Every finding on record at Waukegan Health and Rehab

Based on observation, interview, and record review the facility failed to ensure kitchen cookware was adequately cleaned and sanitized prior to using them for food preparation, failed to ensure food preparation equipment was properly sanitized before use, and failed to ensure food temperatures were taken after final cooking and prior to serving lunch. This has the potential to affect all residents that receive food from the kitchen. The findings include: Centers for Medicare and Medicaid Services form 671 shows there are 82 residents residing in the facility. Facility provided list of residents receiving tube feedings as nutrition shows three residents have orders for tube feeding (R16, R54, R5). R16's meal ticket shows R16 also receives a puree diet.1. On 8/10/26 at 11:05 AM, V6 (Cook) grabbed a full size six inch food service pan full of prepared mashed potatoes, brought it to the garbage can adjacent the 3 compartment sink, and began to discard the mashed potatoes using a spoon. at 11:10 AM, V6 finished discarding the mashed potatoes, placed the food service pan into the empty middle sink of the 3 compartment sink and proceeded to rinse it out. V6 then brought the food service pan directly to the stove top and began filling it with water to boil for a new batch of mashed potatoes. When the water was boiling, V6 prepared the mashed potatoes and put the pan directly into the steam table for service. On 8/10/26 at 1:12 PM, V7 (Food Service Director) said V7 should have just gotten a new pan and started from scratch rather than using the same pan. Facility Cleaning Dishes/Dish Machine policy (no date) states, All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use .2. On 8/10/26 at 11:40 AM, V6 started to prepare the mechanical soft and puree foods. At 11:47 AM, V6 finished the mechanical soft beef cubed steak and brought the food processor pitcher, the lid, and the blade to the 3 compartment sink. V6 washed and rinsed the components in the middle sink, then dipped the components in the sanitizer sink for less than 30 seconds, each item. V6 then placed the items on the side of the sink, allowed to dry momentarily, before picking up the wet components and bringing them back to the puree counter to continue making puree foods. At 11:49 AM, V6 started to puree the peas. When finished, V6 cleaned the food processor components the exact same way as before and brought the wet components back to the puree counter to make the pureed beef cubed steak. On 8/10/26 at 1:12 PM, V7 said all items in the 3 compartment sink should stay in the water for at least a minute and should be allowed to fully air dry prior to using again.Facility Cleaning Dishes/Dish Machine policy (no date) states, All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use . 9. Dishes should be air dried on the dish racks.3. On 8/10/26 at 12:12 PM, V6 began serving lunch without taking temperatures of the food on the steam table. This surveyor requested final cooking temperature documentation and tray line temperature documentation from 8/10/26 for lunch and there were no completed documents. On 8/10/26 at 1:12 PM, V7 said food temperatures should be taken when the items are removed from the oven and again prior to service.On 08/11/26 at 10:06 AM, V7 said V6 didn't document anything for food temps on 8/10/26. Facility Food Temperatures Policy (no date) states, The temperatures of all food items will be taken and properly recorded prior to service of each meal.

Based on interview and record review the facility failed to ensure a resident was safely positioned on the bed while providing care to prevent the resident from rolling off the bed. This applies to 1 (R2) of 2 residents reviewed for falls in the sample of 42. The findings include: On 8/10/26 at 10:15AM R2 was lying in bed on a low air loss mattress. R2 had blue bolsters on both sides of the bed. The bolsters were near the top of the bed and extended down about 1/3 of the mattress. R2 stated that about 1 week ago he was being changed and he was rolled off the bed and hit the floor. R2 stated he was sent to the emergency room, but he did not sustain any significant injuries. Just a few scrapes on his face, a bump on his arm and he did hit his head. R2's Progress Notes dated 7/16/26 state, Patient was being changed with the aide. The pt (patient) stated I am falling. The aide tried to assist him but could not keep him from falling to the floor. He received abrasion on left chin, nose, left side of head. He has discoloration on is left arm. No family to notify. Nurse Practitioner and Doctor notified. 911 called and patient went to ER for eval. He returned from ER. No fractures. Order to put Bacitracin on nose chin and left side of head. On 8/11/2026 at 1:04 PM V2 (Director of Nursing) stated, She was an agency CNA (Certified Nursing Assistant). I remember this situation because I was on vacation. I do not have a phone number for her. R2's Incident Report dated 7/16/26 shows a statement from (V5 Agency CNA) that reads, Thursday, July 16, 2026 about 5:10AM I was in (R2's room) with (R2). During the change of his incontinent product I realized he had a lot of bowel movement. I asked him to move to his right side so I can clean up his backside. He moved over and then stated he was falling and before I could reach out to hold him, he was on the floor. I called out for the nurse; she came and assessed (R2). She called the doctor and then 911. They arrived and took him to the ER for evaluation. He did hit his head .

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 2 residents (R1) reviewed for abuse in the sample of 7. The findings include:R1's face sheet showed he was admitted to the facility 3/17/26 with diagnoses to include senile degeneration of brain, cellulitis of left upper limb, dementia, muscle weakness, and atrial fibrillation. R1's facility assessment dated [DATE] showed he has severe cognitive impairment and requires substantial to maximum assist of staff for most cares. R1's Care Plan initiated 3/20/26 showed, The resident's memory is impaired. Consequently, the resident has problems with decision-making, insight, logic, calculation, reasoning, planning, and judgement. R1's Care Plan initiated 4/2/26 showed, the resident has a history of behavior problem such as hitting staff related disease process. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.R1's 4/19/26 Nurses Note showed, The CNA (Certified Nursing Assistant) who just came back from her break reported to this writer that she saw the two residents by the hallway just outside their bedroom. According to the CNA, [R1] was hit by his roommate on the left side of the face and top of the head, the third punch was blocked by the resident. Both were in their wheelchairs. The two residents were separated immediately, [R1] was removed right away farther from his roommate. Skin assessment conducted immediately and noted redness to the left side of [R1's] face as well as the back of the right hand on the lateral side.R2's face sheet showed he was admitted to the facility 10/4/24 with diagnoses to include chronic congestive heart failure, urinary tract infection, dysphagia, dementia, major depressive disorder, and low back pain. R2's facility assessment dated [DATE] showed he has no cognitive impairment and requires substantial to maximum assist with most cares.R2's Care Plan initiated 1/30/26 showed, The resident demonstrates a potential for situational and/or coping problems in areas such as: Psychosocial well-being mood state and/or behavioral symptoms. Behavior may leave resident susceptible to abuse: This appears related to: . Dementia, depression with psychotic features. Symptoms are or may be manifested by: Cognitive deficits (poor reasoning, poor memory, poor judgement) . Conflictual relationships with staff and peers. Intervene on an incidental or episodic basis to re-direct behavior symptoms that impact others. (4/20/26) Set limits to behaviors. Stay calm when resident is exhibiting agitated behaviors. If behavior is disruptive and if showing aggression towards other residents-separate from other residents.R2's 4/22/26 Physician Progress Note showed, . RN (Registered Nurse) reports that patient has been refusing medications more frequently, recently had an altercation with another resident.The facility's Incident dated 4/19/26 at 7:05 PM showed, Resident to Resident. The two residents were separated immediately, [R1] was removed right away farther from his roommate. Skin assessment conducted immediately and noted redness on the left side of [R1's] face as well as the back of the right hand on the lateral side.The facility's Incident dated 4/19/26 showed, . Patient was sitting in the doorway of his room when resident [R1] was attempting to gain access to his room, resident [R2] swung and struck resident [R1] in the face.On 4/29/26 at 11:36 AM, V8 (Registered Nurse/RN) said, The only injury from the incident was [R1] had some redness on his cheek, and he had some redness on his hand. From what I was told, it was just [R2] that was swinging.On 4/29/26 at 12:17 PM, V7 (CNA) said, I am familiar with the issue. I wasn't the one that witnessed it, but I did hear about it. I was on break and when I got back, [V12 Agency CNA] told me about the situation. I did notice redness on [R1's] face. The redness was around his left cheekbone. He didn't complain of pain to the area but once again he is declining so I don't know if he could.On 4/29/26 at 12:50 PM, V13 (RN) said, I was passing medications in one of the other resident rooms, I heard the CNA who was coming out of the elevator yell. She saw an incident between [R1] and [R2]. She said one resident was hitting the other resident and she ran over to separate them and prevent further contact between the two. That was around 7PM.The facility's policy and procedure revised 2/25/26 showed, Abuse, Neglect and Exploitation. Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse means the willful infliction of injury. which can include staff to resident abuse and certain resident to resident altercations. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse.

