Every finding on record at Westminster Village

Based on observation and interview, the facility failed to post notice of the availability of state agency survey results. This failure has the potential to affect all 43 residents in the facility.Findings include:On 5/27/26 at 10:05 a.m., during the resident council meeting, residents stated they were unaware of where the state agency survey results were located.On 5/28/26 at 9:15 a.m., the facility's survey results were in a file bin attached to the wall in a hallway containing staff offices. There was not a notice to designate the location of the survey results files.On 5/28/26 at 10:42 a.m., V1 Administrator confirmed there is no posting alerting residents and/or the public where to locate survey results. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 5/26/26 documents 43 residents reside in the facility.

Based on observation and interview, the facility failed to post the daily staffing data in a prominent location that is accessible to residents, staff, and visitors. This failure has the potential to affect all 43 residents in the facility.Findings include:On 5/27/26 at 3:05 p.m., and on 5/28/26 at 8:59 a.m., this surveyor was unable to locate the daily staffing data posted anywhere in the facility.On 5/28/26 at 9:09 a.m., V2 Director of Nursing stated the daily staffing data is posted in a hard plastic holder on unit C/D nurses' station.On 5/28/26 at 9:12 a.m., V11 Registered Nurse was at the C/D nurses' station and stated the daily staffing data is usually in a plastic holder setting on the nurses' station counter. At this time, V11 located the daily staffing data sheet on a clipboard, behind the nurses' station underneath the daily assignment sheets. V11 stated, I think it [plastic holder] broke. We will have to get a new one.The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 5/26/26 documents 43 residents reside in the facility.

Failures at this level required more than one deficient practice statement. A. Based on observation and interview, the facility failed to maintain the hot water supply in resident bathrooms and showers in safe operating temperatures. This failure affects seven residents (R3, R11, R13, R36, R47, R48, and R52) out of eleven reviewed for water temperatures on the sample list of 25. B. Based on observation, interview, and record review the facility failed to provide adequate supervision for one of three residents (R8) reviewed for wandering on the sample list of 25. Findings include: a. On 05/26/26 at 12:45 PM, while checking a random sample of the water temperatures in resident bathroom hand sinks utilizing an Illinois Department of Public Health digital automatically calibrating thermometer, the hand sink water temperature in room [ROOM NUMBER] was 120.9 degrees Fahrenheit (F). The water temperature in the hand sink in room [ROOM NUMBER] was 123.0 F. The hand sink water temperature in room [ROOM NUMBER] was 116.9 F. The water temperature in the hand sink in room [ROOM NUMBER] was 123.6 F. The temperature of the water in the hand sink in room [ROOM NUMBER] was 119.3 F. The hand sink water temperature in room [ROOM NUMBER] was 117.8 F. On 5/26/26 at 2:12 PM, V3, Maintenance Director, stated the facility checks the water temperatures in the resident bathrooms weekly. V3 stated she has an upper limit of 112 degrees F. On 5/26/26 at 2:18 PM, with V3, Maintenance Director, utilizing a facility digital thermometer, the water temperatures in the resident hand sink and shower in rooms 5146 was 123.0 F and the shower at the same temperature. V3 measured the water temperature in room [ROOM NUMBER], finding the hand sink water at 117.9 F and the shower at 120.2 F. V3 stated the temperatures in the hand sinks and showers was way too high. V3 stated based on the sample temperatures, she would check all the resident rooms in the facility. The facility's Resident Roster dated 5/26/26 documents R3, R11, R13, R36, R47, R48, and R52 reside in the aforementioned rooms. B. R8's Care Plan dated 5/7/26 documents R8 is diagnosed with Alzheimer's Disease. R8 forgets safety concerns and will walk in his room and hallway without assistance. R8 has a history of wandering. R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired. R8 has physical behavioral symptoms directed towards others such as hitting, kicking, pushing, and grabbing. These behaviors can significantly interfere with R8's participation in activities or social interactions. R8's behaviors can put others at significant risk for physical injury, significantly intrude on the privacy of others, and significantly disrupt care or the living environment. R8's wandering behavior occurred daily. R8's wandering significantly intrudes on the privacy of others. R8's Behavior Note dated 5/29/26 documents V5 Licensed Practical Nurse (LPN) heard her name being yelled and entered R9' room. R8 was standing over R9's bedside and holding R9's wrists bilaterally. R9 was yelling for V5's help. V5 entered the room and removed R8 from R9's bedside and redirected him to his room. R9's Minimum Dated Set dated 5/6/26 documents R9 is cognitively intact. On 5/26/26 at 3:15 PM R9 stated on 5/20/26 at approximately 7:45 PM R8 walked into R9's room uninvited. R9 stated R8 walked over to R9's bed. R9 told R8 to turn around and go out of his room. R8 began to hit R9 and R9 placed his arms up in order to block the blows coming from R8. R8 then grabbed a hold of R9's wrists and R9 stated he began to yell out V5 LPN's name for help. R9 stated V5 entered his room and was able to get R8 to let go and go back into his own room. R9 stated he told staff he did not feel safe any longer, however, did not feel like he should have to move rooms since he was the victim. R9 stated he was told by staff that R8 would have one-on-one monitored from that time forward and R9 stated he felt a little better after hearing that. R9 stated he thought about calling the police but did not. R9 stated R8 had often entered his room uninvited prior to this incident however this was the first time R8 got physically aggressive with R9. R9 stated staff did not do a good job supervising R8. On 5/27/26 at 10:22 AM V4 RN stated R8 is very confused and wanders often into other resident's room. On 5/27/26 at 12:51 PM V5 Licensed Practical Nurse (LPN) confirmed R8 has a history of wandering into the rooms of other residents. On 5/27/26 at 4:49 PM V7 LPN stated R8 wanders a lot and one shift last week R8 had wandered into a female resident's room (unknown) and the resident had to call for staff to help. On 5/28/26 at 9:31 AM V8 LPN stated R8 wanders all of the time. He is very hard to keep out of other resident's rooms because he moves quickly. On 5/28/26 at 10:50 AM R47 stated R8 has wandered into her room on two separate occasions. R47 stated she told R8 to leave and he would take his time leaving but she got up and showed him to the door and shut the door behind him. R47 stated she does want to have to deal with that anymore. On 5/28/26 at 11:05 AM R33 stated R8 wandered into her room uninvited and she told him to get out. R8 was standing by her bathroom door. R33 stated R8 finally turned around and left. On 5/28/26 at 11:10 AM R28 stated R8 came into her room and stood in the doorway however staff came up behind him pretty quickly and redirected him away from her door. On 5/28/26 at 11:15 AM R13 stated she was sleeping and when she woke up, R8 was standing at the end of her bed. R13 stated she did not know him or who he was at the time, and it scared her half to death. R13 stated she wished the facility would do something about it and supervise R8 better because it creates an uneasy environment and she feels like she can't rest peacefully. R13 stated R8 attempted to come into her room again yesterday however staff were already in her room so they told R8 to leave. On 5/27/26 at 3:35 PM V2 Director of Nurses confirmed R8 has a history of wandering into the rooms of other residents. Staff completed every 15-minute checks however they were not doing much so since the incident on 5/20/26, staff are to provide constant supervision. V2 stated sometimes there are call offs or the staff don't have enough to provide constant supervision.

Based on interview and record review the facility failed to protect resident's rights to be free from resident to resident physical abuse. This failure affects two of three residents (R8, R9) reviewed for abuse on the sample list of 25. Findings Include: The facility's Abuse Prevention, Reporting, and Investigation Policy revised May 2026 documents the facility prohibits and is committed to preventing abuse involving any resident. Abuse is the willful infliction of injury. Physical abuse includes hitting, slapping, rough handling or unnecessary force. It is any intentional physical action that causes or could cause harm. R8's Care Plan dated 5/7/26 documents R8 is diagnosed with Alzheimer's Disease. R8 forgets safety concerns and will walk in his room and hallway without assistance. R8 has a history of wandering. R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired. R8 has physical behavioral symptoms directed towards others such as hitting, kicking, pushing, and grabbing. These behaviors can significantly interfere with R8's participation in activities or social interactions. R8's behaviors can put others at significant risk for physical injury, significantly intrude on the privacy of others, and significantly disrupt care or the living environment. R8's wandering behavior occurred daily. R8's wandering significantly intrudes on the privacy of others. R8's Behavior Note dated 5/29/26 documents V5 Licensed Practical Nurse (LPN) heard her name being yelled and entered R9's room. R8 was standing over R9's bedside and holding R9's wrists bilaterally. R9 was yelling for V5's help. V5 entered the room and removed R8 from R9's bedside and redirected him to his room. R9's Care Plan dated 5/5/26 documents R9 is diagnosed with Difficulty Walking and has Impaired coping and Impaired Physical Mobility. R9's Minimum Dated Set dated 5/6/26 documents R9 is cognitively intact. On 5/26/26 at 3:15 PM R9 stated on 5/20/26 at approximately 7:45 PM R8 walked into R9's room uninvited. R9 stated R8 walked over to R9's bed. R9 told R8 to turn around and go out of his room. R8 began to hit R9 and R9 placed his arms up in order to block the blows coming from R8. R8 then grabbed a hold of R9's wrists and R9 stated he began to yell out V5 LPN's name for help. R9 stated V5 entered his room and was able to get R8 to let go and go back into his own room. R9 stated he told staff he did not feel safe any longer, however, did not feel like he should have to move rooms since he was the victim. R9 stated he was told by staff that R8 would have one-on-one monitored from that time forward and R9 stated he felt a little better after hearing that. R9 stated he thought about calling the police but did not. R9 stated R8 had often entered his room uninvited prior to this incident however this was the first time R8 got physically aggressive with R9. R9 stated staff did not do a good job supervising R8. On 5/27/26 at 12:51 PM V5 Licensed Practical Nurse (LPN) confirmed she was the nurse on duty on 5/20/26 when R8 went into R9's room uninvited and stood over R9s bed and grabbed both of R9's wrists. V5 stated R9 called her for help, and she was able to get R8 to let go and return to his own room. V5 confirmed the incident was a physical altercation and stated she called V1 Administrator to report it. On 5/27/26 at 3:35 PM V2 Director of Nurses confirmed a physical altercation occurred between R8 and R9 and she charted the incident as a Behavior Note in R8's medical record. V2 confirmed R8 has a history of wandering into the rooms of other residents, however this was the first time R8 got physical with another resident.

