Health inspection·December 23, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review the facility failed to respond to resident call lights in a timely manner and comply with resident requests for assistance, for four of four residents (R2, R3, R4, R5 and R6) reviewed for call light response in a sample of four. Findings include: Facility Resident Rights Policy, dated 11/5/19, documents: It is the policy of the facility to respect the rights of the resident by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and Residents as outlined by the State of Illinois, Illinois Department of Public Health, Centers for Medicare and Medicaid/CMS; recognizing that society is dynamic and the rights of Residents are continually evolving; and strive to improve the quality of care through a multi-disciplinary approach recognizing that each Resident is an individual with unique needs; and the Facility develops policies and procedures to assist in the support of patient's rights. Facility Assessment, dated 8/23/23, documents: Nursing Services, the Facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure Resident safety and attain or maintain the highest practicable physical wellbeing of each resident, as determined by Resident assessments and individual plans of care and considering the number, acuity and diagnoses of the Facility's Resident population in accordance with the Facility Assessment required; the purpose of the Assessment is to determine what resources are necessary to care for Residents competently during both day-to-day operations and emergencies and is used to make decisions and determine capabilities to provide services to Residents in the Facility, to ensure that each Resident is provided care that allows the Resident to attain or maintain the highest practicable physical and mental well-being Facility Musculoskeletal System diseases/conditions of Muscle Weakness, Difficulty Walking, History of Falling and Fractures and Rheumatoid Arthritis, Compression Fractures and Joint Replacement (Hip and Knee); Specific Care or Practices with Mobility and Fall with Injury prevention with transfers, ambulation assistance ad Restorative Nursing; dealing with Resident's Mental Health and Behavior by managing the medical condition and medication and identifying/implement interventions to help support individuals with issues such as dealing with Anxiety; assessment of medical conditions, early identification of complications and management of medical and psychiatric symptoms; provide support emotional and mental well-being; and identify hazards and risks for Residents Facility Resident Council Minutes, dated 9/6/23, document nine of eleven resident issues with call lights taking 40 minutes to an hour to get answered on third Shift because Certified Nursing Assistants/CNA's and Nursing Department are either smoking or playing on their phones. Page 1 of 9 145021 145021 12/23/2023 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Facility Resident Council Minutes, dated 10/4/23, document issues with call lights taking 30 minutes to an hour to get answered because of staffing; the minutes dated 10/4/23, documents concerns with call lights taking 30 minutes to an hour to get answered because of we are short staffed. Facility Resident Council Minutes, dated 11/1/23, documents that all residents of resident council are concerned that call lights are taking 40 minutes to an hour on the weekends and after supper because staff is talking to other staff members on their phones. Facility Resident Council Minutes, dated 12/6//23, documents that all residents of resident council are concerned that call lights are taking 40 minutes to an hour on Second Shift because they are sitting on their phones. Facility Resident/Family Concern and Grievance Forms, dated 9/6/23, were reviewed. The Grievance Form, dated 9/6/23, documents that nine of eleven Resident Council members are concerned that call lights are taking 40 minutes to an hour to be answered on third shift because Certified Nursing Assistants/CNA's are either smoking or playing on their phones at the nurses station and a follow-up documents that it is still not getting better. Facility Resident/Family Concern and Grievance Forms, dated 10/4/23, document that all residents in attendance are concerned that call lights are taking 30 minutes to an hour to get answered because of staffing and that no follow-up was completed. Facility Resident/Family Concern and Grievance Forms, dated 11/1/23, document that all residents of Resident Council are concerned that call lights are taking 40 minutes to an hour on the weekends and after supper and the follow-up documents resident's new concerns with second shift call lights. Facility Resident/Family Concern and Grievance Forms, dated 12/6/23, document