Based on interview and record review the facility failed to implement safety interventions for 2 of 2 residents (R1, R2) reviewed for safety in the sample of 3. This failure resulted in R1 being hit in the face by R2's involuntary movements. The findings include: R1's face sheet printed on 12/2/25 showed diagnoses including but not limited to Alzheimer's disease, non-traumatic brain dysfunction, and mood disorder. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment and uses a wheelchair. R1's progress note dated 11/25/25 stated: At around 6:30 pm resident was sitting near the first-floor nurses' station next to a male resident who struck her on the right side of her face. Writer immediately separated the residents and assessed resident's eye and face, there appeared to be no injury, 911 called,. Progress notes showed R1 was transported to the local emergency room and returned the same day without injury. R2's face sheet printed on 12/2/25 showed diagnoses including but not limited to Parkinson's disease, dementia, anxiety, legal blindness, and extrapyramidal movement disorder (neurological/range of movement disorder caused primarily by medication side effects). R2's facility assessment dated [DATE] showed R2 has moderate cognitive impairment and uses a wheelchair. R2's progress note dated 11/25/25 stated: At around 6:30 pm resident was sitting next to a female resident near the first-floor nurses' station when he struck the female resident on the right side of her face, writer immediately separated the residents, called 911 for the female resident. Progress notes showed R2 was transported to the local emergency room and returned the same day without injury. On 12/2/25 at 11:14 AM, R1 was attempted to be interviewed. R1 was pleasantly confused and had no memory recall. R1 did not show any signs of injury or pain. On 12/2/25 at 12:55 PM, R2 was attempted to be interviewed. R2 was unable to provide any details regarding the 11/25/25 event. R2's head, hands, and mouth moved uncontrollably during the interview. On 12/2/25 at 10:23 AM, V2 (Licensed Practical Nurse/LPN) stated R1 and R2 both went out the local hospital last week for medical evaluations. R2 has uncontrollable arm movements, and his hands were swinging around and hit R1. V2 said she did not witness it but heard about it during the morning report. V2 said R1 is confused and does not remember anything about it. R1 was not injured during the interaction. On 12/2/25 at 10:50 AM, V1 (Director of Nurses) stated R2 has a history of spastic body movements due to his diagnosis of extrapyramidal movement. He had an involuntary arm movement, and his hand brushed across R1's body. V1 said R2 was seated too close to R1 and his hand hit her face. V1 said the nurse on duty (V3) was present and witnessed the event. On 12/2/25 at 12:07 PM, V3 (LPN) stated he was seated at the nurses' station on 11/25/25 at around 6:30 PM. V3 said he looked up and saw R2's open hand come in contact with R1's face. V3 said it looked unintentional. V3 said he immediately intervened and separated both residents. V3 said R2's body was jumping up and down in his wheelchair. V3 said he has seen R2's body moving the same way in the past. R2's swings his arms around and can't stop the movement. R2 has had the movements since he was admitted (6/2024). V3 said staff try to keep R2 spaced away from other residents. V3 said an aide likely moved R2 too close to R1. It happened so fast there was no time to separate him. Plus, R2 is a tall man with long arms. They really didn't seem all that close, until after it happened. V3 said both residents were sent to the local emergency room. Both residents returned the same day with no injuries or new orders. On 12/2/25 at 12:24 PM, V4 (Certified Nursing Assistant/CNA) stated she was working the PM shift on 11/25/25. V4 said she did not see the event with R1 and R2 but heard V3 yelling Stop it. V4 said she ran down to the nurses' station and V3 had already separated R1 and R2. Both residents were seated in wheelchairs and looked like their normal, confused selves. V4 said R2 has lots of arm movements and has accidentally swung at another resident in the past. R2 has had the uncontrollable arm movements since she has worked there. R2 has a problem controlling his head and hands too. V4 said staff keep him away from other residents and put him in areas where he can't accidentally hit things. R2 sits in the dining room at a table by himself. V4 said the aides push residents in wheelchairs out of the dining room and place them by the nurses' station. Someone must have moved them out and they ended up next to each other. V4 said obviously no one was thinking about keeping R2 away from others that day. On 12/2/25 at 1:37 PM, V6 (CNA) stated R2 tends to have uncontrollable body movements. He is not always aware of his surroundings and his arms move by themselves. Some days the body movements are worse than other, but it goes on throughout the day. R2 will touch his face repeatedly and move his head around. V6 said we try to keep him away from other residents. We sit him alone, so his arms are not swinging out at others. R2's care plan showed a focus area related to impulsive arm movements and decreased coordination. Interventions included: Resident will be seated apart from others at least 3 feet to avoid others being hit.

Based on observation, interview, and record review the facility failed to provide R1 with the necessary care and services to maintain the highest practicable physical and psychosocial well-being for 1 of 6 residents (R1) reviewed for quality of care in the sample of 6.The findings include:On 10/27/25 at 10:35AM, R1 was lying in bed watching television. R1 sat up on the side of the bed and placed her feet on the floor. R1 said, a couple of weeks ago one of the CNAs (Certified Nursing Assistant) took my vital signs and said, I am going to help you with your shower. I told the CNA I can do it myself. I have been here 5 years and only needed someone to help me with my back. The CNA's hands were all over me. I told the CNA to stop. The CNA said, take it easy. In the past, the staff would provide privacy while I washed myself. The staff may have washed my back, now I have a back brush; no one is touching me again. When the CNA started washing me. I told the CNA to stop. The CNA thought I was being funny. I said, you are a sex maniac. You do not belong in the health field. I got myself dressed. I have not seen the CNA after that. When I do it myself, I do not have to rush. I do not have to worry about being looked at. I feel I do a better job. I feel so good, so clean, I am happy.On 10/27/25 at 12:16PM, V10 (CNA) said, R1 can wash independently. R1 will often give herself a sponge bath instead of taking a shower. There have been times where I will go to get R1 ready for the shower and R1 has already completed the bath. R1 does not like to be touched by anyone, ever. R1 refuses the skin check, always.On 10/27/25 at 2:35PM, V9 (CNA) said, staff will always be in the shower room with every resident. We allow the resident to be as independent as their ability allow. We want to maintain the resident's functional ability.On 10/28/25 at 10:15AM, V5 (CNA) said, I do not usually work on R1's unit. I'm the first CNA that showered R1. One of the nurses told me I cannot force the resident to take a shower. I explained to the nurse that I re-direct the residents. I re-directed R1. I explained the rationale and R1 agreed. R1 is alert. R1 knows what is going on. If R1 did not want the shower, R1 would be resistive. R1's Minimum Data Set, dated [DATE] shows, Brief Interview for Mental Status 15/15 Mentally Intact. No upper or lower extremity impairment. Shower: Supervision with touch assist.R1's Care Plan on 10/11/25 shows, Focus: The resident has an ADL self-care performance deficit. Date Initiated: 03/22/2019. Goal: The resident will maintain current level of function through the review date. Interventions: Encourage the resident to use bell to call for assistance. Praise all efforts at self-care. R1's Bathing/Shower preferences was not initiated in the Care Plan until 10/13/2025.R1's Abuse Investigation date 10/13/2025 shows, on 10/11/2025 V5 (CNA) made (R1) feel uncomfortable when the CNA offered to help. The CNA was not aware of R1's showering preferences.

Based on observation, interview, and record review the facility failed to ensure safe food handling practices were followed to prevent cross-contamination. This has the potential to affect all residents that receive food and nourishments from the kitchen. The findings include: Centers for Medicare and Medicaid form 671 dated 5/19/25, shows there are 88 residents that reside in the facility. On 5/21/25 at 10:40 AM, V10 (Director of Culinary Services) said at this time, all residents residing in the facility receive food, beverage, or nourishment from the kitchen at this time; even those receiving a tube feeding because they are ordered pleasure feeding. 1. On 5/19/25 at 11:25 AM, V11 (Cook) dropped a white cleaning towel onto the floor. V11 picked up the towel and continued to wipe down the food prep counter next to the oven, wipe down and clean a thermometer, clean down the prep counter that attaches in front of the steam table, and then placed the towel by the three-compartment sink. On 5/19/25 at 11:36 AM, V10 began the mechanical soft chicken process and used a green handle scoop to scoop portions of chicken into the food processor. When finished, V10 placed the scoop back into the food service pan of chicken with the food contact surface touching the chicken and the handle outside of the food. When V10 returned to the food service pan of chicken to remove portions for the puree chicken, V10 placed the scoop rim side down onto the prep counter that attaches in the front of the steam table, the same place that V11 cleaned with the towel that touched the floor. There was no additional cleaning of the prep counter after being wiped with the towel that touched the floor. On 5/19/25 at 11:49 AM, V10 started the puree process and used a gray handle scoop to scoop portions of rice into the food processor. When finished, V10 placed the scoop back into the food service pan of rice with the food contact surface touching the rice and the handle outside of the food. On 5/19/25 at 11:57 AM, V11 started to place lids on top of the steam table pans and removed all the scoops that were being stored in the food and placed them on top of the lids, uncovered. On 5/19/25 at 12:02 PM, V10 removed all the steam table lids and placed the scoops that were stored on top of the food service lids back into their respective food items. No new scoops for the rice or chicken were used before starting to serve. On 5/21/25 at 8:59 AM, V10 said after V11 dropped the rag, V11 should have immediately brought the rag to the disposal bin underneath the hand sink, washed V11's hands, then grabbed a new towel before cleaning again. V10 also said scoops that have already been used to serve or retrieve food from bins should be left with the food contact surface inside of the food until service has ended to prevent cross-contamination. 2. On 5/19/25 at 11:26 AM, V10 began pureeing creamed corn for lunch. During the process, V10 reached into the bulk bin of food thickener, grabbed the scoop, and scooped out a portion of food thickener to add to the creamed corn. When V10 lifted the food processor lid to pour the food thickener into the product, drops of creamed corn fell on to the scoop. V10 then used the same scoop and scooped out another portion of food thickener to add to the creamed corn. When finished, V10 returned the scoop to the bulk bin and hung it on the storage hook inside of the bin. On 5/19/25 at 11:42 AM, V10 began pureeing chicken for lunch. During the process, V10 reached back into the bulk bin of food thickener and grabbed the scoop that was used during the creamed corn process, with the creamed corn still on the scoop, and scooped out a portion of food thickener to add to the creamed corn. When V10 lifted the food processor lid to pour the food thickener into the product, drops of pureed chicken fell on to the scoop. On 5/21/25 at 8:59 AM, V10 said during the puree process, V10 did not see the food drop onto the scoop. If V10 saw the food drop onto the scoop, V10 would have either washed and sanitized the scoop before using it again or V10 would have grabbed a new, clean, and sanitized scoop to prevent cross-contamination.

