 9/16/21. V11 stated a skin assessment should include all high risk skin areas and pressure points. V11 stated, ideally a head to toe skin assessment should be completed by a licensed nurse. At the very least a resident high risk for skin breakdown should be assessed daily including all high risk skin areas and pressure points. This wound should not have been missed.

These failures require more than one deficient practice statement. A. Based on interview, and record review, the facility failed to identify, observe, assess, notify and implement targeted interventions to prevent the development and/ or worsening of an unstageable pressure ulcer for a resident. These failures include lack of skin assessment checks, bathing, repositioning assists, incontinence care assists, transfer assists for a resident who required extensive assistance, and hydration. This failure affects one R1 of three residents reviewed for pressure ulcers. R1 developed a stage IV pressure ulcer between 7/9/21 (admission) and 7/25/21. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8/16/21, the facility remained out of compliance at a severity level two. The facility is in the process of re-educating the staff on Wound Assessment, Evaluation, Documentation, and the Facility Wound Policy. Findings Include: R1's skin assessment was not documented on admission 7/9/21, daily, or weekly until 7/20/21. On 7/20/21 R1's skin assessment documents that R1 was at high risk for skin breakdown. On 7/25/21 R1's progress note documents that pressure area over coccyx was noted. 3.5 centimeters wide by 3 centimeters deep with an unstageable depth and black in color. A wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/27/21 R1's undated wound notes documented by V10 Facility Wound Physician described R1's wound as an unstageable pressure wound measuring 5.5 centimeters long by 3.5 centimeters wide by 0.5 centimeters deep. At that time, V19 Wound physician debrided 19.25 centimeters of devitalized tissue and necrotic muscle surrounding the facial fiber. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Recommendations including elevating legs, floating heels while in bed, repositioning per facility policy, turning side to side, front to back every 1-2 hours, air loss mattress, daily Multivitamin, daily Vitamin C 500 milligrams, and a daily [MEDICATION(S)] 220 milligrams. R1's emergency room Progress note dated 7/28/21 documents that R1 was taken to a neurology appointment and the neurologist sent R1 from the office to the Emergency Department for further evaluation due to leg weakness and dehydration. On 7/28/21 R1 was admitted to the hospital with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 did not return to the facility. On 7/29/21, R1 was seen by the hospital wound physician. R1 was recommended to have additional debridement of the sacral pressure ulcer. On 8/10/21 at 8:20AM V2 Director of Nursing stated, We don't have daily skin checks for R1, R1 was high risk for skin breakdown. On 8/11/21 at 8:20AM V2 Director of Nursing stated, There are several assessments that are supposed to be done upon admission including a nursing assessment, and skin assessment. I would expect repositioning every two hours and if wheelchair bound, a cushion in the chair. Keeping residents clean and dry with toileting and bathing at least once a week or more if possible. I have already started re-educating staff on documentation. On 8/16/21 at 11:45AM, V8 Assistant Director of Nursing stated, Staffing isn't our problem, it is not following the policy and doing the skin assessments on admission. On 8/11/21 at 9:14AM, V9 Facility Wound Nurse stated, I would expect staff to be repositioning residents every two hours, toileting to keep the skin dry, and to off load pressure areas to prevent pressure ulcers. On 8/11/21 at 9:31AM V1 Administrator stated, I would expect repositioning every 2 hours and sometimes more if required, every two hours for continence checking and our standard is two baths a week. