Every finding on record at Abbington Vlge Nrsg & Rhb Ctr

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a sanitary manner by not labeling stored foods, not performing hand hygiene when necessary, not wearing gloves while preparing ready to eat foods, and not storing personal items in designated areas separated from the resident's food. This failure applies to all 60 residents who receive food prepared by the facility. The findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid dated April 21, 2026, showed the facility's census was 61 residents. 60 residents receive their meals from the facility's kitchen. On April 20, 2026 at 9:55 AM, A large, opened bag of corn, and a small, opened bag of carrots were sitting in the kitchen freezer unlabeled and 9 boiled eggs were sitting in the kitchen refrigerator unlabeled. A large bag of hamburger buns, large bag of hot dog buns, and several loaves of bread were sitting in the kitchen refrigerator unlabeled. V19 (Dietary Manager) said all these items should be labeled. A personal can of soda, personal bottle of juice, and two personal bottles of water were sitting in the kitchen refrigerator. V19 confirmed that these items did not belong to residents. On April 20, 2026 at 11:25 AM, V20 (Cook) was holding a head of lettuce with his bare hands while cutting it, then rinsed the lettuce and donned new gloves without using hand hygiene. V20 placed the lettuce in a container for later use. On April 20, 2026 at 11:32 AM, A personal speaker and cell phone were sitting on the food prep table directly next to the meat slicer. V20 removed gloves, replaced sanitizer in bucket, grabbed a clean pan from the dish storage rack and placed it in the sink, donned new gloves without performing hand hygiene, and began preparing five hamburgers with the lettuce he cut earlier using bare hands which were later placed on tray cart for meal service. On April 20, 2026 at 11:41 AM, V20 (Cook) moved meal prep dishes to the dish machine, removed gloves, wiped his forehead, lifted the lids from the steam table foods, sanitized the food prep table, handled multiple stacks of meal tray lids, then donned new gloves without performing hand hygiene and handled multiple stacks of plates being used for meal service. On April 20, 2026 at 11:50 AM, V20 (Cook) removed and donned new gloves without performing hand hygiene, swiped the back of his hairnet with gloves hands, then opened and began preparing pasta noodles. On April 20, 2026 at 1:05 PM, V20 (Cook) said sometimes he does not use hand hygiene between donning and removing gloves and when he does remove gloves he will just place on a clean pair. V20 said sometimes he'll use hand hygiene between replacing gloves when he's working with vegetables. V20 said he should wear gloves when cutting vegetables and should change gloves immediately after touching hair nets. On April 21, 2026 9:49 at AM, V21 (Dietary Aide) loaded soiled dishes into the dish machine with gloved hands, then moved clean cups to a rack for drying without removing gloves and performing hand hygiene. V21 removed gloves, adjusted the garbage bin bag, then donned new gloves and repositioned clean dishes on the dish machine table without performing hand hygiene. On April 22, 2026 at 1:45 PM, V19 (Dietary Manager) said when staff remove gloves they need to wash, rinse, and sanitize their hands before donning new gloves. V19 also stated when going from dirty to clean dishes staff should remove gloves and clean hands, there should be one staff handling dirty dishes and another handling clean dishes to prevent cross contamination. V19 said if V21 (Dietary Aide) handled the garbage bag and then handled clean dishes she would need retraining. V19 said foods in the refrigerator or freezer are dated on arrival, the receiving date is placed on the box, and when opened they are labeled with the date opened and a use by date to ensure the old items are used first for safety purposes and to prevent people from becoming sick. V19 said personal foods or beverages should not be stored in the kitchen refrigerators used for residents because of possible cross contamination. V19 said there should not be any personal items or speakers sitting on the food prep tables because of cross contamination; phones carry micro bacteria. V19 said fresh food should not be handled with bare hands because of cross contamination and you should wash hands and wear gloves when handling food to prevent outbreak. V19 said if while wearing gloves you touch your hairnet, the gloves should be removed and hands washed and sanitized before donning new gloves. The facility's policy for Labeling and Dating foods received April 22, 2026 states: Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality product for the residents and minimize waste. The facility's policy for Safe Food Preparation and Handling received April 22, 2026 states: Food will be prepared to conserve maximum nutritive value in a safe and sanitary environment. Hands will be washed properly, frequently, and at appropriate times. Employees should never use bare hand contact with any foods ready to eat or otherwise. The facility's policy for Personal Hygiene received April 22, 2026 states: Personal food items will be stored in designated area only. The facility's Sanitation and Food Safety policy for Handwashing received April 22, 2026 states: Food and nutrition services employees will practice safe food handling to prevent foodborne illness. Food and nutrition services employees will thoroughly wash their hands and exposed areas of their arms with soap and water in the designated hand-washing sink at the following times:After touching anything unsanitary (garbage, dirty dishes).After touching bare human body parts other than clean hands and arms (example-adjusting one's hairnet).Between removing gloves or aprons and before putting on new gloves or aprons.After handling soiled equipment and utensils.

Based on observation, interview, and record review the facility failed to follow their policy for monitoring their water management plan for Legionella. The facility also failed to follow their policy for handling soiled linens. The facility failed to follow infection control measures during medication administration. This applies to all 61 residents residing in the facility. The findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid dated April 21, 2026, showed the facility's census was 61 residents. 1. On April 22, 2026, at 11:43 AM, V12 (Maintenance Director) said for the facility's water management plan for Legionella, V12 will flush the water in any unused resident rooms a couple times a week and flush the water in all resident rooms once a month. V12 said he obtains water temperatures in resident bathrooms and showers but does not have a log of water temperatures. V12 said he has asked the facility for a water temperature log to document the temperature he obtains but has still not been provided one. V12 showed the facility's four hot water tanks and mixing valve. V12 said only one of the hot water tanks has a temperature gauge. V12 said he cannot measure the temperature in the hot water tank, just the water temperature in the resident areas. V12 said the facility is currently having construction done outside, in the front of the building and the construction crew broke the water line. V12 said he discarded the ice in the ice machine after the interruption in water. On April 22, 2026, at 1:26 PM, V1 (Administrator) said she provided all of the facility's water management plan documentation for Legionella. V1 said she completed the facility's assessment for a water management plan for Legionella. V1 said she is unaware of any areas in the facility at risk for Legionella growth. V1 said the facility has hot water tanks, a mixing valve, and boilers. V1 said maintenance does not need to have a water temperature log unless there is a problem. V1 said she is unable to provide documentation of monitoring of the facility's water management plan for Legionella. The facility's undated Water Management Program showed Policy: In the event of an outbreak, or a suspicion of a possible outbreak, or as directed by Public Health Officials it is the policy of this facility to establish procedures to reduce risk of Legionella and other opportunistic pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculosis mycobacteria, and fungi) in the facility's water systems. Policy Explanation and Compliance Guidelines: 1. A risk assessment of water system components will be conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. 2. The risk assessment will be completed by facility leadership and the Infection Prevention with collaboration from other facility team members such as maintenance employees, safety offices, risk and quality management staff, and Director of Nursing. 3. Examples of water system components include: a. Hot and cold water storage tanks. b. Water heaters. c Medical devices. d. Pipes, valves, and fittings. e. Expansion tanks. f. Water filters. g. Electronic and manual faucets. h. Aerators. i. Faucet flow restrictors. j. Showerheads and hoses. k. Centrally installed misters, atomizers, air washers, and humidifiers. l. Nonsteam aerosol-generating humidifiers. m. Eyewash stations. n. Ice machines. o. Hot tubs/saunas. p. Decorative fountains. q. Cooling towers. 4. Data to be used in the risk assessment may include, but are not limited to: a. Lab reports. b. Environmental culture results. c. Water temperature logs. d. Water quality reports from drinking water provider (i.e. municipality, water company). e. Community infection control surveillance data (i.e. health department data). 5. Based on risk assessment, control measures will establish to address potential hazards. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. 11. The facility will conduct an annual review of the water management program as part of the annual review of the infection prevention and control program, and as needed, should cases of Legionnaire's disease be identified. 12. The ice machine is inspected monthly by maintenance and cleaned as needed. 13. Sink and showers temperatures are tested minimally weekly. 14. Water heater temperature gauges are checked monthly. Units will be adjusted accordingly to maintain temperatures. 15. In the event of any water system failure or interruption faucets and or toilets will be flushed routinely. The facility doesn't have documentation to show the ice machine was inspected, water temperatures were obtained, water heater temperature gauges were checked, or faucets and toilets were flushed after an interruption in the water system. 2. On April 22, 2026, at 11:52 AM, V14 (Housekeeping/Laundry Aide) was wearing gloves and placing soiled clothing into the washing machine. While wearing the same soiled gloves, V14 went to the dryer and removed clean bed linens to the dryer and was folding the linens. V14 said when she sorts soiled linen and clothing, she only wears gloves. V14 said she does not wear a gown when she sorts soiled linens. V14 said soiled linens are transported to the laundry room through a laundry chute. The laundry chute, located down the hall, emptied into a plastic cart. The laundry cart was overflowing with laundry, and soiled laundry was stuck in the chute. Multiple items of soiled linen were coming out of the laundry chute, loose, and not in plastic bags. Multiple soiled linens were in the plastic cart below the laundry chute and some were loose and not in plastic bags. On April 22, 2026, at 12:22 PM, V1 (Administrator) said soiled linen should be in a plastic bag before going into the laundry chute. The facility's policy titles Handling of Contaminated Linen Policy dated February 2014, showed Policy: To protect employees and residents from cross-contamination while handling contaminated linen. Policy Specifications: 1. The staff member handling contaminated linen shall wear appropriate barriers consisting of, but not limited to: a. Gown. b. Gloves. 2. Contaminated linen will be placed in a biohazard bag. 3. The Electronic Medical Record (EMR) showed that R14 was admitted to the facility on [DATE]. R14's diagnoses included, but were not limited to, multiple sclerosis, major depressive disorder, type 2 diabetes mellitus, cerebral aneurysm, and urinary tract infection (UTI). The care plan dated April 17, 2026, showed that R14 required intravenous antibiotic therapy for treatment of a UTI via a midline intravenous catheter. The Physician Order Sheet (POS) for April 2026 included an order dated April 17, 2026, for Zosyn (piperacillin/tazobactam) diluted in 50 mL of dextrose, to be administered every 8 hours via midline intravenous catheter. On April 20, 2026, at 2:30 p.m., R14 was observed seated in her wheelchair in her room with a blanket covering her lap and lower arms. A midline intravenous catheter was intact in her right upper arm. V4 (Registered Nurse/RN) entered the room to administer the prescribed intravenous antibiotic. V4 donned gloves and prepared the IV medication by spiking an intravenous tubing into the bag of diluted solution of Zosyn with a 50 mL dextrose bag and hanging it on the IV (intravenous) pole. During the process, V4 touched multiple non-sterile surfaces, including the IV pole, IV tubing, the resident's arm, and the resident's blanket. V4 then removed her gloves and donned a new pair without performing hand hygiene between glove changes. V4 proceeded and removed the cap from the midline catheter lumen and left the lumen exposed while continuing to handle the IV bag and tubing. The exposed catheter lumen came into contact with R14's blanket, a non-sterile surface. No clean barrier was placed to maintain an aseptic field. Despite this contamination event, V4 proceeded to connect the IV tubing to the catheter and administered the medication. When interviewed, V4 acknowledged that hand hygiene should have been performed between glove changes and that a clean barrier should have been used. V4 further stated that the catheter lumen should not have been left uncovered and exposed to potential contamination. On April 21, 2026, at 2:42 p.m., V8 (RN/Nurse Consultant) stated that proper infection control practices require hand hygiene between glove changes and the use of a clean barrier to maintain aseptic technique. V8 confirmed that due to the contamination, R14's midline catheter required immediate replacement and blood cultures were obtained. Progress notes dated April 21, 2026, confirmed that blood cultures were ordered and the midline catheter was replaced due to contamination. 4. The EMR showed that R53 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, type 2 diabetes mellitus, and congestive heart failure. On April 21, 2026, at 8:51 a.m., V5 (Licensed Practical Nurse) was observed preparing and administering medications to R53. V5 donned gloves and prepared routine morning medications, including drawing up two types of insulin (Lispro 12 units and Glargine 40 units) into separate syringes. During medication preparation, V5 touched multiple non-sterile surfaces, including a computer screen, medication containers, and the bedside table. Without changing gloves or performing hand hygiene, V5 proceeded to administer both insulin injections to R53's lower abdominal area. When interviewed, V5 acknowledged that her gloves were contaminated and stated that she should have removed the gloves, performed hand hygiene, and donned clean gloves prior to administering the injections. The facility's Infection Control Policy (dated September 1, 2026) requires staff to adhere to aseptic techniques to prevent infection, including proper hand hygiene, maintaining sterile or clean equipment, and preventing cross-contamination between contaminated and aseptic surfaces. The Hand Hygiene Policy (dated September 1, 2026) states that staff must perform hand hygiene before and after glove use, including after glove removal. The facility's policy on Central Venous Catheter (CVC) care (dated January 2026) defines a contamination event as occurring when any key part of the catheter system (e.g., hub, needleless connector, or open lumen) comes into contact with a non-sterile surface, requiring immediate corrective action.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary homelike environment by failing to repair a leaking ceiling in the common area and resident's room. This applies to 4 of 7 residents (R7, R15, R47 and R51) reviewed for homelike environmental concerns in a sample 16.The findings include: On April 20, 2026, at 9:04 AM, there was black substance along the ceiling tile in R51's room by the window. The wall has a bubble-like appearance going from the ceiling down the wall to the floor.On April 21, 2026, at 8:45 AM, R15 was sitting in the dining room. R15 said every time it rains, water comes out of the ceiling. R15 said a resident in the room next to R15's room was screaming out rain one day and R15 saw water dripping onto R7 from the ceiling (R7 is not interview able). R15 said she doesn't think the facility wants to spend the money to fix the roof. On April 21, 2026, at 8:59 AM, R51 said when it rains outside, she can hear the water dripping inside the room. R51 said the water drips on her head and her pillow every time it rains. R51 said she has told the maintenance person, but no one has come to fix it.On April 21,2026, at 11:49 AM, V12 (Maintenance Director) said the ceiling in the dining room on the first floor needs repair. V12 said when it rains the ceiling leaks because the roof needs to be repaired. V12 said he was told when he was hired in late November of 2025 that the roof needs to be repaired. V12 said he replaces the ceiling tile every time it rains. V12 said in R51's room the roof leaks every time it rains. V12 said the black substance on the ceiling appears to be mold on the ceiling tile. V12 said he sees the leakage on the ceiling tile from the last time it rained. V12 said he remembered R51 telling him water leaks on her head when it rains. V12 said the plan for repairing the dining room is a new roof, until then he will continue to replace ceiling tiles after each rain.On April 21, 2026, at 12:25 PM, R47 said he has water dripping in his room when it rains. R47 said when it rains the ceiling in the dining room will leak water. R47 said the water comes in heavy when it rains and he has helped to place buckets under the water to keep it off the floor. R47 said he moves the TV in the dining room to make sure it doesn't get wet from the falling water.On April 21, 2026, at 1:12 PM, V1 (Administrator) said she is waiting for the weather to warm up to be able to fix the roof with tar. V1 said she has been aware since the wintertime the roof needed to be repaired. V1 said the water does come into the first-floor dining room during a rainstorm but does not leak on residents.On April 22, 2026, at 11:47 AM, Maintenance log showed for January 15, 2026, to change ceiling tile. V12 said he completed that order to change ceiling tiles and will have to change them again when it rains.On April 22, 2026, at 2:42 PM, Resident Council Minutes dated January 23, 2026, December 22, 2025, September 29, 2025, and October 24, 2025 all mention for maintenance to check and change ceiling tile in dining room by the television. Council minutes also mention resident requesting for the roof to be repaired,