that all residents of Resident Council are concerned that call lights are taking 40 minutes to an hour on second shift because staff on their phones. Facility Registered Nurse/RN Job Description, undated, documents: direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations and guidelines that govern the long-term care facility; ensure all nursing personnel assigned to you comply with the written policies and procedures established by the Facility; responsible for complying with Facility policies and procedures and making recommendations for revisions; complete accident/incident reports and document appropriately; provide direct resident care as needed; implement and maintain established nursing objectives and standards; makes periodic rounds to observe and evaluate the resident's physical and emotional status to ensure continuing quality resident care; assures resident care delivery in accordance with Facility policies and procedures; responsible for competent administration of care; answers call lights promptly; ensures a safe environment; and reports incident's to the Director of Nursing/DON or Designee immediately. Facility Certified Nursing Assistant/CNA Job Description, undated, documents the purpose of this position is to assist the Nurses in providing of resident care primarily in the area of the daily living routine; knowledge of Department of Public Health (IDPH) regulations as related to duties; answer call lights promptly; check on all new resident and re-admissions; responsible for well-being and nursing care of all Residents assigned to the his/her unit while on duty; and detect and report situations that have a high probability of causing accidents or injuries to residents. 145021 Page 2 of 9 145021 12/23/2023 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/22/23 at 11:29 am, R2, was sitting in wheelchair in dining room, with anti-tippers on wheelchair and stated, I have bad eyesight. Every time I fall, they tell me to put my call light on, but I do not always remember and also, honestly, they take too long to answer my call light. I get impatient, and they take too long to get to me, and I just get up and do it myself, and that is usually when I fall. On 12/22/23 at 11:00 am, R3 stated, They take too long to answer the call lights, sometimes it can take up to over an hour to answer. On 12/22/23 at 11:20 am, R4 (R2's Roommate) stated, (R2) falls a lot. They tell her to sit down and use her call light, but they take forever to get here and answer it, so she just eventually gets up on her own. On 12/22/23 at 10:48 am, R5 stated, The call lights can take a long time, especially when they are changing shifts or its dinner time, we have waited for over 45 to an hour before for them to get answered. On 12/22/23 at 12:03 pm, R6 stated, They say that they are short staffed a lot and that is why it takes them so long to answer our call lights. On 12/22/23, at 2:00 pm, V1 (Administrator) stated, We are constantly in-servicing staff and educating them on the importance of answering the call lights more promptly, we are trying to fix the problem. 145021 Page 3 of 9 145021 12/23/2023 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to develop a Care Plan for one (R1) of three Residents reviewed for Care Plans in a sample of three. Findings include: Facility Assessment, dated 8/23/23, documents: Nursing Services, the Facility much have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical wellbeing of each resident, as determined by resident assessments and individual plans of care. Facility Resident Rights Policy, dated 11/5/19, documents: it is the policy of the Facility to respect the rights of the resident by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents as outlined by the State of Illinois, Illinois Department of Public Health, Centers for Medicare and Medicaid/CMS; recognizing that society is dynamic and the rights of residents are continually evolving; and strive to improve the quality of care through a multi-disciplinary approach recognizing that each resident is an individual with unique needs; and the Facility develops policies and procedures to assist in the support of patient's rights. R1's Physician Order Sheet/POS, dated 12/22/23, documents that R1 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Unspecified Trochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing and Rheumatoid Arthritis. The POS also documents a Physician Order for Anxiety Medication (Alprazolam oral tablet 0.25 milligram/mg every eight hours for anxiety) and Anti-depressant Medication (Mirtazapine one tablet 7.5 mg at bedtime) and to monitor for side effects of falls, orthostatic hypotension, motor changes and behavior and mood changes. The POS also documents a Physician Order for Physical