**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to implement fall prevention interventions for 1 of 5 residents (R35) reviewed for falls in a sample of 24. Findings include: R35's admission Record documents R35 was admitted to this facility on 10/12/2024 with diagnoses of fractured right femur, dementia, weakness and reduced mobility among others. R35's MDS (Minimum Data Set) dated 10/19/2024 documented in Section C, Cognitive Patterns, that R35 is never understood, has short and long term memory problems and due to this, R35 could not participate in a BIMS (Brief Interview for Mental Status) test. The same MDS documents in section J, Health Conditions, that R35 has had 2 falls with no injury since her admission or prior assessment. A form titled Illinois Department of Public Health documented on 10/18/24, R35 fell out of her wheelchair while being transported by staff in the dining room. According to the form, R35 put her foot down and lunged forward out of the wheelchair and onto the floor. R35 was hospitalized and returned to the facility on [DATE]. R35's care plan was reviewed and new interventions put into place. R35's Care plan, with initiation date of 10/11/2024 documented the focus area of: I am (at) risk for falls due to gait/balance problems, unaware of safety needs and hx (history) of actual fall with fx (fracture) . Planned fall intervention with a start date of 10/18/2024, documented R35 will have her foot pedals on her wheelchair. Another fall intervention with a start date of 10/16/2024 documented R35 will remain within staff's line of sight when out of bed. On 11/13/2024 at 8:30am, R35 was observed in the facility's dining room in her wheelchair, with staff but without foot pedals on her wheelchair. On 11/13/2024 at 11:10am, R35 was observed siting in her wheelchair at the nurse's station with V3 (Licensed Practical Nurse) and V5 (Certified Nursing Assistant). R35 did not have foot pedals on her wheelchair. V3 was asked about R35's missing foot pedals and replied, I didn't know she (R35) was supposed to have foot pedals on her wheelchair. V5 then transported R35 from the nurse's station to the group room down the hallway without foot pedals on R35's wheelchair. When asked about the missing foot pedals, V5 said she did not know if R35 was supposed to have on foot pedals. On 11/13/2024 at 12:15pm, R35 was observed in the same group room, in her wheelchair and without foot pedals on her wheelchair. On 11/14/2024 at 9:22am, R35 was observed in her room up in her wheelchair and not in the line of sight of staff. No staff were observed in the hallway near R35's room. On 11/14/2024 at 10:35am, V2 (Director of Nursing) said R35 is supposed to have foot pedals on at all times and especially when staff are transporting her in a wheelchair. V2 agreed R35 should not have been in her room in her wheelchair without staff present. A facility policy titled Fall and Fall Risk, Managing, with revision date of March 2018, documented the following in part: When a resident is found on the floor, a fall is considered to have occurred. Staff will identify interventions related to the resident's specific risks to try to prevent the resident from falling and try to minimize complications from falling. Staff will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer pneumococcal vaccinations for 3 of 5 residents (R20, R31, R29) reviewed for immunizations in a sample of 24. Findings include: 1. R20's admission Record documents an admission date of 08/08/2022 with diagnoses including: chronic obstructive pulmonary disease, peripheral vascular disease, hypertensive heart disease with heart failure, asthma, chronic viral hepatitis C and aneurysm of artery of lower extremity. R20's documented date of birth indicates that R20 is [AGE] years of age. R20's most current Influenza and Pneumococcal Vaccine Consent/Declination dated 09/28/23 documents yes for the statement: Please mark YES or NO for permission to administer the Pneumococcal (PVC15-Pneumococcal Conjugate Vaccination 15) vaccine, yes for the statement: Please mark YES or NO for the permission to administer the Pneumococcal (PCV20- Pneumococcal Conjugate Vaccination 20) vaccine, and Yes to the statement: Please mark YES or NO for permission to administer the Pneumococcal (PPSV23- Pneumococcal Polysaccharide Vaccine 23) vaccine. R20's Immunization Report does not document any pneumococcal vaccinations given. R20's Order Summary Sheet documents active orders as of 11/14/2024 does not document an order for any pneumococcal vaccinations. 2. R31's admission Record documents an admission date of 05/10/24, a date of birth indicating that R31 is [AGE] years of age, and diagnoses including: hypertensive heart disease without heart failure, disorder of kidney and ureter, benign prostatic hyperplasia with lower urinary tract symptoms, and gastro-esophageal reflux disease without esophagitis. R31's Influenza and Pneumococcal Vaccine Consent/Declination dated 05/10/24 documents yes for the statement: Please mark YES or NO for permission to administer the Pneumococcal (PVC15) vaccine, yes for the statement: Please mark YES or NO for the permission to administer the Pneumococcal (PCV20) vaccine, and Yes to the statement: Please mark YES or NO for permission to administer the Pneumococcal (PPSV23) vaccine. R31's Immunization Report does not document any pneumococcal vaccinations given. R31's Order Summary Sheet documents active orders as of 11/14/2024 does not document an order for any pneumococcal vaccinations. 