Every finding on record at St Joseph Village of Chicago

Based on interviews and record reviews, the facility failed to follow their policy to ensure significant weight loss is prevented in the facility for one (R5) out of three residents reviewed for nutrition in a sample of 14. This failure resulted in R5 not receiving suggested supplements and experiencing severe weight loss.Findings include:On 05/06/2026 at 12:12 PM, surveyor reviewed R5's weights from 10/2025 to 04/2026.R5's weight documents in part:03/01/2026: 128.2 lbs.02/01/2026: 131.5 lbs.01/05/2026: 137.6 lbs.12/09/2025: 150 lbs.12/03/2025: 145.0 lbs.11/05/2025: 147.8 lbs.10/02/2025: 147.6 lbs.Based on documented weights, R5 has a 13.1% weight loss in a 6-month period from 10/2025 to 03/2026Based on documented weights, R5 has 9.3% weight loss in a 3-month period from 12/2025 to 02/2026.Based on documented weight, R5 has a 5.1% weight loss in a 1-month period from 12/2025 to 01/2026.On 05/06/2026 at 2:18 PM, V13 (Dietician) stated that when she gets an alert of any weight loss or changes, she looks into their diet, what they are consuming, and looks if we have any supplements. V13 stated that she is familiar with R5 and his weight loss. V13 stated that she talked to R5 and the power of attorney (POA) about adding supplements, to avoid further weight loss to help meet those needs. There are interventions we put in place to address the weight loss. The interventions for example were supplements and putting them in the dining room which encourages them to eat in the dining room. V19 stated that R5 did have significant weight loss. Supplements should have been ordered but I forgot to for some reason. Supplements can be ordered by herself or nurse. V13 verified significant weight loss with surveyor on R5's electronic health record.R5's progress note by V13 on 12/3/2025 documents in part: WEIGHT WARNING:Value: 145.0. Vital Date: 2025-12-03 10:36. -10.0% change [11.6%, 19.0 ]. BMI: 22 [Normal and WNL]BMI: 23.1 [Normal]. Diet: No Added Salt, regular, thin 1200ml Fluid restriction. He has a good appetite, and no medications impacting weight changes. Weight triggered due to 7/2 164 lbs. Family aware of weight changes. Doctor informed.R5's progress note by V13 on 12/31/2025 documents in part: R5 in agreement with supplements.R5's progress note by V13 on 1/5/2026 documents in part: Recommend offering (supplement) after meals.R5's progress note by V13 on 4/2/2026 documents in part: R5 has a significant weight loss over 180 days due to a decrease in appetite from a significant life change.Reviewed R5's full care plan. No documentation of weight loss with appropriate interventions.Reviewed R5's physician order sheet. No order for supplements such as (supplement). No medications ordered to improve appetite. No order for weekly weights.Facility's Weight Management policy (11/08/2025) documents in part: The registered dietician (RD) is responsible for monitoring all weight changes and documenting significant weight loss/gain. Significant weight loss/gain is defined as greater/less than 5% in one month, greater/less than 7.5% in 3 months or greater/less than 10% in one month. Residents noted to have significant weight changes should be placed on weekly weights until their weight stabilizes or until the weight loss is determined to be unavoidable by the Interdisciplinary Team. The RD will review and document those residents who have been placed on weekly weights. A follow up note will be completed a minimum of weekly until weight stabilization occurs. The RD is responsible for developing comprehensive care plans for those residents with significant weight changes and updating care plans with new interventions as needed.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices as evidenced by a.) food not properly labeled, b.) food not properly stored, and c.) not practicing effective handwashing. These deficient practices have the potential to affect 52 residents receiving food prepared in the facility kitchen. Findings include: On 05/05/2026 at 9:39AM during initial kitchen tour with V4 (Dining Services Director) and V5 (Chef), the following food items were found in the walk-in cooler: 1 opened carton of eggs, no open date, no use by date, and not labeled with the food item.1 tray of sliced onions, green peppers, and red peppers wrapped in clear plastic wrap, no preparation date, no use by date, and not labeled with the food item.1 bowl of beef steak wrapped in clear plastic wrap, no preparation date, no use by date, and not labeled with food item.1 opened container of sliced limes wrapped in clear plastic wrap, with a use by date of 05/04/2026.1 opened container of potatoes cut in halves inside of a water solution, no use by date.On 05/05/2026 at 9:56AM the following items were found in the dry storage area:1 gallon container of barbecue sauce with an expiration date of 04/14/2026.On 05/05/2026 at 9:57AM, V4 and V5 state all opened and prepared food items stored in the walk-in coolers should be labeled with the food item, have an open date, use by date, or expiration date labeled on the food items. V5 states the bowl of beef steaks is personal lunch for the staff to consume. V5 states the beef steak should not be stored in the resident's walk-in cooler. V4 and V5 state all expired food items should not be stored in the dry storage area which is available and intended for resident use. V4 states expired food items should be discarded immediately. V4 states if residents consume expired food items, the residents could acquire a food borne illness and become sick due to bacteria. On 05/05/2026 at 10:21AM, V6 (Lead Cook) return demonstrates the process of handwashing in the kitchen. V6 observed washing his hands for approximately 18 seconds and then touches the motion sensor paper towel dispenser twice with his hands after performing handwashing. Facility census dated 05/05/2026 documents that a total of 53 residents reside in the facility.Facility document dated 05/05/2026 titled Diet Type Report documents that one resident does not receive food from the kitchen and is enteral feed only.Facility policy dated 09/01/2023 titled Hand Hygiene documents in part, Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.According to the CDC/Centers for Disease Control and Prevention at https://www.cdc.gov/clean-hands/about/index.html, titled Clean Hands dated 02/16/2024 Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice.Facility policy dated 2020, titled, Labeling and Dating Foods documents in part, Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date. Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. Prepared food or opened food items should be discarded when the food item does not have a specific manufacturer expiration date and has been refrigerated for 7 days, the food item is older than the expiration date.Facility policy dated 10/25/2022 titled Food Storage documents in part, All products should be dated upon receipt. If a product is removed from its original packaging, it should be tightly completely wrapped, placed into a sealable plastic bag or container with tight-fitting lid then labeled and dated.Facility policy dated 07/11/2024 titled Food Storage documents in part, Any expired or outdated food products should be discarded.

Based on observations, interviews and record reviews, facility failed to follow their policy to ensure medications are immediately removed from the locked medication storage area and disposed of for medications that are unlabeled and without secure closure. This failure has the potential to affect all the residents on the 2nd floor.Findings include:On [DATE] at 12:37 PM, surveyor reviewed the medication cart on the 2nd floor. There was only one medication cart. Surveyor opened the top drawer on the medication cart and saw a pill cup with no name, room number or closure, with unknown and unidentified medications in the pill cup.On [DATE] at 12:38 PM, V8 (Registered Nurse) stated that she thinks these are blood pressure pills but not fully sure. V8 stated that medications are to be discarded and not stored in the medication card without proper closure and labeling.On [DATE] at 11:40 AM, V2 (Director of Nursing) stated) that medications stored in the medication cart are already pre-packaged. The medication should be in the correct packet and placed in the correct bins according to the residents, in the medication cart. Pharmacy delivers the medications and nurses appropriately stock it in the medications cart. V2 stated that medications should not be stored in pill cups in the drawers because the medications are unidentified and can be confused with another resident, it is not covered which is an infection control issue. V2 stated that medication should be disposed immediately if opened and unused.Facility's Medication Storage policy ([DATE]) documents in part: Medication that are discontinued, expired, contaminated, deteriorated, or unlabeled and those that are in containers that are cracked, soiled, or without secure closures are immediately removed from the locked medication storage area and disposed of in accordance with policies and procedures. Medications are stored in the packaging, containers or other dispensing systems in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview, and record review, the facility failed to utilize appropriate PPE (Personal Protective Equipment) in a contact precaution room which affected two residents (R2, R30) reviewed for infection control in a total sample of 15 residents reviewed. The Facility also failed to follow their policy to ensure proper hand washing prior to medication administration for three (R13, R5, R19) out of five residents reviewed for medication administration in a total sample of 15 residents. Findings include: On 05/05/2026 at 11:16 AM, surveyor observed there was a contact isolation signage on the R2's door. Surveyor observed the door open, there was a family member inside the room with no gown, gloves. There was a staff member inside the room, with no gown or gloves. On 05/05/2026 at 11:30 AM, surveyors observed there was a family member in V30's room, not wearing proper PPE in a contact isolation room. On 05/05/2026 at 11:43 AM, V7 (Certified Nurse's Aide) stated she was not sure what the contact isolation signage at the door was for. V7 stated all that she was told was to wear personal protective equipment when in close contact with R2. Surveyor asked V7 if she should be wearing a gown and gloves before entering or exiting R2's room. V7 stated if she is feeding, providing activity of daily living task, or changing the linen she must wear a gown and gloves. Surveyor asked to clarify why she was not wearing proper PPE for a contact isolation room. V7 stated she was not wearing the gown and gloves because she was only dropping off the oxygen tank. On 05/06/2026 at 11:29 AM, V3 (Infection Disease Nurse) stated if a resident is on contact precautions, the staff should be wearing gowns and gloves before entering or exiting the resident's room. V3 stated it is important to follow the guidelines to protect the staff and residents from spreading pathogens. V3 stated the nurse on duty will put a sign by the doorway, a fully stocked bin outside of the room, put the order in the computer, make a progress note and communicate with staff. V3 stated families get educated about the precautions and what they should do to keep themselves and the residents safe. V3 stated staff can only encourage and educate the family member to put on a gown and gown but cannot force them. On 05/07/2026 at 2:15 PM, V2 (Director of Nursing) stated that a resident is on contact precaution, gloves, gown, and a mask shield is required. V2 stated staff must follow appropriate PPE once it is made aware that the resident is on contact precautions. V2 stated it is important to follow PPE to prevent the spread of microorganism. V2 stated family is encouraged to wear the proper PPE, however some family members are compliant while others are not. Policy titled Isolation Precautions with review date of 09/01/2023 documents in part, It is our policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents. Contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms which are spread by direct contact with the resident or of the resident's environment. On 05/05/2026 at 9:30 AM, surveyor observed V9 (Registered Nurse) pulling medications for R13. Without washing her hands, surveyor observed V9 put on gloves and dispense medications for R13. Wearing the same gloves, V9 threw away the medication pill packets with hands touching the inside of the trash bag. Surveyor then observed V9 administer the medication to R13 with the same gloves. On 05/05/2026 at 11:15 AM, surveyor observed V10 (Registered Nurse) dispense medications for R5. Without washing his hands, V10 dispensed R5's Gabapentin and Lisinopril. V10 then took the medications in the pill cup with the blood pressure machine, entered R5's room and checked R5's blood pressure using the blood pressure machine. V10 administered the medications and exited the room without using the hand sanitizer machine. V10 goes back to the nurse's station and does not wash his hands. V10 also does not wipe down the blood pressure machine after using it for R5. Surveyor then observed V10 dispensing R19's medications which were Senna Kot and amlodipine. Surveyor then observed V10 approach R19 in the dining room without washing his hands and wiping down the blood pressure machine and he takes R19's blood pressure. V10 then administers the medication to R19 without washing his hands or wearing gloves. On 05/06/2026 at 11:40 AM, V2 (Director of Nursing) stated that hand hygiene is important during medication administration to prevent infection and ensure infection control. V2 stated that nurses are expected to wash hands or use the alcohol hand sanitizer. V2 stated that blood pressure machine should be disinfected after use on a resident. Sanitizing equipment after every use prevents the spread of infection. Facility's Medication Administration policy (06/01/2023) documents in part: Hands are washed before putting on examination gloves and upon removal for administration of topical, ophthalmic, injectable, enteral, rectal and vaginal medications.

