Inspection·December 24, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be redirected. Resident #107 was given toy cars and was unable to be redirected. Resident #107 was given numerous items to assist with behavior. None were effective.Review of a progress note dated 08/18/25 written by Unit Manager #215 who documented Resident #107 attempted to hit residents and staff with magazines. Resident #215 was redirected multiple times, was still showing aggression toward others. Staff notified family, brother started trying and put him to bed. Resident #107 was unable to be redirected.Review of a progress note dated 08/19/25 written by LPN #251 documented while doing the medication pass, continued to redirect Resident #107. Resident #107 was swinging and yelling at all the residents down the hall. Resident #107 came to the front common area with the nurse and continued to yell and raise his hands at staff and residents. When redirected he became very angry and rammed his wheelchair into the back of another resident and when the nurse and multiple aides tried to move Resident #107, he continued to push harder into the other resident. Once separated Resident #107 then took his shirt off and threw it on the ground. He kept picking up the shirt and threw it and kicked it across the floor. The nurse took the shirt to his room. The nurse walked with Resident #107 to his room he kept yelling, he wanted a shirt and he threw the shirt again.Review of a psychiatric note dated 08/22/25 written by Nurse Practitioner #243 who documented Resident #107 was admitted to the facility for respite care which transitioned into long term care. Prior to admission Resident #107 lived at home his entire life. Resident #107 had severe intellectual disability with a mental age of less than two years old. Since 08/14/25 there have been almost daily reports of physical and verbal aggression, including yelling, hitting staff and other residents, and difficulty with redirection. Review of a progress note dated 09/25/25 written by LPN #248 who documented Resident #107 repeatedly struck staff member while he was being changed, the nurse educated Resident #107 on the importance of not hitting staff. Resident #107 continued to hit staff. Resident #107 also verbally assaulted his roommate Resident #108 to the point that the roommate was scared for his own safety in his room.Review of a progress note dated 09/25/25 written by the Unit Manger #215 who documented the Power of Attorney (POA) was made aware of Resident #107's room change and was placed on one-to-one. Resident #107 continued with behaviors toward staff.2.Review of the medical record revealed Resident #108 was admitted on [DATE] and discharged on 11/17/25. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and atrial fibrillation.Review of the quarterly MDS dated [DATE] revealed Resident #108 had a Brief Interview of Mental Status (BIMS) of 12 indicating he had moderate cognitive impairment. Resident #108 required set-up or clean-up assistance for meals. Resident #108 was dependent in dressing upper and lower body, toileting hygiene. Resident #108 was substantial to maximal assistance in bathing, personal hygiene, placing shoes on and off feet, and oral hygiene.Review of the plan of care revealed Resident #108 had feelings of sadness, emptiness, anxiety, uneasiness, bodily complaints, characterized by ineffective coping, low self-esteem, tearfulness, motor agitation, weight loss, withdrawal from care, clinical decline affecting dignity. Interventions included conveying acceptance of residents and provide repeated honest appraisals of resident's strengths to residents, encouraging loved ones to keep in contact. Resident #108 had a risk for negative mood or behavior related to major depressive disorder. Interventions included administer medications as ordered, monitor for dose reduction, resident was supported by mental health services, and social service visits as needed to encourage expression of feelings and to provide support and reassurance.Review of a progress note dated 09/25/25 written by LPN #248 who documented Resident #108 stated he was afraid for his safety due to his roommate, Resident #107's violent nature, the nurse asked certified nurse aid to remove Resident #107 from the room to ensure Resident #108's safety.Review of a progress note dated 09/25/25 written by the Corporate Nurse #207 who documented the roommate (Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #107) was moved to a private room related to Resident #108's concerns.Review of a handwritten statement dated 09/25/25 by Social Worker Director (SWD) #245 documented she went to Resident #107's room to ask about this morning. He said, my neck was hurting. I asked again and he said, my neck was hurting, my birthday was in 18 days. Review of a handwritten statement dated 09/26/25 the Social Worker Director (SWD) #245 