Every finding on record at Pana Health and Rehab Center

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property for one resident (R1) of three residents reviewed for misappropriation in the sample of 3. Findings include:R1's admission Record documented an admission Date of 11/26/24 and listed Diagnoses including Chronic Obstructive Pulmonary Disease, Arteriosclerotic Heart Disease, Atrial Fibrillation, and Diabetes Type 2. R1's Minimum Data Set, dated [DATE] documented that R1 has minimal deficits in cognition. R1's Care Plan dated 12/3/25 documented a problem area, Resident has potential to gift money to the staff.A Police Department Call Detail Report dated 12/4/25 at 3:11pm documented, (V1) called from the facility to let us know that (R1) whom is hospitalized at this time, a family member was alerted by card services that some money had been taken from his debit card that was at the facility. An IDPH Initial Report dated 12/4/25 documented, (R1) Alleged abuse: Misappropriation of property.An IDPH Final Report dated 12/11/25 documented, Power of Attorney (POA) called (12/3/25) and stated she received a text message that RI 's debit card was used. Investigation initiated. (V7, Social Services Designee) spoke to POA and asked her to call the bank and ask if they can tell us a location and exact time the debit card was used. (Local) Police department was notified of the investigation. Interviews with the staff conducted. Interview with resident cannot be conducted at this time because he is in the hospital. Facility often has POA pick up ordered items that are delivered to the facility by the resident and staff are aware not to accept any gifts from resident as he often tries to give items to staff. Staff (are to) immediately report all of these incidents. Two housekeepers stated they had cleaned the room a few days before and placed a few cards in his top drawer. (V7) located the debit card and a credit card in the top drawer of his nightstand and returned it to family. After interviews were conducted with all staff on the hall at the time of the transactions, only one person was seen entering the resident's room and that was the housekeeper, she is required to enter the room twice a day to check the refrigerator temperature. She denies using or seeing any card. One other Certified Nursing Assistant (CNA) states she went into the room to get an attend from the closet and denies seeing or using any card, she admits to seeing cards laying around at other times but not the day in question. No residents seen in resident room although there is no video surveillance. At the time of the call from the POA, the card was immediately found in the resident top drawer where housekeeping had placed it a few days earlier. The POA discussed with bank and this facility discussed with vending machine vendor requesting investigation to a confined time and date of the cards use for the investigation. The vending machine company cannot confirm nor deny the exact date and time of use as charges are not exact. Administrator will follow up with resident when he returns from the hospital.A 12/3/25 screenshot copy from V5, R1's Power of Attorneys phone, documented V5 received alerts on that date at 11:49am and 1:13pm that a charge of $1.35 and a $5.00 account hold for each purchase was taken from R1's account. On 1/15/26 at 2pm, V5, R1's Power of Attorney, stated R1 is a very generous person whom, when he lived independently, had issues with giving away his money, and has tried to offer facility staff money. V5 stated R1 was in the hospital on [DATE] when she got an alert on her phone that his debit card, which he had left at the facility, had been used twice on that date for $1.35 for each purchase on the vending machines in the facility, and additionally a $5 hold charge for each transaction. V5 stated she alerted V7, Social Services Designee, via text on 12/3/25 about the charges. V5 stated V7 confirmed that the debit card was still in R1's nightstand. V5 stated thinking back, there had been a few other random alerts about the card being used in the facility's vending machine at different times since his admission, but R1 was in the building when they occurred. V5 stated it is possible staff were using the card to buy snacks for R1 at his request but looking back she finds it odd as she visits R1 weekly and brings large amounts of his favorite snacks and drinks. V5 stated she deactivated the card and R1's bank reimbursed him for all the charges including the 2 $5 account holds. V5 stated she is not sure if the facility offered to reimburse R1, but if they did he would probably refuse it.On 1/16/26 at 8:15am, R1 was alert to person and place, but not time, stating it was 'The end of January 2026, it's almost February. R1 confirmed his debit card was used for the facility vending machine, While he was in the hospital in December, (2025), and he does not know who used it. R1 stated, There is no reason for you to investigate this, it isn't worth your time, I would have given whoever used it the money, I don't care about it. R1 denied ever having given money or property to staff, and stated staff have never asked him for anything. R1 stated he has offered money to staff at times, but he has been told it's against facility policy for them to take it. R1 stated no staff member has ever asked him for money nor has he ever given any. R1 stated staff have never used his debit card at the vending machine to buy snacks for him. R1 stated the facility offered to reimburse him the money, but he refused to accept it.On 1/16/26 at 9:30am, V6, Licensed Practical Nurse, stated she had observed R1 leaving his debit card laying around, including in the floor, and she told R1 they needed to lock it up, but he refused. V6 stated R1 is always trying to give staff money, and they have to remind him they can't take it. V6 stated V1 told her about the debit card being used but she cannot remember the exact date she discussed this with V1. V6 stated she told V1 that on 12/3/25 as she was passing medications, she saw V4, Housekeeper going in and out of the room a couple of times.On 1/16/26 at 10:10am, V4 stated R1 has a history of offering staff money, but it is against their policy to accept it. V4 stated she and V3 were cleaning R1's room on 12/3/25 while R1 was in the hospital, and V4 did see bank cards in his room while cleaning. V4 stated R1 never asked her to use his card, nor did she ever use it for any reason, and she does not know who did. V4 stated, At some point after, V1 told her the card had been used, and asked her if she had seen the card while cleaning or used it, and V4 confirmed she had seen some cards but did not use any of them. V1 told V4 that V4 had been witnessed coming out of R1's room a couple times, which V4 confirmed and stated once she had checked the temperature of R1's mini fridge, and on the other she had been cleaning with V3. On 1/16/26 at 11:10am, V8, CNA, stated R1 has a history of offering staff money, and it is against policy to accept money from residents. V8 stated she has seen R1 leave his debit card laying around as well as in the bed and on the floor. V8 stated on 12/3/25 she had a resident in the bathroom that adjoins R1's room. V8 stated there are often briefs on the chair in R1's room and she needed one, so she opened the door into the room, saw there were no briefs, and closed the door without entering the room. V8 stated she did not use R1's debit card and does not know who did.On 1/16/26 at 12:15pm, V7 stated on 12/3/25 V5 texted her to let her know R1's card had been used, and V7 and V1 went to R1's room and found the card and brought it to V1's office for V5 to pick up. V7 stated R1 has a habit of offering staff money.On 1/16/26 at 1pm, V1 stated on 12/3/25 V7 got a text from V5 about the card being used. V1 stated V7 went to the room and brought back 3 cards, 2 credit cards and a debit card. V1 stated the only vending machines in the building are in the employee lounge, which is unlocked and accessible to staff, residents, and visitors. V1 stated there are no surveillance cameras anywhere in the building. V1 stated her first interview was V6 on 12/3/25 whom she had recalled seeing close to R1's room on 12/3/25, who stated she had seen V4 going into the room. V1 stated she found out V3 and V4 were cleaning R1's room on 12/3/25 and questioned both, who both denied using the card. V1 stated when R1 returned from the hospital on [DATE] she interviewed him and he did not know who might have used the card. V1 stated the investigation has concluded and it is undetermined who used the card. V1 stated she tried to reimburse R1 the money, but he refused. R1 stated she gave R1 a lockbox for his valuables, which he refuses to use. On 1/20/26 at 8:30am, V3 stated it is against facility policy to take money or property from residents even if it is offered, and it should be immediately reported to V1. V3 stated R1 has previously offered her money which she refused. V3 stated R1 has never given her money or his debit card to use on the vending machine for him. V3 stated on 12/3/25, R1 was in the hospital so she and V4 were deep cleaning his room. V3 stated V4 was cleaning in the drawers and V3 did not see any bank or credit cards and stated she never has seen cash or cards in his room. V3 stated she did not use the card, and she does not know who did. The facility's Abuse Policy dated December 2025 documented, Purpose: To provide guidance and procedures to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Responsibility: The Administrator and/or designee is the facility Abuse Coordinator for the facility. It is the responsibility of the facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. Procedure: (will be implemented by) Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. Any staff member or person suspected of abuse will be escorted by staff out of the facility and will be notified that they are not permitted back into the facility until the investigation has been complete. The facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH (The Illinois Department of Public Health) Ombudsman, local police department, Power of Attorney, MD (Medical Doctor), in a timely manner. The facility immediately and thoroughly investigates all allegations of abuse to include but not limited to interviews or (sic) residents and staff, visitors, (and) vendors. Definitions: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a residents belongings or money without the residents consent.

Based on observation, interview, and record review, the facility failed to ensure that out dated Tuberculin Purified Protein Derivative (TB) solution was removed from the 300 hallway medication refrigerator. This failure has the potential to affect all the residents residing on the 300 hall. Findings include: On 04/01/24 at 02:53 PM, the refrigerator in the 300 hall medication room was inspected and observed to have an open vial of TB solution that was half full with an open date of 11-21 written on the vial. On 04/01/24 at 02:55 PM V5, Registered Nurse (RN), stated that yes everyone in the facility uses the TB solution. She continued to state that each hallway may have their own vial but she wasn't sure, and that she isn't sure for how long the solution is good for after it's opened. She continued to state that night shift does the TB test, so she wasn't really a good person to ask that. V5 verified the open date on the TB solution vial was 11-21. On 04/04/24 at 11:35 AM, V1, Administrator, stated that the TB solution should be discarded 30 days after opening. The TB solution box documented, Discard opened product after 30 days. The facility's Medication Storage Policy, dated 07/01/23, documented, Purpose: To provide guidance to facility nursing staff on the proper storage of medication. Policy: The facility stores all drugs and biological's in a safe, secure, and orderly manner and in accordance with state and federal regulations. It continues, 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biological's shall be returned to the dispensing pharmacy or destroyed.

Based on interview and record review, the Facility failed to follow their policy by not providing written documentation of a bed hold notice for 1 of 1 residents (R76) reviewed for hospitalization s, in the sample of 29. Findings include: On 4/1/2024 at 12:26 PM, R76 stated that he had been hospitalized recently for water on my legs. R76's Progress Notes, dated 3/21/2024, documented that R76 was sent to the local emergency room (ER) due to complaints of having difficulty breathing as well as a weight gain. On 4/2/2024 at 2:53 PM, V10, Licensed Practical Nurse (LPN), stated that when a resident is transferred to the hospital/ER the nurses fill out a form in the computer (Electronic Medical Record/EMR) and provide the resident with a bed hold policy. On 4/2/2024 at 3:07 PM, R76's Bed Hold Notification was requested. On 4/3/2024 at 8:40 AM via Electronic Mail (Email), V1, Administrator (ADM), stated that she was unable to provide the notice as requested. On 4/4/2024 at 9:05 AM, V12, Business Office Manager (BOM) stated, We are supposed to (provide the bed hold notice), but we haven't been. I'll be honest. We will now. The Facility's Bed Hold Notification undated, documented, When a resident is transferred to the hospital, or when the resident takes a therapeutic leave of absence, they have the right to request that their bed be held until their return. Such request is called a 'Bed Hold'. It continues, The bed hold notification will be issued at the time of transfer and in cases of emergency transfer, notice will be given without 24 hours of the leave.