Based on observation, interview and record review, the facility failed to provide timely assistance for incontinence care and grooming to residents who require assistance with ADLs (Activities of Daily Living). This applies to 4 of 4 residents (R13, R29, R30, and R52) reviewed for ADL care in the sample of 16.The findings include:1.The EMR (Electronic Medical Record) showed R29 was admitted to the facility on [DATE], with multiple diagnoses including depressive disorder, hypertensive heart. R29's Care plan dated February 22, 2026, showed R29's ability to transfer, walk in room, dress, eat, toilet, maintain personal hygiene has deteriorated. Care plan continued to show R29 requires staff assistance with toileting due to weakness. disease, heart failure, lymphedema. R29's MDS (Minimum Data Set) dated March 17, 2026, showed R29 was cognitively intact. The MDS continued to show R29 was dependent on facility staff for toileting hygiene and was always incontinent of bladder and bowel. On April 20, 2026, at 12:34 PM, R29 was lying in bed watching TV (television). R29 said the CNAs (Certified Nursing Assistants) are slow to answer the call light. R29 stated she feels like the CNAs come when they want to. R29 said she must wait longer than an hour sometimes and sometimes the CNAs don't come at all. R29 said she checks her phone to see how long it takes the CNAs to come and assist her with transferring to the wheelchair for toileting. 2.The EMR (Electronic Medical Record) showed R30 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, contracture, right hand, contracture, right elbow, congestive heart failure, fracture of part of the neck of right femur. R30's MDS (Minimum Data Set) dated March 20, 2026, showed R30 was cognitively intact. The MDS continued to show R30 was dependent on facility staff for toileting hygiene and was incontinent of bladder. Care plan dated February 13, 2026, showed R30 experiences bladder incontinence depending on staff for toileting and toileting hygiene. Care plan continued to show that R30 has ADL (Activities of Daily Living) deterioration, deconditioning and decline in mobility and requires staff assistance with ADLs. On April 20, 2026, at 10:46 AM, R30 was lying in bed watching TV. R30 said when he pushes the call light it takes the CNAs a long time to answer the call light. R30 says it takes the CNAs over an hour to come assist him to the bathroom. R30 stated he can tell it takes over an hour by the show he is watching on TV when he pushes the call light. 3.The EMR (Electronic Medical Record) showed R52 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease, transient ischemic attack and cerebral infarction, bilateral primary osteoarthritis of hip, sciatica right side. R52's MDS (Minimum Data Set) dated April 10, 2026, showed R52 was cognitively intact. The MDS continued to show R52 was dependent on facility staff for toileting hygiene. R52's Care plan dated March 28, 2026, showed R52 has limited ability to transfer related to osteoarthritis of the hips. Care plan continued to show R52 requires moderate assistance with toileting hygiene and touching assistance with toilet transfer. On April 20, 2026, at 10AM, R52 was sitting in therapy gym, R52 said if he pushes the call light, he must wait an hour or more for assistance to transfer to toilet. R52 said staff don't respond. R52 said two weeks ago he set a timer on his cell phone when he pushed the call light button. R52 said he waits the longest during the morning shift and on weekends. On April 21, 2026, at 11:59 AM, V2 (Director of Nurses/DON) said call lights should be answered within two to five minutes. CNAs are expected to answer the call lights in a timely manner. V2 said CNAs should go to the resident's room and answer the call light to see what is needed. V2 said if the CNA is busy doing patient care the CNA should advise they will be with them soon. V2 said residents who are incontinent of bowel and bladder should be checked to see if they require incontinence care at least every two hours. V2 said her expectation is for CNAs to provide incontinence care when residents are wet with urine upon rounds. The undated facility policy titled Answering the Call Light showed the purpose of this procedure is to respond to the resident's requests and needs. Policy general guidelines showed.2. Be sure the call light is plugged in, some residents may not be able to use call light, be sure to check of these residents frequently.6. Answer call light as soon as possible. 4. The Electronic Medical Record (EMR) showed that R13 was admitted to the facility on [DATE]. R13's diagnoses included, but were not limited to, paranoid schizophrenia, bipolar disorder, malignant neoplasm of the left breast, anxiety disorder, unspecified intellectual disabilities, drug-induced dyskinesia, and borderline intellectual functioning. The Minimum Data Set (MDS), dated [DATE], documented that R13 required staff assistance for hygiene, grooming, and other activities of daily living (ADLs). She was also assessed as having moderately impaired cognition. The care plan, dated March 10, 2026, showed that R13 required maximal to total assistance from staff for most ADLs to ensure her needs were met. This level of assistance was attributed to impaired functional strength, decreased strength in both upper and lower extremities, reduced endurance, impaired balance and gait, and intellectual disabilities. On April 20, 2026, at 10:23 a.m., R13 was sitting in her wheelchair in the dining room. R13 was noted to have visible facial hair, and her fingernails were long with sharp edges. A brownish-black substance was observed beneath her fingernails. V7 (R13's husband), stated that she needed shaving and nail trimming. V6 (Certified Nursing Assistant) was present at the time of observation. V6 stated that R13 required staff assistance for shaving and nail care. The facility's undated policy on Activities of Daily Living (ADLs) states that it is the responsibility of the facility to create and maintain an environment that promotes each resident's quality of life through individualized, person-centered care. The policy further states that all staff, across shifts and departments, are expected to understand and support these principles. The facility is responsible for providing care and services related to ADLs, including hygiene (bathing, dressing, grooming, and toileting). Additionally, residents who are unable to perform ADLs independently are to receive necessary services to maintain proper grooming and personal hygiene.

Based on observation, interview, and record review, the facility failed to follow physician orders to provide dietary interventions for a resident with significant weight loss. This applies to 1 of 3 residents (R58) reviewed for weight loss in the sample of 16. The findings include:The EMR (Electronic Medical Record) showed R58 was admitted to the facility on [DATE], with multiple diagnoses including osteoarthritis, dementia, depression, and vitamin d deficiency. R58's MDS (Minimum Data Set) dated April 15, 2026, showed R58 had severe cognitive impairment and was dependent on facility staff for eating. The MDS continued to show R58 had a significant weight loss and was not on a physician-prescribed weight-loss program. R58's weight loss care plan dated January 19, 2026, showed [R58] is receiving a puree diet with thin liquids. Her current weight is 123.6 pounds (January 5, 2026). Continues with mechanically altered diet related to diagnosis of dysphagia. Receives super cereal at breakfast, [nutritional supplement drink] 120 ml (milliliters) two times a day for additional calories. Receives [wound healing nutritional supplement] and protein powder to enhance healing. Appetite varies 51 to 100 % (percent). Mini Nutritional Assessment done on January 19, 2026 and scored sic. She lost 22.9% in six months. April 16, 2026: Continues with mechanically altered diet. Appetite varies 51 to 100%. Continues with super cereal at breakfast, whole milk at breakfast and dinner, [nutritional supplement drink] 120 ml two times a day, protein powder one scoop three times a day and [wound healing nutritional supplement] one packet two times a day. The care plan continued to show multiple interventions dated January 19, 2026, including Provide diet as ordered. Provide supplements as ordered. A progress note dated March 14, 2026, at 4:14 PM, by V18 showed .Current weight shows 7.4 pound decrease in one month, greater than 5% decrease in one month, 17.2 pound decrease in three months, greater than 7.5% decrease in three months, 26.8 pound decrease in six months, greater than 10% decrease in six months. Due to continued weight loss, recommend whole milk with breakfast and dinner. Continue diet and supplements as ordered. An order dated March 15, 2026, showed Diet: Add whole milk at breakfast and dinner. On April 21, 2026, at 9:03 AM, V11 (Respiratory Nurse) assisted R58 with her breakfast. R58's breakfast meal tray included a pureed meal, super cereal, orange juice, and a carton of 2% milk. V11 said R58's breakfast meal included 2% milk. V11 said R58 usually eats her entire meal tray and drinks everything the staff provide R58. R58's breakfast meal ticket dated April 21, 2026, showed Whole milk. Dislikes: Other: 2% milk. On April 22, 2026, at 9:18 AM, V11 assisted R58 with her breakfast meal. R58 was served 2% milk. On April 22, 2026, at 11:19 AM, V18 (Registered Dietician) said R58 has been having significant weight loss and one of the added interventions was whole milk with breakfast and dinner. V18 said whole milk offers R58 extra calories to assist in R58 gaining weight. V18 said the expectation is facility staff should be providing R58 whole milk at breakfast as ordered.