Based on observation, interviews, and review of records, the facility failed to correctly assess resident limitation and failed to follow their policy on using safety equipment for fall prevention of 1 out of 1 resident (R13) reviewed for accidents and hazards for a total of 15 residents in the sample. These failures have the potential to affect safety of 1 resident (R13) with history of falls.Findings include:R13 is a resident in facility initially admitted on [DATE]. Per clinical record, R13 had a fall in the facility on 04/03/2026. R13 went to hospital diagnosed with left femur/upper leg fracture due to mechanical fall. R13 readmitted in facility on 04/08/2026.On 05/05/2026 at 01:22 PM, R13 was seen inside her room lying on the bed. R13 was alert, verbally responsive and able to express thoughts within topic during conversation. R13 stated that she was waiting to go to therapy. V20 (Certified Nursing Assistant) went inside the room and spoke to R13 about scheduled therapy. V20 went out of the room for a few minutes and came back informing R13 that she would be transferred from the bed to her wheelchair. V20 positioned R13 on the edge of the bed and placed both of her arms under R13's arm. V20 lifted R13 with legs dangling, unstable when standing and unable to bear weight, V20 transferred R13 from the bed to the wheelchair. R13 was seen unable to position her leg and feet to bear weight. V20 had a gait belt wrapped on her waist that she did not use in transferring R13. In the hallway, V20 stated that she was not very familiar with R13 but knows that R13 need assistance during transfer. V20 stated, If residents are heavy, I will ask for help. V20 stated that it is safer to use gait belts, but she can lift R13 and R13 can pivot, she (V20) did not use gait belt. V20 stated that she gets her instruction from the nurse. V9 (Registered Nurse) at the medication cart in the hallway stated that since R13 fell she has been having problems physically and psychologically with transfers. V9 stated that R13 can have one (1) person assist but will call for two (2)-persons to assist R13. V9 stated using a gait belt with R13 will be safer because of her unsteady gait while standing.On 05/06/2026 at 11:28 AM, V2 (Director of Nursing) stated that R13 needs one (1) to two (2)-persons assist. Residents that are non-weight bearing need two (2)-persons or Hoyer (mechanical lift). V2 stated R13's present status is to stand and pivot by using gait belt. V2 said Using gait belt is for safety reason for both residents and staff to prevent injury.Per MDS (Minimum Data Set) of R13 on Functional Abilities dated 04/15/2026 (post fall): R13 was assessed as having functional limitation due to impairment on both of upper extremities. R13 requires bed to chair transfer total dependency, R13 cannot do any activity during transfers.On 05/08/2026 at 01:00 PM, V2 clarified that the assessment should have been bilateral lower extremities instead of bilateral upper extremities.Fall Prevention and Management Policy dated 05/23/2024 notes that fall prevention is achieved through managing risk factors and implementing appropriate interventions to reduce the risk of falls. Gait Belt Usage procedure dated 03/01/2026 outlining the use of gait belt for residents during transfers.

Based on observation, interview, and record review, the facility failed to change oxygen tubing and reservoir for one resident (R23) reviewed for oxygen therapy in a total sample of 15 residents.Findings include: On 05/05/2026 at 12:41PM, R23 observed lying down in bed receiving oxygen therapy via nasal cannula with oxygen tubing connected via oxygen concentrator. Surveyor observed that R23's nasal cannula oxygen tubing was labeled with two dates 04/27/26 and 05/03/26. Surveyor also observed that R23's humidifier was connected to the oxygen concentrator and labeled with a date of 04/27/26.On 05/05/2026 at 1:10PM, V8 (Registered Nurse/RN) now located inside of R23's room and observes that R23's nasal cannula tubing was labeled with two dates of 04/27/26 and 05/03/26. V8 also observes that R23's oxygen humidifier is dated 04/27/26. V8 states she is not sure why R23's oxygen tubing is labeled with two dates. V8 states she did not label the oxygen tubing or humidifier. V8 states she is not sure who labeled the tubing since there are no initials labeled. V8 states resident's oxygen tubing and humidifier should be changed every week on Sundays and as needed. V8 states if resident's humidifiers and oxygen tubing is not changed as ordered, then bacteria could build up in the humidifiers and tubing and cause the resident to have an infection.R23's Facesheet documents that R23 has a diagnosis of chronic obstructive pulmonary disease/COPD.Record review of R23's POS/physician order sheet documents in part, Oxygen tubing to be changed weekly, on Sundays to include date and initials, every night shift every Sunday.Facility policy dated 12/01/2023 titled Oxygen, Nebulizer Equipment documents in part, Change the reservoir every forty-eight (48) hours.Change the oxygen cannula and tubing every seven (7) days, or as needed.

Based on observations, interviews, and record reviews failed to follow their policy to ensure controlled medications are documented for 1 (R34) out of the 4 residents reviewed for narcotics reconciliation in a sample of 15.Findings include:On 05/05/2026 at 12:40 PM, surveyor observed R34's Modafinil bingo card (medication card). R34's Modafinil bingo card shows a count of 13.R34's Modafinil Controlled Drugs Receipt/Record/Disposition Form documents in part: Count is 14.On 05/05/2026 at 12:40 PM, V8 (Registered Nurse) stated that she is supposed to document in the Controlled Drug Receipt/Record Form when the controlled medication is administered. V8 stated that she administered the medication but forgot to document right away.On 05/06/2026 at 11:40 AM, V2 (Director of Nursing) verified that R34's bingo card did not match R34's Modafinil Controlled Drugs Receipt/Record/Disposition Form. V2 stated that it is important to document administered controlled medications to reconcile and maintain the accuracy of the documentation. You have to document in order to track the time, date given, and signature of the nurse to maintain accuracy of the documentation. If it is not documented at the time of administration, you run the risk of double administering the controlled medication.Facility's Controlled Substance policy (2001) documents in part: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Scheduled II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). If the count is correct, an individual resident-controlled substance record is made for each resident who will be receiving a controlled substance. This record contains: the name of the resident, quantity received, number on hand, date and time received, time of administration, method of administration, signature of nurse administering medication. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up. The system of reconciling the receipt, dispensing and disposition of controlled substance includes the following: Records of personnel access and usage, medication administration records, declining inventory records.

Based on observation, interview, and record review, the facility failed to offer an influenza vaccine to a newly admitted resident. This failure affects one resident (R40) in a total sample of 15 residents reviewed.Findings include:On 05/06/2026 at 11:44 AM, surveyor is with V3 (Infection Control Nurse), reviewing immunization records. This surveyor noted R40 was admitted on [DATE], reviewed immunizations records for R40, there is no evidence of R40 receiving an influenza vaccine. There is no record of R40 being offered or declining the Influenza vaccination. V3 stated since R40 was admitted during the peak of the end of the season, R40 did not need the influenza vaccine.On 05/06/2026 at 2:15 PM, V2 (Director of Nursing/ DON) stated if a resident was admitted on [DATE], the resident should had been offered an influenza vaccination. V2 stated the nurse will educate the resident on the vaccine being offered, and hand a consent form before administering the vaccine. V2 stated the flu season is considered from October through March. V2 stated the facility will host 2 clinics in the year, in which residents are being offered either the influenza or Covid-19 vaccines. V2 stated the last clinic that was offered was on April 16, 2026. V2 stated if the resident declines a vaccine offered to them, the staff will educate, provide a handout and encourage to get vaccinated. V2 stated if after education is provided, and the resident is still refusing then we document, and ask the resident to sign a refusal form.Immunization record with review date 04/16/2026 documents R40 has only received the COVID-19 vaccine, and the pneumococcal vaccines were both administered on 04/16/2026. There is no record of the influenza vaccine.Policy titled Immunization program, with review date of 09/01/2023 documents in part, the time frame for immunizations against influenza is generally considered to be from October 1st of each year through March 31st of the following year. Resident, responsible parties, or associates are required to either consent to receive or decline to receive the vaccine in writing on the appropriate form.

Based on review of records and interviews, the facility failed to provide required MDS (Minimum Data Set) discharge assessment for 1 out of 1 resident (R55) reviewed for resident assessments. These failures are not according to CMS instruction and affected 1 resident (R55) in determination of proper tracking of resident placement, monitoring and records.Findings include:On 05/06/2026 at 2:15 PM, an inquiry about R55 present location was made to V1 (Administrator/Executive Director). V1 after checking records, stated that R55 currently resides on assisted living but was in the skilled nursing facility in December. V1 stated that R55 was discharged on 12/27/2025, but MDS staff did not do discharge assessment.Per census list, R55 was admitted in the facility on 12/12/2025 and was discharged on 12/27/2025.Per CMS's RAI Version 3.0 Manual dated 10/2025:Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay, as defined below). This assessment includes clinical items for quality monitoring as well as discharge tracking information. Entry is a term used for both admission and a reentry and requires completion of an Entry tracking record. Entry and Discharge Reporting MDS assessments and tracking records that include a select number of items from the MDS used to track residents and gather important quality data at transition points, such as when they enter a nursing home, leave a nursing home, or when a resident's Medicare Part A stay ends, but the resident remains in the facility. Entry/Discharge reporting includes Entry tracking record, OBRA Discharge assessments, Part A PPS Discharge assessment, and Death in Facility tracking record.