documented she had talked to Resident #108 about his concerns. Resident #108 stated his roommate was yelling and hitting the aides and he thought if he could do that to them, he could do that to me. He stated, I felt scared. The roommate moved to a different room yesterday and the resident stated he was happy about that. Resident did state he did not do anything to me; he did it to the staff.Interview on 12/16/25 at 2:13 P.M. Licensed Practical Nurse (LPN) #248 said she went to Resident #108's room because he was calling out to her in the hallway. She went into the room and heard Resident #107 yelling shut up, shut up! Ill kick your expletive! LPN #248 said Resident #108 was concerned about his safety. LPN #248 said she separated both residents.Interview on 12/17/25 at 3:55 P.M. LPN #253 said when she took care of Resident #107 at the facility when residents or staff would walk by or was near, Resident #107 when he was angry would swing and hit everyone who was in the way. This included staff and other residents. LPN #253 stated she could not remember the staff or the residents' names at that time. No one was hurt, but Resident #107 did yell and swing at everyone.Interview on 12/23/25 at 11:25 A.M. the Director of Nursing (DON) said Resident #107 had developmental delays and was used to one-on-one because where he came from. The DON said she was out of the facility and had to ask to see if anyone had investigated the incident. Interview on 12/23/25 at 1:32 P.M. the Corporate Nurse #207 said she was notified by Licensed Practical Nurse (LPN) #248 that Resident #107 and Resident #108 had a possible altercation. The Corporate Nurse #207 asked the residents be separated and made safe and would get back to the LPN. The Corporate Nurse #207 said it was during shift change that morning and she had never told the Administrator.Interview on 12/23/25 at 1:47 P.M. the Unit Manager (UM) #215 it was reported to her and she interviewed Resident #108 that day who said he was not comfortable in the room with Resident #107 and he was scared. The UM #215 said the incident was discussed in our team meeting that morning about what happened with Resident #107 and Resident #108. The UM #215 asked Resident #108 what Resident #107 had said to him. The UM #215 stated Resident #108 had said that Resident #107 kept telling him to shut up, shut up! Resident #108 had stated Resident #107 was cursing and yelling at him. Interview on 12/23/25 at 1:59 P.M. the Social Worker Director (SWD) #245 said she had interviewed Resident #108 who stated to her that Resident #107 had yelled and hit staff, and not him. The SWD #245 said she had not documented a progress note of the interview with Resident #108 as she did not think it was important. The SWD #245 said the facility had not interviewed all residents who had a BIMS of 10 and above, because the facility determined there was no risk for abuse towards other residents.Interview on 12/23/25 at 5:37 P.M. the Administrator said he was never notified of any possible verbal abuse between Resident #107 and Resident #108 on 09/25/25. Review of the facility policy titled Residents Rights to Freedom from Abuse, Neglect, Misappropriation of Residents Property dated 2025 revealed the facility policy was to ensure that residents are free from abuse, neglect, misappropriation of their property, and exploitation.This deficiency represents non-compliance investigated under Complaint Number 2641868. Event ID: Facility ID: 365917 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of statements, staff interview, review of the Self-Reported Incidents and policy review, the facility failed to ensure allegations of resident to resident abuse were thoroughly investigated and reported to the State Agency when Resident #107 verbally assaulted one resident and had physical aggression towards another unknown resident. This affected one (#108) out of three residents reviewed for abuse. The facility census was 100. Based on medical record review, review of statements, staff interview, review of the Self-Reported Incidents and policy review, the facility failed to ensure allegations of resident to resident abuse were thoroughly investigated and reported to the State Agency when Resident #107 verbally assaulted one resident and had physical aggression towards another unknown resident. This affected one (#108) out of three residents reviewed for abuse. The facility census was 100. Findings Include:1. Review of the medical record revealed Resident #107 was admitted on [DATE] and discharged on 11/11/25. Diagnoses included Parkinson's disease, epilepsy, and intellectual disabilities.