Based on observation, interview, and record review the facility failed to ensure the bathroom was clean and homelike. This applies to 4 of 4 residents (R48, R50, R56, R60) in the sample of 18. The findings include: On 5/20/25 at 9:31 AM, during the resident council meeting, R48, R50, R56 and R60 said the first bathroom/shower room looks like there is mold on the ceiling, it's been like that for a while. There has been no maintenance staff over a month to fix repairs, the last one was fired. On 5/20/25 at 10:06 AM, in the bathroom/shower room on the first floor a brown/yellowish discoloration of dried water rings with pieces of peeled paint and drywall hanging from the ceiling above the toilet. On 5/21/25 at 10:55 AM, V1 (Administrator) said we don't have a maintenance staff right now, our permanent maintenance staff left in October 2024, since then we have hired a couple of new maintenance staff and they have not worked out. The bathroom ceiling does not have mold, there was a leaky toilet upstairs on the 2nd floor that caused the damage. We were waiting to repair the ceiling after we hired a new maintenance staff. The facility did not provide maintenance log for the last three months and did not provide a policy on maintenance repairs when requested.

Based on interview and record review the facility failed to document a numerical value for a peripherally inserted central catheter (PICC) measurements for 1 of 1 resident (R61) reviewed for intravenous (IV) access in the sample of 18. The findings include: R61's face sheet printed on 5/19/25 showed he was a [AGE] year-old male that had the diagnosis of osteomyelitis (bone infection). A facility assessment done on 4/10/25 showed R61's mental status was intact. On 5/19/25 at 12:19 PM, R61 said he was getting IV antibiotics for a bone infection through a PICC that had been removed. R61 said staff did not measure the catheter length or the circumference of his arm. R61's Medication Administration Records (MAR) for April 2025 and May 2025 showed an order to measure the catheter length of the PICC weekly from the insertion site to the tip of the cap and to call the doctor if the length changed more than 2 centimeters. Also, to measure the arm circumference weekly. The measurements were to be done on the following dates: 5/14/25, 5/7/25, 4/30/25, 4/23/25, 4/16/25, and 4/9/25. The MARs had a check mark documented with no numerical value recorded for the measurements. R61's Progress Notes for 5/14/25, 5/7/25, 4/30/25, 4/23/25, 4/16/25, and 4/9/25 did not have a documented numerical value for the measurements of the PICC length or arm circumference. On 5/20/25 at 1:11 PM, V7 (Registered Nurse) said PICC measurements are documented in the MAR or sometimes in the progress notes. V7 said measurements are done to see if the PICC line was pulled out or if the resident has arm swelling by comparing the measurements with a previous measurement. V7 added there should be a number documented for the measurements. The facility's Care and Maintenance of Central Venous Catheter policy dated 1/1/25 showed central lines will be placed after careful considerations of the risk and benefits of use. Risks associated with central line use include infection, deep vein thrombosis, and dislodgement.

Based on observation, interview and record review the facility failed to ensure a resident's splint/palm protector was in place to her left hand for 1 of 4 residents (R36) reviewed for splints/restorative care in the sample of 18. The findings include: On 5/19/25 at 10:30 AM R36 was in bed, asleep with no splint on her left hand. Again on 5/20/25 at 9:00 AM at 12:49 PM R36 was in bed with no splint on her left hand. R36's left hand is contracted in a closed fist position with her fingers pressing into her palm. On 5/20/25 at 12:55 PM V9 (Agency Certified Nursing Assistant) was asked about R36's left hand splint. V9 stated she didn't know anything about it and proceeded to take R36 out of the room in her reclining wheelchair and placed her in the dining room. On 5/21/25 at 9:32 AM V8 (Restorative Nurse) stated, I didn't know she didn't have it. It is a palm protector to keep her fingers from pressing into her palm. She takes it off with her other hand. I don't know where is was, I asked night shift to find it for me. R36's current Physician's Order Sheet shows an order dated 9/10/24 for Splint: Palm Protector for left hand. On during AM cares, off during PM cares. Remove for Hygiene, bathing. Monitor for redness and discomfort. R36's current care plan states, Restorative cna/rna splint program: Application and removal of palm protector for left hand. On during AM cares, off during PM cares. Remove for hygiene, bathing. Monitor for redness and discomfort. The Interventions include: Monitor resident compliance to use of device. Document and report refusals and or unscheduled removal by resident.

Based on interview and record review the facility failed to ensure anti-psychotic psychotropic medications had a stop date of 14 days for 1 of 6 residents (R15) reviewed for unnecessary medications in the sample of 18. The findings include: R15's face sheet shows she has diagnoses including cerebral infarction, unspecified dementia with psychotic disturbance and hemiplegia and hemiparesis. R15's Electronic Medical Record (EMR) shows she entered hospice care on 1/28/25. A Hospice Interdisciplinary Plan of Care completed on 3/20/25 shows an order for R15 to receive Risperdal (risperidone) (Anti-psychotic medication) 1 milligram (mg.) every morning and to continue PRN (as needed) Risperdal 0.5 mg. every 8 hours for agitation. There is no stop date identified. R15's EMR shows the hospice order for the PRN Risperdal was entered into the Physicians Orders with the following statement added, Do not discontinue without discussing with Hospice. A facility provided a not dated Medication Regimen Review Prescriber Recommendations shows the pharmacy had notified the facility on this form of the following for R15, CMS guidelines limit all PRN use of antipsychotics to 14 days and require prescriber examination/evaluation every 14 days to renew orders. Report of the resident's condition from staff to the prescribing practitioner does not constitute an evaluation. R15's Medication Administration Summary shows R15 received 9 doses of the PRN Risperdal on the following dates between 3/20/2025 and 5/21/2025 (3/22/25, 4/14/25, 4/15/25, 4/18/25, 4/27/25, 5/2/25, 5/9/25, 5/14/25, and 5/16/25). On 5/21/25 at 11:23 AM, V2 (Director of Nursing) said R15's medications are being managed by the hospice physician and she had attempted to contact R15's hospice provider for documentation showing that R15 had been re-assessed after 14 days but was not able to obtain those documents. V2 said she found where R15 had changes to the scheduled doses of Risperdal but could not find any stop dates for the PRN Risperdal after 3/20/2025. R15's EMR shows she was being seen by the facility Nurse Practitioner and they did not add any stop dates for R15's PRN Risperdal either. The facility provided Use of Psychotropic Medication Policy implemented on 3/11/25 states, PRN orders for antipsychotic medications only, shall be limited to 14 days with no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when providing high contact care activities for 2 of 18 residents (R7 and R36) reviewed for infection control in the sample of 18. The findings include: 1. R7's Face Sheet printed on 5/19/25 showed R7 had a gastrostomy (tube feeding). R7's Order Summary Report printed on 5/19/25 showed an order for enhanced barrier precautions related to an indwelling medical device of a tube feeding. On 5/19/25 at 9:50 AM, on R7's door was a sign that indicated R7 was on enhanced barrier precautions. The sign indicated staff were to wear gloves and gown for high contact care such as device care or use of a feeding tube. On 5/19/25 at 9:50 AM, R7 was in bed. V5 (Registered Nurse) was holding R7's tube feeding tubing while connecting a syringe that contained fluid to R7's tube feeding. V5 had on gloves. V5 did not have on an isolation gown. On 5/20/25 at 12:41 PM, V6 (Wound Care Nurse) said staff should put on gloves and gown when providing care or touching an indwelling urinary catheter or tube feeding tubing. R7's Care Plan (undated) showed R7 was on enhanced barrier precautions because of a tube feeding. Listed under interventions was apply personal protective equipment per facility policy. Staff to wear gloves and gown when providing direct nursing care. The facility's Enhanced Barrier Precautions policy dated 2/25/25 showed enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. PPE for enhanced barrier precautions is only necessary when preforming high-contact care activities. High-contact resident care activities include device care. 22499 2. On 5/20/25 at 12:39 PM V9 (Agency Certified Nursing Assistant) was providing care for R36. R36 has a gastrostomy tube and an indwelling urinary catheter. There was no sign for Enhanced Barrier Precautions (EBP) on R36's door. V10 dressed R36 and then emptied R36's foley catheter. V10 was not wearing a protective gown while providing care for R36. On 5/20/25 at 11:07 AM V3 (Assistant Director of Nursing/Infection Preventionist) stated, We in-service all the staff and they have to wear PPE, gown and gloves when providing direct care (for resident's on EBP). They should have signs on the resident doors (showing EBP). R36's current Physician's Order Sheet shows and order for Enhanced Barrier Precautions related to indwelling device (urinary catheter and feeding tube).

