Chi Franciscan Villa

On 11/13/25, at 11:03 AM, Surveyor interviewed R2 in R2's room. R2 stated R2 had a fall about 2 weeks ago when trying to get onto the commode from the wheelchair.

Surveyor observed R2 sitting on the edge of the bed with R2's feet resting on a folded-up sheet on the floor. R2 stated R2's family brought in a door mat and placed the folded-up sheet on top of it to prevent R2 from falling.

Surveyor did not observe any signage posted in R2's room reminding R2 to wait for assistance. R2 stated no signs were ever put up in R2's room.

On 11/13/25, at 11:33 AM, Surveyor interviewed certified nursing assistant (CNA)-D regarding trip hazards.

CNA-D stated online training the facility provides touches on trip hazards.

Surveyor asked if the folded-up sheet in R2's room would be considered a trip hazard, and CNA-D replied CNA-D would consider that a trip hazard, but R2 specifically requested it to be there because R2's legs are currently leaking and R2 does not want the floor to get wet.

Surveyor asked what the process is if a resident makes a request that is not considered safe, and CNA-D replied CNA-D was not sure, but the nurse on duty would know the process.

On 11/13/25, at 11:50 AM, Surveyor interviewed Unit Manager-F regarding the process if a resident makes a request that is not considered safe.

Unit Manager-F stated staff would try to have a conversation with the resident and educate them on safe practices.

Unit Manager-F stated a risk versus benefits could be completed, and the resident's care plan could be updated to include the request.

Surveyor asked Unit Manager-F if a folded-up sheet on the floor would be considered a trip hazard, and Unit Manager-F replied yes, that is a trip hazard.

Unit Manager-F was not aware the folded-up sheet was in R2's room and stated Unit Manager-F would educate R2 and remove the sheet.

Surveyor reviewed R2's EHR and did not locate any risk versus benefits or care plan revisions regarding the folded-up sheet in R2's room.

On 11/13/25, at 2:45 PM, Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A regarding fall risk evaluations. DON-B stated a fall risk evaluation would be completed when triggered by the MDS coordinator, after a fall, or if there is a change in condition. DON-B stated the fall risk evaluation is typically completed by the nurse on the floor or the MDS coordinator.

Surveyor shared concern with DON-B and NHA-A that Surveyor observed R2's feet resting on a folded-up blanket and that Surveyor did not observe any signage in R2's room reminding R2 to wait for assistance per R2's care plan. DON-B agreed that the folded-up blanket would be a trip hazard, and staff has talked with R2's family in the past regarding trip hazards, but DON-B would follow up.

On 11/13/25, at 3:08 PM, Surveyor interviewed MDS coordinator-G via phone call. MDS coordinator-G stated fall risk evaluations are completed by MDS coordinator-G only on a quarterly basis when it gets triggered in the EHR that a quarterly MDS assessment is due. MDS coordinator-G confirmed that MDS coordinator-G completed the fall risk evaluation for R2 dated 10/9/25.

Surveyor asked why there was no response for question 2 under the medications section on this assessment. MDS coordinator-G responded MDS coordinator-G must have accidentally clicked to the next page, and the fall risk evaluation was not completed correctly. MDS coordinator-G stated question 2 under the medications section should have been marked as c.

Takes 3-4 of these medications (or medication classes) currently and/or within last 7 days which would have resulted in a higher fall risk score.

On 11/13/25, at 3:34 PM, Surveyor shared concern with NHA-A and DON-B that the fall risk evaluation for R2 dated 10/9/25 was not completed accurately. No additional information was provided as to why R2's fall interventions were not in place to prevent future falls or why an accurate fall risk evaluation was not completed for R2.

Facility ID: