Helia Healthcare of Energy

Inspectors wroteBased on interview and record review, the facility failed to provide timely ADL (Activities of Daily Living) assistance to dependent residents for transfers for 1 (R1) of 3 residents reviewed for ADL assistance in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to adhere to the guidelines for conducting a Resident Assessment to ensure accurate documentation and plan of care follow up resulted for 1 (R1) of 4 residents reviewed for assessments in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 5 residents (R7) reviewed for urinary tract infections in a sample of 39. This failure resulted in R7 being admitted to the hospital for disorientation and acute cystitis without hematuria.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication cart was kept locked when out of staffs visual control. This has the ability to affect all 74 residents living at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that dishes were effectively sanitized in the dish machine. This failure has the potential to affect all 74 residents residing in the facility. The Findings Include:On 1/26/26 at 9:15 AM during the initial tour of the kitchen the sanitizer level in the dish machine was checked with sanitizer strips by V7 (Dietary Manager) and no sanitizer was registering. V7 attempted to run 2 more cycles stating that sometimes after it sits all night the sanitizer tubing gets clogged. V7 stated that she would contact the maintenance department and see if they could get the dish machine to dispense sanitizing solution appropriately due to the sanitizer strip not registering any sanitizer in the machine. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow the recipe for pureed spaghetti and failed to provide the correct amount of bread for the lunch meal for 5 of 5 residents (R9, R12, R30, R45, R52) reviewed for altered diets in the sample of 39. The Findings Include: R9's admission profile documents an admission date to the facility on [DATE]. This same document includes the following diagnosis: Malignant neoplasm of oropharynx, other sequelae of cerebral infarction and generalized anxiety disorder. R9's current month's physician order sheet document that R9 has a pureed diet as tolerated. R12's admission profile documents an admission date to the facility on [DATE] and includes the following diagnosis: Alzheimer's, Dementia, and Cerebellar stroke syndrome. R12's current month physician's order sheet documents that R12 has a puree diet with thin liquids. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain aseptic technique while performing wound care treatment for 2 (R3 & R10) of 8 residents reviewed for wound care treatment and infection control in a sample of 39.

Inspectors wroteBased on interview, observation, and record review, the facility failed to prevent the verbal and physical abuse of a resident from staff for 1 of 7 residents (R7) reviewed for abuse in the sample of 44. This failure resulted in psycho/social harm to R7 having feelings of irritation, anger, and continued complaints of pain to her right shoulder.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from involuntary seclusion for 1 of 7 residents (R7) reviewed for abuse and neglect in the sample of 44. This failure resulted in R7 experiencing feelings of emotional distress and acts of crying out in fear from being placed into her bed without her wheelchair nearby leaving her with no means of transferring out of bed or mobility safely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer/apply pain medications as ordered for 1 of 3 residents (R19) reviewed for pain management in a sample of 44. This failure resulted in R19 experiencing pain with the treatment application to R19's leg wounds.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient staff to meet the needs of the residents timely. This has the potential to affect all 73 residents currently residing at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure that all staff have the appropriate competencies and skill sets to provide care and meet the residents' needs. This failure has the potential to effect all 73 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to use accurately labeled medication/cream, use cream that was not expired, and lock the medication and wound treatment carts. This failure has the ability to affect all 73 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the approved menu by not providing the approved protein and not serving the correct portion sizes. This failure has the ability to affect all 73 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to discard food items in the refrigerator and dry storage that were past the used by/expiration dates. This has the potential to affect all 73 residents living in the facility

Inspectors wroteBased on interview, observation, and record review the facility failure to ensure that all licensed staff had a current license while working at the facility. This failure has the potential effect all 73 residents living at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to supply linens (washcloths) and ensure the call lights were within reach for 6 of 6 residents (R1, R3, R4, R7, R22, R35) reviewed for accommodation of needs in a sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to acquire medication from the pharmacy and administer and document medications as ordered for 4 of 13 residents (R2, R3, R17, R19) reviewed for pharmacy services in a sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain food items served to residents at palatable/hot temperatures for 4 of 4 residents (R1, R2, R3, R14) reviewed for food preferences in the sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement enhanced barrier precautions while providing wound care for 5 of 5 residents (R15, R3, R17, R19, and R1) observed for wound care in a sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to respect resident preferences and privacy for 2 of 4 residents (R17, R19) reviewed for resident rights in a sample of 44.