Therapy, Occupational Therapy and Speech Therapy. R1's current Care Plan does not document R1's Fall Interventions/Fall Risk, Activities of Daily Living level of assistance, Assistive Devices, R1's Diagnoses, Grief of Loss of Spouse/Depression, Medications or R1's Cognition. R1's current two-page Care Plan documents two care areas (Code Status and Activities). On 12/22/23 at 9:15 am, V2 (Director of Nursing/DON) stated, (R1's) Care Plan is not completed and should document R1's Fall Risk status. V2 also verified R1's Care Plan was incomplete and only had two areas of cares (Activity and Code Status). On 12/22/23, at 2:00 pm, V1 (Administrator/ADM) stated, (R1's) Care Plan does not document any level of assistance or care needs that R1 requires. V1 stated R1's spouse passed away two days before (R1) fell and (R1) was grieving the loss of R1's husband. V1 verified that R1 was admitted to the facility on [DATE] with a Right Femur Fracture, Rheumatoid Arthritis and receiving medication for anxiety disorder. V1 verified R1 was receiving Physical and Occupational Therapy for the Right Femur Fracture and that R1's current Care Plan did not have the required documentation to care for R1's Activities of Daily Living assistance needs. 145021 Page 4 of 9 145021 12/23/2023 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish appropriate fall interventions for one cognitively impaired resident (R2) and failed to prevent falls with injury for two of three residents (R1 and R2) reviewed for fall with injuries in a sample of three. These failures resulted in R1 requiring hospitalization, sustaining scalp lacerations and a cervical fracture, and subsequently resulting in R1's death, and R2 requiring hospitalization and sustaining a scalp laceration. Findings include: Facility Fall Policy, dated [DATE], documents: it is the policy of the Facility to provide guidelines for the appropriate handling of a resident's fall, accident or incident; the Facility recognizes each situation is unique and must be handled in the manner is most appropriate at the time and for the nature of the change in the condition; guidelines will be utilized as appropriate to each situation and change in condition. Facility Resident Rights Policy, dated [DATE], documents: It is the policy of the Facility to respect the rights of the resident by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents as outlined by the State of Illinois, Illinois Department of Public Health, Centers for Medicare and Medicaid/CMS; recognizing society is dynamic and the rights of residents are continually evolving; and strive to improve the quality of care through a multi-disciplinary approach recognizing each resident is an individual with unique needs; and the Facility develops policies and procedures to assist in the support of patient's rights. Facility Assessment, dated [DATE], documents: Nursing Services, the Facility much have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the Facility's Resident population in accordance with the Facility Assessment required; the purpose of the Assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies and is used to make decisions and determine capabilities to provide services to residents in the Facility, to ensure each resident is provided care allows the resident to attain or maintain the highest practicable physical and mental well-being Facility Musculoskeletal System diseases/conditions of Muscle Weakness, Difficulty Walking, History of Falling and Fractures and Rheumatoid Arthritis, Compression Fractures and Joint Replacement (Hip and Knee); Specific Care or Practices with Mobility and Fall with Injury prevention with transfers, ambulation assistance ad Restorative Nursing; dealing with resident's Mental Health and Behavior by managing the medical condition and medication and identifying/implement interventions to help support individuals with issues such as dealing with Anxiety; assessment of medical conditions, early identification of complications and management of medical and psychiatric symptoms; provide support emotional and mental well-being; and identify hazards and risks for residents. Facility Registered Nurse/RN Job Description, undated, documents: direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations and guidelines govern the long-term care facility; ensure all nursing personnel assigned to you comply with the written policies and procedures established by the Facility; responsible for complying with Facility policies and 145021 Page 5 of 9 145021 12/23/2023 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0689 Level of Harm - Actual harm Residents Affected - Few procedures and making recommendations for revisions; complete accident/incident reports and document appropriately; provide direct resident