Based on interview and record review the facility failed to implement interventions consistent with a resident's needs and current professional standards of practice to eliminate the risk of a fall for one (R1) resident out of six residents reviewed for quality of care in a total sample of six. This failure resulted in R1 sustaining a fall without significant injury. Findings include: On 07/08/2025, at 1:23 PM, V3 (Certified Nursing Assistant/CNA) stated that she was the assigned CNA for R1 when R1 fell on [DATE]. V3 stated that V3 was going around taking blood pressures and meal tickets. V3 stated I went to his room and he needed something. I told him to give me a second. I am going to take vital signs. I will be right back. At that time he kept getting up and I instructed him to lay back down, and he followed that command. I went to go get another resident's vital signs. When I came to his room, I heard him yell. I heard him say hey. When I looked in his room he was on the ground. V3 stated that R1 had a bump/knot/bruise on the left side of his head. V3 stated that R1 didn't have any other visible injuries, lacerations, or cuts. V3 stated that R1 did voice that he hit his head, but his head was not hurting. V3 stated we asked him these questions, but he was cracking jokes. We sat him up, and put him in our hallway. I fed him dinner before he went to the hospital. While he was waiting for the ambulance, he was doing fine. V3 stated that R1 was a fall risk and staff had to redirect him to use his call light. V3 reported that R1 was a one person assist and V3 would use a sit to stand mechanical lift for R1. V3 stated that R1 was incontinent but he liked to go to the bathroom for continence of bowel. V3 stated he (R1) wanted to get something; I cannot remember specifically. It is probably something he didn't have in the room, and I had to go get. I don't remember at this time what it was. V3 stated that when nursing assistants come on shift, they are required to get all vital signs under their care and get dinner orders by a certain time. V3 stated that R1 was responsive but he had moments and required a lot of redirections. V3 stated maybe he could have forgotten or gotten impatient. V3 stated that she did ask R1 for patience because V3 must have vital signs and dinner order information within the first hour. V3 stated that she told R1 that she would be back. V3 stated that she went to take three more residents' vital signs. V3 stated that it was not even five minutes that went by when she checked on R1. V3 stated I think he got antsy and forgot what he asked me for. If I would have found him 10 to 15 minutes later, it would have been worse. It was probably something he wanted a new container. That is why I told him one second, I'm going to take vital signs. On 07/08/2025, at 1:46 PM, V4 (Registered Nurse) stated R1 has left side weakness and R1 is usually redirectable. V4 stated that R1 told V4, R1 knows he should have not touched his feet. I think he leaned down and he lost his balance. Since he couldn't move his left side, he did not have a chance for support. V4 stated that she didn't know R1 was asking for something. If the resident needs something, they should attend to it. If the CNA needs help, they can ask the nurse for help. V4 stated that R1's fall prevention interventions included reminding R1 frequently to call us for help, give him the call light, bed at lowest position, putting safety floor mats, and doing frequent rounds because sometimes he wants to do something on his own. On 07/08/2025, at 3:30 PM, V2 (Director of Nursing) stated in a perfect world, I would have gotten what R1 wanted. I understand that not fulfilling his needs can lead to a fall. It was not emergency, she was strictly just doing a routine task. V2 stated that attending to resident's needs are number one although vital signs are a critical part of patient care because the residents are getting ready to receive the evening medications. R1's face sheet documents that R1 is a [AGE] year-old individual with diagnoses not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unsteadiness on feet, muscle weakness (generalized), unspecified symptoms and signs involving cognitive functions following cerebral infarction, difficulty in walking. R1's care plan documents in part R1 is at risk for falls and fall related injuries r/t (related to) unsteady balance, left hemiparesis status post-acute stroke right middle cerebral artery distribution infarction. R1 will be free of falls and fall related injuries daily through next the review date. The resident needs prompt response to all requests for assistance. R1's incident note dated 6/6/2025, at 7:00 PM, documents in part resident (R1) was observed lying on prone position on the floor between the bed and the window side. A lump was noted on the left side of the forehead. The resident is able to move his right extremities. The left side is paralyzed as baseline. R1's health status note dated 6/6/2025, at 10:00 PM, documents in part placed call to hospital ER (emergency room) and confirmed that the resident was there. All tests were negative. Nurse in charge stated also that resident will be back to facility within the next few hours. Facility document dated 10/23/2024, documents in part fall prevention & management policy. Fall prevention is achieved through an interdisciplinary approach of education, managing risk factors, and implementing appropriate interventions to reduce the risk of falls. Facility document not dated titled resident rights documents in part the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interview and record review, the facility failed to meet personal care and nursing needs; and failed to ensure that a resident received treatment and care in accordance with professional standards of practice and in accordance with the resident's goals of care for one resident (R1) in a total sample size of three residents. Findings include: Facility's undated investigation form documents in part, At this time, it appears that V7 did not do appropriate rounding, nor did V7 make appropriate inquiries about the care needed for R1. V7's time sheet shows a late arrival to V7's shift. V7 also did not inquire about R1's needs from the nurse on duty. On 08/27/24 at 11:38am, V7 Certified Nursing Assistant (CNA) stated, I (V7) didn't get any report about R1. I (V7) didn't know that R1 needed help or assistance with feeding or being cleaned. I (V7) helped clean R1 when R1's daughter came. Before that I (V7) didn't clean R1 because I (V7) didn't think R1 needed me to do anything. When I (V7) cleaned R1 with R1's daughter, I (V7) realized that R1's wounds were exposed with no dressing on. I (V7) didn't notice any stool inside the wounds but R1 had no bandages on any of the wounds. R1 also had no diaper on. R1's daughter applied the bandages to the wounds. Now they (facility) are telling me (V7) that I (V7) neglected R1. R1's physician order dated 08/21/24 documents in part, Needs 1 to 1 assistance with feeding at every meal/snack. R1's care plan dated 08/18/24 documents in part, R1 has an ADL self-care and mobility usual performance deficit related to poor mobility, incontinence, end of life stages .Will manage ADLs to maintain comfort/dignity during end of life stages .Eating: substantial to dependent with 1 staff assist .Personal hygiene assistance level: substantial to dependent with 1 staff assist .Roll left and right: substantial to dependent with 1-2 staff assist .Toileting hygiene: substantial to dependent with 1-2 staff assist. R1's eating task flowsheet Setup or clean-up assistance- Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity documents yes for R1 on 08/20/24, 08/21/24 and 08/22/24. R1's care plan dated 08/18/24 documents in part, The resident has bowel incontinence .check resident every two hours and assist with toileting as needed .Provide pericare after each incontinence episode. R1's medical diagnosis includes but are not limited to Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease without Heart Failure, Rheumatoid Arthritis, History of Falling, Pressure Ulcer of Right Hip Stage 3, Pressure Ulcer of Right Upper Back Stage 4, Pressure Ulcer of Left Upper Back Stage 4. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 9, which indicates R1 has moderate cognitive impairment. R1's assessment for eating, toileting and personal hygiene are all documented as dependent, which indicates helper does all the effort, resident does none of the effort to complete the activity. R1's nursing progress note dated 08/22/24 documented by V14, Registered Nurse (RN) documents in part, Patient is very contracted and has three sores. dressing sores as ordered. Turning patient every 2 hours. On 08/27/24 at 1:13pm, V9 (CNA) stated, R1 could not reposition herself. R1 was contracted and couldn't move at all. On 08/27/24 at 2:58pm, V10 Registered Nurse (RN) stated, I (V10) do remember admitting R1 and R1 had wounds. R1 was very limited with movement and needed a lot of assistance. R1 was incontinent of bowel and bladder. R1 required assistance with feeding. I always get report to find out who has wounds and I stress to the CNA the importance of letting me know if a wound bandage is soiled. On 08/27/24 at 3:26pm, V12 (R1's family member) stated, I (V12) went to R1's room at 8:45pm on 08/20/24 and the door was completely closed so I (V12) knocked on the door assuming R1 was receiving incontinence care. As I (V12) looked at R1, I (V12) noticed that R1 had food all over R1 and was drenched in sweat. I (V12) told the staff that R1 was a feeder and had told staff that before R1 even came to the facility. V3 (RN) told me (V12) that V3 had no recollection of R1 having wounds. V7 told me (V12) that V7 did not get a report on the residents. When I (V12) pulled out R1's bedside table I (V12) noticed R1 had no diaper on, just a pillow between R1's legs and it was soiled with urine and feces. There was food visible on R1's face, R1's sheets and even on R1's headboard from R1 trying to attempt to feed R1's self. On Sunday when R1 arrived, I (V12) gave report to the charge nurse about how often I (V12) change the wounds and what I use to change the wounds. R1 had 3 wounds, when I (V12) arrived at the facility, R1's wound to the sacrum had a sponge over the wound that was full of blood. R1's other two wounds were not covered. When I (V12) saw that R1 was naked, I (V12) immediately told the CNA to get the nurse. When V3 came in V3 said that V3 had no knowledge of R1's wounds. R1 was contracted and could not feed R1's self or reposition R1's self. On 8/27/24 at 3:48pm, V13 CNA stated, R1 was a feeder. R1 was contracted. The day I (V13) had R1, I had to change R1 and I (V13) repositioned R1 and noticed a big wound on R1's hip. The area was raw and sore without a bandage, so I (V13) put a dry bandage over the reddened area. On the date of the incident 08/20/24 around 8pm, I(V13) heard a lot of commotion, so I (V13) went to check what was going on. The nurse told me that R1's daughter was yelling about another resident in R1's room and R1 naked with no diaper. I (V13) asked R1 if R1 was okay and R1 said no. At that time, I (V13) noticed a lot of open wounds on R1. V12 said that when V12 came in R1's room that R1 didn't have a diaper on. V12 allowed me (V13) to assist V12 with cleaning R1. R1 was on a regular mattress. On 08/28/24 at 10:30am V3 RN stated, R1 had wounds on R1's body. I (V3) was starting the before bedtime medication pass. V12 came to R1's room and found a male resident in the room and asked why the male resident was there and why R1 didn't have a diaper on. V12 questioned me (V3) on why R1 was dirty and V12 stated that R1's wounds needed to be changed. When I (V3) came in R1's room, V12 was cleaning R1 and I (V3) didn't see if the wounds were covered or not, the wounds were already exposed. R1 did not have an incontinence brief on when I (V3) walked in the room. The CNAs can always come and ask the nurse about a resident. Rounds are done every 2 hrs. R1 was not able to reposition self. R1 was not able to feed self, R1 needed assistance. The CNA (V7) did not assist R1 with feeding, V7 thought that R1 could feed R1's self. R1's arms were slightly contracted. R1 was incontinent of bowel and bladder. Diapers are placed on incontinent residents. R1 should have had a diaper on. R1 should have been assisted with R1's meals. For all PRN (as needed) wounds, if I (V3) visually see the wounds are soiled or if the CNAs do their rounds then the CNAs would let the nurse know the wound needs to be changed. I (V3) assumed that the CNA knew R1's status and would reposition R1. I didn't tell the CNA about the resident because I (V3) thought that V7 knew what to do for the resident. On 08/28/24 at 1:45pm, V2 Assistant Director of Nursing (ADON) stated, The facility's expectations is that the nurses should communicate with the CNAs to let the CNAs know what is going on with the resident and also a CNA handoff report should be done. The CNA's have to do frequent rounds on total care residents and if a resident is a high fall risk. 5 hours without checking on an incontinent resident is not acceptable; it should be at least every hour. If a CNA finds a soiled wound dressing that information should be communicated to the nurse right away to make sure that the wounds are clean and redressed. Diapers are for most of our residents who are incontinent. Facility's position description for Certified Nursing Assistant (C.N.A) dated 05/01/24 documents in part, I. Position Summary: Provides certified nursing assistant services to assigned residents in accordance with care plans, community policies and procedures and at the direction of supervisors .II. Key Duties and Responsibilities: 2. Assists residents with or performs activities of daily living for resident in accordance with care plans and established community policies and procedures .3. Assist resident with lifting, turning, transferring, positioning and transporting .6. Delivers nutritional supplements to residents at assigned times and provides resident assistance as needed to ensure intake .III. Essential Functions: 2. Treats residents, families, visitors and associates with dignity and respect. Facility's position description undated for Registered Nurse (RN) documents in part, Position Summary: Provide direct nursing care to the residents and supervises the day-to-day nursing activities performed by the licensed practical/vocational nurse and certified nursing assistants in accordance with current federal, state, and local regulations and guidelines and established facility policies and procedures .I. Key Duties and Responsibilities: Ensures that policies and procedures are complied with by nursing personnel assigned .Performs rounds to ensure resident needs are being met and personnel are performing their assigned duties. Facility's policy titled Activities of Daily Living (ADLs) dated 12/01/23 documents in part, Policy: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .Procedure: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .c. Elimination (toileting). Facility's policy titled Routine Resident Checks dated 07/2013 documents in part, Policy Statement .Staff shall make routine resident checks to help maintain resident safety and well-being .Policy Interpretation and Implementation .2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. Facility's policy titled Perineal Care dated 2021 documents in part, Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.