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as an extensive assist for mobility, toileting, bathing, and transfers, R1 uses a wheelchair. R1's most recent care plan dated 7/12/21 does not document an unstageable pressure wound nor interventions for the sacral pressure wound found on 7/25/21. R1's Activities of Daily Living document dated July 2021 does not document repositioning on 7/12, 7/13, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21 and 7/23 of 2021. R1's Activities of Daily Living document dated July 2021 does not document incontinence care on 7/12, 7/13, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21, 7/23 or 7/28 of 2021. R1's Activities of Daily Living document dated July 2021 does not document transfers for activities of daily living on 7/12, 7/13, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21 or 7/23 of 2021. R1's Documentation Survey Report dated July 2021 does not document R1 having fluid intake on 7/9, 7/12, 7/13, 7/14, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21, 7/22, 7/23 and 7/28 of 2021. On 8/9/21 at 12:11 PM V5 Certified Nursing Assistant stated, When R1 got here R1 was a one assist with a walker. He seemed pretty with it at first but became more and more confused. I found the sore on his bottom and told V9 Facility Wound Nurse. It was black and quarter sized. On 8/9/21 at 12:48 PM V6 Certified Nursing Assistant stated, R1 obviously wasn't turned every two hours all of the time to get that kind of wound. It was black and a little bigger than a quarter. On 8/10/21 at 9:55AM, V9 Facility Wound Nurse stated, I feel like with R1, it was a complete lack of attentiveness. If they didn't reposition him, change him and do skin checks then R1's wound was preventable. On 8/10/21 at 4:46PM V16 Nurse Practitioner stated, When I saw R1 in the facility, I was told that he was eating and drinking ok. When I saw him upon readmission to the hospital, R1 was dehydrated and had clearly lost weight. The pressure ulcer that he developed in the facility was entirely preventable. R1 was not seen by a Dietician during this stay. On 8/11/21 at 8:45AM V10 Facility Wound Physician stated if a resident wasn't turned or bathed the tissue would not have been observed and that would contribute to the ulcer formation. Observations of the tissue would allow for considerations such as mattress type, normal or altered sensation, nourishment, or malnourishment. Without these observations, it could unfortunately contribute to a deep tissue injury like the one R1 acquired and why R1 required such a large amount of necrotic tissue removed. On 8/12/21 at 10:06 AM V22 Hospital Wound Nurse Practitioner stated, I saw R1 on 7/29/21 with an unstageable pressure sore on the coccyx. If R1 wasn't changed, turned, or bathed, then a pressure sore was inevitable. I measured it at 4 centimeters long by 4 centimeters deep by 1.5 centimeters deep. It was nearly a circle, covered with slough and necrotic tissue. An Immediate Jeopardy situation was identified on 8/11/21. The Immediate Jeopardy was identified to have begun on 7/9/21 when the facility failed to initiate treatment and services to prevent pressure ulcers. On 8/11/21 at 2:42PM, V1 Administrator and V2 DON were notified of the Immediate Jeopardy situation. The surveyor confirmed through interview and record review that the facility took the following actions to remove the immediate jeopardy: 1. On 7/28/21 R1 was discharged from the facility. 2. The facility medical director was notified of the immediate jeopardy and approved the action plan on 8/12/21. 3. Individual staff education was completed on 8/13/21 regarding the facility Wound and Ulcer Policy and Procedure and the expectation for admission skin risk assessments. 4. The Facility Wound and Ulcer Policy was reviewed and approved by the Corporate Nursing Staff on 8/12/21. 5. All Clinical Staff were educated on the facility wound and ulcer policy and admission skin assessments on August 12 and August 13, 2021. 6. All Residents in the facility received a head-to-toe skin assessment and care plans were evaluated and updated as needed, completed on 8/15/21. 