care as needed; implement and maintain established nursing objectives and standards; makes periodic rounds to observe and evaluate the resident's physical and emotional status to ensure continuing quality resident care; assures resident care delivery in accordance with Facility policies and procedures; responsible for competent administration of care; answers call lights promptly; ensures a safe environment; and reports incident's to the Director of Nursing/DON or Designee immediately. Facility Certified Nursing Assistant/CNA Job Description, undated, documents the purpose of this position is to assist the Nurses in providing of resident care primarily in the area of the daily living routine; knowledge of Department of Public Health (IDPH) regulations as related to duties; answer call lights promptly; check on all new resident and re-admissions; responsible for well-being and nursing care of all residents assigned to the his/her unit while on duty; and detect and report situations have a high probability of causing accidents or injuries to residents. 1. R1's Serious Injury Incident and Communicable Disease Report, dated [DATE] at 9:34 am, documents R1's fall with physical harm or injury. The report documents R1 was transported and admitted to the local hospital Emergency Department with a Grade Three Odontoid Fracture/Laceration. The report states R1 stood up from R1's recliner and reached for R1's walker and fell forward hitting R1's head on the bedside table. R1 was noted to have two lacerations to the scalp ad R1 complained of neck pain and right hip pain. R1 was sent to the local hospital for treatment and was noted to have a seven centimeter/cm laceration to R1's lateral scalp, a three cm laceration vertical in between eyebrows and a Grade Three Odontoid Fracture requiring sutures to the lacerations and a cervical fusion of the Cervical (C1-2). The report documents R1's Care Plan and interventions were updated. R1's Physician Order Sheet/POS, dated [DATE], documents R1 admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Unspecified Trochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing and Rheumatoid Arthritis. The POS also documents a Physician Order for Anxiety Medication (Alprazolam oral tablet 0.25 milligram/mg every eight hours for anxiety) and Anti-depressant Medication (Mirtazapine one tablet 7.5 mg at bedtime) and to monitor for side effects of falls, orthostatic hypotension, motor changes and behavior and mood changes. The POS also documents a Physician Order for Physical Therapy, Occupational Therapy and Speech Therapy. R1's Physical Therapy/PT Evaluation and Plan of Care, dated [DATE] through [DATE], document R1 was receiving PT Therapy for a Trochanteric Fracture of the Right Femur and was discharged on [DATE] with recommendations for independent transfers using an assistive device (walker) or requires supervision and/or cueing to complete the task without an assistive device. R1's current Care Plan does not document R1's Fall Interventions/Fall Risk, Activities of Daily Living level of assistance, therapy recommendation, assistive devices, R1's diagnoses, medications or R1's cognition. R1's Care Plan documents two areas of care (Do Not Resuscitation Code Status and Activity preference). R1's Minimum Data Set/MDS, Section GG, dated [DATE] and [DATE], documents R1's functional ability requires supervision/touching assistance (verbal cues and/or touching/steadying and/or contact guard assistance) for sit to stand position, chair/bed transfer and walking ten feet. R1's Fall Risk Assessment, dated [DATE], documents R1 is a High Fall Risk (11). The Fall Risk 145021 Page 6 of 9 145021 12/23/2023 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0689 Assessment documents R1 has had no falls in the last three months, requires assistive devices, takes three/four high fall risk medications, and has three or more predisposing conditions increase R1's fall risk. Level of Harm - Actual harm Residents Affected - Few R1's Nursing Note, dated [DATE] at 9:14 am, documents R1's medication administration of Alprazolam Oral Tablet 0.25 milligram/mg, one tablet by mouth, due to R1 being anxious and nervous about spouses' condition (spouse death). Facility Monthly Fall Tracking Forms, dated [DATE] through [DATE], were reviewed. The Fall Tracking Forms document a fall with injury for R1, in R1's room, on [DATE] at 9:34 am. R1 was admitted to the local Hospital. R1 had sustained a bone fracture (Cervical/C1 fracture) and laceration. The Tracking Form also documents R1 has a history of falls. No intervention was documented. R1's Nursing Note, dated [DATE] at 5:55 am, documents, (R1) was tearful this morning. Attentive listening provided with one on ones. States does not wish for anxiety medication at this time. R1's