Based on interview and record review, the facility failed to document changes in skin condition, failed to ensure a physician assessed a new wound. The facility also failed to develop and implement care plan interventions for a resident who was admitted with pressure wounds to both heels, was identified with risk factors for further pressure wound development, and who developed sacral pressure wounds. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 5. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, moderate protein calorie malnutrition, gout, bilateral heel wounds, low back pain, and dysphagia. R1 was discharged from the facility on January 1, 2026. R1's MDS (Minimum Data Set) dated December 11, 2025, showed R1 was severely cognitively impaired and dependent on staff assistance with all ADLs (Activities of Daily Living) including eating, bed mobility, toileting, dressing, bathing and transfer. R1's progress note, dated December 30, 2025, at 11:06 PM, showed R1's physician ordered R1 transferred to the hospital due to abnormal lab results. R1 was transferred to the local hospital on December 31, 2025, at 00:46 AM and was admitted to the hospital with a diagnosis of pneumonia. R1's tissue tolerance assessment dated [DATE], completed by V7 (Registered Nurse/RN) showed R1 needed repositioning more often than every 2 hours. R1's skin condition assessment dated [DATE], showed R1 had a pressure ulcer on his right heel. The assessment also showed, in the interventions section, R1 had pressure relief device in chair, turning and repositioning program, nutrition and hydration interventions and dressing changes all identified as ongoing interventions in the past 7 days. The skin condition assessment showed to initiate care plan. R1's care plan initiated on December 8, 2025, showed there was no care plan in place to address pressure ulcer prevention such as need for turning and repositioning program, due to R1's immobility, incontinence or behavior of being aggressive when touched. The care plan did not include devices staff could use such as a positioning wedge or pillows, to encourage turning and repositioning or a schedule for repositioning for staff to follow. There was no care plan in place to address off loading of resident's heels while in bed. The nutrition care plan did not include strategies for feeding R1 or include what staff should do if R1 refused to eat. R1's daily shower skin check sheets were provided by the facility. R1 had skin check sheets dated December 5, 12, 16, 19, and 23, 2025. On the skin check sheets dated December 5, the skin check indicated R1's skin was intact with the presence of a bruise but no location of where the bruise was. The skin check sheet dated December 16 indicated R1 skin was intact with presence of rash and bruise with no location of where the rash and the bruise were located. The skin check sheets dated December 12, 16 and 23 did not have any documentation including whether or not skin was intact regarding R1's skin. V2 (Director of Nursing) was unable to provide any follow up documentation or interventions that were provided regarding the skin concerns identified. R1's observation note dated December 23, 2025, at 11:51 PM, by V8 (RN) showed R1 developed pressure ulcers on both sides of his sacrum. The observation note showed the skin on the sacrum was reddened with 2 open circular areas with approximate measurements of 3.0 cm (centimeters) x 3.0 cm on the right and left sides of the sacrum, and red tissue in the wound bed. The observation showed V8 cleansed the wound with normal saline and applied A & D ointment and border foam gauze.On January 16, 2026, at 3:23 PM, V6 (Certified Nursing Assistant/CNA) stated she was R1's CNA on the day of R1's admission. V6 stated she recalled R1 had some redness on the skin on the low back and recalled he had wounds on both heels. V6 stated R1 would yell a lot and tell staff to leave him alone. V6 stated R1 did not like to be changed and R1 used to get out of bed into a wheelchair when first admitted and then just stopped getting out of bed. V6 stated she could not recall exactly when R1 stopped getting out of bed.On January 16, 2026, at 3:33 PM, V8 stated V9 (CNA) had alerted him to the presence of the new wounds on R1's sacral area. On January 16, 2026, at 3:36 PM, V9 (CNA) stated on December 23, 2025, was the first time he was assigned to take care of R1 when he noticed the redness and open areas on R1's sacrum and reported the condition to V8. V9 stated R1 needed 2 caregivers' assistance to reposition R1 because he would yell a lot and would swing his arms at staff during care. V9 stated R1 did not like to eat and would refuse to open his mouth at meal times. V9 stated there was no repositioning schedule for R1 that he was aware of and remembered R1 was tall and skinny and did not get out of the bed. On January 16, 2026, at 4:10 PM, V5 (Wound Nurse Practitioner) stated R1 was admitted with pressure wounds on both heels. V5 stated he first assessed R1 on December 5, 2025, and told nursing staff in addition to R1 already having pressure wounds, R1 was at risk to develop additional pressure wounds due to R1's poor nutritional status, immobility, and incontinence. V5 stated he ordered vascular studies for both legs and instructed nursing staff to follow the Facility Pressure Injury Prevention Protocol. V5 stated on the first visit with R1 there was no low air loss mattress on R1's bed. V5 stated R1 was underweight, had protein calorie malnutrition and could become aggressive when touched. V5 stated the last visit for R1 was on December 19, 2025, prior to the identification of sacral area pressure wounds and V5 did not assess the new wounds. Review of R1's physician and physician extender progress notes from December 24 through discharge showed neither the wound physician extender nor medical physician /physician extender assessed R1's sacral wound. On January 20, 2026, at 11:30 AM, V2 (Director of Nursing) stated when a resident is admitted with a pressure wound the expectation is the resident will have a care plan in place to prevent further pressure wound development and a care plan to promote wound healing. V2 stated the expectation is for residents with existing pressure wounds or at risk for developing pressure wounds be repositioned every 2 hours. V2 was unable to provide documentation that R1 was repositioned every 2 hours or provide a plan to meet R1's need for repositioning, prior to R1's development of sacral pressure wounds. The facility's policy titled Skin Alteration and Assessment Policy dated July 2022, showed, It is the policy of this facility to ensure that the facility will assess, treat the skin impairment for residents based on the observation during admission, and/or change in skin condition.2. During shower or while providing ADL care .CNA has to fill out the daily shower sheet form with their findings.3. The assigned nurse will initiate the treatment and /or interventions .11. Resident will be seen by the Wound MD during weekly wound rounds or as needed.15. QA nurse will update the care plan.

Based on observation, interview and record review, the facility failed to serve resident meals at regular times per the facility meal schedule. This applies to all 60 residents residing in the facility receiving oral diets. The findings include: On 9/24/25 in the main dining room, meal times were posted stating that Breakfast would be served at 8:30 AM, Lunch would be served at 12:30 PM and Dinner would be served at 5:30 PM. On 9/24/25 in the main dining room lunch trays began to be delivered at 12:50 PM and were finished being served by 1:00 PM. On 9/24/25 during facility tour, R1, R2, R4, R5 and R7 all stated the meals at the facility were served late. R2 and R4 stated the meal trays arrived 30-45 minutes late, R6 stated sometimes the food came 20 minutes late, and R7 stated the food was usually served an hour late and sometimes received lunch at 1:15 PM. On 9/25/25 at 11:35 AM, R9 stated the food was usually served more than 30 minutes late. On 9/24/25 at 12:23 PM, V4 (Certified Nursing Assistant) stated the meal trays were usually served approximately 25 minutes late. On 9/24/25 at 11:03 AM, V5 (Cook) stated the food service was staffed with two aides in the morning but they were reduced to one aide which slowed down meal service. V5 stated the meal service may be later depending on how many items must be placed on the tray. V12 (Food Service Worker) stated the latest the staff have finished lunch was 1:15 PM. V12 stated in the past they were able to finish plating meals at 12:30 PM. On 9/25/25 at 8:40 AM, V8 (Food Service Manager) stated he was back from vacation and would serve as a second aide to ensure that meals were served on time. On 9/25/25 at 8:45 PM, V1 (Administrator) stated V8 returned from vacation and would serve as the second aide to make sure the meals were served on time. Facility Bed Roster, dated 9/23/25, shows the facility census was 61 residents. On 9/28/25, V1 (Administrator) stated there was one resident in the facility who did not receive oral diets. Resident Council Meeting Minutes, dated 7/25/25, shows the residents expressed concerns that the staff were taking too long to pass trays to residents. Resident Council Meeting Minutes, dated 8/29/25, show, Lunch keeps coming later and later. Facility Meal Schedule Policy, undated, shows, Three meals will be served daily at similar times as served in the community. The policy states mealtimes will be posted throughout the facility where they are accessible to residents and visitors.

Based on interview and record review, the facility failed to provide palatable food at warm temperatures. This applies to 4 of 5 residents (R1, R5, R7, and R9) reviewed for food palatability in a sample of 5. The findings include: 1. MDS (Minimum Data Set), dated 9/3/25, shows R1 was cognitively intact. On 9/24/25 at 1:10 AM, R1 stated his food was often served late and the hot food was cold. 2. MDS, dated [DATE], shows R7 was cognitively intact. On 9/24/25 at 3:50 PM, R7 stated his food is served cold and usually an hour late. 3. MDS, dated [DATE], shows R9 was cognitively intact. On 9/25/25 at 11:35 AM, R9 stated the food was often served late and cold. 4. MDS, dated [DATE], shows R5's cognition was severely impaired. On 9/24/25 at 11:55 AM, R5 stated her food is often served late and the hot food is cold. 5. Resident Council Meeting Minutes, dated 6/27/25, show the residents in the meeting complained that the breakfast meals were always cold when they received them. Resident Council Meeting Minutes, dated 7/25/25, show the residents stated the kitchen food continued to arrive cold, and the CNAs (Certified Nursing Assistants) were taking too long to pass meal trays to residents. Emergency Food Committee Meeting Minutes, dated 9/12/25, shows Residents will have lunch in the dining room to improve food temps. On 9/27/25 at 8:26 AM, V1 (Administrator) stated the facility did not have a policy on food palatability or food temperature expectations at the point of service to residents.