Based on observation, interview, and record review the facility failed to provide adequate supervision for one resident (R2). This failure affected one resident (R1) and has the potential to affect all residents residing on the 3rd floor. Findings include: R1 has a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Hypertensive Heart, Rheumatoid Arthritis, History of Falling, Pressure Ulcer of Right Hip, stage 3, Pressure Ulcer of Right Upper Back, Stage 4, Pressure Ulcer of Left Upper Back, Stage 4. R1 has a Brief Interview of Mental Status score of 09. R2 has a diagnosis of but not limited to Dementia, Hypertensive Heart Disease, Dementia, Type 2 Diabetes Mellitus, Cognitive Communication Deficit, Anxiety Disorder. R2 has a Brief Interview of Mental Status score of 04. R2's Minimum Data Set, dated dated dated [DATE] documents, in part, Sit to Stand: Substantial/Maximal Assistance (Helper does More Than Half the effort), Chair/bed to chair transfer: Partial/Moderate assistance (Helper does Less Than Half the effort), Functional Limitation in Range of Motion: No impairment in upper and lower extremities, Mobility Devices: manual wheelchair. On 8/26/2024 at 3:23pm, surveyor observed R2 wheel himself into the CNA (Certified Nurses Assistant) charting area. Surveyor observed R2 wheel himself down the hall, on the high-end side (309-318) and back to the middle area twice. On 8/26/2024 at 3:24pm, V5 (CNA) stated R2 is a wanderer, and he does wander into other resident's rooms. On 8/26/2024 at 3:15pm, V7 (CNA) stated that R2 does wander around the unit in his wheelchair and that he did remove R2 from R1's room on 8/20/2024. V7 stated that R2 was sitting in his wheelchair on the left side of R1's bed, facing the window, with his pants down to his knees and that his incontinence brief was visible. Progress noted dated 8/20/2024 at 11:35pm by V3 (Registered Nurse) documents, in part, aide (V7) notified writer (V3) that V12 (R1's family member) found another resident (R2) inside resident's room. On 8/26/2024 at 3:37pm, V6 (RN) stated that R2 is a wanderer and that R2 sometimes wanders into other resident's rooms, but then he (R2) comes out on his own before he (V6) must go get him. On 8/27/2024 at 3:14pm V11 (Plant Operations Supervisor stated camera for view of hallway 301-308 does not work. Surveyor reviewed another camera view from the CNA's charting area but V11 could not retrieve the data for August 20, 2024. On 8/27/2024 at 3:26pm, V12 (R1's Family Member) stated when she (V12) went to R1's room at 8:45pm the door was completely closed, so she (V12) knocked on the door assuming R1 was receiving incontinence care but when she (V12) entered, she (V12) saw R2 sitting on the side of her (R1) bed with his (R2) pants down. I grabbed the wheelchair handle and asked R2 who he was and what he was doing there. R2 stated his name and that he was trying to give her (R1) something because she won't eat. I went back out and found the CNA (V7) and had V7 to remove the resident from my mom's room. V7 stated that R2 goes in everybody's room. V12 stated that R2 said, I am trying to give R1 some sugar, as he threw a sugar packet on her over the bed table, but R1 won't eat. On 8/28/2024 at 10:29am, V3 (RN) stated that R2 had been removed from R1's room when she entered R1's room and that we (nursing staff) did not see R2 enter R1's room. On 8/28/2024 at 2:27pm, V2 (Assistant Director of Nurse-ADON) stated potential issues that could arise from the breakdown of supervision for a wanderer and other residents is that they (wanderer) can elope, get hurt or fall. R1's care plan focus dated 8/21/2024 documents, in part, assure the resident that she is safe and secure and assure her that needs will be addressed by trained caregiver. R2's Care plan focus for elopement documents, in part, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books and provides structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Resident Rights for People in Long Term Care Facilities, documents, in part, your right to safety: your facility must be safe. Undated policy titled Safety and Supervision of Residents documents, in part, our facility strives to make the environment as free from accident hazards as possible and resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Position Description titled Certified Nursing Assistant with an effective date of 5/01/2024 documents, in part, follows appropriate safety policies/procedures at all times to protect residents. Undated Position Description titled Registered Nurse documents, in part, promotes and protects all residents' right, follows appropriate safety measures at all times to protect residents.

Based on interview and record review the facility failed to put interventions in place for a newly admitted resident (R199) in a sample of 12 residents. This failure resulted in R199's skin intact with redness progressed to stage three wounds of the buttock and heel. Findings include: According to R199's face sheet printed 6/12/2024, R199 is [AGE] years of age and was admitted to the facility on [DATE] and discharged [DATE]. R199 diagnoses include but are not limited to aftercare following explanation of shoulder joint prosthesis; unspecified rotator cuff tear or rupture of left shoulder; arthropathies, left shoulder; polyosteoarthritis; pressure-induced deep tissue damage of left heel and right buttock with onset date 5/10/24; pressure ulcer of left heel and right buttock, stage 3 with onset date 5/22/24. R199's Admission Evaluation, dated 5/10/2024, indicates skin intact. According to R199's POS (Physician Order Summary) printed 6/12/24, the following orders were placed for R199, air loss mattress, order date 5/22/24; apply alginate calcium to right buttock after cleansing NSS then cover with gauze island dressing every night shift for open wound, order date 5/22/24; apply alginate calcium with leptospermum to left heel after cleansing NSS then cover with gauze island dressing every night shift for open wound, order date 5/22/2024; off load the wound, reposition per facility protocol, float heels, limit sitting for 60 minutes, order date 5/22/24. R199's TAR (Treatment Administration Record) dated May 2024, indicates wound care treatments with start date of 5/22/24 to right buttock and left heel. Treatments completed 5/22, 5/23, 5/24. R199's progress note 5/10/2024 8:10 PM (20:10) documents in part: resident skin intact with redness to buttocks, redness to left heel, resident has bruising to left arm, chest, back and abdomen area, bruising to right arm. R199's progress note 5/14/2024 9:00 PM (21:00) documents in part: Also has sore present on foot. R199's progress note 5/16/2024 3:39 PM (15:39) documents in part: wound care to follow for heel pressure ulcer. R199's progress note 5/19/2024 6:27 PM (18:27) documents in part: Also family meeting scheduled today feels well, receiving supplements for pressure ulcer, yet to be seen by wound care MD. Specialty Physician Initial Wound Evaluation and Management Summary, 5/22/2024, documents in part: Stage 3 pressure wound of the left heel full thickness; etiology, pressure; duration greater than 14 days; wound size, 1.7 x 3.1 x not measurable cm, dept is unmeasurable due to presence of nonviable tissue and necrosis. Stage 3 pressure wound of the right buttock full thickness; etiology, pressure; duration greater than 14 days; wound size, 1.5 x 1.7 x 0.1 cm. On 6/12/24 at 9:34 AM, V17 (Wound Care Nurse) stated V17 has been at the facility as wound care nurse for three years. I'm here one day a week. The night shift nurse does treatments when I'm not here. The Facility does skin assessments on admission and weekly. Treatments are documented on the TAR (Treatment Administration Record). There is only an admission note for R199. I saw R199 with the wound doctor on 5/22/24. When R199 was admitted the nurse charted redness on the left heel and buttock. The doctor charted redness on left buttock and left heel. On 5/22/24 the left heel and left buttock were stage 3, they were open. Redness is not an open wound it is intact. 5/22/24 ordered a low air loss mattress. There were no treatments for the redness. Usually for redness in the buttock area there is an order for barrier cream to prevent from getting worse. Heel protectors or off-loading for redness on the heels to prevent from getting worse. I don't know if that was done. I was not here the day R199 was admitted . The wounds were acquired in the facility. 5/22/24 order for alginate calcium and Medi honey to left heel, alginate calcium to the buttock. The doctor or I did not see R199 after 5/22/24. On 6/14/24 at 12:18 PM, V28 (Wound Care Physician) stated R199 had two wounds, one on the heel and one on the buttock. My date of service is 5/22/24. R199 was admitted 12 days before I saw R199. On 5/22 the heel, post debridement, was stage 3, the buttock was stage 3. I did not debride the buttock. I can't base my presumption on someone else's note I can only base it on my own. I would have seen R199 when they told me to see R199. I would not have delayed seeing R199. The floor nurses notify myself and or the wound care nurse of any new wounds that they want me to see. I round once a week, Wednesday mornings starting at 6AM. Facility system procedure, Skin and Wound Care Program, 2/12/2023, documents in part: To provide clinical systems and resources to identify residents at risk for skin breakdown; implement strategies to prevent and/or manage pressure ulcers and reduce pain and minimize infection; reduce and mitigate the overall incidence of pressure ulcers; reduce risk factors that contribute to the development of pressure ulcers; monitor the incidence and severity of pressure ulcers.