Based on observation, interview, and record review the facility failed to ensure a resident consumed their medications when administering medications for 1 of 18 residents (R42) reviewed for pharmacy services in the sample of 18. The findings include: R42's Care Plan with an initiated date of 4/24/24 showed R42's memory is or may be impaired. Consequently, the resident has problems with decision-making, insight, logic, calculation, reasoning, planning, and judgement. On 5/19/25 at 9:37 AM, R42 was in bed. On the bedside table was a clear medication cup with 4 pills (one white, one yellow, and two brown). R42 said he had not received his morning medications. R42 was asked about the pills on his bedside table. R42 said he was not aware there were pills sitting on his bedside table. R42 added sometimes staff will leave his medication on the bedside table for him to take later. On 5/19/25 at 10:21 AM, the pills remained on R42's bedside table. On 5/19/25 at 10:50 AM, the pills were no longer on R42's bedside table. On 5/19/25 at 11:09 AM, V5 (Registered Nurse) said he noticed the pills sitting on R42's bedside table. V5 said the pills were not from his shift and he disposed of the pills. V5 said sometimes R42 will ask staff to leave his medications at his bedside. V5 added staff should not leave medications at the bedside. They should stay with the resident to ensure the resident takes the medication. R42's Care Plan and Order Summary Report printed on 5/19/25 did not indicate R42 could self-administer medications. The facility's Medication Administration policy (undated) showed when administering medications staff were to observe residents consume the medication.

Based on observation, interview, and record review the facility failed to ensure insulin pens were properly stored and labeled for 2 of 18 residents (R60, R78) reviewed for medication storage in the sample of 18. The findings include: On 5/20/25 at 12:17 PM, the first-floor medication cart was reviewed with V15 (Registered Nurse). Inside the medication cart in the top drawer there was a 1/4 full (Lantus) insulin pen that had no resident name or open date on it and a Humalog Kwik pen belonging to R78. The pen was not opened and the packaging the pen was in was clearly labeled Refrigerate. V15 verified the Humalog was a new unopened insulin pen and should be kept in the refrigerator until it is open for use. V15 also was unable to verify whose (Lantus) insulin pen was inside the cart that was not labeled and said all insulin pens should be clearly labeled with who it belongs to and the open date. On 5/21/25 at 7:30 AM, V2 (Director of Nursing) said that the insulin pens should clearly be labeled and dated when opened and any insulin pen that is new should be kept refrigerated until it is used. A list of residents receiving Lantus insulin on the 1st floor was provided from the facility and it shows R60 and R78 both received the insulin, and the unlabeled pen could have belonged to either one of them. R60's and R78's Physician Order Summaries both show they have current orders for Lantus insulin pens and R78 also has an active order for Humalog (lispro) insulin. The facility provided Insulin Pen policy shows that the pens must be clearly labeled with the resident's name and the date opened, and any unopened insulin pens should be stored in the refrigerator.

Based on observation, interview, and record review the facility failed to ensure dietary supplements were provided for 1 of 6 residents (R22) reviewed for weight loss in the sample of 18. The findings include: R22's face sheet shows she has diagnoses including dementia. R22's Weight Summary shows she weighed 116.4 pounds (lbs.) on 4/1/24 and she weighed 108.3 lbs. on 3/3/25 a 8.1 lb. 7.75% weight loss in 1 year. R22's 3/12/24 Dietary Note completed by V12 (Dietician) shows that R22 has had some weight fluctuations possibly due to dementia. The Dietary Note shows that supplements to promote higher protein and calorie consumption had been added prior to the weight change including yogurt 6 ounces with meals, skim milk three times a day with meals, double eggs at breakfast, and a new dietary supplement of peanut butter and jelly sandwiches with meals was added. On 5/19/25 the noon meal service on the 1st floor was observed. At 1:20 PM R22's meal tray was brought out to her, and staff assisted R22 to start eating and sat at the table with her. On R22's meal tray was a copy of her meal ticket that said 6 ounces of yogurt should be given (if available) with her lunch. There was no yogurt on R22's meal tray and at no time did facility staff go to get one for R22. On 5/20/25 at 12:44 PM during meal service R22 again did not have yogurt on her meal tray. V14 (Certified Nursing Assistant) was sitting at the table R22 was eating at. V14 said they must encourage R22 to wake up and eat but she will eat it just takes her a while. R22's current Weight Loss care plan shows that supplements should be given as ordered. R22's Physician Order Summary shows R22 should receive calorie and protein supplements per dietician recommendation. On 5/20/25 at 1:12 PM, V10 (Director of Culinary Services) said the facility does have yogurt available and if a resident has an order for yogurt with meals it should come out from the kitchen on the meal tray. On 5/21/25 at 7:35 AM, V12 (Dietician) said R22 did trigger for a significant weight loss at one point but they questioned the validity of that earlier weight because it was high for R22. V12 said she did see R22 in March for weight loss and added another supplement. V12 said R22 has been on the yogurt for increased protein and calorie, and she expects the facility to offer the supplement to R22 with her meals because if R22 does eat the yogurt it is good for her.

Based on observation, interview, and record review, facility failed to wash hands and change gloves in a manner to prevent cross contamination and failed to wear personal protective equipment (PPE) during care on a resident on enhanced barrier precaution to 2 of 18 residents (R8, R61) reviewed for infection control in the sample of 18. The findings include: 1. On 06/11/24 at 9:20 AM, V10 (Certified Nursing Assistant-CNA) provided incontince care to R8. V10 removed R8's incontinent brief that was totally soaked with urine. R8 also had a large bowel movement. After providing incontince care and wearing the same soiled gloves and without performing handwashing V10 applied barrier cream to R8, applied new incontinent brief, turned R8 side to side, adjusted R8 in bed, applied new pants to R8 and pulled R8's privacy curtain. V10 then collected the soiled linens and left R8s' room still without removing her soiled gloves and without washing her hands. On 6/12/24 at 9 AM, V11 (Registered Nurse-RN) said staff should change their gloves and wash hands in between care. Once soiled gloves are removed, handwashing should follow to prevent cross contamination and spread of infection The facility policy entitled Hand hygiene/Handwashing dated 5/23 show, hand hygiene means cleaning your hands by handwashing (washing hands with soap and water). Hand hygiene will be performed after removing soiled gloves. 34117 2. On 6/10/24 at 11:27 AM, a sign posted on R61's door for enhanced barrier precautions. R8 was laying in his bed with a gastric tube in place to his abdomen. V7 and V9 (Both Certified Nursing Assistant's) entered R8's room without donning a gown. V7 and V9 provided incontinence care, applied barrier cream, and transferred R8 from his bed to a recliner chair using a mechanical lift. On 6/12/24 at 9:15 AM, V8 (CNA) said staff should wear gown and gloves when providing direct care if a resident is on enhanced barrier precautions. R61's Physician Order Sheets dated June 2024 shows orders for enhanced barrier precautions related to presence of g-tube. The facility's Enhanced Barrier Precautions Policy dated 3/2025 states, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions (EBP) refer to an infections control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities high contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting .

Based on observation, interview and record review the facility failed to ensure a residents prescribed medication was available to administer. This applies to 1 of 7 residents (R6) reviewed for pharmacy services in the sample of 18. The findings include: On 6/11/24 at 9:16 AM, V5 (Licensed Practical Nurse-LPN) during the morning medication pass, Did not administer R6's Depakote 500 mg (milligrams). She said she is out of R6's Depakote and will have to re-order the medication. V5 said she usually re-orders medications when there's about five pills left. If we tell the phamracy we need the medication STAT they will send it right away. R6's Medication Administration Record (MAR) dated June 2024 shows orders for Depakote ER oral tablet extended release give 500 mg two times a day at 9 AM and 5 PM. R6's MAR shows the Depakote was not administered on 6/11/24 (R6 missed two doses). On 6/12/24 at 9:17 AM, V2 (DON) said staff should check the medication convience box if they do not have the medications. V2 said she is not sure if Depakote is located in the convenience box. If the staff do not have the medication they should notify the physician and order the medication STAT thru pharmacy. V5 did not tell me yesterday R6 did not have her Depakote and confirmed Depakote is not located in thier conveinence box, V5 should have ordered the medication STAT. The facility's undated Medication Administration Guidelines Policy states If a medication with a current active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit.