Based on observations, interviews and record reviews, the facility failed to provide timely Activities of Daily Living (ADL) assistance to residents who were dependent on staff for incontinence care. This applies to 3 of 3 residents (R1, R7 and R9) reviewed for incontinence care in a sample of 10. The findings include: 1. Face sheet, dated 9/25/25, showed R1's diagnoses included multiple sclerosis, obesity, congestive heart failure, and neuromuscular dysfunction of his bladder. MDS, dated [DATE], shows R1 was cognitively intact, was completely dependent on staff for toileting and personal hygiene, and was always incontinent of bowel and bladder. Review of R1's care plan showed R1 was totally dependent on staff for toileting and was able to tell staff when he needed to be changed after incontinence episodes. The care plan approaches included providing assistance for toileting after each incontinence episode. The care plan showed R1 was dependent on staff for transfers using a mechanical lift. On 9/24/25 1:10 PM, R1 stated the prior week he asked to be toileted at approximately 10:30-11:00 AM and waited until the next shift. R1 stated the last time his brief was changed was 8:00 AM when he got up from bed. On 9/24/25 at 2:25 PM, R1 asked V4 (Certified Nursing Assistant/CNA) to change his soiled incontinence brief. R1 sat in his room and waited for staff to arrive. On 9/24/25 at 2:55 PM, V4 was entering information into the computer system in the hallway. On 9/24/25 at 3:10 PM R1 was still waiting in his room for his incontinence brief to be changed. At 3:25 PM, R1 decided to leave his room and go downstairs. R1 had not had his soiled incontinence brief changed. R1 returned to his room soon after. On 9/24/25 at 3:28 PM, V6 (CNA) and V7 (CNA) both stated they were not aware R1 needed his incontinence brief changed and stated they got no report from V4 prior to V4 leaving her shift for the day. V2 (Director of Nursing) stated a staff member called in and the current facility staff needed to split the rooms to cover the floor. On 9/24/25 at 3:37 PM, V6 stated he was going to change R1's incontinence brief and then put R1 back in his wheelchair for dinner. V6 and V7 walked into R1's room and began to initiate changing R1's incontinence brief. At 4:00 PM, R1's incontinence brief was examined and appeared extremely full of urine and had a large amount of bowel movement in the brief. V6 and V7 both stated R1's incontinence brief was extremely full of urine and bowel movement. On 9/25/25 at 10:28 AM, V2 (Director of Nursing) stated nursing staff were expected to check incontinent residents' briefs every two hours even if residents were able to verbalize if they were wet or could change themselves. V2 stated on the morning of 9/24/25, V2 saw R1 and knew his incontinence brief needed changing by the smell of urine from R1. V2 stated she texted all the managers on duty on 9/24/25 to alert staff that R1 needed his incontinence brief change because he smelled of urine. On 9/25/25, V4 (CNA) stated she got R1 up out of bed and performed incontinence care for R1 at approximately 8:00 AM to 8:30 AM. V4 stated R1 becomes impatient when he needs to wait to have his soiled incontinence brief changed. V4 stated she overheard R1 tell V11 (Restorative) that he did not want a shower or incontinence care until the next shift. V4 stated R1 did not ask V4 for incontinence care during her shift. V4 stated she never asked R1 if he needed incontinence care because R1 usually asks himself for his incontinence brief to be changed. On 9/25/25 at 10:33 AM, V11 (Restorative) stated between 10:00 AM and 11:00 AM, she asked R1 if he wanted a shower and R1 told V1 that he was scheduled for a shower during the PM shift that day. V11 stated R1 never stated he did not want his incontinence brief to be changed until the PM shift. V11 stated the CNAs should offer residents to have their incontinence briefs changed every two to three hours even if a resident can verbalize that they need changed. On 9/25/25 at 11:28 AM, V1 (Administrator) stated the facility nursing staff should check incontinent residents' incontinence briefs every two to three hours regardless if a resident can verbalize their briefs are soiled. Facility Incontinence Care Policy, undated, shows, Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. Incontinent residents are changed every two hours and more frequently if needed. Facility Activities of Daily Living Policy, undated, shows, 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 2. Face sheet, dated 9/25/25, showed R7's diagnoses included hemiplegia and hemiparesis and dementia. MDS, dated [DATE], shows R7 was cognitively intact, and R7 was dependent on staff for toileting transfers and toileting hygiene. Review of R7's care plan showed R7 was dependent on two staff for transfers with a mechanical lift and was incontinent of bowel/bladder. R7 was care planned for being upset after five minutes if a CNA did not arrive to assist him and care planned to allege that he was waiting for hours. On 9/24/25 at 3:250 PM, R7 stated it took over an hour for staff to arrive to change his soiled incontinence brief. R7 stated he had the same incontinence brief on since 8:30 AM that morning. 3. Face Sheet, dated 9/25/25, shows R9 had a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting her left non-dominant side. MDS, dated [DATE], shows R9 was cognitively intact, was completely dependent on staff for toileting hygiene, and was always incontinent of bowel and bladder. Review of R9's care plan showed R9 was incontinent of bowel/bladder, was dependent on staff assistance for toileting, and required the assistance of two staff utilizing a mechanical lift for transfers. The care plan showed R9 was to be provided incontinence care after each incontinence episode. On 9/25/25 at 11:35 AM, R9 stated she usually waits an hour for CNAs on the first and second shifts to arrive to change her soiled incontinence briefs.

Based on observations, interviews, and record reviews the facility failed to ensure residents had functioning call lights within their reach.This failure applies to 6 of 9 residents (R1, R2, R6, R7, R8, and R9) reviewed for accommodation of needs.Findings include: 1.On September 09, 2025 at 10:45 AM, R1 stated his roommates have no call light. R1 stated R2 (roommate) complains about his call light constantly, and R1 had to pull his call light closer to his bed because it is out of reach. R1's room had only one call light positioned closer to R2's bed and pulled over to R1's bed. R1's Face Sheet showed he is a [AGE] year-old male with diagnoses of multiple sclerosis, chronic congestive heart failure, and recurrent major depressive disorder, and he was admitted to the facility 08/27/2025. On September 09, 2025 at 10:58 AM, R2 stated he doesn't have a call light and he has to yell out or come out of his room for assistance. R2's Face Sheet showed he is an [AGE] year-old male with diagnoses of schizoaffective disorder, stage 2 chronic kidney disease, peripheral vascular disease, lymphedema and prostate cancer, and he was admitted to the facility 09/23/2024. On September 10, 2025 at 8:51 AM ,V2 (Director of Nursing) acknowledged that R2 did not have a call light. V2 stated residents should have call lights and she isn't sure why there is only one call light in R1 and R2's room. R2 responded to V2's statements with talk to maintenance. 2.On September 09, 2025 at 9:24 AM, R6 was asleep in her wheelchair a few feet away from and next to her bed, and her call light was behind her bed on the floor, several feet away from her and out of her reach. V3 (Assistant Director of Nursing) stated R6's call light should be clipped to her wheelchair as R6 could not access it. R6's face Sheet showed R6 is an [AGE] year-old female with diagnoses of partial paralysis due to stroke, vascular dementia, and contractures, and she was admitted to the facility 09/25/2024. 3.On September 09 at 9:30 AM, R7 was lying in her bed in her room. R7 stated her call light doesn't work and she is checked on infrequently by staff. R7 pressed her call light and it did not work. R7 stated her call light hasn't worked since her admission to the facility and she has told everyone that has come into her room about it but there has been no follow up. R7's Face Sheet showed she is a [AGE] year-old female who was admitted on [DATE] with diagnoses of multiple sclerosis, chronic embolism and thrombosis, generalized osteoarthritis, and contracture of right knee. Additionally, there was only one call light in R7's room that she shared with R8. V2 (Director of Nursing) then tested R7's call light and it did not work. 4.On September 09, 2025 at 9:38 AM, R8 sat on her bed with a walker in front of her and stated she doesn't have a call light and would like one. V2 stated R8 is able to use the call light and could not explain why R8 did not have her own call light. R8's Face Sheet showed she is a [AGE] year-old female with diagnoses of cerebral ischemia (insufficient brain blood flow), stage 1 chronic kidney disease, muscle disorders, difficulty in walking, and abnormalities of gait and mobility, and she was admitted to the facility 09/19/2024. 5.On September 09, 2025 at 9:40 AM, R9 was in her wheelchair with a bedside table in front of her near the foot of her bed. R9's call light was several feet away at the head of her bed and out of her reach. V2 stated R9's call light should be next to her, and although R9 could ambulate to access it, it was not advisable because R9's gait is unsteady. R9's Face Sheet showed she is a [AGE] year-old female with diagnoses of Alzheimer's disease, vertigo, difficulty in walking, and lack of coordination, and she was admitted to the facility 11/27/2023. The facility's Answering Call Light Policy Received 09/10/2025 showed: The purpose of this procedure is to respond to the resident's requests and needs.When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.Report all defective call lights to the Maintenance Department promptly.Call lights must be accessible to residents from their bed or other sleeping accommodation. The call light system should be accessible to a resident lying on the floor.