Based on interviews and review of records the facility failed to provide effective supervision, interventions and monitoring to prevent falls per policy for a resident that needs maximal assistance with ADLs/Activities of Daily Living (bed mobility, transfers, and ambulation). Facility also failed to ascertain or to rule out injury had occurred due to the fall. These failures include 1 out of 1 resident (R49) in a total sample of 12 residents reviewed for accidents and hazard. This failure resulted in R49 having 2 falls for a period of 6 days in the facility. R49 sustained left leg/hip severe pain and left leg/hip (femoral) fracture that was determined the day after discharge. Findings include: R49 was [AGE] years old, admitted on [DATE] for respite of 6 days until 1/29/2024. R49 medical diagnosis includes vascular dementia, convulsion, cerebral atherosclerosis. R49's progress notes for history and physical by V4 (Medical Doctor) dated 1/25/2024 documents that R49 was seen confused alert to self only. R49 needs fall and safety precautions. Per R49's progress notes by V10 (Licensed Practical Nurse) dated 1/25/2024 (verified by V2 (Acting Director of Nursing actual date was 1/24/2024) around 6:30 PM, an aide informed V10 that R49 was observed laying on the floor on her left side. Per R49's progress notes by V11 (Licensed Practical Nurse) dated 1/26/2024 documented that another fall incident happened. Per notes, R49 was again observed on the floor. Multiple notes of R49 with pain to the left leg after the first fall are as follows: V10 documented on 1/25/2024 at 6:30 PM for post fall monitoring that R49 was complaining of left leg pain when hospice staff did a range of motion on R49. V10 documented on 1/25/2024 at 11:00 PM during evaluation or assessment there was pain at left lower extremity, posterior thigh. V12 (Licensed Practical Nurse) documented on 1/28/2024 for post fall charting, that R49 complains of severe pain throughout the shift. After Tylenol was administered around 6:00 PM, R49 continues to complaint of severe pain on the left leg. Morphine was administered around 8:20 PM continue to monitor pain. On 06/12/2024 at 1:47 PM, V10 (Licensed Practical Nurse) stated, I was the nurse when R49 fell . I called the doctor and hospice. Hospice nurse came in the facility and did ROM (range of motion). But hospice did not want to pay for X-Ray. On 06/12/2024 at 12:12 PM, V2 (Acting Director of Nursing/Infection Control Preventionist/Restorative) said R49 fell twice during her 5 days stay in the facility. The first fall was on 1/24/2024 at 6:30 PM and another fall on 1/25/2024 . Hospice came early morning 1/26 after the fall. V2 said that she noted that there was documentation of R49 having severe pain on 1/28/2024. V2 said that there was no X-Ray done on record. And that the facility was not aware of any injury R49 sustained due to the fall. On 06/12/2024 at 02:00 PM, V20 (Minimum Data Set Coordinator / Registered Nurse) stated that R49 medical diagnosis includes convulsion, it was included on alteration of neurological status but not included on the fall care plan. When asked about R49's ADL (Activity of Daily Living), how does R49 do with bed mobility, transfers, and ambulation? V20 stated that R49's care plan for transfers and ambulation was not continued. V20 said after reviewing R49's care plan, It was not in the care plan. It does not have to have one. V20 stated that per MDS (Minimum Data Set) assessment, R49 needs extensive assistance. On 06/12/2024 at 03:16 PM, V11 (Licensed Practical Nurse) stated that when she did her rounds R49 was found on the floor. When asked about R49's ADL status on transferring, ambulation, and toileting. V11 said R49 was able to get up and walk. She was able to walk and no limitation going to the bathroom from her bed. On 6/13/2024 at 10:06 AM, V4 (Medical Doctor) stated that there is a collaboration of Hospice and Family. In cases of pain that cannot be controlled we need to intervene, do X-Ray, surgery, or other intervention for comfort reasons. Per facility incident report investigation dated 1/25/2024 document as follows: R49 was only oriented to self. Under predisposing factors: R49 was confused, incontinent, gait imbalance, impaired memory, non-compliant, weakness/ fainted. Under predisposing situation factors: R49 did a room change, wanderer, ambulating without assist, and that R49 cannot retain safety education, requires maximum supervision at all times for safety. R49 second fall dated 1/26/2024 was not included in the incident report. Per V26 (Certified Nursing Assistant) handwritten document included in the incident report, documents that R49 was seen on the floor. Per V26, R49 gets up with little help or no help. V26 full handwritten notes reads: I (V26) walk to room. R49 laying down on floor on left side with pillow under her head. Did not complain about pain. R49 get up with little or no help. On 6/14/2024 at 9:36 AM, V25 after reading the handwritten document that reads: V26 called me asking for help. When I walked in the resident was laying on her left side with a pillow under head. Nurse on duty was informed (V25 signature). V25 verified that it was her handwriting and both she (V25) and V26 wrote in the same piece of paper and gave it to V10 (Licensed Practical Nurse). V25 stated that R49 was confused and has an impaired gait. And that R49 needs supervision at all times. And that V26 was the certified nursing assistant that was assigned to R49 which per the same handwritten note, R49 get up with little to no help. R49's Admission Evaluation dated 1/24/2024, documents that R49 was at risk of fall, at risk of elopement, and has ADL (Activities of Daily Living) deficits on self-care, mobility usual performance that needs to be addressed in the care plan. R49's Minimum Data Set (MDS) assessment on functional dated 1/29/2024 documents that R49 needs substantial or maximal assistance means helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort on all ADLs (Activities of Daily Living) including bed mobility, sit to stand, transfers, and ambulation. R49's care plan dated 1/24/2024 identified R49 of having ADL (Activities of Daily Living) self-care and mobility usual performance deficit. The goal is to improve R49's level of function. But all interventions listed including transfers, positioning, bed mobility were left blank. Although R49 was assessed as elopement risk on admission evaluation (1/24/2024). And was identified as wanderer in the incident report. ADLs and elopement/wandering was not addressed in the care plan of R49. On 1/31/2024, R49 was admitted to the hospital. Per hospital records, R49 sustained left leg fracture. Per R49's X-Ray report done in the hospital dated 1/30/2024 it was documented that R49 sustained an acute displaced and angulated fracture of the left femoral neck. Left femoral neck location is at the top of the thigh bone. The area where R49 was complaining of severe pain. Facility policy on Fall Prevention and Management dated 6/1/2023 reads: Per CMS definition Fall refers to unintentionally coming to rest on the ground, floor, or other lower level. When a resident is found on the floor, a fall is considered to have occurred. Under evaluation, a baseline care plan is developed on admission by the Licensed Nurse based on the Morse Fall Scale result, resident/family input, medical condition of the resident per assessment. Under actions following a fall includes the following: Ascertaining if an injury has occurred and providing treatment as necessary. Addressing the factors for the fall. Under supervision, the facility will provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency based on the individual resident's assessed needs and identified hazards in the resident environment.

Based on observations, interview, and review of record the facility failed to properly store and label fruits and vegetables inside walk-in cooler. And failed to seal properly burger patties and processed turkey chili inside walk-in freezer in accordance with policy of the facility. These failures are potential to affect all 42 residents taking food by mouth. Findings include: On 06/11/2024 at 09:45 AM, with V23 (Food Services Director) at the walk-in cooler 1 discolored cantaloupe not dated. V23 said, I do not think this is mold, but I see what you mean. I will discard it. V23 took the discolored cantaloupe out of the walk-in cooler. Celery labelled as received May 15 with no other date when to discard. There are onions and carrots on a plastic container (not the original package) not dated. At the walk-in freezer turkey chili and around 27 burger patties on a large metal tray, at the bottom plastic wrap not attached from three sides exposing the food to the environment. V23 was asked if these patties are intended to be prepared for residents' consumption. V23 took the metal tray out of the walk-in freezer. Placed it on the table, and V23 said, I will tell my staff, to seal food in the freezer properly. V23 also said that staff are expected not to use food in the freezer that is not properly sealed. Policy of the facility for Storage of Food and Supplies dated 12/7/2020 reads: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain safety and wholesomeness of the food for human consumption. Under fruit and vegetable storage: All perishable fruits and vegetables placed in refrigeration as soon as received. They should remain in the original container until empty. Watch closely to prevent the possibility of decay. Sort and produce daily to remove spoiled pieces. Under freezer foods, wrap food tightly to prevent cross contamination. Per V1 (Administrator) facility does not have any resident that does not take the food by mouth.

Based on observation, interview and record review, the facility failed to follow policy to reconcile controlled medications in order to prevent loss or diversion for one of two carts reviewed for medication labeling and storage. Findings include: On 6/11/24 at approximately 10:00 AM, reviewed 1st floor medication cart: -Observed the number of pills in three bingo cards did not match the corresponding number of pills left on the Controlled Drug Receipt/Record/Disposition forms. The controlled substance was not signed out by the nurse when administered. R150 POS (Physician Order Summary) documents in part: hydromorphone HCL tablet 5mg. R150 Hydromorphone HCL 4mg bingo card indicates 19 pills remaining. R150 Controlled Drug Receipt/Record/Disposition Form for Hydromorphone HCL 4mg indicates amount left is 20. R24 POS documents in part: oxycodone HCL tablet 5mg and pregabalin capsule 75mg. R24 Pregabalin 75mg bingo card indicates 2 pills remaining. R24 Controlled Drug Receipt/Record/Disposition Form for Pregabalin 75mg indicates amount left is 3. R24 Oxycodone HCL 5mg bingo card indicates 21 pills remaining. R24 Controlled Drug Receipt/Record/Disposition Form for Oxycodone HCL 5mg indicates amount left is 22. Reviewed Controlled Substances Count Verification forms for the months of April, May, and June. Found multiple lapses in documentation of nurse initials for multiple days and shifts. On 6/13/24 at 2:28 PM, V2 (Infection Preventionist, Acting Director of Nursing, Restorative Nurse) stated when the nurse administers a controlled substance/narcotic, they remove the controlled substance from the box and the bingo card and document the removal in the narcotic log and on the MAR (medication administration record) right after administration. The nurse should not wait until later after all medications have been passed to document removal in the narcotic log. The previous nurse and the next nurse should count the narcotics together to confirm the number of pills in the bingo card match the number of pills left on the sheet. This is done because they are controlled substances and to verify that they are not diverted somewhere else. The narcotics log has to be signed by both of the nurses to know that the count was done. If the sheet is not signed, I don't know that the count was done. On 6/13/24 at 4:14 PM, V27 (Registered Nurse) stated at the change of each shift, outgoing and oncoming nurse should count the narcotics together, so we know that the count is right, and nothing is missing. Both nurses sign the form to verify that we counted. Controlled Substances, 11/2022, documents in part: Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. Preparation and General Guidelines, Controlled Substances, 3/2021, documents in part: Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration (MAR, Controlled Drug Receipt/Record Disposition Form) 2) Amount administered (Controlled Drug Receipt/Record Disposition Form) 3) Remaining quantity (Controlled Drug Receipt/Record Disposition Form) 4) Initials of the nurse administering the dose, completed after the mediation is actually administered (MAR, Controlled Drug Receipt/Record Disposition Form).