Based on interview and record review, the Facility failed to ensure a resident on blood thinning medication was examined for potential complications following a fall with head injury for 1 of 24 residents (R80) reviewed for quality of care, in the sample of 29. Findings include: R80's Facesheet, dated [DATE], documented that R80 was admitted to the facility on [DATE] and was discharged on [DATE]. R80's Care Plan, dated [DATE], documented that R80 was on a Short term stay in facility for rehabilitation. It further documented that R80 is on anticoagulant therapy, Eliquis (blood thinner medications). It continues to document that the facility was to monitor and report adverse reactions such as blood tinged or red blood in urine and to avoid activities that could result in injury and take precautions to avoid falls. R80's Progress Notes, dated [DATE] at 12:48 PM documented, MD (Medical Director) made aware of resident having blood in catheter tubing. NOR (New Order Received) to hold Eliquis (Blood thinning medication) 2.5 mg (milligrams) HS (bedtime) dose for 3 days and update. R80's Progress Notes, dated [DATE] at 23:24 PM, documented, At 2100 (9 PM) Res (resident) was yelling, 'Help' and when staff went to check on her, she was found lying on R (Right side) on floor in front of recliner. Res states she was leaning over to pick something up off the floor and fell . Res noted to have a large skin tear to RFA (Right Forearm) measuring 16.7 cm (centimeters) x (by) 4.4 cm, skin tear to R lower leg measuring ,d+[DATE] cm x 4.5 cm and a small hematoma (bruise) to R side of head measuring 1.1 cm x 0.7 cm. Areas cleansed with steri-strips and dry drsg (dressing) applied. R80's Progress Notes continue to document that R80 was placed on neuro checks and assisted to bed. R80's Progress Notes also documented that R80's MD was notified at 23:23 (11:11 PM). R80's Progress Notes, dated [DATE] at 12:54 PM, documented that R80 was evaluated by Speech Therapy (ST) and diet was changed to pureed. R80's Progress Notes, dated [DATE] at 3:56 AM, documented that R80 was noted with no respiration or pulse and that the time of death 3:37 AM. On [DATE] at 11:18 AM, V10, Licensed Practical Nurse (LPN), stated that R80 came to the Facility covered in bruises and skin tears. V10 continued to state that R80 fell out of her recliner and had a bruise to her head and an extensive skin tear to her arm. V10 also stated that R80 had quite a bit of bleeding when V10 would perform dressing changes as well as R80 having blood in her urine, therefore staff were holding her blood thinning medication. V10 continued to state that he was R80's nurse on the dayshift prior to her expiring the next day (early morning). V10 stated that R80 usually knew V10's name but kept calling him [NAME]. V10 also stated that there was no other nurse at the Facility named [NAME]. On [DATE] at 11:39 AM, V6, Registered Nurse (RN) stated, Our doctors would want them (resident) sent to the ER (emergency room ) and if they didn't, we would suggest it. We would remind them they hit their head and are on a blood thinner. You always have to be familiar with who is on a blood thinner because they could have a brain bleed. If they (resident) was on Coumadin or Eliquis (blood thinning medications) we would definitely send them out (to the ER). On [DATE] at 1:36 PM, V11, RN stated, More than likely the doctor would say to send them out if they had a fall and was on a blood thinner. On [DATE] at 1:18 PM, V16, LPN stated, (R80) hit her head 'a little bit' and had an abrasion on the side of her head. On [DATE] at approximately 1:30 PM, V18, Speech Therapist (ST), stated that R80 came to the facility with a regular diet ordered. V18, also stated that R80 had a decline in condition, was evaluated, and placed on a pureed diet. V18 stated that R80 expired that night. The Facility did not have a Policy addressing the use of anticoagulants and the need for further evaluation after a head injury.

Based on observation, interview and record review, the Facility failed to follow their Contact/Droplet Precautions Policy while administering medications to 1 of 3 residents (R34) reviewed for Transmission Based Precautions (TBP), in the sample of 29. Findings include: On 4/2/2024 at 8:05 AM, V6, Registered Nurse (RN) was observed passing medications. At this time, there was a Contact/Droplet Precaution sign outside of R34's room. At this time, V6 donned a gown and N95 (mask) and was wearing eyeglasses. V6 did not apply gloves. At this time, V6 stated, (R34) has a Coronavirus, but it is not COVID 19. He (R34) went to the ER (emergency room ) because he had a temp (elevated temperature). He (R34) is on isolation while he is taking his antiviral meds (medications). R34's Progress Note, dated 3/28/2024 at 10:05 PM, documented that R34 returned from the local ER with a diagnosis of a systematic viral illness and was placed on isolation precautions. R34's Progress Note, dated 3/29/2024 at 6:27 AM, documented that R34 continues Droplet isolation due to Coronavirus OC43 and an antiviral medication was ordered by the physician. R34's Progress Note, dated 4/2/2024 at 12:09 PM, documented that R34 continues the antiviral medication. On 4/4/2024 at 10:25 AM, V2, Director of Nursing (DON), stated that R34 was on contact/droplet precautions on 4/2/2024 and that she would expect staff to don a gown, gloves, N95 mask and eye shield while within 6 feet of a resident on contact/droplet precautions. On 4/4/2024 at 12:55 PM, V1, Administrator stated, she would expect gloves to be worn in a resident's room when the resident is on droplet/contact isolation. The Facility's Transmission Based Precautions Policy, dated 7/1/2023, documented, Purpose: To provide staff guidelines for transmission-based precautions to protect residents and themselves while provides cares. Policy: Transmission- Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection or have a laboratory confirmed infection, and is at risk of transmitting the infection to other residents. Responsibility: It is the responsibility of all staff and agents of the facility to adhere to the transmission-based precaution guidelines. It continues, When a resident is placed on transmission- based precautions, appropriate notification is placed on the room entrance door so that personal and visitors are aware of the need for and the type of precaution. It continues, Contact Precautions: Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with he resident or indirect contact with environmental surfaces of resident-care items in the resident's environment. It continues, Staff and visitors will wear gloves (clean-non sterile) when entering the room.

Based on observation, interview, and record review, the Facility failed to ensure resident menus and appropriate serving sizes were followed for 4 of 8 (R3, R5, R6, R7) reviewed for therapeutic diets in the sample of 8. Findings include: 1.R5's Order Summary Report dated 9/13/23 documents R5 is on a regular diet with pureed texture and thin liquid consistency starting on 5/4/22. R5's Diet Card for Lunch on 9/12/23 documents pureed texture with pureed beef tips and mushroom entree. The Facility's Diet Spreadsheet for Day 17 Pureed documents use of #6 Dip (Scoop=6 ounces) for the Pureed Beef Tips and Mushrooms. On 9/12/23 at 12:12 PM, V6, Interim Dietary Manager, stated, We don't have an extra number six scoop for these, so we are using the two-ounce scoop and giving them three scoops each. V9, Dietary Aide, placed two scoops of pureed meat on R5's plate. 2.R3's Order Summary Report dated 9/13/23 documents R3 is on a No Added Salt (NAS) diet, easy to chew (Mech) (EC7) (Easy to Chew 7) texture, thin consistency. R3's Diet Card for Lunch on 9/12/23 documents regular, easy to chew, NAS diet with beef tips and mushrooms entree. The Facility's Diet Spreadsheet for Day 17 Regular Easy to Chew (EC7) documents #6 Dip for the Easy to Chew Beef Tips and Mushrooms (EC7). On 9/12/23 at 12:23 PM, V6, Interim Dietary Manager, stated, That scoop (for the mechanically altered meat) is only four ounces, so you (V9, Dietary Aide) will do one of those scoops and one two-ounce scoop. On 9/12/23 at 12:46 PM. V9, Dietary Aide, plated one scoop of mechanically altered meat for R3. V9 stated, We are just running low. I didn't do (make) enough of it. It's my fault. 3.R6's Order Summary Report dated 9/13/23 documents R6 is on a regular diet, regular texture and thin liquid consistency starting 3/3/23. R6's Diet Card for Lunch on 9/12/23 documents regular diet with ice cream. On 9/12/23 at 12:25, V8, Dishwasher, prepared R6's tray. There was no ice cream placed on the tray prior to placing on the meal cart for delivery to resident. 4.R7's Order Summary Report dated 9/13/23 documents R7 is on a regular diet with regular texture and mildly thick (nectar) consistency. R7's Diet Card for Lunch on 9/12/23 documents regular diet with mildly thick liquids and two whole slices of wheat bread at all three meals. On 9/12/23 at 12:44 PM, V8, Dishwasher, prepared R7's tray. There was only one slice of bread on the tray before it was placed in the meal cart for delivery to resident. On 9/12/23 at 3:14 PM, R7 was sitting in his wheelchair outside his room with a sling on his right arm. R7 stated a few words, but primarily used a dry erase board for communication. R7 communicated the Facility is always running out of wheat bread, salami, Swiss cheese, mayonnaise, and strawberry yogurt. On 9/12/23 at 10:34 AM, V3, Certified Nursing Assistant (CNA) stated sometimes the kitchen makes mistakes, but they usually try to correct them. On 9/13/23 at 9:42 AM, V10, Unit Assistant (UA), stated the kitchen often runs out of food. On 9/13/23 at 9:58 AM, V9, Dietary Aide, stated the Facility does get complaints about running out of food items and the dietary manager is aware. On 9/13/23 at 10:02 AM, V13, Dietary Manager, stated the Facility ran out of items before she worked here, but it is no longer a problem. She would expect staff to follow the menus and look at portion sizes when they are making the resident trays. On 9/13/23 at 2:22 PM, V16, Registered Dietitian (RD), stated different scoops are used to ensure residents get the appropriate amount of calories and protein. If a smaller scoop is used, residents will not get enough protein. If this is happening all the time it could lead to weight loss and different things like medications not working the same. She stated it is important for mechanically altered diets to have the correct scoop sizes. On 9/13/23 at 2:55 PM, V2, Director of Nursing (DON), stated she expects dietary staff to follow meal cards. The Facility's Resident Council Meeting Minutes dated 8/7/23 documents, Menu's not being taken at times & not being given what ordered. The Facility's Therapeutic Diets Policy issued 9/1/21 documents, All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. Therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet is to eliminate or decrease specific nutrients in the diet (e.g., sodium), or to increase specific nutrients in the diet (e.g., potassium), or to provide food that a resident is able to eat (e.g., mechanically altered diet). Mechanically altered diet means one in which the texture of the diet is altered. Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care.

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing is dated when placed for weekly replacement and stored in plastic bag when not in use for 5 of 9 residents (R8, R12, R48, R52, R128) reviewed for respiratory care in a sample of 34. Findings include: 1. On 03/21/23 at 9:35 AM, R8 was sitting in her wheelchair in her room. R8 had her oxygen on and there was no date noted to be on the oxygen tubing. On 03/22/23 at 8:45 AM, R8 is sitting in her room in her wheelchair with her oxygen in place. There was no date noted to the oxygen tubing at this time. R8's Admission Record, print date of 03/22/023, documents R8 has a diagnosis of respiratory failure with hypoxia. R8's Minimum Data Set (MDS), dated [DATE], documents R8 is moderately cognitively impaired. R8's Care Plan, admitted [DATE], documents R8 has impaired gas exchange, has a diagnosis of respiratory failure with hypoxia, administer oxygen as prescribed or per standing order. R8's Physician's Order, 08/29/22, documents R8 is to receive O2 (oxygen) @ (at) 2L (liters) per N/C (nasal canula). Keep sats (saturations) > (greater) than 90%. May gradually taper. 2. On 03/21/23 at 9:24 AM, R12 was sitting in her room in her wheelchair. The oxygen tubing on her portable oxygen concentrator was not dated. There was no bag with a date on the oxygen concentrator she uses at nighttime. On 03/22/23 at 9:10 AM, R12 was up and in her wheelchair getting ready to go down to the activity room. The oxygen tubing on her portable oxygen concentrator was not dated. R12's Admission record, print dated of 03/22/23, documents R12 has a diagnosis of Chronic obstructive pulmonary disease (COPD). R12's MDS, dated [DATE], documents she cognitively intact. R12's Care Plan, admitted [DATE], documents R12 has O2 dependent COPD, and give oxygen as ordered by the physician. R12's Physician's Orders, dated 01/25/23, document R12 is to receive O2 @ 2L per N/C continuously. 3. On 03/21/23 at 9:35 AM, R52 was sitting in her wheelchair in her room. R52 had her oxygen on and there was no date noted to the oxygen tubing. There was a bag taped to the O2 concentrator with the date of 3/6. On 03/22/23 at 8:45 AM, R52 was sitting in her room in her wheelchair with her oxygen in place. There was no date noted to the oxygen tubing at this time. The bag noted on the O2 concentrator had the date of 3/6 wrote on it. R52's Admission Record, print date of 03/22/23, documents R52 has diagnoses of COPD and Chronic respiratory failure with hypoxia. R52's Care Plan, with admitted [DATE], documents chronic oxygen therapy r/t (related to) chronic respiratory failure with hypoxia, COPD, and oxygen as per MD (medical doctor) orders. R52's Physician's Orders, dated 08/25/20, documents R52 is to receive O2 2-3 LPM (Liters Per Minute) NC to keep SPO2 (oxygen saturation) above 92%. 40650 4. On 03/20/2023 at 10:56 AM, R128's oxygen tubing was not dated nor was it on R128. There was no respiratory bag in the resident's room either. R128's Health Status note dated, 03/09/2023 at 5:36 PM documented, (Medical Doctor) here to see (R128) (new order) for (oxygen) at 2 (Liters) to keep sats above 90% till Monday, and CBC and BMP (lab tests: complete blood count, basic metabolic profile) to be done 3/16. On Monday remove (oxygen), wait 30 minutes then recheck (oxygen) levels, call MD and update him after you recheck (oxygen) He will decide then if he wants to keep her on it or remove it. R128's Health Status note, dated 03/14/2023 at 10:33 PM documented, (Resident) resting in bed at this time, no change in condition noted. (pulse oximetry) (within normal limits) (with) supplemental O2 There were no physicians order for oxygen nor was it care planned. 5. On 03/21/2023 at 9:54 AM, R48's nasal cannula oxygen tubing was not dated. It was connected to the portable oxygen tank but that was not turned on. There was no respiratory bag in the resident's room either. R48 stated that they have not changed the tubing. R48's Physicians order, dated 03/14/2023 documented, May apply supplemental (oxygen) to keep (pulse oximetry) (greater than) 90% two times a day for (Congestive Heart Failure). On 03/22/2023 at 2:25 PM, V2, Director of Nurses, stated that she would expect the staff to change oxygen tubing weekly. The facility's policy, Oxygen Administration, dated 05/04/ 2018, documented, 14. Keep a plastic bag available to store the oxygen delivery system (cannula or mask) when not in use. Date and initial the bag when placed and change weekly. 15. Guidelines for changing respiratory equipment will be as follows: A. Oxygen tubing-weekly.