Based on observations, interviews, and record reviews the facility failed to ensure resident's clothing items were labeled and safeguarded from loss. This failure applies to 3 residents (R1, R2, and R3) reviewed for laundry services. Findings include:Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for personal effects by not ensuring resident's clothing items were properly labeled and safeguarded from loss. This failure applies to 3 residents (R1, R2, R3) reviewed for laundry concerns. Findings include: 1.On September 09, 2025 at a10:45 AM, R1 stated he has at least 5-6 pairs of gray pants that are missing, the facility's washing machines are down, his laundry was picked up to be taken out to be cleaned this morning, and he would like to know where his clothes are that were since the first time they were sent out. 2.On September 09, 2025 t 10:58 AM, R2 stated his clothes don't come back from the laundry. 3.On September 09, 2025 at 3:05 PM R3 stated he had some clothing items go missing when he was first admitted to the facility. R3's face Sheet showed he was admitted [DATE]. On September 09, 2025 at 9:57 AM V1 (Administrator) stated a couple of months ago, they switched from in-house laundering of personal clothes to outside laundry services because the washers in the building were broken. V1 stated there have been some complaints about missing clothes. V1 stated there were approximately four grievances of residents reporting missing clothing, along with email communication and documentation between she and the laundry vendor regarding this issue. On September 09, 2025 at 11:40 AM, V13 (Housekeeper) transported a laundry cart with several laundry bags, delivered them to residents room, removed the clothing from the bags, and hung up the clothes in the resident's closets. V8 (Dietary Aide) helped translate with V13. V13 stated she collects clean laundry from the large blue bins on Tuesdays and Fridays and delivers the clothing to the residents. V13 stated she has received complaints from residents about missing clothing. On September 09, 2025 at 11:52 AM, multiple laundry bags in the cart had no clear labeling on them to identify who the clothing items belonged to. V11 (Activity Director) helped translate with V13 (Housekeeper). V13 stated if there is no clear label on the bag, she will open them and look for labels on the clothing to identify who they belong to. On September 09, 2025 at 12:27 PM, a large, tall, blue storage container contained several clear bags of clean laundry with no labeling on the bags. V13 (Housekeeper) opened the bags to identify who the clothes belonged to, and the clothes were also not labeled. V13 she could not determine who the bags of clothing belonged to. On September 10, 2025 at 8:51 AM, V2 (Director of Nursing) stated last week on Tuesday or Wednesday, R1 reported to her that his clothes were missing and she explained to him that clothes are sent out on Tuesday will be returned on Friday. V2 could not explain why R1's clothes that were collected last Tuesday were still missing. V2 stated the CNAs (Certified Nursing Assistants) and nurses inventory resident's items upon admission, and then sometimes family members and activities aides will label residents clothes within 24 hours of admission. V12 (Housekeeping Supervisor) stated either he or the laundry aide label laundry bags with the room and bed numbers, and the CNAs collect laundry bags from the rooms. V12 stated if a resident doesn't have a laundry bag, clear bags are used and labeled, and the bags and clothes should be labeled. Resident Council Concern Form regarding housekeeping dated 05/30/2025 showed a concern regarding residents not getting their laundry back. Resident Council Meeting reports from June to August 2025 showed concerns regarding residents clothes missing from laundry, and a resident reporting his clothes were placed in a clear bag that was not labeled and was missing. Multiple Grievance forms from September 2025 document multiple residents reported missing clothing, including R1. A 09/05/2025 email communication from administrator to the laundry vendor showed the administrator reported residents' clothes had been missing for weeks, laundry bags have been provided to the laundry vendor and not returned, and over 30-40 items are missing. The facility's Personal Effect's Policy received 09/10/2025 showed: .It is the policy of this facility to promptly investigate all reports of missing resident personal property and appropriately resolve the issue.Policy Specifications. To promote resident satisfaction and comfort regarding handling and security of personal property.The facility, at the discretion of the Administrator, may replace any items for which it cannot account .

Based on observation, interview, and record review, the facility failed to follow sanitary practices in the facility kitchen. This applies to 57 residents that received foods prepared in the facility kitchen. The findings include: Facility filled CMS Form 671 dated February 18, 2025, showed that the facility census was 57 residents. Facility provided information that there were no residents on NPO (nothing by mouth) status. On February 18, 2025, at 9:35 AM, during initial tour of kitchen, V6 (Dietary Aide) was washing dishes on the soiled side of the dish machine and was seen putting on new gloves without washing her hands and go to the clean side to pick up cleaned dishes. The hand sink near the dish machine did not have soap nor paper towels. V7 (Dietary Aide) who was in the area stated that there is none and she asked the Housekeeping for supplies, and they did not have it either. A red sanitizer bucket in the kitchen area was tested with a QUATS (quaternary ammonia) test strip and showed an almost white to pale yellow color. This when compared to the color scale of the test strip reel, registered at 0-150 ppm (parts per million). V8 (Cook) stated that she just changed the sanitation buckets and wiped down the counters with the same. In the walk-in Cooler, was a tub of cottage cheese with a broken lid in two places and exposed the contents. The use by date on the tub showed January 31, 2025. In the walk-in Freezer, there was a 4 lb. (pound) plastic bag of sliced strawberries and a 3 lb. plastic bag of blueberries both of which were opened to air. V7 (Dietary Aide) stated that it is used for one resident (R300). On February 18, 2025, at 12:45 PM, V5 (Consultant Dietitian) stated that the QUATS sanitizer strip should test between 150-400 ppm, ideally 200 ppm. V5 stated that the staff should wash their hands before donning clean gloves. V5 added that if not wearing gloves, hands must be washed when going from dirty to clean side of the dish machine. V5 stated that all items that are opened in cooler and freezer must be sealed or wrapped and dated with open on or use by date. Facility policy taken from Policy and Procedure Manual 2017 titled Dish Room Safe Food Handling included as follows: The task of loading the dirty dishes and utensils into the dish machine is handled by one person. The task of removing the clean dishes and utensils from the dish machine is handled by a different person. If there is only one person working in the dish room, the person will remove their gloves, wash their hands, and put on fresh gloves whenever they cross over to the clean side of the dish machine to unload the sanitized dishes and utensils. Facility policy taken from Policy and Procedure Manual 2017 titled Storage of Frozen Foods included that if taken out of original container, food is tightly wrapped and labeled with name of item and use by date. Facility policy titled taken from Policy and Procedure Manual 2017 titled Sanitation Buckets/Wiping Cloths. included as follows: Policy: Wiping cloths kept in a sanitation bucket containing a solution of water and chemical sanitizer are used to sanitize food contact surfaces and equipment too large to immerse in the three-compartment sink. Procedure: In the red sanitation bucket mix the water and the chemical sanitizer. The most common chemical sanitizers are chlorine, iodine, and quaternary ammonia. Sanitizing the food contact surfaces and equipment is accomplished according to the following color chart: Quaternary 150-400 or 200-400 per manufacturers direction.

Based on interview and record review, the facility failed to follow their water management plan for Legionella. The facility also failed to have control measures in their water management plan to address prolonged closure of a resident unit. This applies to all 57 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated February 28, 2025, showed the facility's census was 57 residents. The facility's undated Water Management Program showed Purpose: To manage the risk of exposure to Legionella from the water in the facility. The Identifying Buildings at Increase Risk Assessment was completed. Due to the fact that we are a healthcare facility with residents who stay overnight, a water management program is indicated . The following areas where Legionella could grow and spread were noted: A. Municipal water intake. a. External factors- construction, water main break, disruption in water service: i. The facility will monitor village activity. ii. Test disinfectant (free chlorine) residual values where water enters our building quarterly. B. Ice Machine. a. Possible conditions for bacteria spread. i. The ice machine is visually inspected for signs of biofilm and cleaned monthly by an outside service. ii. Ice machine is fed by all copper piping. C. Sinks/Showers. a. Sinks and showers. i. Temperatures are tested weekly. See spreadsheet for acceptable ranges. ii. Residual free chlorine levels are tested quarterly. iii. Fixtures closest to and farthest away from the central distribution point will be tested . D. Water Heaters. a. Water heater 1, 2, 3, and 4 have temperature gauges which are checked monthly. Units will be adjusted accordingly to maintain temperatures about 120 degrees. E. In the event of any water system failure or interruption, testing the entire system will be completed. F. All testing will be documented and kept in the maintenance director's office. Activities of the water management program will be reviewed during the safety committee meetings and Quality Assurance meetings. The facility does not have documentation to show quarterly free chlorine testing was conducted, monthly ice machine maintenance was conducted, weekly water temperatures of the sinks/showers conducted, or monthly monitoring of the water heaters were conducted. On February 19, 2025, at 10:54 AM, V1 (Administrator) said she does not have any water temperature logs. V1 continued to say V12 (Maintenance Director) does not keep water temperature logs. On February 19, 2025, at 11:14 AM, V12 said he does not have any documentation regarding the control measures of the facility's water management plan for Legionella. V12 said he thinks the ice machine company comes to the facility quarterly for ice machine maintenance. V12 said he does not have documentation to show the last time the company performed an inspection or cleaning of the ice machines. V12 said he does not have documentation of free chlorine testing of the water. On February 19, 2025, at 11:33 AM, V2 (DON/Director of Nursing) said the second floor was closed to residents on April 8 or April 9. 2024, and reopened to residents in September 2024. V2 said the census was low on the second floor until recently. The facility does not have documentation to show control measures were conducted on the second floor during the prolonged closure of the second floor. The facility does not have documentation to show Legionella testing was conducted while the second floor was not being inhabited by residents or prior to reopening the second floor after being closed for five months.