Nursing Notes, dated [DATE] at 10:08 am, document, Staff heard (R1) yelling for help. Upon entering room, noted (R1) lying semi-prone on right side on floor over the top of (R1's) bedside table. Moderate amount of bright red blood noted on head and on floor under (R1). Pressure held to lacerations (twice) on forehead. Repositioned to back and table removed from area. R1 complained of pain in neck and right hip. Emergency (911) called. Daughter called and informed of fall and transport to hospital. (V1/Administrator) notified of fall. R1's Nursing Note, dated [DATE] at 12:27 pm, documents, Family came into facility and stated (R1) has cervical fractures (C1 and C3) and is being transferred to (hospital) via air-evacuation. R1's Nursing Note, dated [DATE] at 12:47 pm, documents the local hospital was called and stated, (R1) was airlifted to hospital with Cervical (C1) fracture. R1's Hospital Record, dated [DATE], documents R1 presented to the Trauma Center with a Chief Complaint of Category Three Trauma and fall. admitted with Diagnoses including Odontoid Fracture, Fall, Closed Odontoid Fracture, Scalp Laceration and Facial Laceration. R1 required surgery (closed reduction of C1-C2 Dislocation). The record documents R1 was sitting in recliner and when standing up, R1 reached for walker and fell forward hitting a nearby table to R1's scalp/face. R1 presented to local hospital where imaging showed a Grade Three Odontoid Fracture. R1 was subsequently transferred to a higher level of care. The record documents a seven centimeter/cm scalp laceration was cauterized to reach metastasis and a three cm veridical laceration in between eyebrows, and multiple bruises to extremities. The record documents R1 had recent Right Hip surgery. The hospital timeline documents R1 admitted to Intensive Care on [DATE], transferred out of Intensive Care on [DATE] and then back to Intensive Care on [DATE] at midnight. On [DATE] at 6:58 pm, R1 was transferred out of Intensive Care and then expired on [DATE] at 3:21 am. R1's Certificate of Death, dated [DATE], documents R1's cause of death as Pneumonia, Odontoid Fracture and Ground Level Fall. On [DATE] at 9:15 am, V2 (Director of Nursing/DON) stated, (R1's) Care Plan is not completed and should document R1's Fall Risk status. (R1's) Fall Risk Assessment does document (R1) was identified as a High Risk for falls. V2 verified R1's Care Plan was incomplete and only had two areas of concerns, Activity and Code Status. 145021 Page 7 of 9 145021 12/23/2023 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0689 Level of Harm - Actual harm Residents Affected - Few On [DATE] at 9:15 am, V1 (Administrator/ADM) stated, (R1's) spouse died on [DATE], just two days before (R1) fell out of chair. Staff heard (R1) fall and went in to (R1's) room. (R1) was laying over the bedside table with lacerations to (R1's) head and was complaining of neck and hip pain. We sent (R1) to (local hospital) and then they life flighted (R1) to a hospital in [NAME]. R1 was independent and able to get up and move around (R1's) room by herself and without any assistance. (R1) was alert and oriented after the Cervical surgery and then all of the sudden (R1) ended up in Intensive Care and ended up dying days later, on [DATE]. On [DATE], at 2:00 pm, V1 (Administrator) stated, It makes sense how you should not just educate someone with memory problems for a fall intervention. R1's Care Plan does not document any level of assistance or care needs R1 requires. V1 verified R1 admitted to the facility on [DATE] with a Right Femur Fracture, Rheumatoid Arthritis and receiving medication for anxiety disorder. V1 verified R1 was receiving Physical and Occupational Therapy for the Right Femur Fracture and R1's current Care Plan did not have the required documentation to care for R1 and R1's medical record had conflicting documentation on R1's level of Cognition and Activities of Daily Living assistance needs. 2. R2's Serious Injury Incident and Communicable Disease Report, dated [DATE] at 10:00 am, documents R2's fall with physical harm or injury. The Report documents R2 was transported and admitted to the local hospital for a fall in R2's room. R2 fell and hit R2's head on roommates' bed and was found to have a scalp laceration. R2 leaned forward to grab something and fell out of R2's wheelchair hitting R2's head on roommate's bed. R2 was found to be laying on the floor beside roommate's bed and R2's wheelchair was sitting in the hallway. R2 received five staples to the laceration and admitted for observation of seizure activity, then re-admitted to facility on [DATE]. R2's Hospital Record, dated [DATE], documents R2's Chief Complaint as an unwitnessed fall from a wheelchair with head injury (struck head on floor), unknown loss of consciousness, staff