Based on observation, interview and record review the facility failed to a) remove medications from the top of the cart when unattended, b) lock the cart when unattended and c) remove expired medications from the cart for one of two medication carts reviewed for medication labeling and storage. Findings include: On 6/11/24 at approximately 10:00 AM, reviewed 1st floor medication cart: -During medication administration with V14 (Nurse), a medicine cup of approximately 10 loose tablets and capsules for a resident was observed on the top of the medication cart that was unattended. -During medication administration with V14, V14 walked away from the medication cart and went into a resident room leaving the medication cart out of view of V14. The cart was observed not locked. -Observed Lantus (insulin glargine) injection pen 100unit/ml, not sealed, labeled with date opened 5/6 and date expire 6/3/24. R23's POS (Physician Order Summary) documents in part: Lantus SoloStar subcutaneous solution pen-injector (insulin glargine). -Observed a controlled substance, a bottle of Hydromorphone 4mg/ml liquid, labeled expired 4/26/24 and the Controlled Drug Receipt/Record/Disposition Form marked expired 4/26/24. R41's POS documents in part: hydromorphone HCL solution 4mg On 6/11/24 at 10:15 AM, V14 (Registered Nurse) stated I poured the cup of medications and when I went into the room the resident was not in there. They had taken the resident to therapy already. Medications should not be left on the top of the medication cart. They should not be left on top of the cart because anybody could come and take them. Some of the residents on this floor have psychiatric diagnoses. I could have trashed the medications since I was not able to administer them. I should have locked the medication cart before I left it unattended. It should be locked so it is not accessible. According to the label, the insulin is expired. It should be discarded. If a resident was administered an expired medication, there is potential for medical issues and for the medication not to work. It may not have the effect as it would if it were not expired. There should not be expired medications in the medication cart. On 6/13/24 at 2:28 PM, V2 (Infection Preventionist, Acting Director of Nursing, Restorative Nurse) stated the expired hydromorphone should have been discarded long ago. The medication cart should not be left unlocked. The medication cart should be locked when the nurse is not at the cart. If the nurse is in the resident room and the cart is out of sight of the nurse the cart should be locked. It should be locked so no one but the nurse has access to it. A cup of medications should not be left on the cart if the cart is not attended. Anyone can pass by and grab and take the medications. The medications should be wasted if the resident is not available to take the medications if already poured. There should not be expired medications on the medication cart. The insulin should have been disposed of on the expiration date. There is potential for harm if a resident is administered an expired medication. On 6/13/24 at 4:14 PM, V27 (Registered Nurse) stated the medication cart should be locked when left unattended. There should be no medications, no sharps, no scissors left on top of the cart. Somebody might grab and take it. It's dangerous especially if it's not their medication. Expired medications should be removed from the cart and wasted for safety of the resident. It's not good to the resident if its expired. Medications with shortened Expiration Dates, 5/26/23, reads in part: Lantus Solostar shortened expiration date is 28 days from open or out of refrigerator. Medication Labeling and Storage, 2/2023, documents in part: The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on interview and record review, the facility failed to initiate a new Level I screen for residents with known mental illness for one (R12) resident reviewed for Pre-Admission Screening and Record Review (PASARR) in a total sample of 12 residents reviewed. Findings include: R12's Facehsheet documents that R12 was admitted to the facility on [DATE]. R12's Facesheet documents that R12 was diagnosed with other bipolar disorder on 05/17/2022, and diagnosed with major depressive disorder, recurrent, unspecified on 05/17/2022. R12's Interagency Certification of Screening Results OBRA-I Initial Screen dated 04/11/2018 indicates that R12 has no reasonable basis for suspecting MI (mental illness). R12's Minimum Data Set (MDS) Section I dated 03/15/2024 indicates active diagnoses of depression and bipolar disease. There is no documentation to show that R12 has a Level II PASARR screening. On 06/12/2024, surveyor inquired to V1 (Administrator) about level PASARR screenings for residents who are admitted to the facility. V1 (Administrator) provided surveyor with R12's PASARR and V1 stated he is not aware of who is specifically responsible for performing the resident PASARR screenings at the facility. On 06/12/2024, V3 (Social Services Director) stated she is not responsible for performing the PASARR screenings in the facility. Facility policy dated 06/01/2023 titled PASARR, Preadmission, Screening & Resident Review-SNF documents in part, Policy: PASARR requires that all people entering Medicaid-certified nursing communities are evaluated for: Serious Mental Illness (SMI); Intellectual Disability (ID); Developmental Disabilities (DD); .This is a federal requirement to ensure that individuals are not inappropriately placed in nursing homes for long term care. Protocol: The PASARR process requires that all Medicaid-certified nursing communities, regardless of payer, be given a preliminary assessment to determine whether they might have SMI, ID, DD. This is called a Level I screen. The NF is ultimately responsible for ensuring that the (Level I) is completed and the determination is on file.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure for food and supply storage to ensure food and dairies in the main cooler were discarded after the expiration date. This failure has the potential to affect 42 residents in the facility who are receiving oral diet. Findings include: On [DATE] at 9:28 AM, during the initial kitchen tour with V4 (Dining Services Director), the following were found in the main cooler: a container of cooked mushrooms labeled today's date ,d+[DATE] and good thru ,d+[DATE]. V4 stated, I think it's expired already. It needs to be thrown out. Also found 5 half gallons of whole milk labeled with best by dates of [DATE]. V4 stated, They are expired and should have been thrown out, they should have been thrown out on Friday. V4 stated if residents are served with expired foods, they could potentially get illness. On [DATE] at 10:22 AM, interviewed V13 (Registered Dietitian) and stated that expired foods and dairies should be removed and disposed of from the main cooler. V13 stated that foods and dairies with best by and expired dates mean that they need to be discarded either that day or the following day. V13 stated that staff are not supposed to be serving expired foods and dairies. V13 stated residents could potentially get sick and get IBS (Irritable Bowel Syndrome) symptoms such as diarrhea, nausea, and stomachache especially with the expired dairy would be the most common. Facility policy titled, FOOD STORAGE & HANDLING dated [DATE] reads in part: PROCEDURE: All manufacturer packaged foods are used or discarded by their used by date which is determined by either their open date or manufacture's use-by date whichever is lesser. FOOD STORAGE TIME Check labels daily and discard outdated food! The facility's roster documents 44 residents in the facility with 2 residents who are NPO (Nothing by Mouth).

Based on observation, interview, and record review, the facility failed to provide turning and repositioning for a dependent resident (R28) for 1 of 20 residents reviewed for improper nursing care. Findings include: R28's comprehensive care plan documents in part that R28 has potential impairment to skin integrity related to poor mobility and history of pressure injury. Focus, initiated 01/06/2022, documents in part that R28 presents with weakness in bilateral lower extremities and limitation in right lower extremity. Intervention initiated 01/06/2022 documents in part: BED MOBILITY: The resident requires extensive assistance by one staff to turn and reposition in bed. R28's Quarterly MDS (Minimum Data Set) dated 03/31/2023 documents in part that R28 requires extensive assist with one-person physical assist. R28's Braden Scale for Predicting Pressure Sore Risk dated 04/01/2023 documents in part that R28 is at risk for developing pressure sores. On 05/23/2023 at 10:28 AM, surveyor observed R28 lying in bed on [R28's] back with the head of the bed elevated less than 90 degrees but greater than 45 degrees. R28 was leaning towards left side. Conducted observations at 10:44 AM, 10:58 AM, 11:10 AM, 11:15 AM, and 11:27 AM. R28 remained lying on back leaning to the left side. At 11:46 AM, V10 (Nurse) was at bedside. R28 remained lying on back leaning to the left side. Conducted further observations at 11:46 AM and 11:55 AM. R28 remained lying on back leaning to the left side. At 12:07 PM, surveyor noted a light blue binder at the nurses' station. In the inside left pocket, there was a hand-written sheet of the residents on the floor with their ADL (Activities of Daily Living) care needs. For R28 it documented in part: Check & change. Extensive assist. At 12:11 PM, R28 remained lying on back side leaning towards left side with head of the bed less than 90 degrees. Staff did not reposition resident further upright or higher in the bed for eating. At 12:21 PM, R28 remained lying on back leaning to the left side. V7 (Certified Nurse Aide) came in the room and asked if R28 needed assistance eating. R28 stated no. V7 left the room without repositioning R28 upright to 90 degrees. At 12:30 PM, R28 remained lying on back leaning to the left side. At 12:41 PM, R28 was asleep in bed lying on backside and leaning to left side. Head of the bed was down less than 45 degrees. No positioning pillows. On 05/24/2023 at 9:45 AM, V10 stated R28 cannot turn from side to side independently. V10 stated R28 needs one assist for bed mobility. When asked what interventions the facility has in place to prevent pressure ulcers, V10 stated to turn and reposition R28 every two hours. Facility's Pressure Ulcer Prevention and Treatment, last revised 03/03/2023, documents in part: Reposition resident per care plan using pressure relieving devices (i.e., low air loss mattress, pillows, etc.) to prevent bony prominences from rubbing as applicable. Facility's Feeding policy, last revised 11/27/2022, documents in part: For a bedbound patient, elevate the head of the bed upright to 90 degrees (unless contraindicated).