Based on observation, interview, and record review, the facility failed to maintain a homelike environment for residents residing in the facility. This applies to 4 of 15 residents (R9, R24, R43, R45) reviewed for homelike environment in the sample of 15. The findings include: 1. Face sheet showed R9 is [AGE] years-old who was admitted to the facility on [DATE], with diagnoses that include radiculopathy of the cervical region, multiple sclerosis, diabetes mellitus with diabetic nephropathy, chronic pain, other muscle spasms, myalgia, difficulty in walking, and other abnormalities of gait and mobility. On February 18, 2025, at 10:45 AM, V13 (Visitor/Volunteer for local church) was in R9's room when R9 agreed to speak with the surveyor. V13 stated she is in the facility regularly visiting residents. R9's bed was close to the window about 2-3 feet away. R9's window did not have a curtain or blinds up to the window. There was a bath towel placed and dangling in between two overlapping windowpanes in the middle of the window. Above the window air conditioner, there was a piece of Plexi-glass that had small holes in it all around the edge. R9 stated it was very cold in her room, especially since there was no curtain at the window. Surveyor observed it to be cold by the window. R9's curtain and its metal rod were lying against the wall between the inner/outside wall and the resident's tall wooden cabinet. R9 stated there has not been a curtain there for at least 3 days. R9 stated she told the staff three days ago that she needed a curtain up to her window. V13 then stated it is a shame how they don't keep up this facility. R9 and V13 pointed to the peeling paint on the ceiling next to the window and there was a pink (hospital) basin on the top of R9's cabinet below the peeling paint and water stain. R9 stated the basin was there to catch the water dripping from the ceiling. On the upper left window frame, there was a peeling paint and a couple of large holes in the dry wall. R9 stated she had told the staff about the peeling paint on the wall and the leakage; however, no one has fixed it. V13 stated the leaking from the ceiling happened in January and they still have not fixed the ceiling or wall. R9 stated one of the staff placed the towel in the window to help with the draft. V13 stated R24, another resident, has the same issue. R9 stated they don't fix anything here and she should not have to live here with these conditions. On February 19, 2025, at 9:00 AM, R9 still did not have a curtain up to her window, the towel was still stuck and dangling in the middle of the window, and the wall and ceiling were not repaired. On February 19, 2025, at 12:48 PM, R9 stated her room was cold and it was very cold last night. R9's window still did not have window coverings including blinds or curtain but still had the towel dangling in the middle of the window. On February 20, 2025, at 9:03 AM, the towel was off R9's window, frigid cold air was observed coming through the windowpanes, where the towel was located. R9 still did not have any window coverings. 2. Face sheet showed R24 is [AGE] years-old who was admitted to the facility on [DATE], with diagnoses that include: poly-osteoarthritis, hypertensive heart disease without heart failure, spinal stenosis, radiculopathy cervical region, and other genetic causes of short stature. On February 18, 2025, at 10:50 AM, V13 (Volunteer) and surveyor walked into R24's bedroom. R24 was lying in bed. R24 stated water was dripping on her for days and the water wet her entire pillow. R24 stated they finally moved her to her current bed. While pointing up above her head at the water-stained ceiling, R24 stated that water has been dripping on her in her current bed also. R24 was angry and stated, You can tell them to fix things, and nothing happens. R24 pointed at the large water stains above her old bed and the wall that had a large area of peeling paint. R24 stated, They don't do anything here. V13 stated, it was sad for her to see the residents living in these conditions. V13 stated she has told the staff more than once about R24's wall. V13 stated the stains and peeling paint have been there at least since January. R24 stated the damaged wall and ceiling has been like that for a while and they moved her bed in January of 2025. R24's Resident Census showed she moved from bed 3 by the window to her current location (bed 2) on January 3, 2025. On February 20, 2025, at 9:23 AM, R24's wall still had peeling paint on the wall and water stains on the ceiling. On February 19, 2025, at 10:23 AM, V1 (Administrator) presented surveyor with maintenance request logs but the original dates of the maintenance request were not present. V1 said she did not know the original dates of the requests and the original forms of maintenance request where she transcribed them from was already thrown away. R24's maintenance request did not appear on any of the maintenance logs. V12 (Maintenance Director) and surveyor went to R9's bedroom. There was still a towel stuck in the window. V12 removed the towel and placed his hand where the towel was and stated There is a draft coming from the window. That is why the towel was probably stuck in there. 41855 3. On February 18, 2025, at 10:09 AM, in R43 there was a cord hanging down from the ceiling. It was a television cord that was in a flex-tube and was running from the television to the cable jack on the opposite side of the room. The television was mounted on the wall approximately two feet from the ceiling. The ceiling in the room was approximately 9 feet. The cord was currently attached to the television and then it was attached in the corner of the room above the room door. The cord from the television to the corner was sagging in the middle where it was not secured to the wall. The cord was connected to random areas on the wall near the ceiling but was sagging in between the areas connected to the wall. As the cord got closer to the left back corner of the room, the cord was coming down lower towards the cable jack. There was a cable splitter with a long, pointed screw that was not connected to anything. On one side of the cable splitter the cable from the television was connected to it and then connected to the cable jack in the wall. The cable jack on the wall was approximately four feet from the floor. There was an area of the wall in the back right corner of the room where the wall was dented in, and dry wall was crumbling onto the floor. 4. On February 18, 2025, at 10:27 AM, in R45's, the metal radiator that runs along the wall in the room under the windows, was dented and the covering was falling off the wall. It had areas of rust on it that were cracking and flaking. On February 19, 2025, at 11:21 AM, V12 (Maintenance Director) said he is only covering this building, until the new maintenance man starts on Monday (February 24). V12 said there is a lot of work to be done in this building for sure. V12 went into R43's and R45's rooms and said the concerns shared by surveyor definitely needed to be repaired.

Based on observation, interview, and record review, the facility failed to ensure residents' rooms were located at or above ground level. This applies to 13 residents (R1, R5, R6, R7, R8, R23, R30, R33, R43, R44, R45, R52, and R53) on the first floor reviewed for room/level/location. The findings include: On February 18, 2025, at 9:58 AM, during the initial tour of the facility, observations were made that seven rooms (101, 102, 103, 104, 105, 106, and 107) were below ground level. The facility's Resident Roster dated February 17, 2025, showed R1, R5, R6, R7, R8, R23, R30, R33, R43, R44, R45, R52, and R53 were all residing in the bedrooms on the first floor below ground level. On February 20, 2024, at 3:27 PM, V1 (Administrator) said she was aware of the facility's noncompliance with having residents residing in rooms below ground level on the first floor. V1 said the facility sent in an application for a waiver. V1 did not provide any waiver but provided a letter received from IDPH (Illinois Department of Public Health) after the previous annual survey was completed. The letter showed, As a result of this survey and any revisits, the Department is recommending to the Centers for Medicare and Medicaid Services and the Illinois Department of Healthcare and Family Services that the facility be certified for continuing participation in the Medicare (Title 18) and Medicaid (Title 19) programs. Based on review of this document, there was no waiver awarded to this building for the rooms located below ground level (101, 102, 103, 104, 105, 106, and 107).

Based on observation, interview, and record review, the facility failed to provide privacy during provision of wound care. This applies to 1 of 15 residents (R41) reviewed for privacy in the sample of 15. The findings include: On February 19, 2025, at 10:30 AM, V3 (Assistant Director of Nursing/ADON/Wound Care Nurse) rendered wound care to R41 who had a pressure ulcer to her left buttock. During dressing change, V3 left R41's bedroom to get additional items to use for the wound care. V3 did not cover R41 with a blanket or a sheet which left R41 naked or exposed from the waist below. On February 20, 2025, at 11:50 AM, R41 said that staff (V3) should have covered her nakedness prior to leaving. R41's MDS (Minimum Data Sheet) dated 1/19/2025 shows that R41 is alert and oriented. On February 20, 2025, at 3:04 PM, V3 (ADON/Wound Care Nurse) stated that staff must ensure that privacy is always provided for dignity. Facility's Policy for Quality of Life-Dignity with revised date of 2017 shows: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation: 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on interview and record review, the facility failed to implement a person-centered care plan for a resident with a diagnosis of PTSD (Post Traumatic Stress Disorder) This applies to 1 of 1 resident (R44) reviewed for PTSD in the sample of 15. The findings include: R44's EMR (Electronic Medical Record) showed R44 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, recurrent, severe with psychotic symptoms, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, and post-traumatic stress disorder, unspecified. R44's MDS (Minimum Data Set) dated December 23, 2024, showed R44 had a diagnosis of PTSD. Progress note dated December 3, 2024, at 2:38 PM, by V21 (Nurse Practitioner) showed R44's history and physical identified R44 as having PTSD and a history of sexual abuse as a child. There was no care plan in place that addressed R44's diagnosis of PTSD (financial abuse, physical assault, sexual assault, mental abuse), nor identified her triggers, nor identified interventions to meet her medical, physical, or mental needs. On February 20, 2025, at 1:20 PM with V18 (Social Services) said she was unaware of R44's PTSD, stating she has only been at the facility for two weeks. V18, went into R44's EMR and pulled up the Trauma-Informed Care Observation done on admission and saw that R44 had personally experienced financial abuse, sexual assault, physical assault, and mental abuse. There were no triggers identified. V18 said she would have to review care plan and see what the previous social worker had addressed in R44's care plan. V18 said had she been aware that R44 had a history of PTSD, she would have met with the resident, identified her triggers, and updated her care plan. On February 21, 2025, at 9:47 AM, V1 (Administrator) said the facility does not have a policy on Trauma- Informed Care for Residents with PTSD.