7. The Facility Interdisciplinary Team will assist V1 and V2 with monitoring the above actions. B. Based on observation, interview, and record review, the facility failed to notify and implement interventions to prevent the development and worsening of pressure ulcers in two (R2, R3) of three residents reviewed for pressure ulcers. Findings include: The Facility Wound and Ulcer Policy and Procedure revised dated 1/10/18 documents, When a resident is found to have a wound a licensed nurse will complete ulcer, either on admission or during their stay the following: care interventions for staff involved in the resident's care are communicated via the resident care plan. Treatment continues per the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's skin assessment dated [DATE] documents R2 at risk for skin alteration. R2's initial wound assessment dated [DATE] documents, Right heel deep tissue injury acquired in the facility. Unstageable size 3 centimeters x 2 centimeters with no odor or drainage. On 8/3/21 the weekly pressure ulcer report documents the wound as unchanged. On 8/10/21 at 1:30PM, V9 Facility Wound Nurse changed the right heel dressing and the wound appeared circular, nickel sized and a deep purple color. V9 Facility Wound Nurse stated, It was just a scab; now it is boggy and a deep tissue injury that is worse, you can tell from the color. R2's order dated 7/23/21 documents Heel Protectors to be worn at all times and heels to be floated while in bed. R2's care plan target date 10/30/21 does not document pressure relieving device use for R2's heels. On 8/9/21 at 2:40PM, R2 was sitting in a wheelchair next to the nurse's station with heels resting on the foot pedals. No heel protectors were on R2's feet. On 8/9/21 at 3:10PM, R2 continued sitting in a wheelchair next to the nurse's station without heel protectors on R2's heels. On 8/9/21 at 3:12PM, V11 Registered Nurse stated, R2 has a pressure wound from resting R2's heels on hard surfaces. I don't know if R2 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/21 at 10:00AM, R2 was sitting in the activity room without heel protectors on properly, allowing R2's heels to rest on the wheelchair foot pedal. On 8/16/21 at 3:30 PM, V9 Facility Wound Nurse stated, R2 should have heel protectors on at all times. The pressure makes the wound worse and it shouldn't happen. On 8/10/21 at 9:45AM, V9 Wound Nurse changed R3's sacral dressing, found a new area on the right medial thigh. At 9:50AM V9, Facility Wound Nurse stated, R3's catheter leaked a couple of times last week and I think the leaking may have caused this new breakdown. R3's progress note dated 7/27/21 documents R3's catheter had come out and bulb was found in R3's bed. R3's progress note dated 8/3/21 documents R3's catheter leaking, there was no physician notification. R3's progress note dated 8/10/21 documents R3 at high risk for skin breakdown. R3's wound documentation sheet dated 8/10/21 documents facility acquired wound found on 8/10/21 4.2 centimeters by 3.1 centimeters by 0.1 centimeters in size, on right medial thigh with scant serous drainage, and granulating tissue. On 8/16/21 at 3:25PM, V2 Director of Nursing stated, I was told the catheter was leaking again last night. They did not notify the physician. On 8/16/21 at 3:30PM, V8 Assistant Director of Nursing (ADON) stated that V8 ADON had instructed the nursing staff to contact the doctor about the persistent leakage of urine, and skin damage. The Facility Policy Wound and Ulcer Policy and Procedure revised date 10/1/2018 documents, All residents will be assessed to determine the degree of risk of developing a pressure ulcer using the (Skin Risk Assessment). The resident will be assessed upon admission, once a week for four weeks, and monthly thereafter. The facility policy revised date 10/1/2018 documents, Moderate Risk Protocol and High-Risk Protocol include daily skin checks completed by direct care staff. The Facility Wound and Ulcer Policy and Procedure revised date 1/10/18 documents Approaches will be placed in the resident care plan. Changes in condition including activity level, mental status, mobility, nutritional status, incontinence are promptly reported. The Facility Wound and Ulcer Policy and Procedure revised dated 1/10/18 documents, Changes in condition including incontinence are properly reported.