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #107 was severely cognitively impaired. Resident #107 required setup or clean-up assistance for meals. Resident #107 was substantial to maximal assistance for oral care, toileting hygiene, personal hygiene, bathing, and dressing upper body. Resident #107 was dependent for placing shoes on and off feet and dressing his lower body.Review of the plan of care dated 08/25/25 revealed Resident #107 had problematic behaviors characterized by wandering, verbal and or physical abuse, throwing objects at others, calling out making disruptive noises, and rejection of care related to his intellectual disability. Interventions included approaching the resident slowly and from the front, be cognizant of not invading resident's personal space, be sure you have the resident's attention before speaking or touching, do not ask the resident to make decisions or ask what was wrong, focus on feelings rather than cause. Do not make unrealistic demands of resident, document summary of each episode, note cause and successful interventions, include frequency and duration, if aggressive try and remove from recreational program, provide individualized program, if strategies are not working, reapproach resident at a later time, initiate psychiatric consult as needed, involve family, encourage resident to call upon them and other support, medication as ordered, reapproach resident at a later time when care was rejected, remove resident from public area when behavior was disruptive, talk with resident in a low pitch, calm voice to decrease and eliminate undesired behavior, and provide diversional activity. Review of a progress note dated 08/16/25 written by Licensed Practical Nurse (LPN) #248 documented Resident #107 was very combative and throwing items at staff and other residents. Resident #107 was redirected but continued to throw items at the staff and other residents. Review of a progress note dated 08/16/25 written by Registered Nurse (RN) #260 who documented Resident #107 was aggressive towards residents and staff this morning. Resident #107 took medication appropriately and remained agitated and yelling at staff and residents.Review of a progress note dated 08/17/25 written by RN #260 who documented Resident #107 yelled throughout the morning in the common area, became aggressive with staff and residents.Review of a progress note dated 08/17/25 written by LPN #253 who documented Resident #107 was hitting numerous residents and staff. Resident #107 also yelled and threw magazines at staff. Resident #107 was unable to be redirected. Resident #107 was given toy cars and was unable to be redirected. Resident #107 was given numerous items to assist with behavior. None were effective.Review of a progress note dated 08/18/25 written by Unit Manager #215 who documented Resident #107 attempted to hit residents and staff with magazines. Resident #215 was redirected multiple times, was still showing aggression toward others. Staff notified the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few family, brother started trying and put him to bed. Resident #107 was unable to be redirected.Review of a progress note dated 08/19/25 written by LPN #251 documented while doing the medication pass, continued to redirect Resident #107. Resident #107 was swinging and yelling at all the residents down the hall. Resident #107 came to the front common area with the nurse and continued to yell and raise his hands at staff and residents. When redirected he became very angry and rammed his wheelchair into the back of another resident and when the nurse and multiple aides tried to move Resident #107, he continued to push harder into the other resident. Once separated Resident #107 then took his shirt off and threw it on the ground. He kept picking up the shirt and threw it and kicked it across the floor. The nurse took the shirt to his room. The nurse walked with Resident #107 to his room he kept yelling, he wanted a shirt and he threw the shirt again.Review of a psychiatric note dated 08/22/25 written by Nurse Practitioner #243 who documented Resident #107 was admitted to the facility for respite care which transitioned into long term care. Prior to admission Resident #107 lived at home his entire life. Resident #107 had severe intellectual disability with a mental age of less than two years old. Since 08/14/25 there have been almost daily reports of physical and verbal aggression, including yelling, hitting staff and other residents, and difficulty with redirection. Review of a progress note dated 09/25/25 written by LPN #248 who documented Resident #107 repeatedly struck staff member while he was being changed, the nurse educated Resident #107 on the importance of not hitting staff. Resident #107 continued to hit staff. Resident #107 also verbally assaulted his roommate Resident #108 to the point that the roommate was scared for his own safety in his room.Review of a progress note dated 09/25/25 written by the Unit Manger #215 who documented the Power of Attorney (POA) was made aware of Resident #107's room change and was placed on one-to-one. Resident #107 continued with behaviors toward staff.2.Review of the medical record revealed Resident #108 was admitted on [DATE] and discharged on 11/17/25. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and atrial fibrillation.Review of the quarterly MDS dated [DATE] revealed Resident #108 had a Brief Interview of Mental Status (BIMS) of 12 indicating he had moderate cognitive impairment. Resident #108 required set-up or clean-up assistance for meals. Resident #108 was dependent in dressing upper and lower body, toileting hygiene. Resident #108 was substantial to maximal assistance in bathing, personal hygiene, placing shoes on and off feet, and oral hygiene.Review of the plan of care revealed Resident #108 had feelings of sadness, emptiness, anxiety, uneasiness, bodily complaints, characterized by ineffective coping, low self-esteem, tearfulness, motor agitation, weight loss, withdrawal from care, clinical decline affecting dignity. Interventions included conveying acceptance of residents and provide repeated honest appraisals of resident's strengths to residents, encouraging loved ones to keep in contact. Resident #108 had a risk for negative mood or behavior related to major depressive disorder. Interventions included administer medications as ordered, monitor for dose reduction, resident was supported by mental health services, and social service visits as needed to encourage expression of feelings and to provide support and reassurance.Review of a progress note dated 09/25/25 written by LPN #248 who documented Resident #108 stated he was afraid for his safety due to his roommate, Resident #107's violent nature, the nurse asked certified nurse aid to remove Resident #107 from the room to ensure Resident #108's safety.Review of a progress note dated 09/25/25 written by the Corporate Nurse #207 who documented the roommate (Resident #107) was moved to a private room related to Resident #108's concerns.Review of a handwritten statement dated 09/25/25 by Social Worker Director (SWD) #245 documented she went to Resident #107's room to ask about this morning. He said, my neck was hurting. I asked again and he said, my neck was hurting, my birthday was in 18 days. Review of a handwritten statement dated 09/26/25 the Social Worker Director (SWD) #245 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete documented she had talked to Resident #108 about his concerns. Resident #108 stated his roommate was yelling and hitting the aides and he thought if he could do that to them, he could do that to me. He stated, I felt scared. The roommate moved to a different room yesterday and the resident stated he was happy about that. Resident did state he did not do anything to me; he did it to the staff.Interview on 12/16/25 at 2:13 P.M. Licensed Practical Nurse (LPN) #248 said she went to Resident #108's room because he was calling out to her in the hallway. She went into the room and heard Resident #107 yelling shut up, shut up! Ill kick your expletive! LPN #248 said Resident #108 was concerned about his safety. LPN #248 said she separated both residents.Interview on 12/17/25 at 3:55 P.M. LPN #253 said when she took care of Resident #107 at the facility when residents or staff would walk by or was near, Resident #107 when he was angry would swing and hit everyone who was in the way. This included staff and other residents. LPN #253 stated she could not remember the staff or the residents' names at that time. No one was hurt, but Resident #107 did yell and swing at everyone.Interview on 12/23/25 at 11:25 A.M. the Director of Nursing (DON) said Resident #107 had developmental delays and was used to one-on-one because where he came from. The DON said she was out of the facility and had to ask to see if anyone had investigated the incident. Interview on 12/23/25 at 1:32 P.M. the Corporate Nurse #207 said she was notified by Licensed Practical Nurse (LPN) #248 that Resident #107 and Resident #108 had a possible altercation. The Corporate Nurse #207 asked the residents be separated and made safe and would get back to the LPN. The Corporate Nurse #207 said it was during shift change that morning and she had never told the Administrator.Interview on 12/23/25 at 1:47 P.M. the Unit Manager (UM) #215 it was reported to her and she interviewed Resident #108 that day who said he was not comfortable in the room with Resident #107 and he was scared. The UM #215 said the incident was discussed in our team meeting that morning about what happened with Resident #107 and Resident #108. The UM #215 asked Resident #108 what Resident #107 had said to him. The UM #215 stated Resident #108 had said that Resident #107 kept telling him to shut up, shut up! Resident #108 had stated Resident #107 was cursing and yelling at him. Interview on 12/23/25 at 1:59 P.M. the Social Worker Director (SWD) #245 said she had interviewed Resident #108 who