Based on observation, interview, and record review the facility failed to apply devices to residents with physical limited mobility to 2 of 2 residents (R37, R61) reviewed for range of motion in the sample of 18. The findings include: 1. R37's Physician Order Sheet (POS) show R37 has diagnoses that include hemiplegia (paralysis) affecting right dominant side due to stroke. The same POS show an order of, Right resting hand splint to right hand. On after breakfast and off after supper daily. remove for grooming, and bathing and prn as needed. Monitor for redness /discomfort or skin changes. R37 also has an order of [R37] to wear sling when up in wheelchair to hold her right arm from falling down to side. On 6/10/24 at 12:36 pm, R37 was in the dining room for lunch. As soon as R37 saw this surveyor R37 used her left hand to lift her right hand showing this surveyor her contracted right hand. V12 Certified Nursing Assistant (CNA) who was with R37 said R37 should have a splint in her right hand. This surveyor asked R37 if she was referring to her hand splint and R37 nodded 06/11/24 at 9:30 AM, R37 was again in the dining room for activities. R37 again showed this surveyor her right hand, still, no splint or device to her right hand. V12 (CNA) said she has been looking for R37's splint since yesterday, she will check R37's drawer. At 10 AM, V6 (Restorative Nurse) said R37 has flaccid right hand and needs the splint and the sling to hold R37's right hand in place and prevent further decline. The facility policy entitled Application of Splints dated 1/3/24 show to properly apply a splint for support, comfort or aid in contracture prevention 34117 2. R61's Physician Order Sheets (P.O.S.) dated June 2024 shows he is a [AGE] year old male with diagnoses including hemiplegia and hemiapresis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarct, hypertension, gout and chronic kidney disease. The P.O.S. shows orders for sling to arm when up in the chair. On 6/10/24 at 10:35 AM, R61 was lying in his bed. His left arm was bent upward resting on his chest. He said he can move his right hand, but can not move his left arm. There was no sling observed in his room. At 11:27 AM, V7 and V9 (Certified Nursing Assistant-CNA's) transferred R61 into his recliner chair and wheeled him in the dining room. V7 and V9 did not apply a sling to his left arm. On 6/11/24 at 1:49 PM, V5 (LPN) said R61 has limited mobility to his left arm, he can't move it too much. When he gets up in the chair he is supposed to wear a splint. On 6/11/24 at 2:00 PM, V6 (Restorative Nurse) said R61 has limited mobility to his left side and should have a sling in place when he is in the chair. R61's Restorative assessment dated [DATE] documents his left and right shoulder, right and left elbow, left and right hand/wrist, are within normal limits. The same assessment shows he is dependent on staff for bed mobility, transfers, toileting, personal hygiene and bathing.

Based on observation, interview and record review the facility failed to ensure a resident who requires assistance with toileting received incontinence care. This applies to 1 of 4 residents (R47) reviewed for activities of daily living in the sample of 18. The findings include: On 6/11/24 at 9:36 AM, R47 was laying down in her bed. A strong permeating smell of urine was present. R47's gown, bed pad, and bed sheet were soaked with urine. R47 said it takes a long time to get help. At 9:47 AM, V8 (Certified Nursing Assistant) came in the room to assist R47 to the bathroom. V8 stated, your soaking wet, I'm so sorry. V8 said she did not change R47 yet, she was busy. R47 was her last resident who needed to be changed. On 6/12/24 at 9:15 AM, V8 (CNA) said residents should be checked and changed every two hours. The facility's Activities of Daily Living Policy dated 2021, states, the facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. the facility will provide care and services for the following activities of daily living: a hygiene,-bathing, dressing, grooming and oral care a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review the facility failed to ensure residents funds were refunded after discharge for 1 of 6 residents (R1) reviewed for personal funds in the sample of 6. The findings include: R1's electronic face sheet show [AGE] year-old male admitted to the facility on [DATE] with diagnoses that include cervical disc disorder with myelopathy, quadriplegia C1-C4 and diabetes. R1 was discharged more than a year ago-11/22/2022 under medicaid/social security. On 2/13/24 at 12:16 PM, V7 (Business Office) said R1's social security check went to his personal account to pay for his stay at the facility (cost care). V7 said R1 was discharged last 11/22/22. V7 said R1's social security check came on 12/2/22 after R1 was already discharged from the facility. V7 said it was only refunded to R1 approximately 2 weeks ago-1/30/24, (more than a year after R1 was discharged ) when she received a call from R1's family and asked about his Social Security check for the month of December 2022. V1 (Asst Administrator) said the facility normally does not issue a check of residents funds when a resident transfers to another facility because the resident might not stay at that facility. V1 agreed that a year to refund R1's social security check was too long. A form entitled Resident Fund Management Service Authorization and Agreement to Handle Resident Funds dated 2/15/2018 show R1 signed (X) with witness, and elected direct deposit of her social security funds with the facility's management service R1's Resident Statement provided to this surveyor on 2/13/24 show, 11/18/22 (R1's) account closed. On 12/2/22 a Social Security check was deposited to his account in the amount of $965.00. A check in the amount of $932.00 was issued to R1 on 1/30/24 more than a year after R1 was discharged .

Based on observation, interview, and record review the facility failed to safely transfer a resident (R1). This failure resulted in R1 being hit in the head with the arm of the mechanical lift, resulting in a large skin tear, being admitted to the hospital, and requirng sutures to her head. This applies to one of three residents (R1) reviewed for safety in the sample of five. The findings include: The facility assessment dated [DATE] shows R1 to be cognitively intact, requires maximum assistance for her activities of daily living and uses a mechanical lift for her transfers. On 12/21/23 at 11:15 AM, R1 said she was being lifted from her bed to her wheelchair using the mechanical lift. R1 said as she was being lowered to her wheelchair, the arm bar on the lift hit her in the head. R1 said she saw stars and was in a lot of pain. R1 said she had to be taken to the hospital for sutures, and had to spend the night and have scans to her brain to rule out a brain injury. R1 said she was very scared and in a lot of pain after the incident. On 12/21/23 at 12:15 PM, V8 Certified Nursing Assistant (CNA) said she was one of the two CNA's transferring R1 when she hit her head. V8 said she was directing the lift and the other CNA (V10) was guiding R1 into her chair. V8 said after R1 was in the chair she moved forward and hit her head on the bar. On 12/21/23 at 12:40 PM, V10 said he was assisting with the transfer of R1 into her wheelchair. V10 said R1 hit her head on the lift bar and it began to bleed. V10 said it happened so fast, but he did not remember where he was during the transfer. On 12/21/23 at 2:23 PM, V2 Licensed Practical Nurse (LPN) said he does the staff training for the mechanical lifts and the staff are trained to always have two staff present, one staff is to drive the lift and the other staff is responsible for guiding the resident safely to their chair or bed. V2 said the lift used for the incident was pulled from use. It was inspected and a padding was added to the arm of the lift. Observations of the facility mechanical lifts was completed on 12/21/23. Numerous mechanical lifts were observed in the facility. Only one lift was observed with padding to the arm of the lift and was located on the first floor. R1 resides on the second floor. A mechanical lift was observed outside R1's room, but no padding was observed to the arm of the lift. The facility report regarding the incident dated 11/23/23 shows R1 recieved a skin tear to her right forehead measuring approximately 10 centimeters. A pressure dressing was applied, 911 was called and R1 was sent to the local hospital. The emergency room report dated 11/23/23 shows R1 had a mechanical lift dropped on her head, which required nine staples and 14 sutures to her right forehead and scalp. The open area was reported to be approximately 12 centimeters in length. R1 was kept at the hospital overnight to rule out brain injury. The facility total mechanical lift competency checklist with a revision date of 4/2008 shows a).two caregivers are present during the transfer, h) gently raises the resident minimally from surface, i). turn resident legs toward the perpendicular support bar during the move and j). gently lower the resident into proper position.