Based on interview and record review the facility failed to report an allegation of physical abuse to the State Survey Agency. This failure affects two of three residents (R8, R9) reviewed for abuse on the sample list of 25. Findings Include: The facility's Abuse Prevention, Reporting, and Investigation Policy revised May 2026 documents the facility prohibits and is committed to preventing abuse involving any resident. Abuse is the willful infliction of injury. Physical abuse includes hitting, slapping, rough handling or unnecessary force. It is any intentional physical action that causes or could cause harm. Allegations involving abuse must be reported to the state surveying agency and other required authorities no later than four hours after the allegation is made known. Investigation results must be reported to the agency within five working days in accordance with federal long-term care requirements. R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired. R8's Behavior Note dated 5/29/26 documents V5 Licensed Practical Nurse (LPN) heard her name being yelled and entered R9' room. R8 was standing over R9's bedside and holding R9's wrists bilaterally. R9 was yelling for V5's help. V5 entered the room and removed R8 from R9's bedside and redirected him to his room. R9's Minimum Dated Set dated 5/6/26 documents R9 is cognitively intact. On 5/26/26 at 3:15 PM R9 stated on 5/20/26 at approximately 7:45 PM R8 walked into R9's room uninvited. R9 stated R8 walked over to R9's bed. R9 told R8 to turn around and go out of his room. R8 began to hit R9 and R9 placed his arms up in order to block the blows coming from R8. R8 then grabbed a hold of R9's wrists and R9 stated he began to yell out V5 LPN's name for help. R9 stated V5 entered his room and was able to get R8 to let go and go back into his own room. R9 stated he told staff he did not feel safe any longer, however, did not feel like he should have to move rooms since he was the victim. R9 stated he was told by staff that R8 would have one-on-one monitored from that time forward and R9 stated he felt a little better after hearing that. R9 stated he thought about calling the police but did not. R9 stated R8 had often entered his room uninvited prior to this incident however this was the first time R8 got physically aggressive with R9. R9 stated staff did not do a good job supervising R8. On 5/27/26 at 12:51 PM V5 Licensed Practical Nurse (LPN) confirmed she was the nurse on duty on 5/20/26 when R8 went into R9's room uninvited and stood over R9s bed and grabbed both of R9's wrists. V5 stated R9 called her for help, and she was able to get R8 to let go and return to his own room. V5 confirmed the incident was a physical altercation and stated she called V1 Administrator to report it. On 5/27/26 at 10:25 AM V1 Administrator stated R9 never told her that R8 hit him. V1 confirmed R8's electronic Behavior Charting documents R8 was in R9's room uninvited and was found by V5, standing over R9's bed, and grabbing onto R9's wrists bilaterally. V1 confirmed she investigated the incident however did not come to the conclusion that the reported incident was abuse and therefor did not report it to the state surveying agency.

Based on observation, interviews, and record review, the facility failed to ensure physician-ordered daily weights were obtained and documented for two (R1 and R4) of the four residents reviewed for edema in a total sample of 10 residents.Findings include:1. R4's Progress note, dated 2/28/2026, documents that R4 discharged from the facility on 2/28/26. R4's Minimum Data Set (MDS), dated [DATE], documents R4 had an active diagnosis of heart failure.R4's Physician Order Summary Report, dated 2/20/2026, documents an order for a daily weight related to history of congestive heart failure (CHF).R4's Medication Administration Record, dated February 2026, documents that no weights were obtained or documented on 2/20/2026, 2/22/2026, 2/23/2026, and 2/24/2026.R4's nursing note, dated 2/28/2026, documented that R4 was observed with an increase in shortness of breath and increased swelling. It also documented that R4 was transferred to the hospital on this date.R4's undated Weight Summary documents that R4's weight on 2/19/2026 was 191.0 pounds. On 2/21/2026 R4's weight was 200.8 pounds. R4's electronic medical record does not document notification to physicians of weight variance.On 4/20/2026 at 10:09 AM, V4 (R4's) family member, stated that R4 has a history of congestive heart failure (CHF) and V4 was concerned about R4 retaining fluid. V4 stated that R4 has been noted to have swelling and increased shortness of breath. V4 stated that R4 was supposed to be weighed daily but the facility has not weighed R4 daily.On 4/21/2026 at 12:52PM, V15 Registered Nurse (RN) stated that V15 was the nurse for R4 on 2/28/2026 and observed R4 with increased swelling to both legs and arms that morning. V15 stated that R4 was also observed with altered mental status that morning. V15 stated that V4 (R4's) family member was in the facility visiting R4 at that time and requested for R4 to be sent out to hospital for evaluation. V15 RN stated that V15 notified V14 Nurse Practitioner (NP) and gave order to send R4 to hospital. V15 stated that R4 had a history of CHF and should have been weighed daily.On 4/21/2026 at 12: 38 PM, V14 Nurse Practitioner (NP), stated that R4 had history of CHF and should have weighed daily. V14 stated that V14 would expect nurses to notify her for at least three pounds weight gain in 24 hours or at least five pounds weight gain in a week to address the issue with interventions.On 4/21/2026 at 11:31 AM, V2 Director of Nursing (DON) stated that based on R4's electronic records, R4's weights were not obtained daily and stated R4 should have weighed daily per physician's order. V2 stated staff should have documented the reason why R4's weights were not obtained. V2 confirmed R4's weights were not documented on multiple dates, and no reasons were documented. V2 stated nurses should notify the physician for weight gain of at least three pounds in 24 hours or at least five pounds in a week.2. R1's Minimum Data Set (MDS) dated [DATE] documents, that R1 has an active diagnosis of heart failure. It also documents that R1 is cognitively intact.R1's Care Plan date initiated 6/11/2018 documents a focus of on-going treatment for congestive heart failure with interventions/tasks dated 6/11/2018 to monitor weight as ordered.R1's Physician's Order, dated 1/13/2026, documents daily weight.R1's Treatment Administration Record, dated 4/21/2026, documents no weights were obtained nor documented on multiple dates of 3/10/2026, 3/11/2026, 3/17/2026, 3/18/2026, 3/22/2026, 3/23/2026, 4/5/2026, 4/7/2026, 4/8/2026, 4/13/2026 and 4/19/2026.On 4/20/2026 at 12:50 PM, R1 was sitting in the recliner in R1's room wearing oxygen at two liters via nasal cannula. R1had ace wraps wrapped around both legs. R1 stated R1's legs are swelling because R1 has congestive heart failure (CHF). R1 stated the staff weighs R1 once a week.On 4/20/2026 at 1:19 PM, V10 Registered Nurse (RN), stated that R1 has swelling to both legs due to R1's diagnoses of CHF. V10 stated that staff apply ace wrap to R1's legs before R1 gets up in the morning. V10 stated there are interventions in placed for R1 to manage the swelling including daily weights but R1 refuses at times. V10 stated if R1 refuses to be weighed, nurses should document the refusal.On 4/21/2026 at 11:31 AM, V2 Director of Nursing (DON) stated that based on R1's electronic records, R1's weights were not obtained or documented daily. V2 stated R1 should have weighed daily per physician's order and that staff should have documented the reason why the weights were not obtained. On 4/20/20/2026 at 11:32AM, V7 Registered Nurse, stated that daily weights are to be done for residents with CHF and nurses are to document the reason if weight is not able to be obtained. V7 stated that nurses are to notify the doctor for weight gain of at least three pounds in a day and at least five pounds in a week.On 4/21/2026 at 12: 38 PM, V14 Nurse Practitioner (NP), stated V14 expected the nurses to notify V14 when there are changes in condition including swelling or increase in swelling.On 4/21/2026 at 11:31 AM, V2 Director of Nursing (DON), stated that the staff should follow doctors order for daily weight and staff should document the reason if weight is not obtained in resident's chart.Facility's Acute Change in Condition and Clinical Monitoring Policy, dated 2/23/2026, documents, Daily weights will be obtained per physician order and documented in TAR/MAR (treatment administration record/medication administration record). If the weight cannot be obtained due to refusal, absence, or clinical limitation: The reason must be documented in the TAR and progress note. A nursing assessment of fluid status must be completed and documented.

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment for a resident on enhanced barrier precautions for 1 of 3 residents (R4) reviewed for infection control in the sample of 3.The findings include:R4's Order Summary Report dated 3/31/26 showed an order for enhanced barrier precautions for a peripherally inserted central catheter (PICC). The order had a start date of 3/26/26.On 3/31/26 at 11:12 AM, there was an enhanced barrier precaution sign on R4's bathroom door. The sign indicated that staff must wear gloves and a gown with device care and use.On 3/31/26 at 11:12 AM, V16 (Registered Nurse) was in R4's room. V16 was handling R4's PICC. V16 had on gloves but no gown. V16 said she was disconnecting R4 from his antibiotic. On 3/31/26 at 12:47 PM, V7 (Infection Control Nurse) said enhanced barrier precautions are precautions to help limit infections. V7 said staff were to wear gloves and a gown when handling a PICC. The facility's Enhanced Barrier Precautions Protocol policy with a revised date of 7/26/21 showed gloves and gowns were to be used during high contact care activities. Examples of high contact care activities included device care or use.