Based on interview, and record review, the facility failed to implement an intervention from a previous fall which resulted in a recent fall, and subsequent injury for one cognitively impaired resident (R1). R1 was sent to the emergency room and treated for [REDACTED]. R1 is one of three residents reviewed for falls in the sample of three. Findings include: R1's Face Sheet dated 1/15/21 documents R1 is diagnosed with [REDACTED]. R1's Minimum (MDS) data set [DATE] documents R1's cognitive status as moderately impaired. The same record documents R1 requires extensive assistance of at least one staff for transfers. R1's Fall Scale assessment dated [DATE] documents R1 is at high risk for falls. R1's Progress Note Fall Interdisciplinary Team (IDT) Review dated 6/22/20 documents R1 slid from his recliner on 6/18/20 with no injuries. The same record documents the intervention for this fall was to disable R1's (electric-powered) recliner. R1's Progress Note Fall Interdisciplinary Team (IDT) Review dated 1/8/21 documents R1 was found on the floor in front of his recliner on 1/7/21. R1 had a laceration to the top of his head and right palm. R1 was sent to the emergency room and returned to the facility with four staples to his head and two sutures to his right palm. The same record documents the intervention for this fall was to disable R1's electric recliner. R1's Care Plan dated 12/2/19 documents the same intervention, to disable R1's electric recliner, for both of the falls that occurred on 6/18/20 and 1/7/21. The Emergency Documentation dated 1/7/21 documents R1 was seen and treated in the emergency room after a fall on 1/7/21 which resulted in a [MEDICATION NAME] head injury, skin tear of the right hand, and laceration of the scalp. On 1/15/21 at 12:50 PM V2 Director of Nurses confirmed R1 had a fall from his recliner on both 6/18/20 and 1/7/21. V2 also confirmed that the intervention for both falls was to disable R1's electric recliner by disabling the electric reclining function, and disconnecting the power box. V2 stated that electric power was still supplied to the recliner at the time of the fall. V2 stated she is not sure how R1's electric recliner got hooked back up to the power box but it should not have been hooked back up at all. V2 confirmed R1 was injured from the fall on 1/7/21 and was sent to the emergency room where he received staples to the [MEDICAL CONDITION] and sutures to the skin tear on his right hand. V2 stated R1 is not safe to operate the electric recliner due to his decreased cognition and lack of safety awareness. V2 confirmed that R1's electric recliner should have been disabled after the 6/18/20 fall and should not have been hooked back up. V2 confirmed if R1's recliner would have stayed disabled like it should have, R1 might not have fallen out of it the way he did on 1/7/21. The Resident Care Policy and Procedure dated April 2019 documents, It is the policy of this facility 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, assess, and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned.

Failures at this level required more than one deficient practice statement. A. Based on record review and interview, the facility failed to implement targeted interventions on two previous falls so as to prevent a third fall with the same identified root cause for one resident (R29). This failure resulted in R29 falling and sustaining a laceration to the forehead and spinal fractures at T8 and T9. R29 is one of twelve residents reviewed for falls in the sample of 23. B . Based on record review, observation and interview, the facility failed to secure the position of a mechanical lift sling and safety strap, during a transfer for one resident (R21), and failed to use a gait belt during transfer for another resident (R15). R15 and R21 are two of twelve residents reviewed for transfers / falls on the sample of 23. Findings include: R29's Physician order [REDACTED]. The same POS documents that R29 is to receive a Nebulizer (breathing) treatment of [REDACTED]. Lexi - Comp Drug Reference Handbook 12th Edition dated September 19, 2001 documents .based on the Albuterol component : Use with caution in patients with Hypertension Adverse reactions .Cardiovascular: Angina, Atrial Fibrillation, chest discomfort, extrasystoles, flushing, dizziness, Hypertension, palpitations and tachycardia R29's Fall Assessments dated 8/5 and 8/7/16 document R29 as high risk for falls. The above Fall Assessments do not address R29's nebulizer treatment of [REDACTED]. The facility policy titled Fall Assssment, Risk Identification and Management Policy