Based on interview and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 3 (R2, R5, R38) of 6 (R13, R21, R37) residents reviewed for falls. This deficient practice resulted in a.) R38 having an unwitnessed fall on 06/26/22 which resulted in a Left femoral neck fracture, s/p (Status Post) hemi-arthroplasty, laceration on left occiput with staples and right elbow skin tear, b.) R5 experiencing 7 unwitnessed falls from 05/06/22 - 07/25/22 and c.) R2 experiencing a fall after being left unattended while toileting. Findings Include: R2 was admitted to the facility 08/03/16 and has diagnosis not limited to [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction Affecting Left Non-Dominant Side, Essential (Primary) Hypertension, Hypertensive Retinopathy, Bilateral, Age-Related Nuclear Cataract, Bilateral. Nonexudative Age-Related [CONDITION(S)], Bilateral, Abnormal Posture, Muscle Weakness (Generalized), Unsteadiness on Feet and History of Falls. Progress notes dated 07/21/2022 document on part: Administration Note: Resident had an unwitnessed fall. CNA V9 (Certified Nurse Assistant/CNA) heard him (R2) shouting and immediately proceed to R2's room. Found resident lying on the bathroom floor right, grabbing on the hand bar. CNA called me to assess the resident prior to putting him (R2) back on the wheelchair. R2 said that he (R2) tried to go out of the toilet by himself and lost his (R2) balance. He (R2) was able to grab the hand bar and slid instead. No wound or pain on head, back and all extremities except for the half inch of skin tear on the left knee. Physician order dated 07/21/22 document in part Daily cleaning of left knee wound with NSS (Normal Saline) and apply border gauze until healed. R2's MDS (Minimum Data Set) Section C- Cognitive Patterns document in part: BIMS (Brief Interview for Mental Status) 13 indicating cognitively intact. Section G - Functional Status document in part: Toilet use; Limited assist, One-person physical assist. Section H - Bladder and Bowel: Urinary Continence; Occasionally incontinent, Bowel Continence: Always Continent. Care Plan document in part: R2 requires supervision to extensive assist with ADL (Activities of Daily Living) care. Assist into motorized wheelchair. Toilet Use: The resident requires limited assist by staff for toileting (dated initiated 01/31/22). R2 is at risk for falls and fall related injuries due to decreased mobility. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance, follow facility fall protocol (date initiated 01/31/22). R2 Root Cause Analysis dated 07/21/22 document in part: Problem: Tried to transfer self to toilet, Why: Needed to use restroom, Why: Long call light and could not wait. R2's Morse Fall Scale dated 07/21/22 document in part: Fall score of 15 indicating Low Risk 0-24. Initial Report dated 07/22/22 document in part: On 07/21/22 at approximately 12:30, staff responded to pt. (Patient) (R2) verbal calls for assistance. Staff entered patient's bathroom and found patient on the floor beside the toilet grasping handrail. Patient stated he (R2) was attempting to transfer himself (R2) to his (R2) wheelchair. Skin tear to left knee. Complaint of mild pain to the left ankle later in the day. R5 was admitted to the facility 04/29/22 and has diagnosis not limited to Muscle Weakness (Generalized), [CONDITION(S)], Dementia with Behavioral Disturbance, [CONDITION(S)] and Urinary Tract Infection. Unwitnessed report dated 05/06/22 document in part: R5 seen by wife lying on the floor. According to R5 he (R5) was trying to get up from the wheelchair going to the bed, R5 fell to his (R5) knees. Unwitnessed report dated 06/02/22 document in part: found R5 sitting by his (R5) knees on the resident's room. Progress note dated 05/12/22 document in part: CNA (Certified Nurse Assistant) went to resident's room to check R5 diaper then he found R5 on the floor. Resident verbalized that he (R5) was trying to get some water then he (R5) fell . Progress notes dated 06/25/22 document in part: NOD (Nurse on Duty) heard resident (R5) shouting for help, found resident on the floor with head beside the drawer/cabinet inside his (R5) room. R5 verbalized that he (R5) was trying to fix his shoes, then he (R5) suddenly fell down. Progress notes dated 07/13/22 document in part: At 12:48, CNA notified writer resident was observed on the floor. Progress notes dated 07/21/22 document in part: Resident (R5) found on the floor by side of bed in a side lying position with neck pillow under head by staff while doing rounds. Progress notes dated 07/27/22 document in part: Found resident sitting on the floor in front of his (R5) wheelchair during rounds. Resident said that he (R5) slid from his (R5) wheelchair and sat on the floor. R5 MDS (Minimum Data Set) Section C- Cognitive Patterns document in part: BIMS (Brief Interview for Mental Status) indicating resident was unable to complete the interview. Section G- Functional Status: Bed Mobility, Transfers, (Extensive Assist, Two + persons physical assist). Toilet use (Extensive Assist, One-person physical assist). R5 Root Cause Analysis dated 05/06/22 document in part: Problem: Resident had a fall Why: Resident self-transfer, Why: Wanted to get in bed, Why: Wanted to lay down. R5 Root Cause Analysis dated 05/12/22 document in part: Problem: Resident had a fall Why: Resident self-transfer, Why: Resident attempted to get water, Why: Tried to get water without help. R5 Root Cause Analysis dated 06/02/22 document in part: Problem: Resident had a fall, Why: Tried to get out of bed, Why: Wanted to put on shoes, Why: Wanted to wear shoes and get out of the bed when he lost his balance. R5 Root Cause Analysis dated 06/25/22 document in part: Problem: Resident had a fall, Why: Tried to fix his shoe and lost his balance, Why: Didn't ask for help with shoes from CNA. R5 Root Cause Analysis dated 07/13/22 document in part: Problem: Resident had a fall, Why: Appeared to have rolled out of low bed to floor, Why: Resident could not recall why. R5 Root Cause Analysis dated 07/21/22 document in part: Problem: Resident had a fall, Why: Tried to get up on his own, Why: stated he was trying to get his toast. R5 Root Cause Analysis dated 07/25/22 document in part: Problem: Resident had a fall, Why: Slid from wheelchair to the floor, Why: Resident could not provide further details. R5's Morse Fall Scale dated 05/06/22 document in part: Fall score of 50, dated 05/12/22 Fall score of 75, dated 06/02/22 Fall score 55, dated 06/25/22 Fall score 75, dated 07/13/22 Fall score 65, dated 07/21/22 Fall score 55 and dated 07/25/22 Fall score 55. Fall Scoring: High Risk 45 and higher. Care Plan document in part: R5 is at risk for falls r/t (Related to Gait/balance problems. fell [DATE], 05/12/22, 06/02/22, 06/25/22, 07/13/22, 07/21/22 and 07/25/22 (Date initiated 05/11/22, Revision on: 07/27/22). Goal: R5 will be free of falls and fall related injury through review date (Date initiated 05/11/22, Revision on: 05/18/22, Target dated 08/08/22). Intervention/Task: Gently remind resident to call for assistance before attempting self-transfers. Keep bed in low position. (Date initiated 05/11/22). Anticipate and meet resident's needs. Ensure the resident is wearing appropriate footwear when ambulating of mobilizing in w/c (Wheelchair). (Date initiated 05/11/22, Revision on 07/27/22). Be sure the call light is within reach and encourage resident to use it for assistance as needed. The resident need prompt response to all requests for assistance. Follow facility fall protocol. Floor Mat at bedside as ordered. (Date initiated 07/22/22) Avoid bedrest and inactivity. Encourage mobility and activity. (Date initiated 07/27/22). R38 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis not limited to Fracture of Unspecified Part of Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Presence of Left Artificial Hip Joint, Muscle Weakness, Alzheimer's Disease, Dementia, Cognitive Communication Deficit, Age related [CONDITION(S)] and History of Falls. R38 MDS (Minimum Data Set) dated 07/13/22 Section C- Cognitive Patterns document in part: BIMS (Brief Interview for Mental Status) indicating resident was unable to complete the interview. Section G- Functional Status: Bed Mobility, Locomotion on Unit, Toilet use (Extensive Assist, One-person physical assist). Progress notes dated 05/19/2022 document in part: *Incident Note: During passing medication heard resident (R38) calling for help; upon attending to resident's room found resident attempting to get up from the floor at the doorway of resident's room door. Upon body assessment noted a 3 cm x 2 cm bump on the top of her head, no discoloration, no bleeding noted. Progress notes dated 06/24/22 document in part: Resident (R38) had an unwitnessed fall. CNA found R38 on bed holding her (R38) elbow with blood. When asked what happen R38 said that she's (R38) looking for something and R38 went out of bed then R38 fell . R38 said she (R38) immediately got back to bed. Progress notes dated 06/26/2022 document in part: *Incident Note: We heard someone screaming and when we check on the resident's room R38 was lying on the floor. As I did the assessment R38 was complaining of leg pain. and I noted a laceration on the parietal area of the head about 3cm. Assessed the laceration cleanse with NSS and apply clean dressing with pressure. Doctor ordered to send out resident to the ER (emergency room ). Progress notes dated 06/26/2022 document in part: Health Status Note: Placed call to Medical Center, according to the ER nurse assigned to the R38, R38 will be admitted due to Close Fracture of the Left Femur. Progress note dated 07/06/22 document in part - Clinical Admission Evaluation: Clinical Interventions: Narrative Note: Received resident from Medical Center via stretcher. There are 24 staples noted on the operative site on the left femoral area and 3 staples on the head. R38's Morse Fall Scale dated 05/19/22 document in part: Fall score of 65, dated 06/24/22, Fall score 80, and dated 06/26/22 Fall score 70 indicating Fall scoring: High Risk 45 and Higher. Route Cause Analysis dated 06/26/22 document in part: Problem: Resident had a fall in her (R38) room right before dinner. Why: Tried to get up to use the rest room alone. Tried to close the door and lost her (R38) balance. Why: Wanted to use the rest room. Why: Resident on water pills. Care plan document in part: R38 has impaired cognition function/dementia or impaired thought processes r/t Alzheimer's, Dementia, Difficulty making decisions, Impaired decision-making, long-term memory loss, short term memory loss. (Date initiated 05/18/22). R38 is at risk for falls r/t confusion, deconditioning, gait/balance problems and unaware of safety needs. R38 fell [DATE] with resulting left femur fracture, left scalp laceration and right elbow skin tear. Left hip fracture resolved with a total left hip hemiarthroplasty on 06/29/22. Surgical skin staples [NAME] the left lateral thigh. Left lateral scalp laceration with staples. Right elbow skin tear with dressing intact. (Date initiated 07/12/22). R38 is status post hospitalization secondary to unwitnessed fall with resulting left femur fracture. R38 is status post left hip hemiarthroplasty. R38 now requires supervision to total assist with ADL (Activities of Daily Living) care. (Date initiated 07/06/22). Interventions: History of Falls. Fall Risk Level: At risk. R38 is at risk for falls r/t (Related to) confusion, deconditioning, gait/balance problems, and unaware of safety needs. Unwitnessed fall on 06.26.22 with resulting left hip fracture, left scalp laceration, right elbow skin tear. Initial Report dated 06/27/22 document in part: On 06/26/22 at approximately 15:30, R38 heard screaming and observed on the floor as R38 had a fall. R38 complained of leg pain and had a 3 cm (Centimeter) laceration to the parietal area of the head. R38 was sent to the hospital. Final report dated 07/01/22 document in part: Per staff, R38 is able to transfer out of bed and attempts to walk without assistive device. R38 has a history of attempting to walk around her (R38) room without assistive device. The origin of the injury occurred due to a fall. Resident lost her (R38) balance when trying to close the bathroom door. There was no witness to this incident. R38 Physician Order dated 07/06/22 document in part: for surgical consult about staple removal head and hip after 2 weeks. R38 hospital Record dated 06/27/22 document in part: R38 presented to the emergency room for an evaluation following an unwitnessed fall. Staples were placed to the left scalp following laceration. Noted left hip fracture on Xray pelvis. CT (Computed Tomography) Head: right posterior scalp soft tissue swelling. Active problems Closed fracture of left femur, Scalp Laceration. Patient was brought to emergency department s/p (Status post) unwitnessed fall. R38 was found on the bathroom floor, laceration on left occiput. Left femoral neck fracture, s/p left hemi-arthroplasty on 06/29/22. Admitting Diagnosis Closed fracture of left femur. Left hip a left posterior scalp with staples. Skin staples were placed to left scalp following laceration. On 07/26/22 at 10:59 AM, R2 stated sometimes I don't feel like I am receiving proper care. I need assistant with everything, the washroom and getting dressed. Last Thursday 07/21/22 the (CNA) Certified Nurse Assistant assisted me to the bathroom. The CNA put me on the toilet and left out of the room. When I finished, I use the call light, but they did not respond, and it was uncomfortable sitting on the toilet. I have left sided weakness and can stand holding on but fell when I tried to get up off of the toilet. The nurse and the CNA came to get me up and my left knee was bleeding. I think my knee touched the wheelchair. A white bordered dressing was observed on R2 left knee dated 07/26/22. On 07/27/22 at 11:07 AM, V4 (Registered Nurse/RN) stated R38 had an unwitnessed fall on 06/24/22. R38 said that she (R38) was looking for something and lost her (R38) balance when she (R38) fell . R38 is a high fall risk. The fall interventions are in the progress notes. There are no fall interventions in the care plan yet. We educate R38 to not get out of bed. R38 does not have any floor mats but uses an abductor pillow when in bed. When a resident falls, the nurse is notified by the Certified Nurse Assistant (CNA), the resident is assessed, if there is a complaint of pain we immobilize before transferring, inform the doctor and notify the family. Residents that are a fall risk the bed is in a low position, floor mats, call light in reach, frequent rounds, and monitoring. On 07/27/22 at 12:31 PM, V4 (Registered Nurse/RN) stated R38 is a resident from assistant living, R38 had an unwitnessed fall and was noted by the bathroom. Upon investigation R38 was trying to use the bathroom and on the way back lost her (R38) balance and was found by the nurse on duty by the bathroom door. R38 has had multiple falls. The interventions in the care plan are to remind R38 to use the walker. All I recall is R38 was a standby assist prior to the fall and tend to get up on own. A head-to-toe assessment was done, and a laceration was assessed somewhere on the head, pain of the leg and there was a femur fracture. On 07/27/22 at 12:44 PM, V6 (Ombudsman) stated the facility has a lot of falls. On 07/27/22 at 03:01 PM, per telephone interview V9 (Certified Nurse Assistant/CNA) stated R2 had a fall on 07/21/22. I transferred R2 to the toilet and told R2 to give me a call when he (R2) was done. R2 takes a while on the toilet so I stepped out of the room, and I went next door with the nurse. When I came out of the room, I saw the call light on and heard R2 yelling. R2 said he (R2) was trying to get himself off of the toilet. R2 was on the bathroom floor stuck between the toilet and the wheelchair. I asked why he (R2) tried to get up and he (R2) said that he (R2) did not want to sit on the toilet. I went and got the nurse, moved the chair back, got on each side of R2, put my arm under R2's arm, lifted R2 up by the pants and transferred R2 to the wheelchair. R2 had a scrape to the left knee. R2 is a one person transfer and need help when transferring. I am not sure of the toileting policy in that facility. Usually, I stay in the room with the resident, but I went in the other room the change the 2 residents. R2 is alert and able to make his (R2) needs known. R2 is not a high fall risk. On 07/27/22 at 03:08 PM, V7 (Certified Nurse Assistant/CNA) stated I was working on Sunday 06/26/22 and R38 was assigned to me. We had just come in, took vital signs, made rounds, and got the dinner orders. I was at the CNA (Certified Nurse Assistant) station near the nurse station with another CNA. We heard a big bang and went room to room then found R38 on the floor one half hour into the shift change about 03:30 PM. R38 head was towards the bathroom door and R38 was between the bed and the bathroom. I asked R38 if anything hurt and did, she (R38) hit her (R38) head. At first R38 denied hitting her (R38) head. We got R38 and sat R38 on the bed. R38 had a hat on and wanted to lay down. I noticed blood spilling on the pillow from the left side of R38 head. R38 head was actively bleeding. The hat was removed, and one nurse applied pressure while the other nurse went to call the doctor. R38 was holding onto the left hip and did not complain of pain until she (R38) was gotten into bed. R38 was sent to the hospital. R38 was mobile and would walk with her (R38) family member. R38 would sometime use the walker and sometimes she (R38) did not use the walker. The walker was at the foot of the bed. R38 would go to the bathroom unassisted because we would see evidence of R38 not flushing the toilet. I believe R38 was a high fall risk. The fall interventions were to have the call light near the bed and let staff know when R38 had to go to the bathroom. R38 was forgetful. When I would see R38 in the doorway without her (R38) walker I would remind R38 to use the walker. R38 was a one assist. On 07/27/22 at 03:55 PM, V1 (Administrator) stated we do not have a toileting policy. Toileting is based on cognition and the need for assistance while toileting. On 07/27/22 at 03:58 PM, V12 (Registered Nurse/RN) stated on 05/19/22 R38 was in the wheelchair because R38 son had just visited. I asked if R38 wanted to go to bed so I asked the CNA to help R38. A little while we were about to go to R38 room, R38 was on the bathroom floor. R38 said that she (R38) wanted to use the bathroom and she (R38) think she (R38) could do it by herself (R38). R38 is a high fall risk, that's why I keep an eye on R38. The fall interventions that were in place are call light in reach, frequent rounding, bed in lowest position and floor mats. R38 most recent fall was on 06/26/22. R38 always wanted to walk. When doing the nursing report the CNA heard R38 screaming and found R38 on the floor. R38 said her (R38) left leg hurt. R38 leg was immobilized, and we transferred R38 to the bed. When assessing R38 in bed there was a laceration to the left parietal area. R38 was sent to the hospital. R38 was impulsive and would get out of bed. R38 really wanted to go to the bathroom on her (R38) own. I witnessed R38 going to the bathroom. R38 did not use the walker because the walker was near the door of her (R38) room. R38 fall interventions were frequent rounding, give something to occupy her, floor mats, encourage not to get out of bed on own and make sure clean and dry. An abductor pillow was initiated after the hospitalization . On 07/27/22 at 04:25 PM, V1 (Administrator) stated we do not have a toileting Policy. On 07/28/22 at 09:35 PM, V8 (Certified Nurse Assistant/CNA) stated me and a coworker were at the CNA care station. We heard a bang and R38 was found lying on the floor by the bathroom. We sat R38 on the bed and R38 CNA notice R38 head was bleeding. R38 tried to do things a lot on her (R38) own and would not ask for assistance. R2 requires assistance to go to the bathroom, getting in the wheelchair and pulling up his (R2) pants. R2 will put on the call light when he (R2) is done in the bathroom. R2 is a fall risk because of the stroke and left side weakness. On 07/28/22 at 10:32 AM, V10 (Nurse Practitioner/NP) stated I saw R38 two times. One on 07/20/22 and 07/27/22. R38 had falls on 05/19/22, 06/24/22 and 06/26/22. R38 is considered a high fall risk. R38 had injuries due to the fall that happen after the fall. The laceration to R38 head could have been avoided. R38 was diagnosed with a left hip fracture 06/26/22. A resident could have [CONDITION(S)] and it is hard to explain because there was no bone density and R38 is [AGE] years old. R38 doctor is on vacation. On 07/28/22 at 11:02PM, V2 (Nursing Supervisor Clinical Service) stated I am notified if there is a fall. Everyone that enters the facility is considered a fall risk and will be assessed by the nurse. The Morse score is done after a fall. The fall risk is based on the score. Some fall interventions are individualized. R2 had a fall on 07/21/22. I am aware of the fall, and we are currently following up. R2 is a post stroke with left sided weakness. R2 is continent of bowel and bladder and is a minimum assist to and from the toilet. R2 is alert and oriented x3 with a BIMS score of 13. Based on that R2 can use the call light, make good judgement but still should have been observed while he (R2) was in the bathroom. The care plan should be updated after a fall and a review of what the staff is doing to prevent falls or injuries to that resident. If the findings of what should be done, we will implement them. On 07/28/22 at 12:25 PM, during the resident council meeting surveyor documented R2 stated I'm not getting the care I need, they left me (R2) too long in the bathroom on last Thursday (07/21/22). I put on the light after number two (Bowel Movement), the CNA (Certified Nurse Assistant) came to tell me (R2) and said she V9 (CNA) was with someone else and would come right back. I (R2) was in there for 20 minutes, I got up myself and fell to my knee. (R2 was observed wearing a watch). I (R2) had a stroke on my (R2) left side and fell on the leg that I can't move. R2 denies injury, other than pain during time of incident. Survey team currently investigating this resident's complaint and incident. R37 and R13, agreed with R2 that they are left in washroom longer than they would like after pulling the call light. On 07/28/22 at 01:31 PM, per telephone interview V11 (MDS Coordinator) stated the care plan is to be updated as soon as possible. The purpose of the fall interventions is to prevent further falls. All residents are at risk for falls, even if they are alert and oriented. The base line care plan is done when the resident is admitted . The nurse generates the baseline care plan. I put an at risk for falls care plan as soon as the resident is admitted . R38 had a fall on 05/19/22, 06/24/22 and 06/26/22. R38 admitted d is 05/10/22. On 07/28/22 V1 (Administrator) stated I see the care plan for R38 was initiated on 07/12/22 after readmission. The CNA stepped out of R2 room to assist another resident when R2 fell . Policy: Titled Fall management, Long - Term Care revised 02/17/22 document in part: Falls are a major cause of injury and death among elderly people. About 1,800 older adults living in long - term care facilities die each year from fall - related injuries, and those who survive typically sustain hip fractures and head injuries that result in permanent disability and reduces quality of life. Special Considerations: After a fall, review the resident's medical history to determine whether the resident is at risk for other specific complications. Complete a fall risk assessment and revise the resident's care plan to include interventions to prevent future falls. Documentation: After a fall, complete a detailed incident report to help track frequent resident falls so that the facility can implement prevention measures for high - risk residents. Titled Fall Prevention, long-term care undated document in part: Preventing falls begins with identifying residents who are at greatest risk. Ensure the resident's care plan addresses the fall risk. Fall prevention should be individualized and comprehensive for each resident.