Based on interview and record review the facility failed to ensure the admissions contract did not waive potential facility liability for losses of residents' personal property. This failure affects all 42 residents in the facility. Findings include: The admission contract folder, provided by V1 Administrator, and reviewed on 6/9/25, included the following: The facility's Skilled Care Establishment Contract Summary documents (the facility) is not responsible for loss of property belonging to Resident due to theft or any other cause unless such loss is caused by the negligent or intentional acts of (the facility) or its employees or agents. The welcome letter with bullet points of condensed information from the contract summary, documents Should your resident's items be lost, please contact Social Services in order to make a report. (The facility) are not responsible for lost or damaged items. On 6/09/25 at 1:40 PM V1 Administrator stated lost or damaged items are replaced by the facility on a case by case basis. V1 stated items can be lost in a person's home and the facility is considered the residents' home. At 2:08 PM V1 confirmed the facility's admission contract is provided and completed for all residents admitting to the facility. V1 confirmed the admission contract documents the facility is not responsible for lost or damaged items unless due to negligence by the facility/staff. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 6/8/25 documents 42 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to prevent further potential abuse by failing to remove an alleged perpetrator (V7 Certified Nursing Assistant (CNA)) from resident care. This failure affects eight (R140, R4, R35, R22, R142, R141, R18, R31) of eight residents reviewed for abuse in the sample list of 32. Findings include: The facility's Abuse Policy dated June 2024 documents If the instance, suspicion, or allegation involves a staff member, the staff member may be suspended, or re-assigned to a duty with no resident contact, pending the conclusion and results of the investigation. On 6/08/25 at 9:30 AM R140's right arm was in a sling and right lower leg/foot was in an orthotic boot. R140 stated R140 prefers not to have male caregivers, and the day after R140 admitted to the facility V7 CNA gave R140 a lecture on why R140 shouldn't be concerned with having male givers. R140 stated V7 said V7 didn't understand why women R140's age don't want male caregivers, since women have babies. R140 stated R140 has a broken shoulder and V7 was aware, but V7 patted R140's shoulder and R140 told V7 that hurts R140's shoulder and to stop. R140 stated V7 then said Oh Lord please forgive me. R140 stated R140 wanted to slap V7 and couldn't believe V7 still works for the facility. R140 stated that same day V7 assisted R140 to sit on the side of the bed, R140's upper torso fell back onto the bed, causing pain to R140's shoulder. R140 stated R140 told V7 that hurt her shoulder, and V7 told R140 I (V7) didn't hurt you (R140). R140 stated the next day V7 lectured R140 about R140's attitude and V7 told R140 that if R140 had a better attitude, R140 would heal faster. R140 stated V7 knew better and knew to take it gently. R140 stated V7 hasn't provided care for R140 since then. R140's Minimum Data Set, dated [DATE] documents R140 is cognitively intact. R140's Census documents R140 admitted to the facility on [DATE]. On 6/08/25 at 10:32 AM V1 Administrator stated there have been no abuse allegations since February 2025 and no grievances for the last three months. V1 stated the only concern R140 had regarding staff was that R140 didn't care for V7 but no specifics were mentioned, so V7 no longer takes care of R140. At this time R140's concerns/allegations were reported to V1. V1 stated this was the first that V1 had heard of this and R140 had never reported that. On 6/8/25 during intermittent observations between 10:00 AM and 1:20 PM, V7 worked on the (specific Hall) and assisted with serving meals in the dining room. V7's Time Card with date range of 5/30/25-6/9/25 documents V7 worked from 6:57 AM until 1:30 PM on 6/8/25. The CNA Assignment Sheet dated 6/8/25 documents V7 was assigned to Group 3. The undated Nurse Report Sheet documents R140, R4, R35, R22, R142, R141, R18, and R31 reside on (specific Hall) in Group 3. On 6/08/25 at 1:40 PM V1 stated V1 initiated an investigation into R140's allegations and spoke with other female residents on R140's hallway, who did not have any concerns with V7. V1 stated V1 followed up with R140 and R140 stated R140 just didn't like V7's mannerisms. V1 stated V1 asked R140 if V7 hurt R140 or if R140 felt afraid of V7, and R140 replied no and denied any malicious behavior of abuse from V7. V1 stated V1 had not removed V7 from resident care after R140's allegations were reported, since R140 did not report these concerns previously or when V1 spoke with R140 today. On 6/10/25 at 11:15 AM V1 confirmed V1 submitted the final report of R140's abuse allegation investigation to the state survey agency on 6/9/25. On 6/10/25 at 10:40 AM V2 Director of Nursing stated V7 was assigned to group 3 on C Hall on 6/8/25.

Based on interview and record review the facility failed to document a root cause or obtain witness statements for fall investigations for four residents (R8,R17,R25,R35) of four residents reviewed for falls in a sample list of 32 residents. Findings include: 1. R8's progress note dated 04/24/2025 at 6:46AM documents (R8) called and when CNA answer call light found him on floor bedside bed with blood on tray table and floor from apparent nose bleed. ROM within normal limited. Orient to person, time and situation but did not know where he was. Pupils equal but no reaction to light. Assisted up by three people, gait belt and walker. After getting him to bed wanted to know why cowboys went outside the window. (R8) had abrasions on nose, chin and right knee and skin tears to both hands. Areas cleaned and steri strips applied to both hands. TPR (Temperature, Pulse, Respirations) 98.9,80,18 and BP (Blood Pressure) 149/66. Accucheck (blood glucose) 233. Sent to ER (Emergency Room) per 911. Phone with (R8). The facility provided an incident report. However, there was no documentation included to support a root cause analysis was conducted or witness statements were obtained. On 6/9/25 at 3:07PM V2, Director of Nursing (DON) stated the facility does not document a root cause analysis or witness interviews. When asked how the facility determines appropriate interventions to implement following a fall V2 replied V2 looks at the incident report and decides what interventions should be implemented. 2. R17's progress note dated 3/29/25 at 10:29AM documents (R17) slid down the legs of her (Geriatric) chair and landed on her bottom. (R17) transferred via two assist to the wheelchair. Vitals WNL (Within Normal Limits). No injury noted. some pain noted to coccyx. Will continue to monitor. R17's R17's progress note dated 2/16/25 at 12:47AM documents : Alerted by a visitor that (R17's) chair was tipped over and resident was falling. Upon arrival to dining, (R17) was sitting at the footrest part of the (Geriatric) chair. (R17) was helped up to chair. Assessed no injuries found at this time. (R17) denies pain at this time. VS (Vital Signs): T-97.8, P-114, R-20, P-114, BP-158/83, O2 (Oxygen) -92% RA (Room Air). The facility provided an incident report. There was no documentation included to support a root cause analysis was conducted or witness statements were obtained. On 6/9/25 at 3:07PM V2, Director of Nursing (DON) stated the facility does not document a root cause analysis or witness interviews. When asked how the facility determines appropriate interventions to implement following a fall V2 replied V2 looks at the incident report and decides what interventions should be implemented. The facility's policy Falls and Fall Risk Management dated 1/2/24 documents Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling.The facility's Falls-Clinical Protocol revised March 2018 states The staff will evaluate and document falls that occur while the individual is in the facility;for example, when and where they happen, and any observations of the event etc. 3.) On 6/09/25 at 10:21 AM R25 was asleep and lying in bed on a raised edge mattress. R25's bed was low to the floor and a fall mat was on the floor next to the bed. R25 did not have a bed alarm in place. R25's Minimum Data Set (MDS) dated [DATE] documents R25 has severe cognitive impairment, is incontinent of bowel and bladder, is dependent on staff for toileting hygiene, and requires substantial/maximal staff assist for transfers. R25's Care Plan dated 3/11/24 documents R25 is at high risk for falls and includes fall interventions for a bed alarm, low bed with wheels locked, and fall mat. These interventions are also listed on R25's Kardex Report dated 6/9/25. R25's care plan also includes to assist with activities of daily living and an intervention dated 4/24/25 to offer toileting when R25 is awake during rounds. R25's nursing note dated 4/24/25 at 7:53 AM documents around 3:15 AM R25 was heard yelling for help and was found sitting on the floor next to her bed. This note does not document a fall mat, bed in low position, or bed alarm were in place at the time of her fall. This note does not document when R25 was last checked on or toileted prior to the fall. R25's Unwitnessed Fall Report dated 4/24/25 documents R25's fall as described in the nursing note. This report does not document what fall interventions were in place at the time of the fall or when staff last observed R25 or provided incontinence care prior to the fall. There are no documented interviews with staff who were working when R25 fell or that a root cause was identified. On 6/09/25 at 10:06 AM V13 Registered Nurse stated a fall mat was a previous fall intervention, but V13 was unsure if a fall mat was in place when R25 fell on 4/24/25. V13 stated V13 documents implemented fall interventions on the risk management incident report. V13 stated R25 did not use a bed alarm at that time. V13 stated R25 does not use her call light, requires mechanical sit to stand lift and staff assistance for transfers, R25 is toileted during the day, and is checked for incontinence every two hours during the night. On 6/09/25 at 10:18 AM V2 Director of Nursing (DON) provided R25's fall investigation/incident report dated 4/24/25. V2 confirmed all of R25's 4/24/25 fall investigation was provided and there were no documented staff interviews or statements or that a root cause was identified. V2 confirmed the investigation did not document fall interventions in place or when R25 was last checked on or toileted. 4.) On 6/08/25 at 10:09 AM R35 stated she fell about two months ago in her room, and R35 was independent with walking at that time. R35 stated R35 was standing and getting something from the dresser, R35 turned, her feet twisted and she fell. R35 stated R35 broke a couple ribs, which have now healed. R35 stated after the fall, the facility gave R35 a walker to use and now R35 calls for staff assistance when walking or transferring. R35's MDS dated [DATE] documents R35 as cognitively intact and requires partial/moderate staff assistance for transfers and walking. R35's Monthly Nursing assessment dated [DATE] documents R35 is alert and oriented, has recall ability, continues on hospice care, is weak and requires one person assist for transfers and ambulation. R35's Care Plan dated 3/20/25 documents R35 is at high risk for falls and includes interventions for nonskid socks, call light in reach with ongoing education, and assist with Activities of Daily Living implemented 3/20/25. This care plan documents additional interventions were added on 5/7/25 to remind R35 to use her call light before attempting to walk/transfer and on 5/11/25 for a bed alarm. R35's Nursing Note dated 5/7/2025 at 12:00 PM documents nurse was notified that R35 had fallen. R35 was found sitting on her buttocks next to her bed. R35 stated R35 was ambulating with her walker to get a sweater, fell and hit her left side on the couch. Approximately one and a half hours later R35 complained of left rib pain rated an 8 on a 1-10 scale. Hospice was notified and orders received for rib x-ray. X-ray completed and awaiting results. R35's Nursing Note dated 5/8/25 at 4:20 AM documents R35's left rib x-ray showed a nondisplaced left lateral 10th rib fracture. R35's Unwitnessed Fall report dated 5/7/25 and the facility's report for this fall, dated 5/8/25, sent to the state survey agency do not include any documentation that staff were interviewed regarding R35's fall to determine when R35 was last observed or checked on by staff prior to her fall. R35's unwitnessed fall report documents R35 was ambulating without assistance. On 6/08/25 at 2:17 PM V3 Registered Nurse stated R35 was found on the floor on her buttocks and R35 reported that she was walking with her walker, her feet got tangled, and R35 fell. R35 complained of pain and a rib x-ray was completed. V3 confirmed R35 had a rib fracture from her fall on 5/7/25. On 6/09/25 at 3:05 PM V2 stated V2 had no documentation that any staff were interviewed regarding R35's fall. V2 confirmed there is no documentation of when R35 was last checked on/observed prior to the fall and R35's activity at that time.