Based on interview and record review the facility failed to ensure a resident was assisted in safe manner to prevent injury for 1 of 3 residents (R1) reviewed for safety in the sample of 4. This failure resulted in (R1) sustaining a fall and receiving a right ankle fracture. The findings include: R1's face sheet shows she has diagnoses including: Parkinsonism, anxiety disorder, auditory and visual hallucinations, and a history of falls. R1's current care plan shows on 10/6/23 Impaired Memory care plan was initiated which says R1 is having impaired memory and problems with decision-making, insight, logic, calculation, reasoning, planning and judgement. R1's active Fall Risk care plan initiated 3/9/17 shows R1 is at risk for falls and she requires a one person assist for transfers. R1's active Transfer-Restorative care plan initiated on 3/9/17 shows R1 is unable to transfer independently and requires a one person assist and a gait belt for transfers. R1's Physical Therapy Progress Report from 10/27/23-11/13/23 shows that she requires partial to moderate assist supervision and touching with transfers to and from bed, chair, wheelchair and the toilet. R1's Electronic Medical Record (EMR) show the following progress notes: 11/16/23 at 5:04 PM, physician progress note completed by V12 (Nurse Practitioner/NP) states, Patient {R1} seen for a rehab follow-up. She was recently hospitalized for altered mental status, she is feeling tired and appears to be more lethargic. Needs min/mod assist from staff for positioning and activities of daily living (ADLs). High fall risk: follow all facility fall precautions. 11/22/23 at 5:54 PM, nurses note completed by V5 (Registered Nurse/RN) states, CNA (Certified Nursing Assistant) notified resident fell in the bathroom, writer checked the resident and found on the floor. Per CNA was trying to clean the resident after a BM (bowel movement) resident holding the rails with the standing position and per CNA moved for wipes at that time resident loosing balance and fell . CNA notified can see the resident twisting the right ankle. Resident cannot move right leg, has pain in the right ankle. Resident alert but confused and lethargic. Called 911 and resident sent to (a local emergency room ). 11/22/23 10:36 PM, nurses note completed by V5 shows R1 was admitted to the hospital and has a diagnosis of a Bimalleolar ankle fracture, acute kidney injury and dehydration. Hospital records from a local community hospital dated 11/23/23 show that R1 presented to the emergency room for evaluation after a fall at the nursing facility. She complained of right hip and right ankle pain and was diagnosed with acute mildly displaced fractures of the medical and lateral malleoilli. Surgical intervention was not required. On 11/30/23 at 8:35 AM, R1 said she is unable to recall the incident when she fell and doesn't recall a CNA in the bathroom with her. She said prior to her fall she could stand with staff help to get into her wheelchair and use the toilet, but now she cannot. On 11/30/23 at 8:48 AM, V4 (Restorative Nurse) said in the month or so prior to R1's recent fall she had been more depressed and slowed down due to the death of her husband. V4 said R1 has been a 1 person assist with a gait belt for toileting. V4 said gait belts should be used by all staff for resident transfers and ambulating. He said he does investigate resident falls to determine the cause but he has not yet spoken with V7 who is an agency CNA that was in the bathroom with R1 when she fell . V4 said he was told by the nurse on duty (V5) that V7 was cleaning stool off of R1's bottom and had turned away from R1 to get [NAME] wipes and R1 fell . On 11/30/23 at 9:20 AM, V7 (Agency CNA) said R1 had put the call light on in her bathroom and she went in to assist her. R1 had stool on her bottom and needed help to clean it off so V7 had R1 grab the bar on the wall in the bathroom and stand up. V7 said she was cleaning R1's bottom and needed more wipes so she turned away and left R1 standing by herself at the grab bar and went to the sink area in the bathroom and got more wipes. By the time she turned back around she saw R1, she was already falling and she saw R1's ankle twist. V7 said she was not aware that R1 was a fall risk and needed a 1 person touch assist and a gait belt for transfers. V7 said she believes to an extent had she used a gait belt it would have prevented R1's fall and had she known she was a fall risk and required a 1 person transfer assistance she would not have left her standing at the bar alone to get wipes she would have pulled the call light and gotten another staff person to assist her. On 11/30/23 at 9:27 AM, V5 (RN) said she was called to come to the bathroom by V7 because R1 had fallen in the bathroom. V5 said V7 told her that she was cleaning stool off of R1 and turned to get wipes and R1 fell . V5 said the facility protocol is for gait belts to always be used to assist residents to transfer and all staff should know to use them. V5 said since V7 was from agency maybe she didn't know to use one. On 11/30/23 at 9:33 AM, V3 (Medical Director and R1's physician) said he was out of town when R1 fell but his team was notified and followed R1 at the hospital. V3 said this type of ankle fracture is consistent with a fall. He said the CNA should have followed facility protocol and used a gait belt to assist R1 and he believes it could have helped the CNA prevent R1 from falling. On 11/30/23 at 10:45 AM, V11 (Physical Therapist) said R1 had a recent decline but was improving at the time of her fall. V11 said R1 required 1 person, a contact guard assist and the use of a gait belt for transfers. She said R1 should not have been left standing at the bar without support. On 11/30/23 at 11:01 AM, V2 (DON) said a gait belt is considered part of a staff uniform and V7 should have known to use it. V2 said she was not aware that V7 did not use a gait belt because she has not be able to get in touch with her until today. The facility provided and not dated, Gait Belt policy says that gait belts should be used by all staff and are used to prevent injury during transfers and ambulation.