Based on observation, interview and record review, the facility failed to perform hand hygiene to prevent cross contamination and the spread of infection for 3 of 9 residents (R21, R45, R35) reviewed for infection control in the sample of 34. Findings include: 1. On 03/21/2023 at 12:30 PM, V11, Registered Nurse (RN), and V9, Certified Nurse Assistant (CNA), performed incontinent care for R21. Both V9 CNA and V11, RN, donned and doffed gloves without the benefit of hand hygiene, several times, during the procedure. 2. On 03/21/2023 at 12:45 PM, V8, CNA, and V10, CNA, transferred R45 to the toilet using a gait belt. After R45 was finish using the toilet, V8, with the same gloved hands, took a soapy washcloth and cleansed R45's peri rectal area and buttocks. V8 and V10 then transferred R45 back to her wheelchair with the same gloves they used to cleanse R45 touching the arm rest of R45's wheelchair and gait belt on the resident and then fastened R45 chair alarm seat belt. 3. On 03/21/2023 at 10:55 AM, R35 was sitting on the toilet with call light on, with the sit to stand lift connected to the belt around her. V10, CNA, performed hand hygiene and donned gloves. V10 operated the sit to stand lift and took R35 out of bathroom and to her bedside. V10, with the same gloved hands, took a soap and water washcloth from the sink, cleansed front to back of peri rectal area. While wearing the same soiled gloves, V10 got another washcloth from the sink, cleansed the peri rectal area again, front to back and then back to front with same cloth several times, all without glove changes and benefit of hand hygiene. On 03/22/2023 at 02:25 PM, V2, Director of Nurses (DON), stated that she would expect the staff to perform hand hygiene after they remove their gloves. The facility's policy, Hand Hygiene Protocol, dated 07/26/2021, documented, Use an alcohol based hand sanitizer: Before resident contact. It continues, Before moving from work on a soiled body site to a clean body site on same resident. It continues, Immediately after glove removal.

Based on observation, interview and record review, the facility failed to perform complete incontinent care for 2 of 6 residents (R45, R35) reviewed for incontinent care in the sample of 34. Findings include: 1. On 03/21/2023 at 12:45 PM, V8, Certified Nurse Assistant (CNA), and V10, CNA, transferred R45 to the toilet using a sit to stand mechanical lift. After R45 was finish using the toilet, V8 used a soapy wash cloth and cleansed R45's peri rectal area using back and forth strokes and not turning the wash cloth to the clean area. V8 continued to cleanse the buttocks, but did not cleanse the labia, groin area or abdominal folds. V8 and V10 then transferred R45 to her wheelchair. R45's Minimum Data Set (MDS), dated [DATE], documented that R45 requires extensive assist of 2 staff members to use the toilet and was frequently incontinent of urine. R45's Care plan, dated 01/30/2023, documented, TOILET USE: Assist me to the toilet every 2 hours and as needed. I am frequently incontinent and need assistance with hygiene care as needed. 2. On 03/21/2023 at 10:55 am, R35 was sitting on the toilet with call light on, with the sit to stand l mechanical lift connected to the belt around her. V10, CNA, had wash cloths in the sink with warm water and soap. V10 operated the sit to stand lift and took R35 out of bathroom to her bedside. V10 used a soap and water wash cloth to cleanse front to back of peri rectal area but did not cleanse R35's abdominal folds and bilateral groins. V10 used another wash cloth, cleansed the peri rectal area again, front to back and then back to front with same cloth several times. R35's Care plan, dated 06/01/2021, documented, Moisture barrier with incontinent care, Use mild cleansers for peri-care and washing. It continues, TOILET USE: assist me to toilet at least every 2 hours and (As needed). provide incontinent skin care per protocol. R35's Admission record, dated 03/22/2023, documented a diagnosis of Malignant neoplasm of bladder. On 03/22/2023 at 2:30 PM, V2, Director of Nurses, stated that she would expect the staff to perform complete incontinent care including abdominal fold, groin areas and labia. The facility policy, Perineal Care policy and procedure, dated 11/2016, documented, Cleanse the perineal area: for female genitalia - use gentle downwards strokes from the front to the back of the perineum, using a clean section of the washcloth or pre-moistened wipe with each stroke.

Based on observation, interview, and record review the facility failed to ensure medications were properly administered and/or stored for 1 of 5 residents (R64) reviewed for medications in the sample of 34. Findings include: 1. On 03/21/23 at 12:20 PM, R64 was sitting in his room. A medication cup with medications in it was setting on R64's over the bed table. When R64 was questioned about the medication on his over the bed table, R64 stated it was his Gabapentin he takes. He said he knows he should have taken it when the nurse handed it to him, but he didn't because he likes to take it with food. R64's Admission Record, print date of 03/22/23, documents R64 has a diagnosis of Peripheral Vascular disease, unspecified, Muscle wasting and atrophy, and Type I Diabetes Mellitus. R64's Minimum Data Set (MDS), dated [DATE], documents R64 is cognitively intact. R64's Care Plan, with admitted [DATE], does not have any documentation regarding R64 being able to administer his own medications. R64's Physician's Order, dated 02/02/23, documents R64 is to receive Gabapentin Oral Tablet 600 by mouth three times a day for Neuropathy related to type 1 diabetes mellitus with diabetic polyneuropathy. On 03/21/23 at 12:35 PM, V4, Licensed Practical Nurse (LPN), stated she handed R64 his pill and then she was called away. V4 stated he usually takes his medications she didn't don't know why he didn't take it this time. On 03/21/23 at 12:37 PM, V4 went in to check on R64 at this time to see if his medication was still sitting in his room. After coming out of his room, V4 stated that R64 just told her that he likes to take his meds with food so now she knows. On 03/21/23 at 12:44 PM, V2, Director of Nursing (DON), stated she would expect the nurse to watch the residents take their medications unless they were assessed and able to administer their own medications. The facility's Medication Administration Policy, dated 1/11/10, documents Objective: To provide accuracy during medication pass to assure quality care for residents. Policy: It is the policy of this facility to accurately administer medication following physician's orders. It further documents 13. Make sure the resident takes the medication. Generally- Do not leave meds at bedside (may be exceptions after thorough assessment and care planning).

Based on observation interview and record review the facility failed to provide food at a palatable temperatures during meal service. This had the potential to affect all 72 residents in the facility. Findings include: Resident Council minutes dated 11/2/21, 12/6/21 and 1/3/22, documented, the food continues to be served cold. The concerns addressed to the dietary manager, with dietary manager documentation of, hot food is always temped where it should be before going onto the steamtable. The Facility's Quality Assurance Performance Improvement, (QAPI) dated, 1/3/22, documented an action Plan titled, COLD food, that addresses issues of, monitor temperatures in the kitchen before serving, with the first tray and last to be served on each cart, monitor pass times, educate staff to keep door closed to cart during serving and random interviews with residents after meals. On 02/07/22 at 11:45 AM, entered kitchen food was placed in the steam table. The following meal service was temped for the following; Ham slices at 152 degrees (F), (Fahrenheit), Peas at 162 degrees( F), Sweet Potatoes at 160 degrees (F), gravy at 150 degrees (F), pureed Ham at 170 degrees (F), pureed Peas at 164 degrees (F) and pureed Sweet Potatoes at 142 degrees (F). On 2/7/22 at 11:50AM, 12 meal trays that contained the meal in Styrofoam closed container, were loaded onto an uninsulated roll hall cart. On 2/7/22 at 11:55AM, the cart was then transferred to the 300 hall, with the first tray delivered by two staff members at 11:55AM, to the residents rooms, with the last tray delivered at 12:05PM with 11 meal trays distributed. On 2/7/22 at 12:07 PM, the 12th meal tray was temperature checked with the following; Ham at 90 degrees (F), peas at 110 degrees (F) and cubed sweet potatoes at 100 degrees (F). On 02/7/22 at 1:04 PM through 1:15PM, the following were interviewed; R19, R6, R42 and R50, they all stated the lunch served today was warm and has been this way for quite a while. On 2/8/22 at 12:30 PM, V1, Administrator, stated he is aware of residents voicing concerns of the food low temperatures with monitoring by kitchen and administration staff. V1 continued to state the kitchen has been serving meals using Styrofoam since October not due to quarantine status, but kitchen staffing. On 2/8/22 at 12:40 PM, V10, Dietary Manager, stated the food is served in Styrofoam due to three kitchen staff out on quarantine status and due to staffing issues, washing meal plates is time consuming. The facility's procedure, entitled, Time and Temperature Standards, dated 6/2018, documented, Serving: Maintain internal temperature at more than 135 degrees (F). The Facility's Resident Census band Conditions of Residents, CMS 672 dated 2/1/22, documented the facility had a census of 72 residents.