4. R8's current physician's orders printed 6/10/25 include a physician's orders for an indwelling urinary catheter. R8's hospital admission paperwork dated 4/29/25 to 4/30/25 documents R8 was diagnosed and treated for a Urinary Tract Infection. On 6/8/25 at 2:00PM R8 was observed to have a urinary catheter attached to a drainage bag hanging on the side of his bed. There was no sign on the door to indicate Enhanced Barrier Precautions (EBP) were in place and no bin of Personal Protective Equipment observed outside R8's door. On 6/9/25 at 3:07 PM V2, Director of Nursing verified that since R8 has an indwelling urinary catheter he should be on EBP and further verified R8 is not on EBP. Based on observation, interview and record review the facility failed to initiate/maintain Enhanced Barrier Precautions (EBP) for four (R26, R241, R36, R8) of four residents reviewed for EBP on a sample list of 32 residents. Findings include: The Policy dated 4/1/2024 for Enhanced Barrier Precautions for Skilled Care states that staff is to wear a gown and gloves while performing high- contact care activities with all residents who are at higher risk of acquiring infection. These include residents with any indwelling medical device, and gowns and gloves used during the high- contact resident care activities should be removed and discarded after each resident care encounter. Residents who require Enhanced Barrier Precautions will have signage on their door and will have the appropriate Personal Protective Equipment (PPE) stocked outside their room along with the appropriate waste containers to dispose of the PPE. 1. R36's Minimum Data Set (MDS) dated [DATE] documents R36 is cognitively intact. R36's Physician Order dated 6/7/25 documents to cleanse coccyx wound, apply collagen, and cover with a bordered foam dressing daily and as needed. R36's Physician Order dated 6/3/25 documents to monitor drain to left lower quadrant for signs of infection. On 6/8/25 at 8:35AM R36 was sitting in her wheelchair holding her surgical drain. R36 stated the facility just drained it. No EBP signs were posted for R36's room and no PPE supplies were in the hallway or in R36's room. On 6/8/25 at 11:26 AM, R36 stated that facility staff just brought in gowns/gloves for EBP, which facility staff have never worn while providing care for R36 and her drain. 2.) R26's MDS dated [DATE] documents R26 is cognitively intact. On 6/8/2025 at 9:00AM, R26 was lying in her bed on R26's left side with barrier cream at the bedside. R26 stated she has a wound on her buttocks that is getting smaller. There were no EBP signs on the door and no PPE supplies seen in R26's room or down the hallway. 3.) R241's MDS dated [DATE] documents R241 cognitively intact. On 6/8/25 at 8:37PM, R241 was sitting in her recliner with her left arm in a sling and left leg extended with a surgical incision on her left hip. There were no EBP Signs posted for R241's room. On 6/8/25 at 11:33AM V3 Registered Nurse stated EBP are to be used for any open areas on a resident. When asked about R36, R241 and R26 she stated that PPE supplies were just brought into those rooms this morning. On 6/9/25 at 10:30AM V8 Infection Preventionist stated that any open wound needs to have signs and PPE supplies for EBP.

Based on observation, interview, and record review the facility failed to respect the dignity of one resident of 12 residents (R5) reviewed for dignity in a sample list of 32. Findings Include: R5's current diagnoses list printed 6/10/25 includes the following diagnoses: Parkinson's Disease, Cognitive Communication Deficit, Difficulty in Walking, Muscle Weakness, Lack of Coordination, Dysphagia, Psychotic Disorder, Anxiety, and Major Depression. On 6/8/25 at 8:45AM R14, (R5's roommate/spouse) stated The staff always leave my wife in the dining room until last. She is in the dining room now with her breakfast all over her wheelchair. Sometimes they really rush (R5). She has Parkinson's and it upsets me to see this. (R5) gets anxious and will fight them (the staff). R5 was observed to be in the dining room with only one other resident. R5's head was tipped forward and R5 appeared to be asleep. R5 had food on her pants, face and the sides of her wheelchair. There was visible dried debris in R5's wheelchair seat. On 6/10/25 at 10:15AM V17, CNA (Certified Nurse's Aide) stated, I work down this hall most of the time. We do leave (R5) up a little longer than most residents because we have to have two CNAs available to transfer (R5) since (R5) will get anxious and fight us sometimes. On 6/10/25 at 10:40AM V2, DON (Director of Nursing) verified that if R14 wishes his wife not to be left in the dining room so long efforts should be made to accommodate that wish. The facility did not provide a policy specifically for resident dignity.

Based on interview and record review the facility failed to protect the resident's right to be free from misappropriation of property for one of one resident (R14) reviewed for misappropriation in a sample of 32 residents. Findings include: R14's Minimum Data Set (MDS) dated [DATE] documents R14 is cognitively intact. On 6/8/25 at 8:45AM R14 stated In February my lock box with my wallet and cards went missing from my room. I had the key but I went to the box to get my wallet out and the whole box was gone. They tried to say maybe my wife (roommate) misplaced it but they searched the whole room and it was never found. My kids canceled my cards and got me a new one. Now they keep the box locked in the medication room and I sign out my wallet when I take it and return it. I often go out to breakfast with my friends so I keep $100.00 or less to do that. I don't like to have to mess with ATM (Automated Teller Machines) machines so my son-in-law brings me cash and I keep only a debit card now. When asked if he had any cash R14 stated yes around $80.00. On 6/10/25 at 9:56 AM V20, R5 and R14's family member, stated My husband gets money for (R14) so he can go out for breakfast. Until his lockbox came up missing in February he had a couple credit cards and the cash in his wallet. He kept the box in his room and he had the key. The facility and us searched and searched and the box or the wallet was never found. My husband gets money $100.00 at a time and brings it to (R14). I have a receipt from the day before to prove $100.00 was removed from the bank and given to (R14). We keep records of (R14's transactions.) On 6/10/25 at 10:00AM V1, Administrator stated she was not aware (R14) had any money but an investigation had been done and a new lock box provided which is now kept in the medication room for (R14) to sign his wallet in and out. V1 provided documentation of a complete investigation and documentation the missing lock box was reported to the local police. V1 stated she was not aware (R14) had any money missing, but will look into it. The facility's Abuse policy revised June 2024 states it is the policy of (the facility) to prohibit and prevent instances of abuse, neglect, mistreatment, and misappropriation of property of it's residents.

Based on interview and record review the facility failed to complete a baseline assessment or identify and track targeted behaviors, prior to restarting an antipsychotic medication for one resident (R14) of five residents reviewed for unnecessary medication in a sample list of 32 residents. Finding Include: R14's current physician's orders include an order dated 4/16/25 for Olanzapine (antipsychotic) Oral Tablet 2.5 MG (milligrams), Give 1 tablet by mouth one time a day. R14's Medication Administration Record (MAR) documents this medication had previously been discontinued on 3/19/25. There is no documentation to indicate a baseline assessment was completed when restarting this antipsychotic medication. There is no documentation of identification or tracking of target behaviors for the justification of this medication. On 6/9/25 at 3:07PM V2, Director of Nursing (DON) verified there was no assessment completed or targeted behaviors identified for R14 when the Olanzapine was restarted. The facility's policy for psychotropic medication revised 3/25/25 documents It is the policy of (the facility) that psychotropic drugs are not used if avoidable and never as a chemical restraint. They are to be used with a physician's order, written permission of the resident or legal representative, an appropriate diagnosed indication need. Behavior monitoring will document specific behavior that indicates the need for administration of the medication.

Based on observation, interview, and record review the facility failed to ensure a care plan was accurate and updated to reflect current fall interventions for one (R25) of four residents reviewed for falls in the sample list of 32. Findings include: On 6/09/25 at 10:21 AM R25 was asleep and lying in bed with a raised edge mattress. R25's bed was low to the floor and a fall mat was on the floor. R25 did not have a bed alarm. R25's Minimum Data Set, dated [DATE] documents R25 has severe cognitive impairment, is dependent on staff for toileting hygiene, and requires substantial/maximal staff assist for transfers. R25's nursing note dated 4/24/25 at 7:53 AM documents around 3:15 AM R25 was heard yelling for help and was found sitting on the floor next to her bed. This note does not document the use of a bed alarm. R25's Care Plan dated 3/11/24 documents R25 is at high risk for falls and includes a fall intervention for a bed alarm initiated 3/11/23. R25's Kardex Report dated 6/9/25 documents the use of a bed alarm as of 3/11/23. On 6/8/25 at 5:04 PM V15 Certified Nursing Assistant stated R25 had rolled out of bed and was found sitting on the floor mat next to her bed in low position. V15 stated R25 has not used a bed alarm in the 2-3 years that V15 has worked at the facility. On 6/09/25 at 3:05 PM V2 Director of Nursing (DON) stated the Kardex contains information that is pulled from the care plan, and this is what the CNAs reference for fall interventions. V2 reviewed R25's Kardex and confirmed bed alarm is listed as of March 2023. V2 stated V2 thought R25's listed fall interventions are current. V2 entered R25's room and confirmed R25 does not have a bed alarm in place. V18 and V19 CNAs stated R25 has never had a bed alarm. On 6/10/25 at 9:20 AM V2 stated a former Assistant DON added the bed alarm on R25's care plan back in 2023. V2 stated R25 has never used a bed alarm, so it shouldn't be on R25's care plan and R25's care plan will need to be updated.

Based on observation, interview, and record review the facility failed to coordinate hospice care to address positioning needs for one (R25) of one resident reviewed for positioning in the sample list of 32. Findings include: On 6/08/25 at 9:07 AM R25 was in the dining room sitting in a reclined geriatric chair. R25 was leaning to the left with her left arm/side resting on the arm rest of her chair. There was a scabbed area on R25's left outer wrist. At 11:54 AM R25 was in the reclined geriatric chair. R25 was leaning to the left and a pillow was positioned underneath her left arm. On 6/8/25 at 12:32 PM the pillow underneath R25's left arm had fallen, and R25 was still leaning to the left on the arm rest of the chair. V6 Certified Nursing Assistant lifted R25's left arm and placed the pillow underneath R25's arm. V6 stated R25 has leaned like that ever since V6 has worked in the facility, which has been about two to three months. R25's Minimum Data Set, dated [DATE] documents R25 has severe cognitive impairment and has impaired range of motion to both upper and lower extremities. R25's active Care Plan documents R25 receives hospice care and to work cooperatively with the hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. This care plan does not address R25's positioning needs. R25's Nursing Note dated 5/27/2025 at 10:47 PM documents the following: R25 was sitting in the reclined geriatric chair with her arm reaching behind the chair. R25's arm was caught between the arm rest and the back of the chair. R25 verbalized pain when staff tried to remove R25's arm from between the chair, and R25 had a skin tear to the left arm, near her wrist. The wound was cleansed and adhesive strips were applied to close the wound. There is no documentation in R25's nursing notes that hospice was consulted regarding R25's positioning needs, positioning devices or support aides. On 6/09/25 at 11:50 AM V12 Registered Nurse stated R25 always leans to her left, staff use pillows as positioning aids and reposition R25 as needed. V12 stated R25 got a skin tear to her left hand while leaning in the reclining geriatric chair when R25's arm was wedged between the back of the reclined geriatric chair and the arm rest. V12 stated R25's chair was partway reclined back, how it is now. V12 confirmed when the chair is reclined there is a gap between the back of the chair and the arm rest. V12 stated R25's skin tear happened when the staff removed her arm from between the chair which caused sheering of R25's skin. V12 stated V12 didn't think there was a pillow in place at that time. V12 was unsure if hospice was consulted in regards to R25's positioning needs or to see if hospice could provide positioning devices or support aides. V12 stated hospice provided R25's geriatric chair. On 6/09/25 at 12:18 PM V2 Director of Nursing stated V2 has only mentioned in passing to R25's hospice nurse about R25 leaning to the left. V2 stated staff use pillows when R25 is in the reclining geriatric chair and staff lay R25 down when R25 is leaning, but R25 tries to crawl out of bed at times. V2 confirmed no other positioning devices have been used or attempted, and confirmed there is no documentation of coordination with hospice regarding R25's positioning needs. V2 stated R25's care plan should address R25's leaning and positioning needs. V2 stated V2 will follow up with hospice today to see if they can provide something to assist with R25's positioning. On 6/10/25 at 9:33 AM V2 confirmed R25's care plan does not address R25's leaning and positioning needs. V2 stated V2 spoke with hospice and staff are going to try using a foam wedge for left sided support and positioning when R25 is in the reclining geriatric chair.