3. R29's admission Record documents an admission date of 01/09/24, a date of birth indicating that R29 is [AGE] years of age, and diagnoses including: dementia, chronic kidney disease stage 3, peripheral vascular disease, type 2 diabetes mellitus with diabetic chronic kidney disease, and hypertensive heart disease without heart failure. R29's Influenza and Pneumococcal Vaccine Consent/Declination dated 01/09/24 documents yes for the statement: Please mark YES or NO for permission to administer the Pneumococcal (PVC15) vaccine, yes for the statement: Please mark YES or NO for the permission to administer the Pneumococcal (PCV20) vaccine, and Yes to the statement: Please mark YES or NO for permission to administer the Pneumococcal (PPSV23) vaccine. R29's Immunization Report does not document any pneumococcal vaccinations given. R29's Order Summary Sheet documents active orders as of 11/14/2024 does not document an order for any pneumococcal vaccinations. The Centers for Disease Control website (https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html), Pneumococcal Vaccine Recommendations (dated October 26th, 2024) documents that the recommendation for adults 50 years or older for routine vaccination as Administer PCV15, PCV20, or PCV21 (Pneumococcal Conjugate Vaccination 21): who have never received any pneumococcal conjugate vaccine and whose previous vaccination history is unknown .If PCV15 is used, administer a dose of PPSV23 one year later, if needed. Their pneumococcal vaccinations are complete. On 11/14/24 at 2:10 PM V1 (Administrator) stated, they do not have any documentation for R20's, R31's or R29's pneumococcal vaccinations. She stated, she does not know if the residents need the vaccination or which vaccination. V1 stated R20, R31, and R29 have signed consent forms documenting they would receive the pneumococcal vaccination. The facility policy dated 08/2016 titled, Pneumococcal Vaccine documents in part: 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series with thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 4. Pneumococcal vaccines will be administered to resident (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. 7. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

Based on observation, interview, and record review, the facility failed to implement fall prevention interventions to prevent falls for two (R2 and R11) of three residents at risk for and reviewed for falls in the sample of twenty three. Findings include: 1. On 07/10/22 at 10:32am, R2 was observed lying in his bed asleep. Gripper strips were noted to be adhered to the floor beside R2's bed. R2's Care Plan with a review date of 05/11/22 documented a problem area of (R2) is at risk for falls, with a corresponding intervention, (Staff) educated on replacing nonskid strips to floor after waxing floor. R2's Fall Investigations documented the following: 03/17/22: Resident was sitting on bathroom floor in front of toilet. Injuries: None noted. Conclusion: Replaced gripper strips in front of the toilet as an intervention. 04/07/22: (R2) was on the edge of the bed when he slid to the floor. No apparent injuries. Conclusion: We will replace the nonskid appliques on the floor beside the bed . 04/24/22: Resident had an unwitnessed fall, found in floor of resident room. Injuries: Hematomas left forehead, left shoulder, left upper arm. Conclusion: Residents room was just recently waxed and nonskid strips were not in place. (V1 Administrator) educated staff on ensuring that fall interventions are properly in place (for) all residents. 2. R11's Care Plan with a review date of 06/15/22 documented a problem area,(R11) is at risk for falls, with a corresponding intervention, Nonslip strips to the floor at the bedside. R11's Fall Investigations document the following: 10/14/21:Resident was (found) on floor against bed on her buttocks. Injuries: None noted. Conclusion: Floor recently waxed by maintenance, gripper strips not intact, staff reeducated on the importance of fall interventions. A Fall Prevention Policy (S.A.F.E.) with a revision date of February 2014 documented, Definition: The S.A.F.E. Program promotes Safety Assessment, fall prevention, and Education of both staff and residents .Residents found to be at high risk for falls are placed on the SAFE Program and specific interventions are implemented to meet individual need. On 07/13/22 at 9:11am, the above referenced falls of R2 and R11 were reviewed with V1. V1 stated it is V6's (Maintenance Director) job to replace the gripper strips after the floors have been waxed. V1 also stated V6 is to be checking all gripper strips at least monthly and replacing them as needed. On 07/13/22 at 1:42pm, V6 stated he is the staff member responsible for replacing gripper strips after the floors are waxed. V6 stated it is possible he forgot to replace the above referenced strips, but he could not remember specifically. V6 stated he does daily environmental rounds and checks items in resident rooms including gripper strips and replaces them when they appear worn. V6 stated it is possible at the time of R2's falls, he did not realize the strips in R2's room were worn enough to need replacement, but they have since been replaced.

Based on observation, record review, and interview, the facility failed to provide aseptic catheter care for one (R31) of one resident at risk for and reviewed for UTI (Urinary Tract Infections) in the sample of twenty-three. Findings include: On 07/12/22 at 9:52am, V7 and V8 (both Certified Nursing Assistants/CNAs) were observed providing catheter care to R31. After handwashing and donning gloves,V8 grasped the distal end of the catheter tubing, and wiped the tubing back and forth from meatus to distal end without changing the position of the washcloth or using a clean washcloth for each wipe. R31's Care Plan with a review date of 07/12/22 listed a problem area, (R31) has a (trade name indwelling) catheter, with a corresponding intervention, Catheter care prn (as needed) and every shift. Monitor/Report/Record to MD (Medical Doctor) for signs and symptoms of UTI. R31's 6/26/22 Urinalysis documented, Clarity-cloudy. Blood: Small amount (present). Leukocytes (white blood cells): Large (amount present). Bacteria-4 plus. Comment-(obtain) urine culture. A Catheter Care Policy with a revision date of January 2017 documented, Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. On 07/13/22 at 1:51pm, V2 (Director of Nurses/DON) confirmed the above observation did not represent aseptic technique during catheter care. V2 stated CNA staff would be re- educated regarding proper technique for catheter care.