Based on interview and record review, the facility failed to attempt Gradual Dose Reductions (GDR's) and put resident centered behavior tracking in place for 4 of 5 residents (R18, R27, R33, R53) reviewed for [CONDITION(S)] medications in the sample of 41. Findings include: 1. R18's Face Sheet, print date of 2/1/22, documents R18 was admitted on [DATE] with diagnoses of [CONDITION(S)] Disorder and Anxiety. R18's Pharmacy Recommendation, dated 6/29/21, documents, Resident receives the following medication used for depression: [MEDICATION(S)] 60 mg (milligram) Q (every) AM for Depression since 3/22/2020 resident also continues on [MEDICATION(S)] 5 mg bid (twice a day) and [MEDICATION(S)] 25 mg q 6 hours prn (as needed) itching. The Centers for Medicare and Medicaid Services (CMS) requires attempts at dosage reductions on antidepressant medications used for managing behavior, stabilizing mood, or treating psychiatric disorders twice a year, in two separate quarters (with at least one month between attempts), within the first year of admission or initiation, and annually thereafter unless clinically contraindicated. Resident is due for an evaluation. Please complete on of the following sections. 1. ( x) Further dose reduction is clinically contraindicated due to: ( ) The continued use in accordance with relevant current standards or practice. A dose reduction at this time would likely impair resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder as supported by the following CLINICAL RATIONALE AND EVIDENCE OF THE FOLLOWING SYMPTOMS: (no documentation available for review). R18's Pharmacy Recommendation, dated 8/31/21, documents, Resident receives the following medication used for anxiety: on [MEDICATION(S)] 5 mg bid for anxiety since 7/31/2020. The Centers for Medicare and Medicaid Services (CMS) requires attempts at dosage reductions on antidepressant medications used for managing behavior, stabilizing mood, or treating psychiatric disorders twice a year, in two separate quarters (with at least one month between attempts), within the first year of admission or initiation, and annually thereafter unless clinically contraindicated. Resident is due for an evaluation. Please complete on of the following sections. 1. ( x) Further dose reduction is clinically contraindicated due to: ( ) The continued use in accordance with relevant current standards or practice. A dose reduction at this time would likely impair resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder as supported by the following CLINICAL RATIONALE AND EVIDENCE OF THE FOLLOWING SYMPTOMS: (no documentation available for review). R18's Order Summary Report, dated 2/1/22, documents, [MEDICATION(S)] Tablet 5 mg. Give 1 tablet by mouth two times a day for anxiety. Start date of 7/31/2020. R18's Order Summary Report, dated 2/1/22, documents, [MEDICATION(S)] Capsule Delayed Release Particles 60 mg. Give 60 mg by mouth in the morning for depression. On 2/8/22 at 4:00 PM, V2, Director of Nurses (DON), stated, I review the the pharmacy recommendations and then pass them on to the Doctor. He gives them back to me and I did not see that he had not addressed the reasons he does not want to her to have a dose reduction. 2. R33's Face Sheet, documents R33 was admitted on [DATE] with diagnoses of Alzheimer's Disease, Dementia and [CONDITION(S)] Disorder. R33's 2/2022 Physician Orders document, [MEDICATION(S)] HCl Tablet 10 MG. Give 10 mg by mouth at bedtime for depression. Start date of 8/30/2019. R33's last Pharmacy Gradual Dose Reduction Recommendation for [MEDICATION(S)] was 12/08/2020. On 2/8/22 at 4:00 PM, V2 stated that R33 should have had an attempted dose reduction on 12/4/21 and it was missed. 3. R53's Face Sheet, print date of 2/1/22, documents R53 was admitted on [DATE] with diagnoses of Dementia with behaviors and Major Depressive Disorder. R53's 2/2022 Physician Order Summary documents, [MEDICATION(S)] Tablet 0.25 MG. Give 0.25 mg by mouth every 8 hours as needed for anxiety. Start date of 9/28/21 and [MEDICATION(S)] Tablet 0.5 mg. Give 0.5 mg by mouth two times a day related to unspecified Dementia with Behavioral Disturbance. Start date 10/12/21. R53's 12/2021 - 2/9/2022 Medication Administration Record (MAR) documents, R53 received [MEDICATION(S)] 0.25 mg tablet 7 times as an as needed medication. R53's Nurses Note, dated 10/5/21 at 3:44 PM, documents, This nurse knocked on residents door. Door slightly ajar. Resident slammed the door and stated, 'this is my room!' This nurse knocked again stating I was the nurse. Resident opened the door and invited this nurse in. Resident is agitated and tearful with increased resp (respiration) rate. Resident went on to state that there were people trying to kill her and her children. Resident stated men and woman were shooting needles out of small guns into her neck. The resident stated there was a woman with a large knife trying to stab her from across the street. Resident then stated that when she was eating she looked at her arm and food began to leak out of her arm like it was blood and had to dive behind a car to keep the small man in the bed in the window from shooting her and her kids. Resident worried he will set her and her children on fire in the middle of the night. Resident also stated that if these people come on her property that they will be arrested, but the police won't do anything to stop them from trying to kill her and her kids. Resident then stated she was awaiting three surgeries to remove her liver, spleen and another part she can't remember. This nurse provided TLC (tender loving care) to resident somewhat successful. Resp even and unlabored, no longer tearful. Resident states she is still worried but not as much. Resident is currently sitting in chair in room. PRN (as needed) acetaminophen administered as ordered c/o (complaint of) pain. Call light within reach. Staff will continue to monitor. R53's Nurse Note, dated 10/5/21 at 10:04 PM, documents, Writer took HS (hour of sleep) meds (medication) into room and noted res (resident) was in the BR (bathroom). Res came out and stated, 'I was hiding in there from those people.' Writer reassured res that the room was safe and that writer had meds for her. Res sat down and proceeded to take meds without difficulty. Res resting quietly in recliner at this time. R53's Nurse Note, dated 10/6/21, documents, Primary care physician stated he wants to be notified on 10/7/21 about residents behaviors following the start of the [MEDICATION(S)] 0.5mg BID. R53's Behavior Tracking does not address the use of [MEDICATION(S)] for hallucinations. R53's Behavior Tracking address exit seeking only. On 1/31/22 at 2:30 PM, V25, Licensed Practical Nurse (LPN), stated that R53 does have hallucinations of her old neighbors trying to kill her and that she has 45 children. V25 stated she doesn't have them as often now but she does still have them. On 2/8/22 at 4:00 PM, V2 stated she thought the initial order for an as needed psychotropics needed to be for 14 days only and then after that is could be long standing. V2 also stated that R53 should be behavior tracked for her hallucinations. 4. R27's current physician orders dated 2/1/2022 documents that R27 is currently receiving [MEDICATION(S)] 37.5mg in the AM and 25mg at hs and [MEDICATION(S)] 5mg Three times a day. R27's face sheet dated 11/30/2018 documents that R27 has a diagnosis to include unspecified Dementia with behavioral disturbances. R27's In Home Medical Group (IHMG) sheet dated 8/11/2021 documents increase am dose of [MEDICATION(S)] to 37.5mg. R27's IMHG dated 12/22/2021 documents increase [MEDICATION(S)] 5mg am and pm Start [MEDICATION(S)] 2.5mg in afternoon. R27's sheet dated 1/5/2022 documents increase [MEDICATION(S)]. R27's physician order dated 2/2/2022 documents [MEDICATION(S)] 25mg at hs and [MEDICATION(S)] 37.5 mg by mouth in the morning. Physician orders dated 2/1/2022 documents [MEDICATION(S)] 5mg three times a day. R27's medication review dated 1/21/2021 documents see report for any noted irregularities and/or recommendations. Report dated 2/13/2021 documents no irregularities. Report dated 3/16/2021 documents no irregularities/or recommendations. Report dated 4/21/2021 documents see report for any noted irrregularities and/or recommendations. The pharmacy note to attending physician dated 4/29/2021 documents pharmacist recommended dose reduction to - trial reduction of [MEDICATION(S)] 25mg BID to [MEDICATION(S)] to 12.5mg am and [MEDICATION(S)] 25mg pm. The physician did not mark agree or disagree with any type of rational, The physcian marked further dose reduction clinically contraindicated but to behavioral interventions continue to be attempted. R27's physician orders do not document an attempted dose reduction, but an increase. The Facility Policy [CONDITION(S)] Medication dated 11/28/17, documents the requirements for Gradual Dose Reduction must be followed.

Based on observation, interview and record review, the facility failed to complete a restraint assessment including the risk versus benefits of a seat belt with alarm for 1 of 2 residents (R24) reviewed for physical restraints in the sample of 41. Findings include: R24's Admission Record, admitted [DATE], documented a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's Physical device/Psychoactive Medication initial Quarterly Evaluation, dated for the following; R24's admission quarterly evaluations dated from 2/19/20 through 12/2/20 documented, device recommendations of a lap buddy when up in wheelchair for a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/17/21, documented a physical restraint of a lap buddy placed over the seat-belt, due to resident had physically destroyed the seat-belt beyond repair. On 8/16/21 and for the last physical restraint evaluation, dated 11/15/21, documented the use of a lap buddy. The facility failed to do an initial evaluation for a physical restraint provided on 12/9/21. R24's Fall Occurrence Report, dated 12/8/21 at 9:00PM, V2, Director of Nursing (DON), documented, R24 was observed in front of nurses station, in a wheelchair, placing self under the lap buddy and sliding out onto the floor. New intervention to be put into place is to discontinue the lap buddy and sensor alarm in chair and add seat belt alarm when in wheelchair. On 2/2/22 at 2:00PM, V2 stated she could not provide an initial evaluation of R24's seat belt restraint that was initiated on 12/9/21. V2 stated she was not aware that a new physical restraint assessments needed to be completed, since R24 was previous placed with a lap buddy physical restraint. V2 continued to state, R24 had literally positioned her body under the lap buddy and to the ground, in which the incident happened so quick, V2 could not prevent the fall. R24's Care Plan, dated 1/11/21, documented, Focus area; entitled, I am at risk for falls r/t (related to) Alzheimer's dementia with poor safety awareness, weakness from [CONDITION(S)], ([CONDITION(S)] attack), medications that may cause [CONDITION(S)] or dizziness vision and communication impairments and incontinence, initiated, 10/27/19. Intervention, dated 12/9/21, documented, Seat belt alarm while in wheelchair. Release q (every) 2 hours and PRN (as needed) when in direct supervision of staff, and check seat belt alarm for fitting, placement, and working condition every shift and report any damage to the supervisor. The Facility's policy and procedure, entitled, Restraint Program Policy and Procedure, revision date of 11/10/15, documented, Prior to the use of any restraint, each resident is assessed for potential alternatives. During this investigation ,on 1/31/22 through 2/9/22, R24 was observed in a wheelchair, stationed either a the nurses station or propelling herself down halls. R24, had visual and hand helded sensory objects at all times, seat belt alarm attached and sent to room for toileting assistance every one-two hours. On 2/2/22 at 9:30AM, V7, Certified Nurse Aide (CNA), stated she has cared for R24 for a long while and she is one to get up out of her wheelchair unassisted, has had many falls and the seat belt alarm is for her safety. V7 revealed that R24, is capable of removing and attached her seat belt.

Based on observation, interview and record review the facility failed to perform proper hand hygiene to prevent the spread of infection for 3 of 5 (R5, R39, R47) residents reviewed for and infection control in the sample of 41. Findings include: 1. On 02/08/22 at 9:40 AM, V22, Certified Nurse Aide (CNA), provided incontinent care for R5. V22 put gloves on without hand hygiene prior to glove placement, pulled R5's incontinent brief down which was soiled front and back with a large amount of loose smeared brown stool. V22 took a wet cloth and put cleanser on the cloth, cleansed her front perineal area, rolled R5 on her right side, removed the soiled depends, with the same gloves V22 picked up a wet wash cloth and took the bottle of cleanser and put some cleanser on the cloth, cleansed the rectal area. V22 then removed her gloves washed her hands, placed a new incontinent brief down on the bed. On 2/9/22 at 8:45 AM, V2, Director of Nursing (DON), stated, she would expect staff to use appropriate hand hygiene and use hand hygiene prior to applying gloves. The facility Policy and Procedure for Resident Care dated 12/05, revised 11/2016 documents, Policy: Following evidence based practice, glove changes and the performance of hand hygiene during perineal care may be limited to before initiating perineal care, any time gloves are visably soiled, and at the completion of perineal care. 2. On 02/01/22 at 10:30 AM, V8, Licensed Practical Nurse (LPN), placed surgical mask over N95, donned gown. V8 then donned gloves, V8 did not sanitize her hands prior to donning gloves. V8 entered R39's room. 3. On 02/08/22 at 1:15PM ,V15, CNA, had gloves on and used cleansing cloths to perform catheter care for R47. V15 Cleansed penis, pulled foreskin back, cleansed head, then cleansed the catheter tubing. V15 then cleansed R47's groin. V15 removed her gloves. V15 donned new gloves and cleansed R47's scrotum.V15 did not sanitize her hands prior to donning gloves. On 2/08/22 at10:47 AM V2 Director of Nursing (DON) stated that she would expect staff to sanitize hands prior to donning glove. The Facility Donning and Doffing PPE (Personal Protective Equipment) and Isolation Competency, undated, documents performs hand hygiene.