Based on observation, record review and interview, the facility failed to maintain fall prevention measures for 1 of 8 residents (R7) reviewed for falls in a sample of 12. R7 has a history of falls: 6/18/11 sustained a left hip fracture and 3/1/12 sustained a left femur fracture with left prosthetic hip dislocation. Findings include: 1. R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Care plan dated 4/17/12 describes R7 as having long and short term memory deficit, modified impaired cognitive skills for daily decision making and periods of inattention and disorientation. Incident Report dated 6/18/11 shows R7 sustained an unwitnessed fall in the dining room at 6:20 p.m. Report states that staff heard a loud noise, alarm went off and R7 was observed on the floor. Upon assessment, R7 complained of pain when left leg was touched and noted with shortening and external rotation of the left leg. R7 was sent out to the hospital and diagnosed with [REDACTED]. Fall prevention interventions that were in place at time of fall includes use of non-slick footwear, safety alarm device when up in chair and in bed, engage in ambulatory program, instruct on safety measures to reduce fall risk, instruct on use of call light, bed in lowest position with wheels locked. On 9/29/11 R7 was eased down to the floor by staff during transfer with staff assist. R7 did not sustain any injuries. On 3/1/12 staff heard a loud noise coming from R7's room and R7 was found lying on her left side. R7 was in a confused state and unable to say what happened. A full body assessment was done and no injuries found. Nurses' notes dated 3/3/12 at 3:11pm states R7 was found to have a swollen left knee and the left leg looked shorter than right. Stat X-ray examination of the left hip and knee was ordered. There is no evidence that R7 was assessed for pain in the affected area. X-ray report dated 3/3/12 shows "displaced" head of left femur prosthesis. There was no result reported for the left knee X-ray. At 11:52 pm, R7 was exhibiting agitation especially when touched or moved. On 3/4/12 at 11:21 am, R7 complained of pain when being turned. On 3/5/12 at 12:57 a.m., R7 was observed with left knee redness and swelling and complained of pain "to all areas". An amended X-ray report was received on 3/5/12 which showed "dislocated" head of left femur, and left knee X-ray showed an "oblique and slightly spiral fracture of the distal shaft of the femur". R7 was then sent to the hospital for evaluation, 5 days following the fall. Hospital progress notes shows a [DIAGNOSES REDACTED]. R7 underwent open reduction of the left femoral shaft fracture. On 4/24/12 at approximately 10:15am, R7 was in bed, alert but confused, with unintelligible speech. R7's call light was not within easy reach. E3 (Nurse-Care plan coordinator) was present and stated that R7 is able to use the call light, and proceeded to adjust the location. E3 went on to say that R7 is at high risk for falls and uses body sensor alarm and fall mats on both sides of the bed. At approximately 12:30pm, R7 was in her bed, alert and apparently confused. R7 was lying on her left side, propped into position with pillows. R7 appeared to have poor trunk control, requiring total assist with bed mobility. Minimum Data Set ((MDS) dated [DATE] confirms R7 poor trunk control. The floor mat to the left side of the bed was not in place. Z1, Volunteer, was present in R7's room and was frantically verbalizing concern for R7 lying on her left side with only upper side rail in place and the missing floor mat. Z1 stated that R7 should have full side rail to prevent another fall related serious injury. Z1 went on to say that she often enters R7's room and finds fall mats not in place. E5 (Certified Nurses Aid-CNA) entered the room approximately five minutes later and stated that she was in the process of feeding R7. E5 made no attempt to put the missing floor mat in place. At 1:30pm, surveyor entered R7's room accompanied by E4 (Restorative Nurse). R7 was still lying on her left side, left floor mat was not in place, the bed was not in it's lowest position. E4 stated that these measures should be in place at all times and immediately educated E5 on the importance of maintaining fall prevention measures. Review of R7's current care plan dated 4/17/12 shows no inclusion of use of safety alarms, fall mats at both sides of the bed and bed in lowest position. E3 (MDS/Care Plan Coordinator) provided surveyor with an updated care plan dated 4/24/12 which incorporates these additional interventions. E3 stated that she omitted the inclusion of these measures in the care plan.