states mental status is altered and R2 sustained a Right Posterior Scalp Laceration. The record documents R2 was alert upon arrival, does not answer questions appropriately and is confused at baseline. The record documents the Nursing Home staff stated R2 has frequent falls, is ambulatory minimally with staff assistance only and spends most of time in wheelchair. The record documents R2's Medical Diagnoses including Bipolar Disorder, Left Eye Blindness, Borderline Personality Disorder, Cerebral Vascular Accident/CVA, Pseudo seizures and Vascular Dementia. R2 received a Comminuted Tomography/CT scan showed evidence of scalp trauma in the Right Occipital Region. R2's current Care Plan documents R2 has blindness in the Left Eye, had a Right Humerus Fracture, orders for medication administration of an Anti-depressant and Anti-psychotic, alteration in ability to care for self and needs assistance, requires extensive one to two staff assistance with transfers and requires an assistive device. The Care Plan also documents R2 is a high risk for Falls. R2's Care Plan documents an intervention for R2's falls on [DATE] and [DATE] as Education; [DATE] and [DATE] falls as continue current Care Plan; and [DATE] fall as putting a sign on the mirror to remind R2 to stay seated when washing hands. R2's MDS, Section GG (Functional Abilities and Goals) documents R2 requires partial/moderate assistance with sit to stand, chair/bed-to chair transfer and walking ten feet. R2's Fall Risk Assessment, dated [DATE] and [DATE], documents R2 is disoriented to person, place and time, has had three or more falls in past three months, is chairbound and requires assistance, poor eyesight, balance problems, requires assistive devices, takes three/four high risk medications and has one/two predisposing Diagnosis and a Fall Risk Score of 20 (High Risk). R2's Fall Risk 145021 Page 8 of 9 145021 12/23/2023 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0689 Assessment, dated [DATE], documents R2 has a Fall Risk Score of 22 (High Risk). Level of Harm - Actual harm Facility Monthly Fall Tracking Forms, dated [DATE] through [DATE], document falls for R2: in R2's room on [DATE] at 1:40 pm, no injury and the intervention was education resident ; in R2's room on [DATE] at 1:15 pm, no injury and the intervention was to continue current care plan; [DATE] at 2:15 pm in R2's bathroom, with no injury and the intervention was to keep R2 in areas of visualization unless in bed; [DATE] at 3:55 pm in 'other' location, no injury and the intervention was Occupational Therapy to evaluate and treat; [DATE] at 5:34 pm in hallway and R2 sustained a scratch to R2's face and the intervention was for staff to close R2's door when R2 leaves room; [DATE] at 4:45 pm in R2's room with no injury and the intervention was to put a sign on the mirror to remind resident to stay seated when washing hands; [DATE] at 10:55 pm in R2's bathroom with no injury and the intervention was to frequently toilet R2; [DATE] at 10:00 am in R1's room, R2 was admitted to the local Hospital and sustained a laceration and required five staples to the scalp and the intervention was to move closer to the nurses station; [DATE] at 6:26 pm in R2's room and R2 sustained remained in the Facility and sustained an abrasion to the scalp and the intervention was to educate R2 on asking for help; [DATE] at 3:00 pm in R2's room, with no injury and the intervention was to continue plan of care; and on [DATE] at 2:45 pm in R2's room, does not document any injury or fall intervention. Residents Affected - Few On [DATE] at 11:20 am, R4 (R2's roommate) stated, (R2) falls a lot. She just fell a little while ago and bumped her 'noggin' and had to go to the hospital. They tell (R2) to sit down but she has a head injury from a long time ago and does not have good memory, she just does not understand all the time. On [DATE] at 11:29 am, R2, was sitting in wheelchair in dining room, with anti-tippers on wheelchair and stated, I have bad eyesight. Every time I fall, they tell me to put my call light on, but I do not always remember and honestly, they take too long to answer my call light. I get impatient, and they take too long to get to me, and I just get up and do it myself, and is usually when I fall. On [DATE], at 2:00 pm, V1 (Administrator) stated, I do not think some of the interventions, such as education, are appropriate for (R2's) falls, because she does have memory issues. (R2) has definitely had a lot of falls, but we are not always sure what are the best interventions. V1 verified R2's [DATE] fall resulted in a scratch to R2's face and on [DATE], R2's fall required emergent hospital care for five staples to a scalp laceration and R2's [DATE] fall resulted in an abrasion to R2's scalp. 145021 Page 9 of 9