Based on observation, interview and record review, the facility failed to identify and assess prior to developing unstageable and stage 3 pressure injuries. These failures resulted in R49 developing multiple unstageable pressure injuries. The failure also resulted in R49 developing a [CONDITION(S)] infection in R49's sacral wound. This applies to 2 of 5 residents (R49 & R58) reviewed for pressure injuries in the sample of 18. The findings include: 1. R49's face sheet lists his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R49's face sheet shows, he was admitted to the facility on [DATE]. R49's skin observation tool dated June 2, 2022 on admission shows, he had a stage two pressure injury to his coccyx. There were no other pressure injuries documented on the initial skin assessment. R49's skin impairment/wound form dated June 8, 2022 (6 days after admission) shows, Initial Findings: stage 4 pressure injury: full thickness skin and tissue loss to sacrum. Measurement of wound (Length X Width X Depth): 7.5 cm (centimeter) X 7.5 cm X 2.0 cm. 50% slough, 25% eschar (dead tissue), Other: exposed tissue: muscle. Moderate serosanguineous drainage. Additional wound: Stage 4 pressure injury: full thickness skin and tissue loss to left heel. Measurement of wound: 1.0 cm X 1.0 cm X 0.1 cm. R49's wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R49 was only admitted with a stage 2 pressure injury to coccyx/sacrum. R49's census report shows, he was sent to the hospital on July 6, 2022 and readmitted to the facility on [DATE]. R49's skin observation tool on re-admitted d July 11, 2022 shows, Description: stage 4 coccyx, fresh dressing present, redness to buttocks, back thighs, areas to bilateral heels. Specialty equipment is in place as ordered? none ordered. What equipment is ordered: not applicable. There is no assessment of R49's wounds. R49's skin impairment/wound form dated July 13, 2022 (2 days after re-admission) shows, deep tissue pressure injury persistent non-blanchable deep red, maroon or purple discoloration to right ischial. R49's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Measurements: 15 cm X 17.5 cm X 2 cm. 60% granulation, 20% necrotic/eschar and color, 20% slough and color. Wound 2: pressure left heel unstageable. Measurements: 4 cm X 3.5 cm X 0.1 cm. 40% granulation, 50% black necrotic/eschar and color. Wound 3: pressure right ischial deep tissue injury. Date reported: July 13, 2022. R49's census report shows, he was sent to the hospital on July 23, 2022 and returned to the facility on [DATE]. R49's skin observation tool on re-admitted d July 27, 2022 shows, Stage 4 coccyx, slight bruising to bilateral arms, areas to bilateral heels. There is no other documentation or assessments of wounds on re-admission. R49's progress notes dated July 28, 2022 shows, resident readmitted back to the facility with unstageable pressure injuries to left heel, to right back, and coccyx. Treatment orders in place . Another progress note on the same date shows, pressure injury to right buttock has changed from DTI to unstageable, and new pressure injury to right back unstageable post hospitalization . There are no assessments on re-admission on July 28, 2022. R49's census report shows, he was sent to the hospital on July 31, 2022 and returned to the facility on [DATE]. R49's skin observation tool dated August 2, 2022 (while he was in the hospital) shows, left heel, unstageable, sacrum, treatment in progress. See progress notes, other right ischial and right back. R49's re-admission data collection tool dated August 9, 2022 shows, Skin Condition: right buttock- open wound, left buttock- open wound, right thigh-redness, left thigh-redness, right heel-black discoloration, left heel-black discoloration, left gluteal fold-open wound, right gluteal fold- open wound. The right heel that was first documented by the facility on July 11, 2022 is now an unstageable upon re-admission. There are no assessments of right heel when first discovered on July 11, 2022. There is nothing documented about the right back unstageable wound. There are no assessments of any wound on re-admission. R49's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound 2: pressure left heel unstageable. 6 cm X 4.5 cm X 0.1 cm, 100% necrotic/eschar color, Wound 4: pressure right ischial stage 3, 4.5 cm X 3 cm X 0.2 cm 50% granulation, 30% slough. Wound 5: pressure right heel unstageable, 3 cm X 3.5 cm X 0 cm, 100% necrotic/eschar color. Wound 6: pressure left ischial stage 2, 3 cm X 2 cm X 0.1 cm. Wound 7: pressure low right back unstageable, 7 cm X 5 cm X 0.2 cm, 50 % yellow/ necrotic/eschar color. R49's census report shows he was sent to the hospital on September 5, 2022 and readmitted on [DATE]. R49's re-admissions data collection tool dated September 9, 2022, shows nothing for skin conditions. There are no assessments documented. R49's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R49's skin impairment/wound form dated October 11, 2022, shows Initial findings: left lateral leg unstageable pressure injury: obscured full-thickness skin and tissue loss. 4 cm X 4 cm X 0 cm. 80% eschar. Additional wound: right lateral leg unstageable pressure injury: obscured full-thickness skin and tissue loss. 5 cm X 5 cm. 80% eschar. R49's progress notes dated October 11, 2022, shows Resident has unstageable pressure injuries to left and right leg due to heel protectors. Heel protectors removed and treatment in place. Will use pillows to offload heels. R49's census report shows he was sent to the hospital on October 11, 2022 and readmitted to the facility on [DATE]. R49's re-admission data collection tool dated October 18, 2022, shows nothing for skin conditions. There are no assessments documented. R49's progress notes dated October 21, 2022 (3 days after re-admission), shows skin check post hospital stay. Resident seen by wound care NP. See progress notes . Pressure injures to sacrum, left heel, right ischial, right heel, right lower back, left lateral leg, and right lateral leg. Resident currently on isolation for [CONDITION(S)] in the wound. Has ongoing IV (intravenous) antibiotic therapy . On October 24, 2022 at 11:13 AM, R42 was lying in bed on his back. He had gray boots on his feet that went up to just below his knee. He was on contact isolation for [CONDITION(S)] in his sacral wound (infection). At 11:45 AM, V13 (R42's wife) stated he has two new pressure injuries to his lateral legs because the boots caused friction. He is not supposed to be wearing those boots anymore. (He was wearing the boots that caused the friction/wound to his lateral legs). On October 26, 2022 at 9:09 AM, R42 was lying in bed. V4 (Wound Care Nurse) was changing the dressings on his wounds. His right lateral back had a large tennis ball-size open wound. There was yellow and pink tissue inside of the wound. The area around the wound was red. He had a grapefruit-sized open area to his sacral area. There was yellow and black tissue inside the wound. The area around the wound was red. His right ischial had approximately half-dollar-sized open area with yellow tissue inside the wound. The area around the wound was red. His right lateral leg had two wounds that were black in color. One was the size of a dime but elongated. The second was smaller than a dime and elongated. The left lateral leg had a dime-sized wound that was black in color. Both heels were a little bigger than a half dollar in size. Both had a large amount of bloody drainage. They were red and bloody in color. On October 25, 2022 at 3:17 PM, V4 (Wound Care Nurse) stated, if she wasn't here when R49 was readmitted then there are no assessments until she came back to work. The nurses are able to do the assessments but didn't do them. R49 developed his lateral leg wounds from the boots he was wearing because they were rubbing on his skin. He is high risk for pressure injuries. R49's Minimum Data Set, dated dated dated [DATE], shows he is cognitively intact and requires extensive assist of one person for bed mobility, total dependence of two people for transfers, and total dependence of one person for toilet use. R49's care plan initiated on June 7, 2022 (admitted was June 2, 2022) shows, Focus: The resident was admitted with a stage 4 to sacrum, unstageable to left heel, unstageable right ischial, unstageable right heel, and stage 4 to right low back (initial admission assessments show he was only admitted with a stage 2 on his sacrum. Skin observations show left heel, right low back, right lateral leg, left lateral leg and right ischium developed in the facility) related to impaired mobility, weakness, friction, and shear. Interventions: Antibiotic for [CONDITION(S)] (date initiated July 23, 2022), assess, record, monitor wound healing every shift. Report improvements and declines to the MD (medical doctor), monitor/document/report PRN (when needed) any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth), stage (date initiated June 7, 2022). R49's care plan initiated on June 2, 2022 shows, Focus: The resident has potential for impairment to skin integrity. Co-morbid conditions, presence of [CONDITION(S)], impaired mobility/strength. Interventions: follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's pressure ulcer prevention effective date November 28, 2012, shows, Purpose: To prevent and treat pressure injury (s). If a PU/PI (pressure ulcer/pressure injury) is present, the facility will provide treatment and services to prevent infections and development of additional PU/PUs . Guidelines: 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. The facility's management of wounds (no date) shows, Policy: Our mission is to facilitate resident independence, promote resident comfort, and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective wound management program, allowing our residents a means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. 1. Assessing the resident: Since the assessment is the beginning of any wound management program, it is the policy of this facility to assess the entire person, not just the wound. It is on this assessment that the plan of treatment will be based. This assessment will begin at the time of admission and will continue throughout the resident stay. It will include the resident physical health, common risk factors, nutritional status, and wound pain level. This assessment will be done using the following policies: Pressure injury risk assessment: to be done on all residents on admission, weekly for the first four weeks, then quarterly and with change in cognition or functional ability using a valid pressure ulcer risk assessment tool. Skin assessments: to be done according to the skin assessment protocol schedule. Nutritional and hydration screening: to be done on admission, quarterly, with a significant change, for any resident with a current wound or Braden less than 12, and when wound stalling has occurred. 2. Assessing the local wound condition: It is the policy of this facility to use a uniform wound assessment that will provide a consistent means of wound evaluation. This assessment will facilitate continuity of care and communication among staff. This documentation will be completed using the following: Wound assessment policy and procedure. 2. R58's face sheet shows she is a [AGE] year old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R58's Minimum Data Set assessment dated [DATE] shows she has moderately impaired cognitive deficits, no rejection of cares, and is total dependent on staff with two persons assist with bed mobility and transfers. R58's Skin Braden Scale assessment dated [DATE] shows she is a high risk for developing pressure sores. On 10/24/22 at 9:39 AM, R58 was lying in her bed. V4 (Wound Care Nurse) assisted R58 on to her side, a foam dressing was in place to her right upper shoulder, and a foam dressing in place to her sacrum. V4 said R58 has an acquired stage 3 pressure ulcer to her right shoulder. On 10/24/22 at 2:02 PM, V4 said R58 is total dependent on staff for care, repositioning, and a high risk for developing pressure ulcers. In March 2022, she developed a stage 3 pressure ulcer to her right shoulder blade area from the friction of the wedge cushion against her skin. V4 said they are now using a soft pillow for positioning. R58's wound progress notes dated 10/19/22 documents a stage 3 pressure ulcer to the right upper back measuring 5 cm (centimeters) x 6.5 cm x 0.9cm. R58's wound progress note dated 3/16/22 documents a new acquired stage 3 pressure ulcer to the right shoulder measuring 1.2 cm x 1 cm x 0.1 cm. The same note showed to avoid bony prominences under direct pressure. The facility's Pressure Ulcer Prevention Policy revised 8/2022 states, To prevent and treat pressure injury (s). If a pressure ulcer/pressure injury is present, the facility will provide treatment and services to prevent infections and development of additional pressure ulcers/pressure injures. A Braden assessment will be completed upon admission, weekly and first four weeks after admission .inspect skin daily, turn dependent residents approximately every two hours, or as needed and position with pillow or pads protecting bony prominences .