Inspectors wroteBased on interview and record review the facility failed to immediately report an allegation of staff to resident abuse to the administrator and failed to identify an incident of possible misappropriation of a resident's property and report the incident to the Illinois Department of Public Health for 2 of 7 residents (R2 and R7) reviewed for abuse and neglect in the sample of 44.

Inspectors wroteBased on interview and record review the facility failed to thoroughly and immediately investigate allegations of abuse and potential theft, failed to prevent further potential abuse/neglect from occurring while allowing staff to continue to have direct care with residents after allegations were made, and failed to conclude willful intent occurred involving a staff to resident altercation for 2 of 7 (R2 and R7) residents reviewed for abuse in a sample of 44.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a dependent resident timely ADL (Activities of Daily Living) assistance with transfers for 1 of 6 residents (R1) reviewed for ADL assistance in the sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to administrated medications as prescribed by a physician for 2 of 13 (R11, R12) residents reviewed for medication administration in a sample 44.

Inspectors wroteBased on interview and record review the facility failed to transport a resident in the appropriate wheelchair to prevent an accident for 1 (R1) of 3 residents reviewed for accidents in a sample of 10. This failure resulted in R1 falling face first into the dining room floor resulting in a left nasal bone deformity and both ulnar and olecranon fracture of the left upper extremity.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents are free from significant medication errors for 1 of 3 residents (R1) reviewed for medication errors in sample of 13. This failure resulted in R1 receiving another resident's medication and being hospitalized for hypoglycemia. Findings Include:R1's Face Sheet shows documents an admission date of 10/16/2023 and includes diagnoses of Type 2 diabetes mellitus without complications, Alzheimer's Disease, Iron Deficiency, Cholecystitis, Renal Insufficiency, and Diaphragmatic Hernia without Obstruction. R1's Minimum Data Set (MDS) dated [DATE] documents in section C, Cognitive Patterns, documents a Brief Interview for Mental Status (BIMS) score of 5, indicating R1 has severe cognition impairment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide behavioral health services for residents with mental illness, and to maintain/improve resident's psychosocial well-being for 1 of 3 residents (R1) reviewed for behavioral services in a sample of 9. This failure resulted in R1 voicing feelings of isolation, suicidal ideations with a plan of strangulation, and engaging in self-injurious behaviors. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 4/14/25 when the facility failed to implement increased monitoring for R1, remove hazardous objects from R1's room, and refer R1 for recommended counseling services. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 8/22/2025 at 9:03 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to properly dispose of controlled substance medication for 2 (R2 and R3) of 6 residents reviewed for pharmacy services in a sample of 13. The Findings Include:1. R2's Face Sheet dated 07/17/25 documents an admission date of 12/19/24 with diagnoses in part of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, pain in left knee, malignant neoplasm of oropharynx, squamous cell carcinoma of skin of scalp and neck, malignant neoplasm of esophagus. R2's Minimum Data Set (MDS) dated [DATE] documents in Section C a BIMS (Brief Interview for Mental Status) score of 13, which indicates that R2 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, record review the facility failed to ensure prevention of misappropriation of resident property for 3 (R2, R3, and R5) of 6 residents reviewed for abuse in the sample of 13. The Findings Include:1. R2's Face Sheet dated 07/17/25 documents an admission date of 12/19/24 with diagnoses in part of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, pain in left knee, malignant neoplasm of oropharynx, squamous cell carcinoma of skin of scalp and neck, malignant neoplasm of esophagus. R2's Minimum Data Set (MDS) dated [DATE] documents in Section C a BIMS (Brief Interview for Mental Status) score of 13, which indicates that R2 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to report allegations of abuse and misappropriation of property within the required time frames for 3 (R2, R3, and R5) of 6 residents reviewed for abuse in a sample of 13The Findings Include: 1. R2's Face Sheet dated 07/17/25 documents an admission date of 12/19/24 with diagnoses in part of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, pain in left knee, malignant neoplasm of oropharynx, squamous cell carcinoma of skin of scalp and neck, malignant neoplasm of esophagus. R2's Minimum Data Set (MDS) dated [DATE] documents in Section C a BIMS (Brief Interview for Mental Status) score of 13, which indicates that R2 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate and complete investigations of abuse allegations in accordance with required time frames for 3 (R2, R3, and R5) of 6 residents reviewed for abuse in a sample of 13The Findings Include:1. R2's Face Sheet dated 07/17/25 documents an admission date of 12/19/24 with diagnoses in part of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, pain in left knee, malignant neoplasm of oropharynx, squamous cell carcinoma of skin of scalp and neck, malignant neoplasm of esophagus. R2's Minimum Data Set (MDS) dated [DATE] documents in Section C a BIMS (Brief Interview for Mental Status) score of 13, which indicates that R2 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary supervision was provided to prevent a fall with injury for 1 (R1) of 3 residents reviewed for accidents and supervision. This failure resulted in R1 being found in the floor resulting in mildly displaced left lateral sixth and seventh rib fractures and an acute, mildly displaced, and angulated fracture of the left femoral neck.