dated 3/20/12 documents that the fall assessment may address assessment of factors listed but not limited to the following: Mental Status, Age, general state of health, mobility, previous falls and Medications which may cause dizziness. The Minimum Data Set ((MDS) dated [DATE] documents R29 as severely cognitively impaired, Visiually impaired, not steady, only able to stabilize self with staff assistance and needs two plus staff members for assistance in transfers. The facility reports titled Occurrence Report and Fall Investigation document R29 with the following falls and possible root causes: 7/29/16 - Observed on floor sitting at 8:20 pm, had gotten up to go to the bathroom and prior to this R29 had a breathing (nebulizer) treatment in recliner (at 8:00 pm) and was put to bed. Intervention(s) - pressure alarm, make more room for accommodating resident. No intervention is identified for posssible root cause of nebulizer treatment. 8/2/16 - Observed on floor sitting at 5:35 pm, transferred from wheelchair to bed. Intervention(s) - hipsters and fifteen minute rounding 8/5/16 - Observed on floor on back at 8:20 pm, transferring from bed to go to the bathroom. Possible root cause documented as Nebulizer treatment (scheduled 8:00 pm). Interventions - Habit training program, low bed and non-skid socks. There is no targeted intervention documented for the possible root cause of the nebulizer treatment. 9/13/16 - Observed on floor lying face down at 4:20 pm, attempting to get out of wheelchair. Possible root cause documented as Nebulizer treatment (scheduled 4:00 pm). Interventions - Wedge cushion to wheelchair. There is no targeted intervention documented for the possible root cause of the nebulizer treatment On 11/4/16 at 8:55 am, E19 Registered Nurse stated that R29 was given a hand held nebulizer treatment while sitting in R29's wheelchair. E19 stated that E19 had left the room. E19 stated shortly thereafter E19 heard R29 yelling and went to R29's room and found R29 lying face down on the floor. R29 complained of back pain and had a cut on the forehead. E19 acknowledged that it was normal routine to leave R29 with the nebulizer treatment and continue with E19's medication pass. E19 stated I won't make the mistake of leaving a resident with a nebulizer treatment alone again. On 9/14/16 the facility faxed a report titled Report to Illinois Department of Public Health documenting on 9/13/16, R29 was injured after a fall. The report documents that R29 was left alone in R29's room taking a nebulizer treatment per self. R29 was then heard yelling and the nurse (E19, Registered Nurse) came to R29's room and observed R29 lying on the floor with a 2 milliner laceration to the forehead. R29 was sent to the emergency room for evaluation and treatment. R29 returned to the facility and the facility was informed that R29 had 8th and 9th healing rib fractures and spinal transverse process fractures at T8 and T9. The emergency room Report dated 9/13/16 documents that R29 had an unwitnessed fall while finishing a nebulizer treatment and that facility staff think she was attempting to go to bed. R29 is noted to have back pain. The Hospital Computerized Tomography report dated 9/13/16 documents the following on R29: status [REDACTED]. 2. Right Transverse Process Fractures of T8 and T9, acute inn appearance. The report is signed by Z1, Radiologist. A facilty policy titled Self Administartion of Medication Protocol dated 10/2005 documents If the resident wishes to self medicate, the Interdisciplinary Team (IDT) must assess the resident's cognitive, physical and visual abilties. If the IDT determines that the resident is not capable, medications will be administered by the nurse. E2, Director of Nursing acknowledged on 11/3/16 at 1:15 pm, R29 was not cognitively intact to self administer R29's own medication. E2 acknowledged the medication of Duoneb/Nebulizer treatment was listed as a possible root cause for R29's falls and there were no targeted interventions for this. E2 stated We missed it. E2 stated that no assessment for self-administration of medication had been done on R29. B. 1. R21's, Order Summary Report (Physician order [REDACTED]. R21's, Fall Risk assessment dated [DATE] documents R21 is at high risk for falls. R21's, Minimum (MDS) data set [DATE] documents R21 is moderately cognitive impaired. R21's, Care Plan dated 9/18/16 documents the following: I am a two person transfer since my left hip fracture (12/20/15). I use a mechanical lift for transfers .explain procedure. Ensure my safety during transfers. On 11/2/16 at 9:12 am E9 and E10, Certified