Based on observation, interview, and record review the facility failed to provide feeding assistance, implement nutritional recommendations, evaluate nutritional supplement intakes, notify the physician of significant weight loss, and ensure significant weight loss was evaluated by a dietitian for two (R5, R21) of two residents reviewed for nutrition in the sample list of 31. These failures resulted in R5 experiencing a severe weight loss of 16.65% (percent) in six months and R21 experiencing a 15.6% severe weight loss in two months. Findings include: The facility's Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol dated September 2017 documents the physician will be notified of significant weight loss including persistent changes in baseline appetite/food intake, and the physician will help identify medical conditions that may cause the weight change and will consider if any additional diagnostic testing is indicated. This policy documents the staff and physician will identify and implement appropriate interventions to address weight loss and will monitor the resident's nutritional status including response to interventions. 1.) R5's Minimum Data Set (MDS) dated [DATE] documents R5 has moderate cognitive impairment, requires setup assistance for meals, and has had a significant weight loss of 5% or more in one month or 10% or more in six months that was not prescribed. R5's Weight Log documents R5's weight as follows: 107.1 lbs (pounds) on admission of 9/7/23 105.8 lbs on 9/17/23 101.5 lbs on 10/1/23 (5.2% loss since 9/7/23) 100.5 lbs on 11/1/23 96.0 lbs on 12/1/23 (10.4% loss since 9/7/23) 95.2 on 1/1/24 (11.1% loss since 9/7/23) 92.6 lbs on 2/1/24 (13.5% loss since 9/7/23) 90.5 lbs on 3/1/24 (15.5% loss since 9/7/23) 85.7 lbs on 4/1/24 (5.3% since 3/1/23) 84.6 lbs on 4/3/24 (16.65% since 10/1/23) R5's Care Plan dated 1/15/24 documents an intervention for supervision/touching assistance for eating with the helper providing verbal cues/touching/steadying trunk. R5's Care Plan dated 9/20/23 documents R5 is at risk for malnutrition, is underweight, and has a Body Mass Index (BMI) of less than 19. This care plan includes interventions to assist with feeding as needed, encourage oral intake, offer snacks between meals and document acceptance, nutritional supplement 120 ml (milliliters) three times daily (TID), frozen nutritional supplement PRN (as needed), obtain weights as ordered, and notify the physician of significant weight loss. There is no documentation in R5's medical record that any new nutritional interventions were implemented after 12/18/23. R5's Meal Intake with date range 3/12/24-4/10/24 documents of the 88 meals 11 meals had 0-25% consumed, 28 meals had 26-50% consumed, and two meals were refused. R5's March and April Medication Administration Records (MARs) document to administer the frozen nutritional supplement PRN and does not document that R5 was offered this supplement. R5's Nutrition/Dietary Notes document R5 was evaluated by V20 Registered Dietitian (RD) on 9/13/23, 12/18/23, and 3/15/24. On 9/13/23 V20 recommended adding nutritional supplement 60 ml three times daily and a frozen nutritional supplement PRN. On 12/18/23 V20 documented R5's weight loss is likely secondary to decreased appetite and oral intake, and behaviors of refusing meals, supplements, and medications. V20 recommended to increase the nutritional supplement to 120 ml three times daily, continue with the frozen nutritional supplement PRN, and R5's family will encourage the frozen nutritional supplement in the afternoon. On 3/15/24 V20 documented R5 requires varying levels of feeding assistance including independent, supervision, and fully dependence on staff. V20 did not document new recommendations to address R5's continued significant weight loss. There is no documentation that R5's weight is monitored more frequently than on a monthly basis, R5's October significant weight loss was evaluated by V20 Registered Dietitian or that any new nutritional interventions were implemented after 9/13/23 until 12/18/23. There is no documentation that V20 evaluated R5 after 12/18/23 until 3/15/24. There is no documentation that R5's trending significant weight loss that began on 10/1/23 was reported to or evaluated by a physician. On 4/08/24 at 11:53 AM R5 was sitting in the dining room and had not taken any bites of food from the meal which consisted barbecued ground beef sandwich, mashed potatoes with gravy, peas, and lemon dessert bar. No staff was sitting with R5 to provide cueing or assistance. At 12:14 PM V24 Certified Nursing Assistant sat next to R5 and offered assistance/cueing. R5 only accepted a few bites of food from V24. V24 asked R5 if R5 wanted something else to eat and R5 did not respond. V24 did not offer R5 a frozen nutritional supplement. At 12:19 PM V13 Registered Nurse (RN) sat down beside R5 and fed R5 bites of food. At 12:26 PM R5 ate half of R5's sandwich and 75% of the mashed potatoes with V13's assistance. On 4/9/24 at 11:30 AM R5's Family (V12) stated R5's family visit often at meal time to feed R5, as R5 eats better when someone assists R5 with meals. V12 stated R5's family are concerned that staff may not be assisting R5 with meals. R5 ate 75% of the noon meal on 4/9/24, with V12's assistance. On 4/10/24 at 11:40 AM R5 was sitting in the dining room with a small cup of the nutritional supplement and a plate of ground meat, green beans and mashed potatoes with gravy. R5 was able to use the fork to take bites of mashed potatoes, but had difficulty getting bites of the ground meat and green beans as they fell off of R5's fork. No staff was sitting with R5 to provide cueing or assistance. V11 Certified Nursing Assistant (CNA) was asked if any residents require eating assistance in this dining room (where R5 was eating). V11 stated there are no residents who require help with eating on a consistent basis. At 12:00 PM V11 began giving R5 bites of food, after it was pointed out that R5 was having difficulty eating. At 12:30 PM V11 was asked how much of the noon meal R5 consumed and V11 stated I don't know, I walked away. On 4/10/24 at 2:15 PM V14 (R5's Family) stated R5 typically does better if someone assists R5 with meals and R5 eats better with a spoon instead of a fork. V14 stated R5 does not show interest in the frozen nutritional supplement and asked if there were alternative options to this supplement and if R5 could be weighed weekly instead of monthly. On 4/10/24 at 10:18 AM V2 DON (Director of Nursing) stated V20 RD reviews the weights monthly and V20's recommendations are given to the physician to review, which is how the physician is notified of weight loss. V2 stated the frozen nutritional supplement is given by the nurses and signed out on the MAR when given. At 12:55 PM V2 confirmed R5's weight loss has not been reported to or evaluated by a physician. At 1:31 PM V2 stated staff should offer assistance if R5 is not eating or having difficulty eating, but R5 does not always accept assistance. V2 stated maybe we should schedule R5's frozen nutritional supplement to be given routinely. On 4/10/24 at 11:57 AM V20 RD stated if there isn't a nutrition note, then V20 likely did not see R5 during the months that were not documented in R5's dietary notes (October 2023, November 2023, January 2024, and February 2024). V20 stated V20 runs a weight report monthly to see if there are any significant weight changes and then V20 follows up on those weight changes. V20 stated V20 originally spoke with R5's family and they were going to give R5's frozen nutritional supplement in the afternoons, and R5 refuses R5's supplements at times. V20 confirmed staff should offer the frozen nutritional supplement at meals if R5 has poor appetite or isn't eating, and this supplement could prevent further weight loss. V20 stated V20 talks with the nurses to determine if supplements are given and accepted. V20 stated the nutritional supplement 60 ml TID was ordered in September 2023 and increased in December 2023 to 120 ml TID. V20 confirmed there were no other nutritional interventions implemented between September 2023 and December 2023. V20 stated V20 gives V20's recommendation forms to the nurses to follow up with the physician. V20 stated a big part of R5's weight loss is R5's poor intakes and poor appetite, and confirmed staff should offer assistance when R5 is having difficulty eating or poor appetite. V20 confirmed if staff do not assist R5 when needed, this could contribute to R5's weight loss. On 4/10/24 at 12:55 PM V20 confirmed there were no new nutritional interventions recommended or implemented for R5 after 12/18/23. 2.) R21's Physician Order dated 3/9/24 documents to administer (nutritional supplement) twice daily (does not specify Original or Plus version) and may substitute with (comparable alternate nutritional supplement) 120 ml TID. R21's March and April 2024 MARs document administration of this order, but do not document if or when the alternate supplement was given or the amount of (nutritional supplement) given. R21's Weight Log documents R21's weight as follows: 81.5 lbs (admission weight) on 12/12/23 78.4 lbs on 12/31/23 75.6 lbs on 1/1/24 (7.2% loss since 12/12/23) 74.1 lbs on 1/14/24 68.8 lbs on 2/1/24 (15.6% loss since 12/12/23 and 9% loss since 1/7/24) 69.8 lbs on 3/1/24 74.6 lbs on 4/1/24 and 70.1 lbs on 4/3/24 R21's Dietary/Nutrition Note dated 12/19/23 documents R21's BMI is 15.1, R21 is underweight related to inadequate oral intake and poor appetite. This note documents V20's recommendation of (nutritional supplement) Plus twice daily that is provided by R21's family, and give (comparable alternate nutritional supplement) 120 ml TID when unavailable. This note documents R21's family requested to be notified when supplement is running low. R21's Dietary/Nutrition Note dated 3/7/24 documents R21 accepts the comparable alternate nutritional supplement when the ordered supplement is unavailable. This note documents R21's meal intakes average 50-75%, but vary with occasional poor intakes and refusal of meals. This note documents the recommendation to continue with the same supplement amount and frequency noted on 12/19/23. There is no documentation in R21's medical record that R21's trending weight loss that began on 12/31/23 was reported to or evaluated by a physician. On 4/08/24 at 11:48 AM R21 was eating independently in the dining room. At 12:26 PM R21 ate approximately 75% of R21's meal. On 4/08/24 at 12:35 PM R21 stated R21's weight was down to 62 lbs at one time, and R21 didn't like that. R21 stated R21 has difficulty gaining weight and last week R21 weighed 70 lbs. R21 stated R21's appetite is pretty good and R21 has an upcoming doctor appointment to have R21's esophagus stretched, which usually helps with R21's eating. R21 stated the nurses give R21 a nutritional supplement that R21 likes. On 4/10/24 at 9:44 AM V7 Registered Nurse stated R21 gets (nutritional supplement) per orders and (comparable alternate nutritional supplement) can be given if the (nutritional supplement) is unavailable. V7 entered the medication room and showed the nutritional supplement bottles that are administered to R21. This supplement was not the Plus version of the (nutritional supplement) as ordered. On 4/10/24 at 1:31 PM V2 confirmed there is no documentation that R21's physician was notified of R21's weight loss. On 4/10/24 at 11:57 AM V20 RD stated there is a difference in the Original and Plus versions of (R21's ordered nutritional supplement). V20 stated (nutritional supplement) Plus is R21's preferred supplement that R21 was taking at home, and R21 should receive one bottle (237 ml) twice daily. V20 confirmed (nutritional supplement) Plus is ordered for R21 and provided by R21's family. V20 stated V20 was not aware that R21 was not receiving the ordered supplement and V20 will need to follow up on this right away as the Original and Plus supplements do not have equivalent nutritional content. V20 stated more of the Original will need to be given to equal the amount of Plus ordered. V20 confirmed the order should specify Plus, and not receiving the ordered supplement could have contributed to R21's weight loss.