Inspectors wroteBased on interview and record review, the facility failed to notify the Power of Attorney (POA) of a fall and change in resident's condition for 1 (R1) of 3 residents reviewed for accidents. This past noncompliance occurred between 4/5/25 and 4/5/25. Findings Include: R1's admission Record documents an admission date to the facility of 3/16/25 with diagnoses including displaced intertrochanteric fracture of right femur, altered mental status, unspecified, alzheimer's disease, unspecified and dementia in other diseases classified. This same document under emergency contacts listed V3 (Family) as emergency contact power of attorney for healthcare and primary financial contact. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 3, indicating R1 had severe cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from employee to resident verbal abuse for 1 of 10 residents (R3) reviewed for abuse in a sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient staff to provide care in a timely manner for 5 of 12 (R1, R3, R4, R8, and R11) residents reviewed for sufficient staff in the sample of 12. This failure has the potential to affect all 77 residents currently residing at the facility. Findings Include: The facility Midnight Census report dated 2/18/25 documents 77 residents currently reside at the facility. 1. R1's Resident Face Sheet with a print date of 2/18/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, heart disease, hypertension, urinary incontinence, and history of falling. R1's MDS (Minimum Data Set) dated 1/8/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure incontinence care was provided timely and failed to ensure they had enough supplies to provide care for 4 of 5 (R1, R3, R8, R11) residents reviewed for activities of daily living in the sample of 12. Findings Include: 1. R1's Resident Face Sheet with a print date of 2/18/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, heart disease, hypertension, urinary incontinence, and history of falling. R1's MDS (Minimum Data Set) dated 1/8/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact. This same MDS documents R1 requires partial/moderate assist with showers/bathing, dressing, personal hygiene, and transfers. This MDS documents R1 is frequently incontinent of bowel and bladder. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were able to choose the time they got up for 1 of 4 residents (R4) reviewed for resident rights in the sample of 12. Findings Include: R4's Resident Face Sheet with a print date of 2/19/25 documents R4 was admitted to the facility on [DATE] with diagnoses that include repeated falls, low back pain, arthritis, and pain. R4's MDS (Minimum Data Set) dated 1/7/25 documents a BIMS (Brief Interview for Mental Status) score of 05, which indicates R4 has a severe cognitive deficit. This same MDS documents R4 requires partial/moderate assist of staff for dressing and transfers. R4's current Care Plan documents a Problem area with a start date of 12/27/24 of, resident has had a decline in ADL (Activities of Daily Living) function and requires assistance with transfers and mobility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and treat pressure wounds for 3 (R1, R2, and R3) of 4 residents reviewed for pressure wounds in the sample of 6.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to notify the physician of a resident's change in condition for 1 of 4 residents (R1) reviewed for physician notification of change in condition in a sample of 7.

Inspectors wroteBased on interviews and record review, the facility failed to implement ordered treatments for wound care for 1 of 5 (R1) residents reviewed for pressure ulcers in a sample of 7.

Inspectors wroteBased on interview and record review the facility failed to follow orders by placing a resident on hospice and failed to get a timely X-ray for a Covid positive resident having respiratory distress for 2 of 2 residents (R80 and R81) reviewed for quality of care in a sample of 39. This failure resulted in R80 being admitted to the hospital for 5 days with hypoxemic respiratory failure.

Inspectors wroteBased on interview and observation, the facility failed to have enough staff to provided consistent care to residents. This has the ability to effect all 76 residents living at this facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a clean and sanitary environment to perform dietary services. This failure has the potential to affect all 76 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dignity while assisting dependent residents during mealtimes for 10 of 10 residents (R4, R7, R23, R32, R51, R52, R53, R54, R60, R63) reviewed for dignity in a sample of 39.