Nursing Assistants (CNA), transferred R21 from a wheel chair to the toilet, using a mechanical stand lift. E10 fastened the mechanical lift sling loosely over R21's breast. E9 and E10 fastened the mechanical lift leg strap loosely around R21's calves. R21's left bent knee was supported against R21's right bent knee. R21's left knee was not supported by the left knee / shin support pad. R21's right knee / shin was supported by the right knee / shin support pad. E9 raised R21 with the mechanical lift. R21 did not stand upright. The mechanical stand lift waist sling rode up under R21's armpits. R21 stated It hurts up and under my arms.E9 and E10 continue to transfer R21 by wheeling the mechanical stand lift fifteen feet, from R21's bedroom into the bathroom. E9 and E10 did not adjust the mechanical stand lift straps. R21 dangled over the toilet, hanging by R21's chin high, scrunched shoulders. R21's shoulders were compressed by waist sling strap while E9 removed R21's pants and incontinence brief. On 11/1/16 at 9:36 am, E10, CNA stated I do know I'm suppose to tighten the waist strap and place it around the waist as low as I can. I was trained to do that so it (mechanical lift sling) does not ride up. I should have done that (tighten) and the leg strap . On 11/03/16 at 8:50 am, E2, Director of Nursing stated the following: Straps (mechanical stand lift safety straps) for safety are always necessary. Leg strap placement and the waist, should be snug . The (Manufacturer, Mechanical Stand Lift) Operation Manual dated 4/20/13, documents the following: Position the belt around the patient's / resident's lower back, just above the beltline. Fasten buckle to secure belt .Assist the patient / resident in placing their feet on the foot plate, with their shins against the support pad. If needed fasten velcro strap around patients lower legs . B 2. R15's, POS, dated November 2016, documents the following Diagnoses: [REDACTED]. R15's Fall Risk assessment dated [DATE] documents that R15 is at high risk for falls. R15's Care Plan dated 10/11/16 documents the following: Assess my ambulation for steadiness and endurance. When you ambulate me or transfer me, use a gait belt. On 11/2/16 at 1:50 pm E6 and E7, CNA's, transferred R15 from R15's bed to a recliner chair. R15 walked with a front wheeled walker. E6 and E7 guided R15's walker on each side, by holding onto the walker side bars. As E6 and E7 guided R15 backwards to a seated position in the recliner, R15 stated Oh, my knees buckled, am I doing it right. No gait belt was used for R15's transfer. On 11/02/16 at 1:55 pm, E6 stated I should have used a gait belt when I transferred (R15), I usually do . The facility Gait Belt Policy and Procedure dated 6/15/09 documents the following: It is the policy of this facility to provide a safe environment for all residents. Using gait belts enable the facility to better provide security for the residents during standard non - mechanical assisted weight bearing transfers and assisted weight bearing ambulation .Gait belts will be used on all residents requiring non - mechanical assistance with transfers and / or ambulation .

Based on observation, interview and record review the facility failed to assess, provide a wheelchair which fit properly and obtain a timely treatment order for 1 of 6 sampled residents with pressure ulcers (R6). These failures resulted in R6 using a wheelchair which was too small. The side of the wheelchair arms caused pressure on the right lateral hip, resulting in an unstageable pressure ulcer on the right lateral hip for R6. In addition the facility failed to follow the physician's orders [REDACTED]. Findings include: 1. The December 2010 Physician order [REDACTED]. The skin assessment dated [DATE] states R6 is mild risk for the development of pressure ulcers. The Nurse's Notes dated 12/8/10 at 8:45pm state a "Stage 2 ulcer on (R6s) R(right) hip......Ulcer is scabbed and red area around ......" The note documents triple antibiotic ointment was applied with a dressing and a note was left for the Physician to be notified in the morning. The Nurse's Notes dated 12/9/10 at 8:45am state, "...R hip wound area...unstageable pressure ulcer noted to R hip measuring 5.0 by 2.0cm(centimeter)...., covered with brownish-yellow eschar-dry and hard-peri wound noted to be red and warm to touch, (R6) complained of pain to area......noted R hip to be rubbing on w/c(wheelchair)-therapy notified to obtain a larger w/c for (R6)...." The physician progress notes [REDACTED]. Continue Santyl debridement, will add ABX(antibiotic)-Keflex 500mg(milligrams) tid(3 