Based on observation, interview and record review the facility failed to adhere to infection control practices related to 2 of 2 residents(R17, R25) failing to don face masks while in the hallway. Findings include: 1. On 11/9/20 at 9:45 AM, in the COVID-19 Red Zone 1, R17 is in her wheelchair propelling herself out into the hallway. R17 has no mask on. R17's Minimum Data Set (MDS) dated , 9/23/20 documents Basic Interview for Mental Status (BIMS) is 3, severely cognitively impaired. R17's Care Plan dated 11/4/20 documents, Resident is at risk for psychosocial well being concern related to restrictions to COVID-19 social precautions. Resident is at risk for complications related (r/t) diagnosis (dx) of COVID-19. Resident is at risk for decline in Activity of Daily Living (ADL) functional status r/t [DIAGNOSES REDACTED]. Risk for complications due to COVID 19 will be minimized through next review date. Resident needs will continue to be met during placement in designated isolation area through duration of isolation. Resident ADL functional status will be maintained during placement in designated isolation area through duration of isolation. INTERVENTIONS: Maintain droplet isolation precautions as per protocol. Vital signs every 4 hrs and as needed (PRN). Continue visitor restrictions as per IDPH guidelines. Report any new onset symptoms such as, cough, runny nose, temperature of 100.4 or 2.0 degrees above baseline. Provide alternative communications for family and friends. Provide support and allow Residents to express feelings, fears and concerns. Observe for psychosocial and mental status changes- document and report as indicated. COVID-19 assessment 2 times a day (BID) and PRN. Provide activities of choice, as able. R17's Care Plan does not address residents with cognition impairment to provide masks for residents when in the hallway. On 11/9/20 at 9:55 AM, Surveyor asked V11, Certified Nurse Aide (CNA) if (R17) should be out of her room without a mask. V11 stated, No, she shouldn't. 2. On 11/9/20 at 9:50 AM in the COVID-19 Red zone 1, R25 is in her wheelchair and self propelled herself out of her room up to the nurses station. R25 had no mask on. V12 Agency Registered Nurse (RN) and V13 Agency Licensed Practical Nurse (LPN) were sitting at the nurses desk and neither one redirected her to her room or got her a mask to put on. R25's Minimum Data Set (MDS) dated , 9/29/20 documents Basic Interview for Mental Status (BIMS) is 00, severely cognitively impaired. R25's Care Plan dated 11/4/20 documents, Resident is at risk for psychosocial wellbeing concern related to restrictions related to COVID-19 social precautions. Resident is at risk for complications r/t dx of COVID-19. Resident is at risk for decline in ADL functional status r/t [DIAGNOSES REDACTED]. effects related to restrictions related to COVID-19 social precautions through next review date or when restrictions are discontinued. Risk for complications due to COVID 19 will be minimized through next review date. Resident needs will continue to be met during placement in designated isolation area through duration of isolation. Resident ADL functional status will be maintained during placement in designated isolation area through duration of isolation. INTERVENTIONS: Maintain droplet isolation precautions as per protocol. Vital signs every 4 hrs and PRN. Continue visitor restrictions as per IDPH guidelines. Report any new onset symptoms such as, cough, runny nose, temperature of 100.4 or 2.0 degrees above baseline. Provide alternative communications for family and friends. Provide support and allow Residents to express feelings, fears and concerns. Observe for psychosocial and mental status changes- document and report as indicated. COVID-19 assessment BID and PRN. Provide activities of choice, as able. R25's Care Plan does not address residents with cognition impairment to provide masks for residents when in the hallway. On 11/10/20 at 1:18 PM, V2 Director of Nurses (DON) stated, Staff should redirect the resident to go back to their room or get them a mask and put it on them. The facility Policy and Procedure for COVID-19 Testing and Response Plan revised 10/27/20 documents in part, 11. Infection Prevention and Control: B. Resident approaches, v. Positive or symptomatic residents should be given a surgical mask and encouraged to wear it at all times. These residents should be wearing a surgical mask when close contact with others is anticipated.

Based on interview and record review the facility failed to provide resolutions/investigations into resident grievances. This has the potential to affect all 90 residents living in the facility. Findings include: Facility Grievance Log dated February 2020, documents the following: 1) 2/9/2020, concern regarding extended call light times with no resolution noted; 2) 2/18/2020, concern for resident that is confused is wandering into another resident's room. No resolution noted. 3) 1/19/2020, concern for nail trimming, orientation board, no glasses on yesterday, low potassium diet but served orange juice. Resolution noted was to educated staff on family concern. Facility Grievance Log dated March 2020, documents the following: 1) 3/13/2020, concern for food. There is no investigation marked nor resolution to the concern. 2) 3/13/2020, but does not list a concern, investigation, nor resolution. 3) 5/23/2020 concern for food, with a comment of coffee and hot chocolate was cold. There is no investigation nor resolution marked on the grievance log. 3) 9/20/2020 documents a concern for a missing watch that reflects it was investigated, but does not list a resolution. Concern form dated 1/1/2020, documents a concern for cold food on the hall carts. The follow-up, signed by V3, Dietary Manager (DM), documents I received a hall tray and yes it was not super hot, they all can be warmed up in the microwave. We have 4 microwaves in this building. Concern form dated 2/27/2020, documents a concern for cold food. The follow-up signed 2/27/2020 by V3, DM, documents, We are very sorry if you have cold food, please know you can always ask for a new plate from dietary or we have 4 microwaves that can make your food hotter for you! Concern forms provided by the facility documents in part the following: 3/5/2020 Residents are stating the food on the buffet isn't always hot; 8/6/2020 Food is served cold; 9/4/2020 Food is cold; Concern form dated 6/4/2020, documents in part a concern for call lights taking to long to answer. The follow-up signed 6/15/2020, by V2, DON, documents, Call light audit. Concern form dated 7/2/2020, documents a concern for call lights taking to long to answer. The follow-up signed 7/13/2020, by V2, Director of Nursing (DON), documents, Call light audit. It would be helpful to know the shift! Concern form dated 8/6/2020 documents a concern for cold food. The follow-up signed 8/10/2020 signed by V3, DM, documents, We strive to serve hot delicious meals. If your meal is not as hot as you would like, we can always put it in the microwave to warm it up. On 10/5/2020 at 2:10PM, R67 stated there is a problem with the coordination between the cooks and the time it takes for the food to get to me. Food is always cold, especially eggs. On 10/8/2020 at 10:55AM, V12, Regional Nurse Consultant (RNC), stated heating food in the microwave is not the way to resolve cold food and that the residents should be able to get their food at a temperature that is acceptable. V12, RNC, further stated, there needs to be resolution to the cold food. On 10/8/2020 at 11:40AM, V1, Administrator, stated the grievances are to be filled out and resolved by the department in which the grievance is about, documented on the Grievance Log, and to ensure that it is followed up on if it is not resolved. Facility Grievance Log dated March 2020, documents the following: 5/23/2020 concern for food, with a comment of coffee and hot chocolate was cold. Facility policy entitled Grievance Resolution dated 10/16/14, documents in part, 4. The ED (Executive Director) is responsible for reviewing the concern, discussing the concern with the customer within 24 hours of receiving the completed form. The Resolution further documents in part, 6. The ED may refer the concern to a Designee to assist with the investigation and resolution of the concern. The Director or Designee(s) are responsible for documenting actions taken and providing follow-up within 72 hours. If the concern cannot be resolved, the reason(s) must be documented. The Resident Census and Condition of Residents form (CMS 672), dated 10/1/2020, documents that the facility has 90 residents living in the facility.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner. This has the potential to affect all 90 residents residing in the facility. Findings Include: On 10/3/2020 at 11:07AM in the dry storage room [ROOM NUMBER], cereal was noted in plastic container on a rack without a seal on the lid. V3, Dietary Manager (DM), stated the facility used to have an open buffet prior to COVID and decided to use the containers for storage area to hold the cereal. On the open shelving units were the following open without a date on it: large bag of opened cheeto puffs, large bag of open stuffing, and a large bag of opened rice. Next to the opened bag of goods was a large bag of Thick it, used for thickening the fluids for residents on thickened fluids without the benefit of an date on it when opened. V3, DM, stated: We usually open and then tie it back up. When asked if that is how the bag is supposed to be, V3 stated: It doesn't look like it. V3 further stated: The plan is for all of it to go in the trash, because I am not sure when any of it was opened. On 10/3/2020 at 11:15AM, dry storage room [ROOM NUMBER] was found with the following items open with no open date recorded on the products: 2 bags of pasta noodles, 2 bags of noodles, and 1 bag of cracker crust powder. Plastic containers of spices covered with grim on the tops, inside the lid, and around the outside of the container as follows: Onion powder spice, container labeled garlic powder but the contents had garlic salt with rice, and a large container of pepper. Noted in the cabinet in the kitchen were multiple 18 ounce spices open, undated as follows: Thyme , ground Basil, Italian seasoning, Nutmeg,(NAME) Celery flakes, and Cinnamon. All were caked in crusted, grimy areas throughout the outer part of the container and underneath the lid. On 10/3/2020 at 11:35AM, when asked by surveyor why the opened spices, bags of food were not dated, V3, DM, stated some of the spices in the containers come in bulk and the facility add the spice to the container because it is easier to pour. V3, DM, further stated anything opened should be dated the date it was opened and should be kept clean. Facility Form entitled Food Storage Chart, undated, documents in part: After a food item is opened, it will be covered, labeled, the 'use by date' will be put in, initialed and stored. Facility form entitled Food Labeling and Dating, dated 6/18, document in part, 1. Proper food labeling includes: name of product, date stored and in some cases, the time of the day. 2. The food must be labeled and dated if it is removed from its original container. The Resident Census and Condition of Residents form (CMS 672), dated 10/1/2020, documents that the facility has 90 residents living in the facility.

Based on observations, interview and record review the facility failed to have residents call lights within reach of the resident for 4 of 14 residents (R19, R26, R70, and R79), reviewed for accommodations of needs, in a sample of 33. Findings include: 1. R19's Electronic Health Record (EHR) documents R19 was admitted to facility on 9/20/2016 with a [DIAGNOSES REDACTED]. R19's Minimum Data Set (MDS), dated [DATE], documents R19 is an extensive assistance two person for transfers, dressing, and toileting. R19's Care Plan dated 9/21/20 documents: (R19) is at risk for falls. She has dementia with cognitive loss, [MEDICAL CONDITION] with leg contractures. Attempts to get up unassisted. INTERVENTIONS: Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance. Provide a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach. On 10/5/2020 at 9:15 AM, R19 sat in a wheelchair inside room yelling Hey, Hey, Hey. R19 then stated, I want to go to bed. On 10/5/2020 at 9:20 AM, V18 Housekeeper, entered the room and around R19's wheelchair looking for R19's call light and located R19's call light stuck inside the drawer next to R19's bed. V18 stated, The call light should be within reach of the resident. 2. R26's EHR documents R26 was admitted to facility on 9/27/2018 with a [DIAGNOSES REDACTED]. R26's MDS dated [DATE], documents R26 requiring extensive assistance two person for transfers, dressing, and toileting. R26's Care Plan undated, documents: I have a history of falls. I am at risk for falls related to medications, incontinence, impaired balance and gait. I get up unassisted and am unsafe to do so. I have impaired safety awareness and poor insight to my deficits 2nd to dementia. INTERVENTIONS: Be sure my call light is within reach and encourage me to use it for assistance as needed. Provide prompt response to all requests for assistance. On 10/5/2020 at 8:30 AM, R26 was observed in room with wheelchair next to bed attempting to self transfer. R26 stated, turning wheelchair around, I don't know where my call light is. R26 stated, I'm ready to lay down. R26's call light observed towards the floor entangled in residents back wheel to the wheel chair. On 10/5/2020 at 8:40 AM, V16 Certified Nurses Assistant (CNA) and V17 CNA, entered room and assisted R26 to bed. 3. R79's EHR documents R79 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R79's MDS dated [DATE] documents R79 requiring assistance of one staff member for transfers, toileting, and dressing. R79's Care Plan dated 9/9/2020 documents: (R79) is at risk for falls. She has dementia with cognitive loss, weakness, unsteady gait and medications that may cause dizziness. She has a h/o an ischemic [MEDICAL CONDITIONS], AFIB, [MEDICAL CONDITION] and weakness. INTERVENTIONS: Make sure my call light is always within my reach. On 10/5/2020 at 2:35 PM, R79 sat in a wheelchair and stated, I've got to poop. R79 stated, I don't know where my call light is. V14, CNA and V2, Director of Nursing (DON) then entered R79's room and began looking for R79's call light which was located wrapped around R79's bed rail against the wall out of reach for R79. At that time V14, CNA stated, I didn't get her up, call lights are to be in reach of the residents. 4. On 10/5/2020 at 2:13PM, R70 stated call lights are not within reach all the time, especially at night. R70 further stated the call lights can be way down at the foot of the bed and having to wait for staff to come in to get help. Resident Council Precautionary Isolation Questionnaire dated 8/6/2020 documents: Nursing Concerns/Suggestions: Needs more help. Call lights aren't always in reach. Resident Council Precautionary Isolation Questionnaire dated September 2020 documents: Call lights taking too long to answer. Facility's form on Call Lights, dated 8/1/05, documents in part: Objective: To Respond to resident's requests and needs. Policy: It is the policy of this facility to maintain the highest quality of care for its residents. Procedure: 1. Answer call light promptly, 4. Listen to resident's request. 5. Respond to request. If item is not available or request questionable, get assistance from a charge nurse. 6. If you are unable to meet resident request or need, leave call light on and obtain assistance from charge nurse. 7. Make certain call light is within resident's reach before leaving the room.