Based on observation, interview and record review the facility failed to label opened prepared foods with the date and time in the refrigerator. This failure has the potential to affect all 90 residents who reside in the facility. Findings Include: The facility's midnight census as of 4/8/24 is documented as 90. On 4/08/24 at 9:00AM, Cole slaw, whipped topping, and sour cream were observed in the refrigerator not labeled with a date or the time in which they were opened. At this same time, (V21), Dietary Manager stated I can't say how long these items have been in the refrigerator since they are not labeled. I will discard them. Food items should definitely be labeled with the date and time opened before being placed in the refrigerator.

Based on observation, interview, and record review the facility failed to obtain orders for oxygen, failed to store, change, and label oxygen and nebulizer tubing in accordance with facility policy (R16, R19, R26) and failed to provide routine cleaning of a humidifier (R15). R15, R16, R19, R26 are four of five residents reviewed for respiratory care in the sample list of 31. Findings include: 1.) On 04/08/24 at 11:18 AM there was a humidifier on the table in R15's room. R15 stated R15 was unsure what the machine is used for. There is no documentation in R15's medical record that R15 uses a humidifier or routine cleaning/care of the humidifier. On 4/08/24 at 1:51 PM V13 Registered Nurse confirmed R15's humidifier and stated V13 is unsure how often it is used. V13 stated R15's family brought in the humidifier and provides care/maintenance for the machine. On 4/09/24 at 12:53 PM V2 Director of Nursing (DON) stated V2 provides a list of humidifiers to housekeeping staff to clean monthly. V2 stated V2 was unaware that R15 had a humidifier, which was brought in a couple months ago. V2 stated we do not obtain physician orders for humidifier use and the facility does not have a policy for humidifiers. 2.) On 04/08/24 at 10:44 AM and 1:40 PM R16's undated nebulizer mask and tubing were lying uncovered on top of R16's night stand. There were droplets of medication in the nebulizer chamber. At 10:44 AM R16 stated R16 had a respiratory infection that is improving, and R16 takes nebulizer treatments at least daily. R16's March and April 2024 Medication Administration Record documents R16's Albuterol nebulizer was administered six times, with the last administration on 4/7/24. R16's medical record does not document orders for routine changing of nebulizer equipment. 3.) On 04/08/24 at 11:24 AM R19 was lying in bed wearing oxygen at 2.5 liters per nasal cannula. The humidification bottle was dated 3/20/24 and the tubing was not labeled with date. R19's Physician Order dated 8/2/23 documents to change R19's oxygen tubing and humidification bottle weekly on Wednesdays. 4.) On 4/08/24 at 10:13 AM R26's oxygen tubing and nasal cannula was lying on the floor, and the tubing was dated 4/4/24. R26's oxygen concentrator did not contain a storage bag for R26's oxygen tubing. R26 stated R26 only wears oxygen at night. On 4/09/24 at 11:25 AM R26's oxygen tubing was labeled with a date of 4/4/24. R26's Order Summary dated 4/9/24 documents R26 admitted on [DATE], and does not include orders for oxygen administration or to routinely change oxygen tubing and humidification bottle. On 4/09/24 at 12:53 PM V2 DON stated oxygen and nebulizer tubing should be changed weekly and labeled with a date, nebulizer tubing should be cleaned after use and stored in bag when not in use, and nasal cannulas should be stored in a bag when not in use. V2 stated yesterday V2 saw that R26 had thrown R26's nasal cannula on the floor. V2 stated we could provide a bag for R26's oxygen tubing, but R26 won't use it. V2 was asked if R26's oxygen tubing was changed and V2 stated V2 would have to look at the labeled date on the tubing. On 4/09/24 at 3:48 PM V2 stated there should be oxygen orders and orders for routine changing of oxygen and nebulizer tubing. The facility's Oxygen Therapy policy dated March 2024 documents the physician's order for oxygen administration should include the device and liter flow rate, oxygen tubing will be labeled with a date and changed weekly, and the tubing will be stored in a bag to prevent contact with the floor. The facility's Nebulizer Therapy policy dated 3/20/23 documents orders after nebulizer treatment administration, rinse the pieces used to administer the medication, allow to air dry, and once dry store the tubing covered. This policy documents to change the disposable nebulizer equipment weekly and label with a date.

Based on observation, interview, and record review the facility failed to implement enhanced barrier precautions as recommended by the Centers for Disease Control and Prevention. This failure affects five (R31, R97, R149, R150, R33) of five residents reviewed for enhanced barrier precautions in the sample list of 31. Findings include: 1.) On 4/09/24 at 1:26 PM V11 and V15 Certified Nursing Assistants entered R31's room and provided urinary catheter care. V11 and V15 did not wear gowns during R31's care and there was no signage posted on R31's door to indicate enahanced barrier precautions (EBP) use when providing R31's cares. R31's Care Plan dated 2/19/24 documents antibiotics were ordered to treat a Urinary Tract Infection. This Care Plan documents R31 has an indwelling urinary catheter due to urinary retention and includes interventions for contact isolation due to colonization of MRSA (Methicillin Resistant Staphylococcus Aureus (multidrug resistant organism). On 4/10/24 at 2:30 PM V2 Director of Nursing/Infection Preventionist stated the facility does not have a policy for EBP yet. V2 provided a copy of EBP signage and stated the policy will be based on the EBP signage. The EBP signage provided by V2, documents to perform hand hygiene upon entering and leaving the room, wear gloves and gown for the following high contact resident care activities - dressing, bathing/showering, transferring, changing linens, providing hygiene, changing incontinence briefs, assisting with toileting, device care/use (central lines, urinary catheters, feeding tubes, tracheostomy), and wound care (any skin opening that requires a dressing). 2.) R97's Care Plan dated 4/5/24 documents R97 has an indwelling urinary catheter. On 4/8/24 at 10:24 AM there was no signage posted on R97's doorway to indicate EBP use when providing R97's cares. On 4/9/24 at 1:14 PM V11 and V15 provided R97's urinary catheter care. V11 and V15 did not wear gowns during R97's care. The CDC Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated June 2021 documents a recommendation for EBP use (gloves and gown) when providing high contact cares for residents with indwelling devices or wounds to prevent the spread of multidrug resistant organisms. 37813 3.) R149's Order summary printed 4/10/24 at 3:38PM includes the following Physician's order: Right buttock pressure area: Cleanse with Normal Saline, apply skin prep around wound bed, apply hydrocolloid every 3 days and PRN (as needed) every night shift. On 4/8/24 at 9:00AM, R149 was observed sitting in R149's room. R149 had a urinary catheter in place with the drainage bag on her chair. There was no sign on R149's door indicating enhanced barrier precautions and there was no PPE (Personal Protective Equipment) available upon entering R149's room. 4.) R150's Order Summary printed 4/10/24 at 4:03PM includes a physician's order originating 3/27/24 for Right buttock open area: Cleanse with Normal Saline, apply hydrocolloid every evening shift every 3 day(s). This order summary also documents a physician's order originating 4/9/24 for Left buttock open area: Cleanse with NS (normal saline), apply skin prep around wound bed, apply hydrocolloid every evening shift every 3 day(s). On 4/10/24 at 11:15AM, R150's treatment was observed being applied by V6, Registered Nurse (RN) R150 had a Stage II pressure ulcer on right and left buttocks. V6 did not wear a gown during R150's wound treatment. There was no sign on R150's door indicating enhanced barrier precautions and there was no PPE available upon entering R150's room. 5.) On 4/10/24 at 10:50AM, V6 was observed applying a wound treatment to the open pressure ulcers on R33's right and left buttocks. V6 did not wear a gown while completing the treatment to R33's open wound. On 4/10/24 at 11:00 AM, V22 Certified Nurse's Aide (CNA) and V23 Certified Nurse's Aide (CNA) proceeded to perform catheter care for R33. Neither V22 nor V23 wore a gown. There was no sign on R33's door indicating enhanced barrier precautions and there was no PPE available upon entering R33's room. V22 stated (R33) isn't on any isolation so we just need to wear gloves.