times day) (for) 14 days. E6, Certified Occupational Therapist Aide(COTA), stated on 12/15/10 at 11:20am that R6 was in a standard wheelchair (18 inches wide) and it was putting pressure on her hip. E6 stated when R6 got up up you could see R6's hip rubbing the side of the chair. E6 stated she provided R6 with a wider wheelchair on 12/9/10. E2, Acting Director of Nursing, stated on 12/15/10 at 11:20am that E7, CNA(Certified Nurse Aide), reported the area on R6s right hip(12/9). E2 stated the area looked like a "thick black scab with a red peri wound." E2 stated "it had to have been there awhile." E2 stated R6's wheelchair was too small and that caused the wound to her right hip. E2 stated she was told by E7 that she(E7) had reported the area on R6's right hip to E8, RN(Registered Nurse) earlier(prior to 12/8). E3, Corporate RN, stated 12/15/10 at 12:05pm during her investigation she was unable to find out the specific date that E7 reported the area on R6's right hip to the nurse, E8. E3 stated that E7 described the wound on R6's right hip as looking like a "skin tear" when she initially reported the area to E8. E3 stated that E7 thought it wasn't more than a couple of days between when she initially saw the area on R6's right hip and when she saw it again. E3 stated that E7 saw the area had no dressing in place, so E7 then reported the area a second time to the nurse. On 12/15/10 at 3:10pm R6's pressure ulcer on the right lateral hip had a dry hard yellow substance covering the entire ulcer. The substance was starting to loosen slightly at the edge. The peri wound surrounding the ulcer was red. E5, RN, stated at the time of the observation that R6's ulcer was caused by pressure from the side of the wheelchair, which was too small for R6. E9, Licensed Practical Nurse, stated on 12/15/10 at 1:50pm that R6's right lateral hip area currently measures 5cm by 1.5cm. E9 stated the ulcer looks better than it did last week. E9 stated the peri wound is not as red, but with the yellow slough, she is still unable to stage the area. 2. The Nurse's Notes dated 12/14/10 state R8 has a pressure ulcer to the coccyx measuring 1.5cm by 1.0cm with a depth of 0.2cm . The physician's orders [REDACTED]. On 12/15/10 at 2:10pm E5, RN, did the treatment to R8's coccyx. E5 cleaned the ulcer with wound cleaner, applied skin prep to the peri wound and then applied the dressing. E5 did not apply the Santyl as ordered by the Physician. E5 stated following the treatment that she didn't think Santyl was to be used for R8's coccyx. E5 then checked the treatment record and physician's orders [REDACTED]. E5 stated she must have looked at the treatment record wrong.

Based on interview and record review the facility failed to ensure that hazards in the resident's environment were identified and measures taken to minimize those hazards to prevent injury for 1 of 5 residents sampled for falls (R2) in a total sample of 24. R2 was allowed access to the remote control of a mechanical lift chair which resulted in a fall with a first cervical vertebrae fracture. Findings include: The physician's orders [REDACTED]. Minimum Data Set ((MDS) dated [DATE] and 5/4/10 documents that R2 was severely cognitively impaired, was totally dependent with the assist of two staff for transfers, toilet use and required a mechanical lift for all transfers. Fall assessments dated 2/21/10, 5/3/10 and 7/23/10 states that R2 was at high risk for falls. Nurses notes dated 5/7/10 at 11:40 AM reads "heard alarm going off...... found (R2) lying face first on floor, no moving, .......(R2) complained of neck, head and shoulder pain. Left resident on floor without moving...." Facility notes from the investigation report stated that " (R2) was face first on floor with face near the bed, lift chair behind him in up position, had remote in right hand..." Hospital report titled "Preliminary Radiology Consultation Report" dated 5/7/10 for R2 states "Comminuted Left C1 (first Cervical) Articular Pillar Fracture and Transverse Process...." R2's care plan dated 5/6/2010 under the section titled "Focus" states Resident at risk for falls related to diminished ADL (Activities of Daily Living) Skills, Impaired Balance, Diminished Range of Motion..." Intervention for this problem which was initiated 2/2/2010 states "Provide recliner lift chair for (R2)." E3, Corporate Registered Nurse stated on 12/17/10 at 11:20 AM that the "Corporation does not have an assessment for lift chair usage and therapy states it was outside their realm that it was a nursing function to assess the cognitive aspect for the usage of the lift chair."