Based on observations, interviews and record reviews the facility failed to provide adequate supervision during snack/meal time for one resident (R1) who needs supervision and assistance with activities of daily living (ADL), this failure resulted in R1 sustaining first and second degree burns to left abdomen and left thigh. The facility also failed to supervise and prevent a fall for one cognitively impaired resident (R5) who is high risk for falls. This failure resulted in R5 sustaining a fracture during a fall incident. Both residents (R1 and R5) are two of the three residents reviewed for incidents with injury inside the sample of 17. Findings include: 1. R1 is a [AGE] year old female who has multiple medical [DIAGNOSES REDACTED]. Based on R1 ' s Minimum Data Set ((MDS) dated [DATE], R1 needs supervision and assistance with Activities of Daily Living (ADL). Incident report dated 6/14/14 at 3:50 PM indicated; 1. R1 tried to grab the cup of hot soup with her bad (weak) left hand and bumped it and cup fell over. R16 has diabetic neuropathy with some weakness to left side. 2. R1 reported to nurse that she reached for her cup of soup with her left hand and accidentally spilled on her (R1's) left side of abdomen and thigh. Areas were reddened and blistered. Primary physician was notified and initially gave treatment order but due to multiple allergies [REDACTED]. The investigation report dated 6/14/14, E16 (Certified Nursing Assistant/CNA) reported at 4:00 PM, R1 asked E16 to heat some soup in the microwave. The soup was so hot, E16 put ice cubes to cool it a little. The soup was still a little hot. R1 said okay. E16 placed the soup down on R1's bedside tray and walked out. On 6/17/14 to 6/18/14 R1's right side of bed was positioned against the privacy divider wall. A rolling bedside table was in front of R1, but positioned more on left side of bed. On 6/17/14 around 1:00 PM to 2:00 PM, R1 was in bed, talked in a low inaudible tone but able to demonstrate clearly how she reached for the soup and how she dropped it. On 6/19/14 at 10:15 AM R1's left side of bed was repositioned against the window. E4 (Nurse) stated, it's better that way/safer that way so R1 can use her right hand/arms more. E4 rendered wound care to R1. R1 has first and second degree burns to left abdomen and left thigh. The center of the burns are second degree and covered with blisters and measured as follows; Left Abdomen- Length (L) 1.5 centimeter (cm) X Width 5 cm and Left Upper Thigh- (L) 13 cm X (W) 31 cm. On 6/18/14 at 10:10 AM Z1 (Wound Care Physician) stated R1 sustained burns from incident. First and second degree burn to left lower abdomen and left thigh. The center are second degree and the surrounding areas are first degree burns. On 6/19/14 at 12:05 PM R1 stated, the noodle soup was boiling hot. E16 placed the soup in front of R1 in the bedside rolling table and left the room. The table was not very near to R1. So R1 reached over and grabbed the soup with her left hand. Soup was too hot, R1's left hand and arm was too weak. R1 accidentally dropped the soup. The noodles covered R1's left thigh. R1 screamed in pain. That's how staff heard her (R1). E16 left the room without ensuring hot soup was within R1's reach on stronger right side, resulting in R1 dropping the soup and sustaining first and second degree burns. 2. R5 is an [AGE] year old female admitted to the facility on [DATE] to recover from a hip fracture after having fallen at home. R5's additional [DIAGNOSES REDACTED]. R5's Fall Risk assessment dated [DATE] scores R5 as a "12". According to this Assessment, any score over 10 indicates the resident is at high risk for falls. R5's care plan for falls with a start date of 7/9/13 reflects initial interventions for R5 to have a bed and wheel chair alarm; the wheel chair alarm was discontinued per this care plan on 7/10/13, the same day it was initiated. On 7/26/14, a self-release belt was implemented. Incident Report for R5 dated 8/16/13 timed at 10:50 am reflects R5 was found sitting on the bathroom floor in her room, in front of the toilet. The fall investigation form states, "therapy left her unattended". It also indicates that R5 attempted to self-transfer from the toilet to the wheel chair. The incident report indicates R5 has an unsteady gait and moderate cognitive impairment. R5 sustained a bruise to her hand, but no other injury at the time. The incident report also indicates, for corrective actions, do not leave resident alone on toilet. There is no care plan update for this 8/16/13 fall per R5's fall care plan. A Fall Risk assessment dated [DATE] again scores R5 as a 12, again indicating high risk for falls. A Nursing note dated 11/15/13 at 5:00 pm states staff heard the alarm sounding (this alarm was documented as discontinued) and staff observed the resident standing up going to bathroom by herself, stating R5 almost fell . 12/9/13 Nursing note timed at 1:00 pm states R5 was still observed going into bathroom by herself. 12/10/13 (time illegible) nursing note again states R5 still gets up to the bathroom by herself. Care plan entry dated 12/20/13 documents implementation of a sensor pad alarm when in wheel chair along with the velcro self-release belt. Incident report dated 1/29/14 timed at 10:45 am reflects staff heard R5's alarm sounding from resident's room and went in to check on her. Staff found R5 in a standing position and observed R5 fall, trying to support her weight with her left hand. R5 was diagnosed with [REDACTED]. The facility care plan for falls for R5 reflects on 1/29/14, 1:1 (one to one) and q (every)every 15 minute checks were implemented, as well as therapy screen. According to E8 (Restorative Nurse) 15 minute checks were instituted until 1/30/14 and 1:1 monitoring was done for that day (1/29). Hipsters were also added as an intervention.(this is used to try to prevent severe injury but will not prevent falls). 1/29/14 Fall Risk Assessment now scores R5 as a "14", again at high risk for falls. Again on 2/9/14, Incident report for R5 timed at 6:00 pm reflects staff heard R5's alarm sounding from her room and when they went to investigate, they found R5 sitting on the floor in front of her chair. The cause of the event was described as R5 having no safety awareness. R5 was assessed and found to have no apparent injury. R5's 2/9/14 Fall Risk Assessment score was 14. R5's fall care plan reflects 1:1 was again initiated on 2/9/14, and on 2/11/14, a 72 hour voiding assessment on R5. On 6/18/14 at 1:30 pm E8 stated he believed R5's 1:1 continued for a while, but he had no evidence to indicate for how long it was done or who did the 1:1 monitoring. On 3/17/14 at 3:30 pm, R5's next incident report reflects on this date, R5 fell again in her washroom. On 6/20/14 at 12:20 pm, E18 (Business Office Manager) stated on that date, she heard R5's alarm sounding and found R5 alone in her bathroom. At that time, R5 was standing by the toilet. E18 stated she had R5 sit on the toilet, and then left her to go to the doorway of the room to call for assistance from other staff. Next, she heard a thud, and saw R5 had fallen on her side and was lying next to the toilet. R5 was assessed to have no injuries. R5's fall care plan contains no evidence of review of R5's fall prevention protocol and no new intervention documented. (Incident report states 1:1 instituted at the time and front and back tippers were added to R5's wheel chair). Again, these interventions do not appear on R5's care plan. There is no indication on R5's incident report whether or not 1:1 monitoring was done, and for how long. On 6/18/14 at 1:30 pm, E8 reviewed R5's care plan and agreed that the care plan had not been updated. He could not provide any additional information as to who did R5's 1:1 or for how long it was continued. He also stated that the tippers were added to her wheel chair as an incidental item, not because her fall had anything to do with her wheel chair tipping. There were no interventions put in place that would effectively prevent and/or reduce R5's falls, since current interventions had proven ineffective, as R5 continues to fall. According to E8, 1:1 monitoring is temporary, to try to help establish any patterns or trends in a resident's behavior. There were no further fall risk assessments completed for R5 after her 2/9/14 assessment; none were provided by the facility after all fall risk assessments for R5 were requested. R5's 4/16/14 incident report timed at 10:25 am reflects another unwitnessed fall in R5's room. Incident Report reflects that R5's alarm was heard sounding and upon investigation, R5 was found in her room sitting on the floor after attempting to self-transfer from the bed to the wheel chair. R5 was assessed to have no injuries. The incident report reviews the interventions in place and states they tried a push button belt alarm which R5 did not want, and it was discontinued. Although this report states R5's care plan was reviewed and updated, there is no intervention for this 4/16/14 fall. According to E8, R5 remained with either group or one on one monitoring, which was unchanged. E8 agreed R5's care plan did not reflect an update and agreed the same interventions were utilized. These interventions had proven ineffective, as R5 continued to fall in her room. On 6/18/14 at 10:10 am, E6 (RN) stated R5 falls a lot, and "we really can't leave her alone". On 6/19/14 at 1:05 pm, R5 was observed sitting in her room in the dark, with the television on. Only her roommate was in the room. R5 was in her wheel chair with her alarm and self-release belt on. No staff were present or within sight of R5's room except for E6, who was at the nurse's station on the telephone and was not looking in R5's direction. R5's care plan, under approaches, also states, "assess, evaluate any patterns to falls, and eliminate factors that may increase potential for falls/injury". The one consistent fact from all 5 of R5's falls in the facility is that R5 falls when she is left alone in her room. R5 is documented to have dementia and poor safety awareness as well as making frequent trips to the washroom. The facility did not institute increased monitoring for R5 until after R5 fell and fractured her wrist, despite several nursing notes indicating staff were aware that R5 tried to self-transfer in her room. The increase in monitoring that was instituted was temporary. The facility also did not increase toileting for R5 as a fall intervention, according to R5's fall care plan. On 6/18/14 at 1:30 pm, E8 stated that R5 wants to go to the bathroom many times a day, sometimes just to look in the mirror or wash her hands, as well as to void. The facility did not review and revise R5's fall interventions/approaches in R5's care plan after her last 2 falls. They also did not institute effective interventions as R5 is still being left unsupervised in her room where she has fallen 5 times, rather than being observed out in a common area except for when she is sleeping. Based on observation, interview and record review the facility failed to procure safe toilet grab bars and maintain emergency call light strings in the first and second floor male and female shower rooms This effects all residents that use the showers. During the environmental tour on 6/17/14 and again on 6/20/14 The first and second floor shower rooms have new grab bars attached to the toilet seat. The grab bars come in two parts. One part attaches to the toilet seat. The other part includes the hand grips and the adjustable legs. At the juncture where the two parts slide into each other, the male and female parts fit very loosely allowing the hand grips to wobble back and forth several inches. This does not provide a steady grab bar for the residents trying to sit down or stand up. On 6/19/14 E1 said, "The showers could be used by all the residents. If we put screws in the grab bars it might void their integrity. " During the environmental tour on 6/17/14 the call strings to the emergency call lights in the shower rooms were wrapped around the grab bars. If residents fall on the floor they will not be able to pull the call light string. During the environmental tour on 6/17/14 and 6/20/14 in the second floor shower rooms, one shower stall did not have a pull string attached to the emergency call. E2 presented in-service sign in sheets for 6/18 and 19/14. E2 stated staff had been trained not to wrap call strings around grab bars.

Based on observation, interview and record review the facility failed to ensure residents who are at high risk for falls are supervised to the level necessary to prevent falls. This is for 1 of 3 residents sampled for falls. (R1) This failure resulted in a fall with left hip fracture. Findings includes; R1 was in noted in the dinning room in a wheelchair eating her lunch. When asked, R1 replied that she did not have pain. R1 did not respond to further questions, she continued to eat. In an interview with E2, the director of nursing, she states that R1 was found on the floor in her room by a housekeeper. E2 states that the resident was not interviewable because of her Alzheimer's Dementia. E2 further states that R1 has poor safety awareness and a bed and chair alarm. In an interview with E3, a certified nurse assistant, she states that R1 required a lot of one on one time. E3 states that R1 would talk about her days as a nurse. E3 states that R1 needs a lot of re-direction and was not steady on her feet but wants to walk independently.. In an interview with E4, a certified nurse assistant, she states that R1 frequently tried to transfer herself from her wheelchair to the bed. E4 states that R1 does not remember that she can not transfer by herself. E4 states she needs to be engaged in a lot of activities to keep her busy. R1's record contains a "Resident Fall Risk Assessment" dated 5/25/11 that states she is a high risk for falls. R1's record contains multiple nursing notes in "Nurses's Notes" that state R1 fell frequently. Nursing documentation on the following dates states falls: " 1/24/11 fell from wheelchair", "4/26/11 fell with eyebrow laceration", "6/19/11 fall", "6/20/11 found on floor." On 7/19/11 "Nurses Notes"state "Res found lying on the floor with head up. ...Send to ER for eval..." R1's record contains a "Comprehensive Care Plan" that lacks a change in intervention after each fall episode to prevent future falls.