Based on observation, interview, and record review the facility failed to utilize the safest assistive devices for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure resulted in (R1) slipping from a sit to stand lift and sustaining a dislocated shoulder requiring closed reduction. Findings Include: 1. R1's Care Plan updated 3/5/24 includes the following diagnoses: Fall, Chronic kidney Disease Type III, Congestive Heart Failure, Muscle Weakness, Difficulty Walking, Unsteadiness on Feet, Abnormal Gait, Lack of Coordination, and Abnormal Postures. This Care Plan documents R1 is High Risk for Falls. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately cognitively impaired, has functional limitations to all four extremities, uses a manual wheelchair and is totally dependent to roll wheelchair 150 Feet. This MDS also documents R1 is dependent for Sit to Stand, Toilet Transfer, and Toilet hygiene. R1's Care Profile Audit Report printed 3/26/24 documents: On 2/21/24 at 11:26AM Sit-to-Stand (lift). On 2/21/24 at 2:43PM (Sling type mechanical lift). On 2/27/24 at 7:36AM (Sling type mechanical lift). R1's Physical Therapy Note dated 3/10/24 by V12, Physical Therapy Assistant (PTA) documents Precautions/Contraindications: Fall risk, Lower extremity Edema, Low Activity tolerance, (sling type Mechanical Lift) transfer, Left Lower Extremity Numbness, Limited bilateral shoulder flexion, Bilateral Hand and Wrist Edema, and Left Quadriceps Weakness. R1's Incident Note dated 03/11/2024 at 12:39PM by V6, Registered Nurse (RN) documents (R1) assisted to toilet with Sit to stand lift, two CNAs used sit to stand trial to clean (R1) when (R1) slid out of sling and was lowered by CNA to floor. Range of Motion Within Normal Limits, (R1) complains of pain in Right upper arm. (R1) assisted by three staff and (sling type mechanical lift) to bed. (R1) complains of increasing pain in Right shoulder and inability to move. Grip equal and pulses even bilaterally. Power of Attorney present and requesting (R1) to be seen. Ambulance called and R1 sent to emergency room at approximately 11:45AM. R1's emergency room report from 3/11/24 at 4:11PM documents reports to Emergency Department status post fall with obvious right shoulder deformity. R1's X-ray dated 3/11/24 at 1:45PM documents Comparison to 2/12/24 (Chest X-Ray) Impression: Right Glenohumeral Shoulder Dislocation. Further notes by emergency room staff document R1 required closed reduction for shoulder dislocation. On 3/26/24 at 2:00PM V6, RN stated I was (R1's) nurse the day (R1) slid out of the sit-to-stand. I hadn't worked that hall for a while and I thought (R1) was using a sit to stand so I told the CNAs they could use the sit-to-stand to clean (R1) after a bowel movement. (V8 and V9) Certified Nurse's Aides (CNAs) transferred (R1) from the chair to the toilet using a (sling type mechanical lift). (R1) had a bowel movement and so they could clean (R1), the CNA's used a sit to stand lift. They reported to me that when they stood (R1), (R1) was weak and began to slip so they eased (R1) to the floor. (R1) was in between the toilet and the door on the floor when I got to the room. (R1) was moaning a little and said her right shoulder hurt. We got the (sling type mechanical lift) and put (R1) in bed. I didn't see any redness or swelling. I put ice on the shoulder and elevated (R1's) right arm on a pillow. R1's power of attorney was here and requested we send (R1) to the hospital. I notified (V3, Assistant Director of Nursing) and we sent (R1) to the hospital. On 3/26/24 at 2:30PM V8, Certified Nurse's Aide (CNA) stated I was with (R1) when (R1) fell (3/11/24). We moved (R1) to the toilet with a (sling type mechanical lift). We thought we could clean (R1) easier with the (sit to stand lift) so we stood (R1) up from the toilet with the sit-to-stand lift. (R1) was too weak and slipped out of the sit to stand sling. (V9) Certified Nurse's Aide and I assisted (R1) to the floor. Once we had (R1) on the floor (R1) was moaning in pain and I thought (R1's) shoulder looked a little crooked. (V6) came in and the three of us got (R1) in the (Sling type mechanical lift) and took (R1) back to bed so (V6) could look at (R1). (R1's) family member was here and asked (R1) be sent to the hospital and that is what we did. On 3/26/24 at 3:00PM V4, Occupational Therapist, Director of Therapy verified the Physical Therapy noted 3/10/24 documents (R1) required a (sling type mechanical lift) for transfer. On 3/26/24 at 4:00PM V10, Nurse Practitioner, stated I wasn't there so I couldn't say for certain the fall from the lift caused (R1's) shoulder dislocation, but (R1) was a larger person and slipping out of a lift, would have put pressure on (R1's) shoulders.

Based on observation, interview and record review, the facility failed to provide supervision, after assisting a resident to the bathroom, for one of three residents (R125) reviewed for falls in a sample of 22. This failure resulted in R125 falling, while self-transferring from the toilet, sustaining a left distal femur fracture. Findings include: A Fall Prevention policy dated 5/2021 states, A resident that has been identified as a moderate risk for falls but is at an increased risk for falling if left unattended while on the toilet, will not be left unattended while on the toilet. R125's Minimum Data Set (MDS) assessment dated [DATE] documents R125 is moderately cognitively impaired and requires extensive assistance for transfers, toileting, and personal hygiene; is unsteady during transitions and is only able to stabilize with staff assistance when moving from a seated to a standing position. R125's Fall Risk assessment dated [DATE] documents that R125 is at high risk for falls. R125's Nurse's note dated 11/19/21 at 7:50p.m. documents that R125 was assisted to the toilet by a CNA (Certified Nurse Aide), and left alone in the bathroom while the CNA left to grab some hair curlers. This note further documents that as the CNA was returning to the bathroom, R125 was attempting to stand without assistance and fell before the CNA could catch R125. R125's nurse's note dated 11/20/21 at 6:50a.m. documents that R125's physician ordered X-rays to be taken because R125 was experiencing pain to her left hip and knee. R125's nurse's note dated 11/20/21 at 3:37p.m. documents R125's X-ray report showed that R125 had sustained an impacted fracture of R125's lateral distal femur. R125's nurse's note dated 11/21/21 at 11:49a.m. documents that the hospital reported to the facility that R125 was diagnosed as having a left distal femur fracture. R125's fall investigations dated 11/21/21 and 11/26/21 documents that R125 fell in the bathroom on 11/19/21 when the CNA turned away from R125 to get more hair rollers. This investigation documents R125 was initially assessed as having no injuries but later R125 began to complain of knee and hip pain. Additionally, this investigation documents an X-ray showed that R125 had sustained a left lateral distal femur fracture at which time R125 was sent to the emergency room for further evaluation. R125's left femur X-ray report dated 11/20/21 states, There is subtle bony irregularity along the superior aspect of the lateral femoral condyle. This raises concern for an acute nondisplaced fracture in the setting of osteopenia. On 12/7/21 at 9:01a.m. R125 was lying in bed with a large splint wrapped around R125's left upper leg. V6(Registered Nurse) was at R125's bedside and stated that R125 was unable to get out of bed at this time because R125 has a left distal femur fracture. On 12/8/21 at 11:00a.m. V3 (Assistant Director of Nurses) stated that she investigated R125's fall, with fracture, which occurred 11/19/21. V3 stated that R125 needs supervision while on the toilet because R125 is a fall risk and has a history of trying to get up from the toilet without assistance, which could result in a fall. V3 stated that after R125's fall with fracture 11/19/21, V9, the CNA who was assisting R125 in the bathroom when she fell , was educated to never turn her back on a resident while that resident is sitting on the toilet. A document from V9's employee file dated 11/22/21 and signed by V2 (Director of Nurses) and V3 states, Spoke with (V9) regarding (R125's) fall. Explained that when providing care that you never turn your back on a resident. CNA verbalized that she understood.