stated to her that Resident #107 had yelled and hit staff, and not him. The SWD #245 said she had not documented a progress note of the interview with Resident #108 as she did not think it was important. The SWD #245 said the facility had not interviewed all residents who had a BIMS of 10 and above, because the facility determined there was no risk for abuse towards other residents.Interview on 12/23/25 at 5:37 P.M. the Administrator said he was never notified of any possible verbal abuse between Resident #107 and Resident #108 on 09/25/25. Review of the Self Reported Incidents dated from 08/01/25 through 12/24/25 revealed no reports were made for the alleged incidents on 08/19/25 and 09/25/25.Review of the facility policy titled Residents Rights to Freedom from Abuse, Neglect, Misappropriation of Residents Property dated 2025 revealed the facility policy was to ensure that residents are free from abuse, neglect, misappropriation of their property, and exploitation. The facility shall review altercations from resident to resident as a potential situation of abuse. Staff will monitor behaviors that may provoke a reaction by residents including verbal aggressive behavior such as cursing and screaming and physically aggressive behavior including hitting, kicking, throwing objects, and threatening gestures.This deficiency represents non-compliance investigated under Complaint Number 2641868. Event ID: Facility ID: 365917 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall interventions were in place for a resident who was at high risk for falls. This affected one (#92) out of three residents reviewed for falls. The facility census was 100. Findings Included:Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall interventions were in place for a resident who was at high risk for falls. This affected one (#92) out of three residents reviewed for falls. The facility census was 100.Findings Included:Review of the medical record revealed Resident #92 admitted to the facility on [DATE]. Diagnoses included palliative care, Parkinson's disease, chronic obstructive pulmonary disease, and dementia.Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #92 had an unfinished Brief Interview of Mental Status (BIMS) indicating severe cognitive impairment. Resident #92 required setup and clean-up for meals. Resident #92 was dependent for personal hygiene, placing on and off shoes, bathing, dressing lower body, and toileting hygiene. Resident #92 was substantial maximal assistance for oral hygiene and dressing upper body. Review of the plan of care dated 11/03/25 revealed Resident #92 had a potential for falls related to impulsivity or poor safety awareness. Interventions included assist the resident on and off the toilet, do not leave resident unattended in the bathroom, do not leave unattended in the dining room, a dycem mat in the wheelchair, evaluate medication regimen, fall matt to the left side of the bed, get resident up into wheelchair when restless, keep bed in lowest position, keep call bell within reach, encourage to use call bell, keep environment clutter free, keep room well lighted, make sure wearing proper footwear, and use a gait belt with transfer.Review of the Morse Fall Scale assessment dated [DATE] revealed Resident #92 was a fall risk with a high risk for falling score of 65.0. Resident #92 had fallen before, had more than one diagnoses in chart, had no ambulatory aids, had no intravenous apparatus, was weak, overestimates or forgets limits when alone. The Morse fall scoring was: low risk was 0-24, moderate risk was 25-44, and high risk was a score of 45 and higher.Review of the fall and incident log dated 07/01/25 to current revealed Resident #92 had falls on 07/10/25, 07/11/25, and 07/29/25. Observation on 12/23/25 at 9:30 A.M. Resident #92 had no call light, it was wrapped under the bed wheel. Interview on 12/23/25 at 9:30 A.M. with Certified Nursing Assistant (CNA) #225 verified Resident #92 had no call light in reach and the call light was under the bed wheel. Observation on 12/23/25 at 10:45 A.M. Resident #92 was in her bed that was in the high position. Resident #92's fall mat was located on the right side of the bed. No staff were observed in the room.Interview on 12/23/25 at 11:03 A.M. CNA #220 verified when entering the room Resident #92's bed was in the high position with no staff present in the room. CNA #220 verified that the fall mat was on the right side of her bed.Review of the facility policy titled Accidents and Incidents-Investigation and Reporting dated July 2017 revealed all accidents or incidents involving residents, employees, visitors, vendors, occurring on our property shall be investigated and reported to the administrator. This deficiency represents non-compliance investigated under Complaint Number 2620622 and 2566128. Event ID: Facility ID: 365917 If continuation sheet Page 7 of 7