Inspectors wroteBased on interview, observation and record review the facility failed to provide showers and assistance with meals to 5 of 10 residents (R4, R9, R23, R39, R52) reviewed for activities of daily living in a sample of 39.

Inspectors wroteBased on interview, observation, and record review the facility failed to follow dietary order ordered by the physician for 4 (R39, R43, R50 and R53) of 22 residents reviewed for dining in a sample of 39.

Inspectors wroteBased on interview and record review the facility failed to provide the writtten notice of the resident's potential liablity for a non-covered stay (SNFABN) for 2 of 3 residents (R71 and R73) reviewed for Beneficiary Protection Notification in the sample of 39.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the diet as ordered for one (R81) of 22 residents reviewed for dining in a sample of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to discard expired medications for 1 of 1 resident (R8) reviewed for expired medications in the sample of 39.

Inspectors wroteBased on interview, observation and record review the facility failed to serve food at a preferred temperature for one (R53) of one resident reviewed for food temperature preferences in a sample of 39.

Inspectors wroteBased on observation and interview, the facility failed to implement infection prevention strategies while performing wound care for 2 of 3 residents (R1, R66) reviewed for wound care in a sample of 39.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe resident transfers were provided to prevent accidents for 2 (R1 and R2) of 3 residents reviewed for accidents and supervision in the sample of 4. This failure resulted in R1 sustaining a laceration to the right foot requiring sutures and R2 sustaining a fibula fracture.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medication in accordance with professional standards for 2 (R1 and R3) of 3 residents reviewed for medication administration in a sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure catheter care was provided per current standards of practice for 2 of 8 (R25 and R34) residents reviewed for catheter care in the sample of 45. This failure resulted in R34 developing a urinary tract infection that required hospitalization on 12/10/2023. Findings Include: 1. R34's undated Resident Face Sheet documents R34 was admitted to the facility on [DATE] with diagnoses that include spinal stenosis, diabetes, acute kidney failure, urinary tract infection, muscle wasting, atrophy, dependence on supplemental oxygen, and hypertension. R34's MDS (Minimum Data Set) dated 9/14/23 documents R34 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R34 is cognitively intact. This same MDS documents under Section I, R34 has neurogenic bladder and obstructive uropathy. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure sufficient staff were available to provide needed care in a timely manner. This failure affected (R31, R34 and R64) and has the potential to affect all 74 residents residing in the facility. Findings Include: 1. R34's undated Resident Face Sheet documents R34 was admitted to the facility on [DATE] with diagnoses that include spinal stenosis, diabetes, acute kidney failure, urinary tract infection, muscle wasting, atrophy, dependence on supplemental oxygen, and hypertension. R34's MDS (Minimum Data Set) dated 9/14/23 documents R34 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R34 is cognitively intact. This same MDS documents under Section G that R34 is totally dependent on staff for bathing and requires physical assist of two staff for toileting. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare meals as indicated per the facility menu. This failure has the potential to affect all 74 residents residing in the facility. Findings Include: 1. On 12/20/23 at 01:40 PM, R131 who was alert to person, place and time; and stated portion sizes of food are inconsistent at times. R131 stated she has spoke with V2 (Dietary Manger) regarding her concerns and feels she is making a good faith effort to get them resolved. Review of the lunch menu for 12/20/23 read as follows: Meatloaf, Mashed Potatoes, [NAME] Beans, Wheat Bread, Cherry Chocolate Bar, Margarine, Coffee/Tea. On 12/20/23 at 12:38 PM, V6 (Cook) was observed slicing multiple sizes of meatloaf slices in the baking pan. V6 stated 4 oz (ounces) is the meatloaf portion served. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in clean and sanitary condition, and effectively sanitize equipment and work surfaces. This failure has the potential to affect all 74 residents residing in the facility. Findings Include: On 12/19/23 at 09:45 AM, V6 (Cook) was asked to check the sanitizer concentration level of the dishwasher. V6 was observed dipping a chlorine sanitizer test strip into the dishwasher water at multiple times of the wash cycle, never registering sanitizer. V6 was then observed holding the strip in the dishwater water throughout the entire dishwasher cycle, demonstrating varying colors present on the strip throughout the cycle beneath the water. V6 stated she will have maintenance check the dishwasher to see why she's having trouble getting the test strips to register. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, comfortable, and homelike environment for 4 of 4 residents (R26, R30, R36, and R64) reviewed for environment is a sample of 45. Findings Include: On 12/21/23 at 2:27 PM, a tour was conducted with V5 (Maintenance) noting the following findings in which V5 provided the size dimensions given: -The room occupied by R26 has an approximate 2 inch wide circular hole in the closet door. -The room occupied by R30 and R64 has multiple paint chipped and peeling areas approximately 4 foot x 4 foot on the walls. -The room occupied by R36 has non-functioning blinds, which are observed as being diagonally raised across the window and the door handle sticks, requiring twisting force to open. [...]