Based on observation, interview and record review, the facility failed to implement interventions to prevent falls and failed to complete a thorough post fall investigation. These failures affect three of three residents (R1, R2, R3) reviewed for falls in the sample of three. These failures caused R1's fall resulting in R1's sternum fracture, severely comminuted fractures of the jaw, and concussion. These failures also caused R2's fall resulting in a nondisplaced hip fracture. Findings include: 1.) R1's Progress Notes dated [DATE] at 11:16pm document R1 admitted to the facility at 6:10pm with diagnosis of Urinary Tract Infection (UTI) and Age Related Debility. R1's Physical Therapy (PT) Discharge Summary dated [DATE] documents R1 was discharged from Physical Therapy (PT) on [DATE]. This summary documents R1 requires Stand By Assist (SBA) for all functional mobility due to decreased awareness of limitations. R1 has limited potential for further gains and R1 will not likely reach independent levels. R1's Care Plans dated [DATE] document R1 is at risk for falls with a goal of no serious injury. These Care Plans document R1's fall prevention interventions including assist R1 with activities of daily living. These Care Plans document R1 needs limited assist for transfers and supervision with toileting and personal hygiene. R1's Minimum Data Set (MDS) dated [DATE] documents R1 requires supervision with transfers, toileting, personal hygiene and walking in R1's room. R1's Progress Notes dated [DATE] document R1 fell while opening R1's bathroom door and hit R1's face. This note documents R1 had a medium laceration below R1's chin and had a lot of generalized pain. R1 was transferred to a wheel chair and complained of intense sternal pain. R1 was transferred to the emergency room . On [DATE] at 4:28am, the hospital notified the facility R1 was being transferred to a hospital out of town with a diagnosis of a fractured sternum and fractured jaw. The facility's fall investigation file for R1's fall on [DATE] at 10:00pm documents the following: R1's Resident Fall Report documents R1 was ambulating independently in R1's room. The facility failed to document R1's temperature and pulse post fall documenting forgot but were WNL (within normal limits). This report documents R1 sustained a laceration to the chin and an abrasion to the right knee. R1 was transferred to the emergency room for sternal pain and laceration. This report also documents (R1) is independent. When cleaning up for the night, (R1) went to close (R1's) bathroom door. (R1) fell for some reason and fell on (R1's) face. R1 knocked on the bathroom door until someone found R1. This report documents the root cause of R1's fall was that R1 lost balance when closing a door but does not document an investigation in to why R1 lost R1's balance or why R1 was left alone while up in the bathroom. R1's The Story of My Fall sheet dated [DATE] at 10:00pm documents V4, Certified Nursing Assistant (CNA) encouraged (R1) to do (R1's) cares. This sheet documents What fall interventions were in place? (R1) was independent. This sheet is blank for the question if fall interventions were in place/applied appropriately. This sheet documents what time R1 was last toileted with the answer independent. The facility's final report to the State Survey Agency dated [DATE] documents staff were doing rounds and heard a faint knocking on R1's door to the hall and found R1 on the floor by R1's bathroom. R1 was sent to the hospital for complaints of pain upon movement in sternal area and then transferred to a hospital out of town and admitted with diagnoses of Bilateral Mandibular Condyle Fractures and Sternal Fracture. R1's Hospital Trauma Evaluation History and Physical (H&P) dated [DATE] documents Trauma Level 2 and R1 was involved in a ground level fall at the facility. It was unclear how long (R1) was down before (R1) was found. R1 fell forward hitting R1's chin and chest. (R1) is currently complaining of severe chest pain, mandible pain making it difficult to talk. This H&P documents R1 is assessed and having difficulty taking big breaths due to pain. R1 is having bilateral mandibular tenderness with mild swelling and chin laceration. R1 is also having difficulty opening R1's mouth fully due to pain. R1's chest had area of redness, mild swelling and severe tenderness over the right upper chest. R1's Computed Tomography (CT scan) dated [DATE] of the facial bones and mandible documents R1 with moderate to severe head trauma after a fall at the facility. This result documents R1 demonstrates a severely comminuted intra-articular fractures of the mandibular condyle bilaterally extending in to the mandibular rami. The fracture appears to be displaced on the right side with dislocation at the right temporomandibular joint. R1's CT scan results of the chest dated [DATE] documents Rib fracture suspected, traumatic. R1 presents to the emergency department after having a ground level fall. These results document R1 has a nondisplaced lower sternal fracture with a small amount of retrosternal hematoma. R1's Physician Note dated [DATE] documents R1's diagnoses including fall from ground level resulting in sternal and bilateral mandibular fractures. R1's After Visit Summary dated [DATE] documents R1 had a concussion (hit head on a counter during a GLF (ground level fall) that fractured (R1's) mandible and sternum.) R1 will need close supervision . This summary documents recommendations from V6, R1's Oral Surgeon for R1 to be served a pureed diet for comfort for ,d+[DATE] weeks with advancement to soft chew as tolerated due to R1's mandible fractures. R1's Progress Notes dated [DATE] at 5:40am document R1 was found on the floor in front on the bathroom with R1's walker at R1's side. R1 stated that R1 lost R1's footing and fell backwards on R1's buttocks and hit R1's head. R1's head was noted to have a slightly raised reddened area to back of the head. On [DATE] at 10:42am R1's talking was limited and hard to understand as R1 was unable to fully open/move mouth due to jaw fractures and dislocation as well as pain from those injuries. At this time R1 reports R1 was taking short breaths because of sternum pain when R1 breathes. R1 stated R1 broke R1's chest bone (sternum) while using hand to point to sternum and R1's jaw. When R1 was asked about R1's pain related to the fractures, R1 stated, oh, I definitely have pain and reported ear pain due to R1's jaw injury. R1's right side of temple/face area has significant amount of blue/green bruising. R1 was able to recall R1 fell causing the fractures of the jaw and sternum, but unable to provide a cause of the fall. R1 also stated R1 had another fall but was unsure of the date/time of the second fall. R1 stated, I hope I didn't break any bones that time. On [DATE] at 3:49pm, V3, Assistant Director of Nursing (ADON) stated V1, Director of Nursing (DON) and V3 review the fall reports together and V3 enters the information in to the facility fall management electronic record. V3 stated R1 was independent when (R1) fell . When asked about how V3 was aware R1 was independent V3 stated might have been passed on. V3 stated the certified nursing assistant (CNA) completes the document titled The Story of My Fall and the nurse completes the other handwritten assessments/investigation paperwork. V3 confirmed the handwritten documents from the staff document R1 was independent although R1's Care Plans and Physical Therapy notes document R1 required assistance. V3 stated therapy notifies nursing of resident's needing assistance with activities of daily living (ADL) and that the staff should be reviewing each resident's Care Plans to see the level of assist the resident requires. V3 stated V3 had not received the investigation documents related to R1's fall on [DATE] as of [DATE]. V3 stated during review of what the staff submit regarding falls, V3 and V1 try to find a reasonable intervention if needed instead of or in addition to the intervention the nurse who completed the fall investigation implemented. On [DATE] at 3:40pm, V4, Certified Nursing Assistant (CNA) stated R1 was in R1's bed when V4 told R1 it was time for bed time cares and placed R1's items in R1's bathroom and left the room. V4 stated V4 left everything on the sink for (R1) to do it. I left the room and came back and R1 had gotten up and in to the bathroom and started to complete bedtime cares. V4 stated V4 left R1 standing alone in the bathroom and went to let the nurse know R1 was doing night time cares and the nurse was like okay. V4 stated R1 went in to the bathroom to complete cares independently and V4 was not with R1 while R1 ambulated to the bathroom. V4 stated V4 had come back to R1's room and peeked in on R1 who was still brushing R1's teeth. V4 stated another resident, R4, had requested to be assisted to the bathroom so V4 left R1 alone in R1's bathroom to assist R4 in another room. V4 stated when V4 came out of R4's room, there were more call lights so V4 went and answered other call lights as call lights kept going off. A little while later (V4) heard a knock on a door and I had to figure out where it was coming from. V4 stated V4 finally figured out the knock sound was coming from R1's room. V4 stated V4 opened R1's door to R1's room and that is when V4 found R1 on the floor. V4 stated V4 didn't know how long it had been since V4 had checked on R1 nor how long R1 was on the floor. V4 stated staff review resident's Care Plans to find what level of assist the resident's require. V4 stated V4 knew R1 needed assistance with hygiene, but was never told R1 could not walk by self or that R1 was not independent. 2.) R2's Physical Therapy Evaluation and Plan of Care dated [DATE] documents R2's diagnoses including Fracture of [MEDICATION(S)] Vertebra, [CONDITION(S)] and Collapse, Difficulty walking Unsteadiness on Feet and History of falling. This evaluation documents R2 has a history of falls and feels unsteady when standing and walking. This evaluation documents R2's right and left lower extremity strength as impaired and R2's current mobility assessment for walking 10 feet, 50 feet and 150 feet as requiring supervision or touching assistance. R2's fall investigation documents R2 had a fall on [DATE] at 11:50am and documents the following: R2's Resident Fall Report documents prior to the fall on [DATE] at 11:50am, R2 was ambulating independently in R2's room. This report documents R2 was found on the floor sitting against the wall. R2 was upset after being told R2 could not return to R2's apartment, went to the bathroom and lost R2's balance when walking out of the bathroom and fell . This report documents R2 stated R2 hit head off of wall a little bit. The root cause documents loss of balance due to R2 was worked up after being told R2 couldn't go back to R2's apartment. The area Fall Risk Category does not document what fall risk category was identified for R2. There is no documentation R2 was safe to be independent in R2's room. This report documents R2 complained of left shoulder, left leg and groin pain and had redness to the left arm by R2's shoulder and was sent to the emergency room for evaluation. R2's The Story of My Fall dated [DATE] at 11:50 documents R2 stated R2 forgot to use R2's walker when coming out of the bathroom. R2 stated there were no staff present when R2 fell and R2 was not wearing R2's glasses when R2 fell . This report documents fall interventions that were in place including R2 was using walker, but does not document R2 had supervision or assistance of staff while R2 was ambulating. R2's Computed Tomography (CT) scan of the left hip results dated [DATE] documents R2 was found to have a nondisplaced fracture at the medial posterior of the left femoral metadiaphysis. R2's hospital orthopaedic consultation report dated [DATE] documents R2 who lives at a facility, fell and x-rays show a periprosthetic femur fracture around a left hip hemiarthroplasty. This report by V7, R2's Orthopaedic Physician documents V7 feels R2's surgical risk is too high and recommended nonoperative treatment with toe-touch weight bearing for four to six weeks. R2's Final Report dated [DATE] for R2's fall on [DATE] at 11:50am documents R2 was admitted to the hospital with nondisplaced fracture of the left hip. This report also documents R2 did not receive surgical intervention and returned to the facility with toe touch weight bearing and orders for Physical Therapy and Occupational Therapy. R2's Physician Progress Notes dated [DATE] document R2 was admitted to the facility on [DATE] following hospitalization for a left femur fracture. These notes document Recurrent fall resulting in Left Periprosthetic Hairline Fracture. On [DATE] at 3:49pm, V3, ADON stated V3 completed the investigation for R2's fall on [DATE] and R2 was independent. V3 stated the root cause was R2 lost R2's balance due to being worked up about discharge plans. V3 stated V3 could not remember if R2 was wearing R2's glasses at the time of the fall. V3 confirmed the investigation sheets document in one area R2 wears glasses but was not wearing them at the time of the fall and in another area R2 doesn't wear glasses. V3 stated V3 was not sure why the pressure alarms were implemented on R2's care plans to prevent falls on [DATE]. V3 stated R2 does not have them now because R2 is wanting to go back to the assisted or independent living community. V3 was unsure why R2's care plans and care Kardex document R2 is to have pressure alarms to R2's bed and wheelchair or when they were discontinued. V3 confirmed the investigation documents R2 was ambulating independently when R2 fell . V3 stated therapy notifies nursing of resident's needing assistance with ADL's and that the staff should be reviewing each resident's Care Plans to see the level of assist the resident requires. 3.) R3's Care Plans dated [DATE] document R3 has a history of multiple falls. There is no Goal documented for R3's Fall Care Plan. R3's interventions to assist in preventing R3 from falling include pressure alarm in bed and chair and to make sure R3's call light is within reach and encourage use. R3's Resident Fall Report dated [DATE] documents R3 was found on the floor at 3:30pm with R3's pressure alarm sounding. R3 stated R3 wanted to see R3's mother, walked and fell on the floor. This report documents the root cause of the fall as self transfer due to decline in cognition and confusion and forgetfulness. There is no fall risk category identified in this report. The intervention was to instruct to call for help before attempting activity by R3's self. R3's The Story of My Fall dated [DATE] at 3:30pm documents staff last assisted R3 at 3:00pm. R3's Resident Fall Report dated [DATE] at 3:15pm documents R3 was found lying on the floor near R3's wheelchair. This report documents R3's pressure alarm was not sounding. R3 stated R3 was walking over to the ironing board and R3's leg gave out. This report documents a fall alarm was in use, but not sounding and was noted to be plugged in but did not sound. There is no documentation the pressure alarm pad was evaluated or that the pressure alarm pads were being checked for function or replaced when expired. R3's The Story of My Fall documents the fall occurred on [DATE] at 3:00pm, which is 15 minutes prior to what is documented on R3's Resident Fall Report for the same fall. This report documents the call light was not within reach and was on the wall on one side of the room, (R3) was on the opposite side of the room. This report documents a chair alarm was in place, applied properly and functioning, which is not consistent with the Resident Fall Report for R3's fall on [DATE]. R3's Progress Notes dated [DATE] at 3:29pm document R3 was found on the floor. This note documents R3 was noted to have a 6cm (centimeter) x 6cm hematoma noted to R3's posterior cranium (head). This note documents R3's pressure alarm was plugged in, but did not sound when R3 stood up on R3's own unassisted. This note documents the pad was replaced, but does not document the pad or alarm box attached to the pressure pad was evaluated as to why it was not sounding. On [DATE] at 11:00am, R3 was up in R3's wheelchair with pressure alarm in R3's seat of R3's wheelchair so the wheelchair pressure alarm pad was unable to be observed. V9, Registered Nurse (RN) retrieved R3's pressure alarm from R3's bed. R3's pressure alarm pad on R3's bed did not have the date the pad was installed on R3's bed or the expiration date documented on the pad. There is no documentation when this pad was placed or when it expires (needs to be replaced.) V9 stated V9 was unsure of how often the bed sensor pads were supposed to be replaced. The undated label on the disposable bed sensor pad documents 90 day warranty and to write the pad's start date and warranty expiration date to track use. There are boxes labeled to write today's date and expiration date on the top of the sensor pad. Important Warnings It is important to implement and enforce the following warnings in order to keep all equipment functioning properly. Instructions for Set Up and Use: It is the responsibility of the facility to follow the instructions for set up and use carefully as outlined on this pad. At the end of the sensor pad's service life, the sensor pad must be disposed of. This device should not be a substitute for routine visual monitoring protocol by caregiving personnel. test the fall management system on a regular basis to ensure proper operation. The disposable sensor pad is warranted for singe resident use for the warranty period specified (in days) on this pad. The warranty starts from the date the pad is installed on the patient's bed or chair. The facility's Fall Prevention Policy dated February 2021 documents the policy is to assist in minimizing injuries related to falls and decrease falls. This policy documents Fall assessments are to be completed by the nurse on day of admission, quarterly and with change of condition and reviewed after each fall. All employees must observe residents for safety. The facility's Falls - Clinical Protocol dated [DATE] documents the physician will help identify individuals with a history of falls and risk factors for subsequent falls. The nurse shall assess and document/report information including vital signs and musculoskeletal function. The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls (for example, increased fracture risk in someone with [CONDITION(S)] .) For a resident who has fallen, staff will attempt to identify possible causes. Causes refer to factors that are associated with or that directly result in a fall. The staff will collect and evaluate information until either the cause of the falling is identified or it is determined the cause cannot be found or finding a cause would not change the outcome or management of falling and fall risk. Based on the assessment the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.