Based on observation, interview and record review the facility failed to provide effective supervision and effective interventions to prevent falls for 5 of 5 residents (R36, R8, R71, R61, R82) reviewed for falls in the sample of 33. Findings include: 1. R36's Electronic Health Record (EHR) documents R36 was admitted to facility on 10/29/2019 with a [DIAGNOSES REDACTED]. R36's Minimum Data Set ((MDS) dated [DATE] documents R36 requires extensive assistance of two persons for transfers, bed mobility and toilet use. R36's Care Plan dated 8/17/2020 documents: (R36) am at risk for falls related to poor safety awareness, cognitive loss, impaired balance and gait. I attempt to get up unassisted and I am unsafe to be up without assistance. I take medications that may contribute to the risk of falls. I have a Hx of falling. INTERVENTIONS: Call Don't Fall signs for closet and bathroom doors. Anticipate and meet (R36) needs. Bed placed in room where resident can exit on her right side to maximize ease of transfer/safety. Catch A Falling Star program. Make sure my call light is always within my reach. Transfers: sit-to-stand with assist of 2. Leave wheelchair next to bed (with wheels locked) when I am in bed. R36's Progress Note dated 5/14/2020 documents: Writer heard resident yelling for help. Went to check on resident and found her sitting upright on the floor next to her bed. Resident stated she was trying to get up so she could go to the bathroom and slipped off of the edge of the bed. Resident denied hitting her head. Denies any pain with ROM. No injuries noted. Neuros initiated. VS at the time of the fall: bp 161/87. p 121. r 20. t 98.5. bs 250. spo2 97%. VS reassessed: bp 142/80. t 97.4. r 18. p 80. Faxed report to MD. POA is aware. R36's Progress Note dated 7/20/2020 documents:Writer called to residents room by staff. Res lying face down in doorway of her room. Res stated I was picking up my face mask off of the floor. Res c/o right hip pain. Res denies hitting her head. Pillow put under her head. Res left on floor @ this time. T99.7 106 22 195/108. O2 sat 94%. Called Dr. with no answer. R36's Progress Note dated 7/23/2020 documents: (R36) was observed on floor by staff. Resident was sitting on the floor with her back against the bed. Resident denied any pain. No injuries noted at this time. Writer called MD about the 2nd dose of [MEDICATION NAME], and let MD know about the fall. Writer told MD that resident was asleep when Writer went to her room to give the 2nd dose. MD told writer not to give it to her. POA aware. Will continue to monitor. R36's Progress Note dated 8/4/2020 documents: CNA observed resident slide out of w/c onto floor. Resident was reaching for lotion at her sink. Her brakes on w/c were not locked, causing slide. Resident landed on her buttocks. Assessment complete. No injuries noted. Resident denies pain. VS stable. Resident reminded to use grabber and call light when needing assistance. POA and MD aware. Will continue to monitor. R36's Progress Note dated 8/9/2020 documents: Writer called to residents room by staff. Res lying on left side on floor. Res was in bed, res stated I was sitting on the side of the bed, & I slid off onto the floor. Res denies pain. ROM WNL for resident. No shortening or rotation noted. No redness or bruising noted. Res assisted up per mechanical lift & sat in w/c. Res also stated she had to go to the bathroom to have a BM. T 98.2 P 84 R 20 B/P 157/74. 2. R61's EHR documents that R61 was admitted to facility 5/29/2020 with a [DIAGNOSES REDACTED]. R61's MDS dated [DATE] documents R61 requires extensive assistance of two staff members with transfers, bed mobility, dressing and toileting. R61's Care Plan dated 8/31/2020 documents: (R61) am at risk for falls. I had several falls prior to admission. INTERVENTIONS: have a tool box in my room I like to tinker with. I also enjoy watching me tv, oldies, westerns, fishing and anything about cars. I will flip through magazines such as country living, fishing or cars and read the papers. Catch a falling star program. Ensure resident is in a high traffic high visibility area when in wheelchair; reflectors on w/c wheels. Frequent visual checks, fill out paper at the desk. Make sure my call light is always within my reach. Sign placed in room to remind staff to assist resident to a high traffic/high visibility area when up in w/c for closer supervision. Transfers: sit-to-stand with assist of 2. R61's Progress note dated 6/18/2020 documents: Writer called to residents room by CNA, res was sitting on floor in front of recliner. Recliner was tipped forward. Res unable to explain what he was doing. ROM WNL for resident no internal/external rotation noted. No shortening noted. Res assisted up per mechanical lift & transferred to w/c. T 97.2 92 20 108/58. R61's Progress note dated 6/25/2020 documents: (R61) noted to wander into RM 301. Staff found res lying on floor appearing to be fixing the bed. Res states he seen a bunch of people over there, but unable to state what happened. No injuries noted. ROM WNL, MAE without difficulty. Neuro's initiated. Res was combative and refused to let staff take VS at this time. R61's Progress note dated 7/5/2020 documents: (R61) observed on floor in hallway next to w/c. res appears to have gotten up without assistance. no injuries noted. neuros initiated. MD and POA aware. R61's Progress note dated 7/9/20 documents: (R61) observed laying on floor on left side next to recliner. no injuries/pain. neuros initiated. MD and POA aware. R61's Progress note dated 7/10/20 documents: (R61) observed sitting on floor next to bed in another resident's room. res appears to have been trying to fix air mattress box. skin tear and bruise to RUE. steri strips applied. MD and POA aware. R61's Progress note dated 8/15/20 documents: (R61) Staff noted that res had taken off lap buddy and was standing in doorway holding onto the rail. Res started to sit down and staff was able to lower res to floor. No injuries noted. ROM WNL, MAE without difficulty. VSS. Will cont to monitor. Res has been wandering the hallways, into other res rooms and repeatedly taking off lap buddy. Staff attempted to re-direct res with interventions being ineffective. R61's Progress note dated 8/ 0 documents: (R61) observed sitting on floor in doorway. When asked what he was doing res stated I don't know. ROM WNL for resident. No shortening or internal/external rotation noted. No redness or bruising present. Res assisted up per 2 assist & mechanical lift & sat in Broda chair. Neuros initiated. Dr. & POA made aware. On 10/06/2020 at 3:00 PM, R61 was observed sitting outside nurses station and no staff supervision. On 10/08/20 at 09:00AM, R61 was observed sitting outside nurses station and no staff supervision for over 15 minutes. 3. R82's EHR documents that R82 was admitted to facility on 10/8/2019 with a [DIAGNOSES REDACTED]. R82's MDS dated [DATE] documents R82 requires extensive assistance of 1-2 staff members for transfers, dressing and toileting. R82's Care Plan dated 9/21/2020 documents: (R82) am at risk for falls rt Alzheimer's dementia with poor safety awareness, weakness from [MEDICAL CONDITION], medications that may cause [MEDICAL CONDITION] or dizziness, vision and communication impairments, and incontinence. INTERVENTIONS: Anticipate and meet my needs. Be sure my call light is within reach when I am in my room; remind me and encourage me to use it for assistance as needed. Provide prompt response to all requests for assistance. Catch A Falling Star per protocol. Ensure that sensor alarm is in working order and in place at all times. Every 15 minute visual checks. R82's Progress note dated 4/22/2020 documents: (R82) It appears root cause of the fall that occurred on 04/18/20 @ 1710 is resident removed lap buddy and got up unassisted pushing her w/c and fell backwards. Floor nurse noted abrasion to posterior scalp and sent resident to PCH ER for eval and treatment. Fall team met and discussed fall and decided the best intervention to prevent future falls is to exchange lap buddy with a notched hugger lap cushion. Release every 2 hours and PRN and when in direct supervision of staff. Care plan updated and staff made aware of changes. R82's Progress note dated 4/28/20 documents: (R82) CNA notified writer that res was on the floor. Writer observed resident on floor at 4:30. Res appeared to have slipped on emesis while getting up. Assessment completed, and a reddened area was noted on resident's lower back. Vitals were BP 122/81, pulse 96, resp 18, temp 97.5, O2 97%. Res denies pain. Intervention in place is increased visual checks for resident. R82's Progress note dated 6/8/20 documents: (R82) Resident was seen by writer taking off lap buddy and promptly falling to floor after attempting to stand up. Resident landed on her right buttock. A physical assessment was performed and found no injuries to resident. Resident was lifted using a mechanical lift and placed back into her w/c. Resident's vitals at time of fall were BP 121/88, P 82, R 18, T 97.4, and SpO2 of 97%. Resident seemed to have been reaching for washcloths on a nearby bedside table. When asked what the resident was attempting to do, she stated, It looks good over there. POA was called at 1950 with no answer, a voicemail was left. DON was notified at 1953. MD was notified at 1955. Intervention in place to prevent future falls is to keep personal items within arms reach at bedside table at all times. Will continue to monitor. R82's Progress note dated 7/1/2020 documents: (R82) found on floor in room [ROOM NUMBER], res was seen falling by family member outside window. Res noted on floor beside bed B on buttocks. Res w/c directly behind her. Res without injuries. Res denies pain. DON/POA/MD aware R82's Progress note dated 7/5/2020 documents: (R82) was found sitting on the floor in (another) RM. Res had wandered into room, took off lap buddy, and attempted to ambulate. Res is unable to state what happened. No injuries noted. ROM WNL. Neuro's initiated. VS 148/86 72 18 97.4. Res had previously taken lap buddy off several times during the shift. Interventions were ineffective. R82's Progress note dated 8/13/2020 documents: (R82) self ambulating and fell . Assessment complete. No injuries noted. VS stable. Neuros initiated. Transferred back to bed with mechanical lift. POA and MD aware. R82's Progress note dated 8/21/2020 documents: (R82) Writer called to residents room, res sitting on floor in front of her w/c. Res had taken her lap buddy off. Alarm was sounding. Res stated I was getting that water that was on the floor. No water noted on the floor. ROM WNL for resident. No internal/external rotation noted. No redness or bruising noted. Res was assisted up per mechanical lift & sat in her w/c. Lap buddy reapplied & taken to the desk for supervision. Dr. & POA made aware of fall with no injuries noted. R82's Progress note dated 8/28/2020 documents: (R82) observed on floor in hallway laying on right side. no c/o pain or injury. neuros initiated. POA and MD aware. R82's Progress note dated 8/29/2020 documents: (R82) observed on floor in oakwood dining room. no injuries or c/o pain. neuros initiated. MD and POA aware. R82's Progress note dated 9/22/2020 documents: (R82) observed on knees on floor in hallway next to w/c. res appears to have gotten up by herself and lost balance. no injuries or c/o pain. MD and POA aware. 4. R8's Electronic Medical Record (EMR) [DIAGNOSES REDACTED]. R8's Fall Investigation report dated 6/3/20 documents, Writer was called to resident's room at 2:10 PM, because resident was sitting on the floor and she was crying. Writer asked her if she was in pain and she was showing her right hand. Asked her what she was trying to do and she was so upset she was unable to tell writer. Writer assessed Range of Motion (ROM) to legs and she complained of (c/o) pain in right leg. Writer then came to call Medical Doctor (MD) at 2:15 PM, and Power of Attorney (POA) at 2:16 PM to make aware of sending her to emergency room (ER) due to (d/t) complaints of pain. Called Ambulance at 2:20 PM. And report was called to ER at 2:25 PM. Writer went back down and spoke with resident after she had stopped crying and she said she was trying to get her walker. Resident's walker was behind her and tipped on its side. Ambulance left with resident at 2:35 PM. R8's Nurses Notes dated 6/4/20 document, It appears root cause of fall that occurred on 06/03/20 @ 2:00 PM is resident tripped over her 4 wheeled walker. Resident was sent to ER for eval and treatment d/t pain in right leg and right hand. Resident returned from hospital with [DIAGNOSES REDACTED]. Splint may be removed in 4 weeks. R8's Nurses Note dated 6/25/20 document, Resident was found kneeling next to her bed with walker in front of her at 4:15 PM. Resident was unable to state what she was doing. Observed bed spread dragging the floor next to her. No injuries noted. MD office notified at 4:30 PM. POA notified at 4:34 PM. R8's Care Plan dated 4/7/20 documents, Focus: Risk for Falls r/t unsteady gait and decreased safety awareness. Up ad lib with 4 wheeled walker. Hx of falls. Interventions: Call, don't fall sign placed on bathroom door. Administer medications as ordered by MD. Monitor for effectiveness and side effects. Update MD as needed. Heed FDA black box warnings. Analyze all falls. Update interventions accordingly. Notify staff of any changes. Catch a falling star program. Ensure bed is kept in lowest position, lock brakes of bed. Ensure call light is available to Resident. Ensure environment is free of clutter. Floor should be free of glare, liquids and foreign objects Ensure resident does NOT have a bed spread on her bed. Evaluate fall risk on admission and PRN. Evaluate Resident's environment to identify factors known to increase risk of falls. Fall Risk Assessment quarterly and prn. Give frequent cues and reminders for safety. If fall occurs, alert provider. Lap tray used instead of over bed table. Needs assistance to get up and get dressed in the A.M. follow restorative plan. Over bed table removed from room since resident has been known to try to use it as an aid to walk. Properly identify Resident to indicate a fall risk to caregivers. Review medications for drugs that increase the risk of falls. Sign placed in room to remind staff that there should NOT be any over bed tables in room. Up ad lib with 4 wheeled walker. Wanderguard Ankle device. R8's Minimum Data Set ((MDS) dated [DATE] documents Basic Interview for Mental Status (BIMS) is 4, severely cognitively impaired. Functional Status, Transfer 1/2 supervision with 1 person physical assist. 5. R71's EMR [DIAGNOSES REDACTED]. R71's Nurses Notes dated 4/16/20, documents, At 1:15 PM, resident noted to be sitting on the floor in her bathroom changing the toilet paper roll. No injuries noted. Resident stated she did not fall. Resident was gotten up with a mechanical lift and placed in chair. Vital signs (V/S) 129/57-67-18-96.5. R71's Nurses Notes dated 4/20/20 document, Resident was observed on the floor in her room next to her sink after the Business Office Manager (BOM) heard a a loud noise and went to check on resident. She was sitting on the floor with her legs out in front of her she preceded to get up on her own. Writer went to resident's room and resident was standing next to wheelchair. She denies any pain or injuries. No injuries' observed upon assessment. V/S 145/73 95.9 60 18 98% R71's Nurses Notes dated 5/5/20 document, At 10:40 AM, staff saw resident sitting on the floor. Resident was cleaning up the ice off the floor because her pitcher fell . Resident stated she did not fall, but sat on the floor. No injuries noted. She was able to get self up off the floor. MD office notified at 10:43 AM. R71's Nurses Notes dated 5/6/20 document, Writer saw resident bent over trying to get her book off the floor when resident fell . Resident did not hit head, no injuries noted. She was able to get self up using walker. Called MD at 1:45 PM. R71's Nurses Notes dated 5/15/20 document, Resident found laying on right side on the floor at 3:35 PM. Assessment complete and no injuries noted. Resident stated she was trying to pick up the paper with her phone numbers on it up off the floor. Resident was able to get self up off the floor. MD office notified at 3:45 PM. Neuro's initiated. R71's Nurses Notes dated 6/1/20 document, 12:15 PM, Was called to the room by staff and resident was noted in sitting position in the middle of her room on the floor. Staff witnessed incident. Resident stated that she was trying to use the bathroom and fell . Call light in off position and noted resident up several times this morning unsupervised ambulating. V/S within normal limits (WNL). ROM WNL No c/o pain voiced. Assisted from floor with mechanical lift and bathroom care needs. Explained the importance of using the call light and staff assistance. Placed on 1 hour toileting schedule. MD and POA made aware. R71's Nurses Notes dated 6/3/20 document, 8:10 AM, Writer called in to residents room because resident was sitting on the floor on her buttock with back against the door. Resident said she was standing up against the door and decided she did not want to stand anymore so she sat on the floor. No injuries noted. MD notified. POA notified. R71's Nurses Notes dated 7/2/20 document, 7:15 PM, Writer was near resident's room and heard a soft thud; writer investigated and found resident on the floor next to a chair in her room, sitting on her buttocks. When asked what she was attempting to do, she stated that she was reaching for her shoes. Resident's shoes were not on her feet, but on the floor nearby. CNAs working at the time state that the resident had on her shoes during last visual observation. An assessment was completed and found no injuries. Vitals at time of fall were BP 195/86, T 96.8, P 80, R 20, and O2 96. Resident denies pain, has been continent of B&B. Resident frequently gets up without assistance and is noncompliant with using the call light system. Writer reminded resident of the importance of using the call light for assistance before transferring. Intervention in place to prevent future falls is to initiate 15 minute checks of resident. POA and on call nurse for DON aware. Will notify MD. R71's Nurses Notes dated 7/11/20 document, 8:16 AM, Writer heard an thud in room while sitting at desk. Went to check on resident and she was noted on floor in sitting position leaning towards the right side with shoulder up against the wall by sink. When assessed denies hitting head. ROM WNL. Angry with staff and stated that she did not fall she was on the floor praying. Assisted from floor with mechanical lift. Neuro check initiated. Explained the importance of using the call system and she stated she is fine and to leave her alone. 15m checks in place. POA and MD made aware. R71's Nurses Notes dated 7/16/20 document, 12:45 PM, Was called to the room by staff and resident was noted laying on left side next to wheel chair. Stated that she was bending over to pick up napkin. Noted a bruise to the L side of head measuring 7 x 5cm. Neuro checks initiated. V/S WNL. ROM WNL. No c/o pain voiced. Assisted from floor with mechanical lift. MD and POA made aware. R71's Nurses Notes dated 7/19/20 document, 1:30 PM, Writer was called in to residents room at 1:30 PM because resident was on hands and knees trying to pick up pie that had dropped on the floor. No injuries noted. Resident got self back up and sat in her wheelchair (w/c). MD notified at 1:50 PM. POA notified at 2:00 PM. R71's Nurses Notes dated 7/20/20 document, 8:15 AM, Was called to the room by staff and resident was noted in the sitting position in front of closet. Wheel chair was left in front of the sink and walker not in use. Resident stated that she did not fall that she was on the floor doing exercises. V/S WNL. ROM WNL. No c/o pain voiced. Was able to get self from floor back to wheel chair. POA and MD made aware. R71's Nurses Notes dated 8/11/20 document, At 7:40 AM, writer was called to resident's room and resident was on knees curled up with head resting on floor and against the door. Denied any neck pain. Sat resident on bottom and assessed, no injuries noted. Resident stated she was picking stuff up off the floor. POA notified. MD office notified and aware. R71's Nurses Notes dated 9/13/20 document, 2:50 PM, CNA and writer heard a crash and resident was sitting on floor with a box of candy next to her. Resident noted to be on floor at 2:50 PM. No injuries noted. Resident got self back up. She stated she was getting the box of candy off the floor that she dropped. POA made aware and he wants the alarm back on her if possible. Writer told him we would speak to the doctor, he was fine with that, but stated that if he wouldn't do it then he was going to call him and talk to him himself. Report faxed to MD. R71's Nurses Notes dated 9/22/20 document, 1:55 PM, Resident fell attempting to transfer self from w/c to couch in family room. No injuries reported. IDT discussed fall and decided the best intervention to help prevent future falls is for staff to offer to assist resident to couch in family room throughout waking hours; if resident wants to sit on the couch place chair sensor alarm under her and place portable call bell within her reach and frequenting observe resident while sitting on couch. Care plan updated and staff made aware of changes. R71's Nurses Notes dated 9/26/20 document, 7:55 AM, Writer was called to resident's room at 7:55 AM, resident laying on the floor on right side. She said she was reaching for a pencil under her bed. Resident noted to have abrasion to forehead, elbow and right shin. Neuro's initiated. Resident got self up and sat on bed. MD notified 8:40 AM. Called POA at 8:45 AM, no answer. R71's Nurses Notes dated 10/7/20 document, 6:55 AM, Writer was called in to resident's room because staff saw resident lean out of her chair and fall to the floor and bump her head at 6:55 AM. No injuries noted. She was able to get self up and sat back in w/c. Neuro's initiated. POA notified at 7:03 AM. Report faxed to MD at 7:06 AM. Care Plan dated 9/11/20, documents in part, Focus: Prior to admission I had multiple falls which lead to my hospitalization . I remain at high risk for falls. I have advanced [MEDICAL CONDITION], impaired safety awareness and I get up unassisted and I am unsafe to do so. I take medications that may contribute to my risk. Orthostatic [MEDICAL CONDITION]. Interventions: Call Don't Fall sign on Bathroom door and one placed in room where she can view it while lying her bed. Catch a Falling Star program. Ensure environment is free of clutter. Floor should be free of glare, liquids and foreign objects. Fall Risk Assessment quarterly and prn. Frequent visual checks, fill paper out at the nurses station. Housekeeping to check and ensure toilet paper roll does not get empty in bathroom twice daily. If resident is noted to be leaning in wheelchair, assist her to an upright position. Make sure my call light is always within my reach. Make sure you keep a clear pathway to my bathroom. Monitor B/P and HR, update MD as needed. Offer a magazine for me to browse through when I am not busy. Offer to assist to couch in family room throughout waking hours; if she wants to sit on the couch place chair sensor alarm under her and place portable call bell within her reach. Frequent visual checks while sitting on couch. Offer to toilet her every 1 hr while she is awake during the day. Place box of candy on sink with shelf liner under it to help prevent box from sliding/falling to the floor. Place food in individual bowls for meal times. Place shelf liner on over bedside table under water pitcher. Provided resident with a portable hand held vacuum so she can vacuum her floor at her convenience to help prevent resident from leaning over in her w/c to pick (clean) up items off the floor. Reacher is to be hung in visible area in residents room to remind her to use it . Right side 1/2 lap tray (removable) placed on wheelchair to help support frequently used items. I am more accepting of tray use if you place my frequently used items on the tray itself. Room near nurse's station for better visibility by staff. Sensor alarm to be in place when up in chair (chair only); check that alarm is turned on and functioning frequently. Shelf liner over and under w/c cushion. Sit at edge of bed for a while before standing, stand up slowly. Therapy staff to educate resident on safe location to perform exercises. Transfers: Assist of one with wheeled walker and gait belt. Upper bed rails in use to aid in mobility. Activities to put cards together, like a book, so she can read them often. Activity staff will offer 1:1 program 3x/week focusing on gardening, music, card games, puzzles books, reading and visiting with me. Administer medications as ordered; observe for adverse effects; update MD as needed. Analyze all falls. Update interventions accordingly. Notify staff of any changes. Anti-roll back device on w/c wheels. Assist me to keep non-skid footwear on at all times while I am up. Assist resident with putting on or fixing her shoes as needed. Brake extender placed on right side of wheelchair (due to presence of 1/2 lap tray). R71's MDS dated [DATE] documents BIMS is 8 cognitively impaired. Functional Status, Transfers 3/2 Extensive assist of one. Walk in room [ROOM NUMBER]/2 extensive assist of one. Walk in corridor 3/2 extensive assist of one. On 10/6/20 at 12:30 PM, R71 is in her wheelchair eating lunch she is bending all the way over trying to pick up something on the floor. No staff are around to assist R71. On 10/7/20 at 12:20 PM, R71 is sitting in her wheelchair bending over trying to pick something up on the floor. No staff are around to assist R71. On 10/8/20 at 9:45 AM, V2 Director of Nurses (DON) agreed the fall interventions are not working. The facility Policy and Procedure titled Fall Assessment and Management Policy, revised 4/2019 state in part the following: Policy: 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. Procedure: Each resident will be assessed using the Minimum Data Set (MDS) upon admission, quarterly and with any significant change assessment. C. The potential for fall will be care planned when appropriate, based on the results of the Fall Risk Assessment. The interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the resident. E. The fall Risk Assessment may address assessment of factors listed. Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall.