Inspectors wroteBased on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity and respect for 3 of 3 residents (R31, R34, and R64) reviewed for call lights in the sample of 45. Findings Include: 1. R34's undated Resident Face Sheet documents R34 was admitted to the facility on [DATE] with diagnoses that include spinal stenosis, diabetes, acute kidney failure, urinary tract infection, muscle wasting, atrophy, dependence on supplemental oxygen, and hypertension. R34's MDS (Minimum Data Set) dated 9/14/23 documents R34 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R34 is cognitively intact. This same MDS documents under Section G that R34 requires two person physical assist for toileting. On 12/21/23 at 1:28 PM, R34 stated they have enough staff, most of the time. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of resident weight loss for 3 of 6 residents (R25, R42, R70) reviewed for weight loss in the sample of 45.

Inspectors wroteBased on interview, observation and record review the facility failed to provide feeding assistance and failed to ensure showers were provided as scheduled for 3 of 4 (R8, R34, and R132) residents reviewed for Activities of Daily Living in the sample of 45. Findings Include: 1. R132's Care Plan dated 10/27/23 documented a problem area, admitted to (the facility) for long term care. I require a Baseline Care Plan identifying care needs, risks, strengths and goals within the first 48 hours, with a corresponding approach, Nutrition: I will eat regular meals. I will eat in the dining room. My fluids are regular. I need limited assist with eating. My weight is at risk for weight loss. R132's Medical Record contained no documentation of Physicians diet orders, weight orders, nor any Dietary department documentation. R132's Weight Record documented the following: 10/31/2023 175.4 lbs. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure immunizations were administered per current standards of practice for 1 of 5 (R45) residents reviewed for immunizations in the sample of 45. Findings Include: R45's undated Resident Face Sheet documents R45 was admitted to the facility on [DATE] with diagnoses that include muscle wasting and atrophy, hypertension, diabetes, and morbid obesity. R45's MDS (Minimum Data Set) dated 11/15/23 documents R45 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R15 is cognitively intact. R45's Preventative Health Care Report dated 10/1/22 to 12/21/23 documents under pneumococcal vaccine dated 10/10/23, Not recommended at this time. On 12/22/23 at 9:00 AM, R45 stated he would like to receive the Prevnar immunization, should he be eligible. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure a functioning call system for 1 (R11) of 24 residents reviewed for call systems in the sample of 45. Findings Include: On 12/19/23 at 10:21 AM, R11 was observed sitting on the side of her bed, yelling for help, as she had visibly been incontinent of bowel. R11's call light was observed as being activated, but not illuminating on the light above the outside of R11's door. On 12/19/23 at 10:23 AM, V20 (CNA) responded to R11's yelling. R11 told V20 she was dirty. V20 was notified of the potentially malfunctioning call light, in which she wiggled the call light cord at the wall plug in, in which the light then flickered on and off with cord movement. V20 stated it might be when the recliner is pushed up against it, it caused it not to work. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a fall care plan was initiated and interventions were implemented for 2 of 3 (R1 and R2) residents reviewed for falls in the sample of 7. Findings Include: 1. R1's Resident Face Sheet with a print date of 11/29/23 documents R1 was admitted to the facility on [DATE] with diagnoses that include Parkinson's disease, abnormalities of gait and mobility, anemia, history of falling, psychotic disorder with hallucinations, and insomnia. R1's MDS (Minimum Data Set) dated 10/21/23 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R1 is cognitively intact. This same MDS documents R1 requires partial/moderate assistance with transfers and that R1 has had falls with a major injury since admission to the facility. [...]