Based on interview and record review the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) to residents for 2 of 3 residents (R341 and R342), reviewed for Beneficiary Protection Notification in the sample of 33. Findings include: 1. R341's Notice of Medicare Non-Coverage (CMS Form ), dated 3/31/2020, documents that R341's Medicare services coverage ended on 3/31/2020 based on facility initiated discharge from the services. R341's record does not document that R341, or his responsible party, received the SNF-ABN notice in advance so R341, or his responsible party, could make an informed decision about whether he wished to continue these services if he or his responsible party wanted to assumed financial responsibility. Nurse's Note dated 3/30/2020 at 11:52AM, documents R341's wife was discussed discharge plans, but fails to document information regarding Notice of Medicare Non-Coverage. 2. R342's Notice of Medicare Non-Coverage (CMS Form ), dated 8/3-/2020, documents that R342's Medicare services coverage ended on 8/30/2020 based on facility initiated discharge from the services. R342's record does not document that R342, or her responsible party, received the SNF-ABN notice in advance so R342, or her responsible party, could make an informed decision about whether he wished to continue these services if she or her responsible party wanted to assumed financial responsibility. Nurse's Note dated 8/31/2020 at 9:32PM, documents R342 was discharged home with her son, but fails to document information regarding Notice of Medicare Non-Coverage. On 10/8/2020 at 2:15PM, V1, Administrator , stated the facility does not have a policy on Beneficiary notification of days left, but it should have been done.

Based on interview and record review, the facility failed to implement fall precaution interventions as outlined in the care plan for 1 of 3 residents (R1) reviewed for falls in the sample of 4. This failure resulted in R1 sustaining a left [MEDICAL CONDITION]. Findings include: R1's Minimum Data Set (MDS), dated [DATE], documents R1's cognition is severely impaired and requires extensive assist of 2 staff for transfers. R1's Fall Risk, dated 6/1/2020, indicates R1 is a high fall risk. R1's Care Plan, dated 6/25/2020, documents, (R1) has a remote history of a fall at home that fractured her left hip. She gets up unassisted and is unsafe to do so. It further documents an intervention, if restless in bed, assist up into w/c (wheel chair) and then assist to a high traffic/high visibility area for closer supervision; reflectors on w/c wheels. This intervention was implemented on 8/1/19. R1's Progress Notes, dated 7/11/2020 at 5:30 PM, documents that R1 was observed on the floor and was complaining of left hip pain. R1's Progress Notes further document that on 7/12/2020 at 12:07 AM radiology results were received and that R1 had a left [MEDICAL CONDITION]. R1's Patient Report, dated 7/11/2020, documents R1's left hip is fractured. The facility's Occurrence Log, dated 7/11/2020, at 5: 30 PM, documents, Resident fell out of her wheelchair attempting to self transfer back in bed. Staff report resident was attempting to crawl out of bed to get into her wheelchair prior to fall. Staff had assisted resident in her wheelchair per resident's request but left resident in her room instead of placing resident in a highly traffic/highly visible are as per care plan. Interventions implemented to help prevent future falls include: in-service given to re-educate staff on care plan and safety interventions and placed a sign in resident's room to remind staff to assist resident to a high traffic/highly visible area when up in wheelchair for closer supervision. On 7/21/2020 at 11:45 AM, V20, Care Plan Coordinator, stated, (R1) fell out of her wheelchair in her room. Her care plan has a ton of fall prevention interventions. We are running out of ideas. On 7/13/2020 her care plan was revised and we put up a sign in her room to remind staff to place in a highly visible area, which was already an intervention. I do not believe the staff were following her care plan interventions. On 7/23/2020 at 11:34 AM, V25, R1's Primary Care Physician, stated, In an ideal setting she (R1) shouldn't have been left unattended. I would expect staff to have knowledge of her care plan and follow it. On 7/23/2020 at 12:08 PM, V2, Director of Nursing, stated, Yes, I would have expected the staff to know and follow her care plan. The kardex is on the door. They should not have left her unattended. The facility's Employee Disciplinary Action Form, dated 7/12/2020, documents, Description of Violation: Staff member assisted resident to chair and left her unsupervised. Failure to follow care plan. This form further documents, Employee Statement: I was not aware that resident needed to be supervised. No reflectors on wheelchair. The facility's Fall Assessment and Management policy and procedure, dated 4/2019, 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. It continues, D. All staff providing care to the resident will have access to the care plan and/or kardex.

Based on interviews, observations and record review, the facility failed to assess, monitor and provide effective alternative fall prevention measures for 5 (R16, R19, R20, R4, R14) of 15 residents on a sample of 21 residents reviewed for fall prevention. This failure resulted in R16 sustaining nasal fractures on the 10/26/10 fall. Findings include: 1. R16's Minimum Data Set ((MDS) dated [DATE] identifies her to require extensive assist of one staff for transfers and ambulation. The MDS also indicates she has standing/sitting balance deficits and is unable to do either without human assistance. According to the care plan, R16 was to have a personal alarm on in August 2010. The MDS indicates that in August of 2010, R16 had short term memory loss with moderate cognitive impairment. The fall assessment dated [DATE] identifies R16 to only be at moderate risk for falls. The facility failed to assess R16 as a high fall risk due to having repeated falls documented on 8/5/10 (2), 8/16/11, 10/26/10 and 12/24/10. The OCCURRENCE report dated 8/5/10 indicates she was found "upright next to bed with legs bent @ (at) knees and folded under her" at 6:50am. The alarm was not sounding as her elbow was still on the pad but she was on the floor. The intervention recommendation is for side rails up when in bed with bed rail pads. R16 was to have upper rails up according to her care plan. On 8/5/10, at 10pm, R16 fell again. The OCCURRENCE report indicates that staff responded to R16's alarm and found her on the floor. No visible injury was noted. Identified preventative measures at the time included an alarm which was sounding. The report indicates she was found "lying on pad at bedside." The report also indicates R16 complained of hitting head but had no visible signs of injury except a 3cm skin tear to the back of her right hand which was steristrips by facility staff. Interventions added following the fall include low bed with mats. There is no mention of the bed rails with pads implemented earlier that day. On 8/16/10 at 5:10am, R16 was again found on the floor when staff responded to her alarm. It states she was found "lying on bedside mat." Nurses notes describing what happened, documents "resident believes she can walk by herself and is status [REDACTED].) The root cause indicates "due to resident action or internal risk factors." but doesn't reflect whether her bed was in low position or whether the bed rails with pads were up or not. In addition, the documentation fails to determine why staff was unable to respond timely enough to prevent her from falling again. Recommendations indicate X-rays of back and hips will be done along with a urinalysis/culture due to resident complaining of back and right leg pain. On 10/26/10 at 1400 (2pm), R16 was again found on the floor when staff responded to her alarm sounding. The nurses notes describe the incident occurring when "resident attempted to stand up. She is unable to walk and fell to floor." The OCCURRENCE report indicates she was sitting in her room just prior to the fall and sustained head trauma in the fall with the center side of nose bleeding and swollen. R16 was transferred to the emergency room and diagnosed with [REDACTED]. New interventions implemented after returning to the facility included a lap cushion. On 12/24/10 at 7am, R16 again was found on the floor when staff responded to her alarm sounding. The OCCURRENCE report indicates R16 was out of bed lying on her stomach with head and upper chest on bed. The report indicates her upper rails were up , lower rails down and the bed was in low position. The root cause documents "Due to resident action or internal risk factors" as the causative factor in the fall. There is no documentation to support that the facility assessed why staff was unable to respond to R16's alarm in a timely manner to prevent her from falling to the floor. According to R16's Care Plan dated 3/22/06, she has poor safety awareness, decreased mobility, history of falls and CVA with right hemiparesis. Interventions include apply positioning materials in her wheelchair when up in the wheelchair (12/29/07), call light within reach, reinforce need to call for help (3/22/06), analyze all falls, top bed rails up for bed mobility, bed sensor alarm when in bed (3/19/10), offer reminders to call for assistance when needed although the facility identified her to have a "problem with short term memory" and on 3/2/11, staff added a self releasing belt alarm on when in wheelchair" but no information could be provided as to why it was added in March 2011. On 4/26, 4/27 and 4/28/11, R16 was observed to be either in bed (low position) with mats on both sides or in the wheelchair with a self release belt on. 2. R14's MDS of 3-28-11 documents R14 as requiring extensive assistance of 2 for transfer. R14 was observed on 4-27-11 at 10:10AM to be transferred from her wheel chair to the toilet and then to bed by E9 CNA/Shift Coordinator and E10 CNA using a mechanical standing lift. The CNA's placed the waist strap over R14's breast and back by shoulder blades causing R14's arms to come up and elbows raised up to her head. R14 cried out during the transfer. According to the manufacturer's Operation Manual for the lift, that was provided by the facility, the belt is to be placed around the patient's lower back, just above the belt line. During an interview with Z1, Manufacturer's Technical Support, on 4-27-11 at 3:35PM, Z1 stated the strap for the mechanical standing lift is to be placed at the lower back and not up over the breast. Z1 was told R14 has a G tube. Z1 stated the facility should use the Transport Attachment for transferring residents with G tubes. Z1 stated he was sure R14 would be uncomfortable with the belt placed over her breast and upper back. Z1 stated misplacement of the belt could be dangerous, injuring the resident or causing a fall. 3. R4's MDS of 3-14-11 documents R4 requires extensive assistance for transfers. R4 was observed on 4-26-11 at 12:25PM to be transferred from her wheel chair to bed by E7, Certified Occupational Therapy Assistant and E8, CNA, using a standing mechanical lift. E7 and E8 failed to lock R4's bed in place before the transfer and the bed rolled during the transfer. 4. R19's MDS, dated [DATE], documented R19's cognition as moderately impaired with short and long term memory loss, extensive assistance of one person physical assistance with mobility and two plus persons physical assistance with transfers. It was also noted R19 was not steady, only able to stabilize with human assistance for moving from seated to standing position and surface to surface transfer. R19's Care Plan, initiated date 12-15-10, documented R19 was at high risk for falls with at least one intervention for a sensor alarm to be on at all times. R19's Fall Report, dated 12-11-10, documented "R19 was trying to get up out of his wheel chair and slide to the floor on his knees. Apparently the pelvic restraint (assistive device) was not tight enough." R19's assistive device was not properly attached allowing R19 to slide from his wheel chair to the floor on his knees. R19's Fall report, dated 3-25-11, documented "R19 was sitting on the edge of chair and was roaming the hall way. Resident slipped out of chair onto floor...Resident did hit R (Right) hip area." It was also noted that R19's alarm was sounding. R19 slipped out of his chair and fell before the staff responded to his alarm R19's Fall report, dated 3-26-11, documented "R19 had a sensor alarm pad in chair alarm was not sounding because res (resident) head and shoulders were still on the pad. (pPostioning material) was above and below sensor alarm pad in place on the seat cushion....Sister in law came in to visit res and came to get nurse because she found res sliding out of chair. She stated "he's gonna be on the floor if someone doesn't come help." Staff were not aware R19 was sliding from his chair until visitor informed staff. 5. R20's MDS, dated [DATE], documented extensive assistance of one person physical assistance with mobility and two person physical assistance with transfer and walking, not steady, only able to stabilize with human assistance for moving from seated to standing position, walking, turning around and facility the opposite direction while walking, moving on and off toilet and surface to surface transfer. R20's Fall Report, dated 12-24-10, documented R20 was found on the floor in a sitting position with wheel chair tipped to the right side, attempting to get back up and his alarm was sounding. A large knot, approximately 5-10 minutes later was noted on his brow/forehead area with some leaning noted. R20 was sent to a local hospital for evaluation and treatment. R20's fell before the staff responded to his alarm. R20's Fall Report, dated 1-1-11, documented R20's alarm was sounding and fell after he transferred himself into his reclining chair from his wheel chair. R20 complained his wrist hurt. R20 fell after self transferring and the staff responded to his sounding alarm. R20's Fall Report, dated 1-5-11, documented R20 was found by Certified Nursing Assistants sitting on the floor in his room in front of his wheelchair with his alarm sounding. It was also documented that R20 stated "I was just getting up and lost my balance so I sat down on my butt." Staff were unable to respond to his alarm before R20 fell . R20's Fall Report, dated 1-5-11, also documented Recommendations for fall prevention "Ambien and Tylenol q.h.s. (every evening)." E2, Director of Nursing (DON), provided, during refutation, on 4-29-11, medication administration documentation that R20 was administered "Ambien and Tylenol", in part, on 1-5-11, 1-7-11, 1-10-11, 1-11-11, 1-12-11, in the evening. During an interview with E2,on 4-29-11, E2 stated that R20 was restless at night and family requested medication. The facility did not provide documentation that other fall preventative measurements were assess or implemented related to R20's restlessness prior to medication administration.