Based on observation, interview, record review, the facility failed to provide hygiene and grooming for residents who require assistance for activities of daily living (ADL) care. This applies to 3 of the 4 residents (R4, R9, R31) reviewed for ADL care in the sample of 15. The findings include: 1. On February 18, 2025, at 11:04 AM, R4 was in her bedroom sitting in her wheelchair. R4 displayed overgrown facial hair on the upper lip and chin, long nasal hair which was sticking out from her nostrils, jagged and discolored fingernails, and uncombed/disheveled hair. On February 19, 2025, at 11:08 AM, V19 and V20 (Both Certified Nursing Assistant/CNA) rendered incontinence care to R4. R4 remained with overgrown nasal hair, facial hair, jagged and discolored nails, and uncombed disheveled hair. After V19 and V20 completed the incontinence care, they left R4 to attend to another resident without offering to shave her facial hair, trim her nasal hair, comb her hair, and provide nail care. On February 20, 2025, at 10:20 AM, R4 remained with overgrown facial hair on the upper lip and chin, jagged and discolored fingernails and overgrown nasal hair sticking from her nostril, uncombed/disheveled hair. Surveyor brought the concern of R4's grooming to V11. R4's MDS (Minimum Data Set) dated January 13, 2025, shows that R4 is totally dependent on staff for hygiene care/grooming care. 2. On February 18, 2025, at 11:08 AM, R31 was in her bedroom. She was alert and oriented, and pleasant upon approached. R31 displayed jagged and discolored fingernails and curly facial hair. On February 20, 2025, at 11:15 AM, R31 was resting in bed, alert and oriented. She remained with jagged and discolored fingernails, and curly facial hair. R31 verbalized that she wanted her facial hair shaven, and her fingernails clipped and cleaned. R31's MDS dated [DATE], showed that R31 requires substantial to maximal assistance for grooming and hygiene. On February 20, 2025, at 3:00 PM, V3 (Assistant Director of Nursing/ADON) stated that nail care and shaving is supposed to be done during shower days and as needed. Hair care is to be done daily and as needed, this is to be done as part of the personal hygiene and grooming. 43389 3. Face sheet showed that R9 is [AGE] years old who was admitted to the facility on [DATE], with diagnoses that include radiculopathy of the cervical region, multiple sclerosis, diabetes mellitus with diabetic nephropathy, chronic pain, other muscle spasms, myalgia, difficulty in walking, and other abnormalities of gait and mobility. R9's Minimum Data Set (MDS) dated [DATE], showed her to be cognitively intact and requiring substantial/maximal assistance for toileting hygiene. On February 18, 2025, at 12:10 PM, R9 was assisted to the bed for a head-to-toe assessment. V14 (Registered Nurse) assessed R9 and as she pulled down R9's pants to assess her hips and thighs, it showed that R9 was wearing double incontinence briefs. V14 removed the fasteners from the right side of the two incontinence briefs. The inner was soiled from the front to the back. V14 then closed both incontinence briefs and went to the R9's left side. Surveyor asked if R9 was wearing 2 incontinence briefs. R9 then stated they always put two incontinence briefs on her. The staff did not respond to the question. V14 then opened both incontinence briefs on R9's left side and examined R9's left hip and groin area. The brief closest to R9's skin was again observed to be soiled. V14 then refastened both incontinent briefs onto R9's hip and was about to grab R9's pants when surveyor asked if R9 incontinent brief was soiled. In response, V14 said, No. It is dry, as she grabbed R9's double incontinent briefs at the crouch area and squeezes it. V14 then reopened the left side of R9's incontinence briefs, looked and said, Yes, it is soiled. On February 20, 2025, at 3:35 PM, V3 (Assistant Director of Nursing) stated that when a resident has a soiled incontinence brief, the resident should be cleaned immediately. V3 stated, residents should be kept clean, dry, and comfortable. V3 stated it is not a practice of the facility to put residents on double incontinence briefs because of risks of urinary tract infections. R9's physician orders do not include any diuretics. R9's Elimination and Activities of Daily Living care plans dated October 7, 2024, showed the following: R9 requires partial/Moderate assistance 1 person with personal hygiene and maximal assistance with toileting hygiene. R9 has alteration in elimination as evidenced by urinary incontinence and bowel incontinence requiring incontinent care. R9 continues to use the toilet for needs. One of the approaches to care for R9 was to provide R9 with incontinence care as soon as incontinence was noted. The facility's incontinent care policy showed the following: Purpose: to keep skin clean, dry, and free of irritation and odor.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed foot care is seen by a podiatrist. This applies to 1 of 1 resident (R26) reviewed for foot care in the sample of 15. The findings include: On February 19, 2025, at 9:44 AM, V11 (Certified Nursing Assistant) rendered hygiene care to R26. During hygiene care and skin assessment, it was observed that R26 had overgrown toenails. The long nails curled over the top of each toe. V11 stated that she already reported it to the nurse a while ago. V11 was not sure why it has not been clipped yet. On February 19, 2025, at 3:15 PM, R26 was sitting on his wheelchair and stated that he wishes that someone would clip his toenails because it is too long. R26 said that his toenails has not been cut since he came in the facility. R26 stated he mentioned to his CNA multiple times that he wanted his toenails clipped. On February 19, 2025, at 2:17 PM, V10 (Nurse) stated that whenever they do admission, they (nurses) do head to toe assessments, and when they see anything that needs attention of the physician, they would refer the resident. One of the routine consents that they obtained is the podiatry consult. R26 was admitted on [DATE], and he signed consent for podiatry service at the time of his admission. R26 should have been seen by the podiatrist. R26's Minimum Data Set (MDS) dated [DATE], shows that R26 is alert and oriented and requires substantial/maximal assistance for grooming/hygiene.

Based on observation, interview, and record review, the facility failed to apply pain adhesive patches to residents that had a Physician order for the same. This applies to 2 of 2 residents (R19, R203) reviewed for pain management in the sample of 15. The findings include: 1. R19's face sheet showed diagnoses of radiculopathy, cervical region, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, other reduced mobility, bilateral primary osteoarthritis of knee. R19's quarterly MDS (minimum data set) dated February 4, 2025 showed that R19 was cognitively intact. R19's POS (Physician Order Summary) included as follows: Lidocaine adhesive patch, medicated, 4%, apply one patch topical. Special Instructions: apply to bilateral lower heels for pain. Apply at 6:00 AM and remove at 6:00 PM. Lidocaine adhesive patch, medicated, 4%, apply one patch topical. Special Instructions: site lower back, apply at 6:00 AM and remove at 6:00 PM. Lidocaine adhesive patch, medicated, 4%, apply one patch topical. Special Instructions: site neck, apply at 6:00 AM and remove at 6:00 PM. On February 18, 2025 at 11:12 AM, R19 stated that he is in pain scored at 8/10 and has not got his pain patch for a week. R19 stated that he has pain in his heels, neck and lower back. R19 stated They say they don't have any (pain patch). That's not good at all. R19's roommate R203, who was in the room, chimed in from behind the curtain He (R19) did not get a pain patch. I heard the nurse say that they don't have any. On February 18, 2025 at 11:28 AM, V4, RN (Registered Nurse) stated that R19 gets a pain patch which is applied by the night nurse. V4 stated that R19 also gets Norco (Acetaminophen tablet 650 mg) every 6 hours as needed and he already received the same that morning. On February 18, 2025 at 11:54 AM, R19's neck and heels were checked in presence of V4 and there was no patch. R19 stated again that he does not have any on as they haven't had any for a week. V4 stated that she was aware that there was no Lidocaine patch on February 17, 2025. V4 stated Yesterday they told me that they don't have any. But I thought they got it after that. He (R19) did not tell me this morning that he did not get a pain patch. When asked is she was going to notify the doctor, V4 stated He already got his Norco. It is not time for him to get it again. On February 20, 2025 at 9:20 AM, V17 (Licensed Practical Nurse) confirmed that she worked overnight (February 16-February 17, 2025) as the night nurse and administers the pain patch in the morning. V17 recalls one instance where there was no Lidocaine patch available and she explained it to R19 and gave him an as needed Norco. V17 stated that she also does not put it on R19's shower days and the AM nurse is supposed to put it on after his shower at 10:30 AM. R19's care plan initiated February 4, 2025 showed that R19 has complained of chronic neck (radiculopathy cervical), lower back pain related to history of compression fracture of left-spine he sustained from fall at home April/2022 prior to admission to facility. Interventions included to apply Lidocaine pain patches to neck, lower back, bilateral lower heels daily and remove after 12 hours. 2. R203's face sheet included spinal stenosis, cervical region, arthritis due to other bacteria, right ankle and foot, osteomyelitis of vertebra, lumbar region. R203's admission MDS dated [DATE] showed that R203 was cognitively intact. R203's POS had an order for Lidocaine adhesive patch, medicated 4 %, 1 patch, topical. Apply to the neck for pain. Apply at 6:00 AM and remove at 6:00 PM. On February 18, 2025 at 2:48 PM, R203 stated that he is supposed to get a patch on his neck but has not gotten one in the last two or three days. R203 stated They said they don't have any. R203 stated that he has a pain score of 7/10. This information was relayed to V4 (RN) who stated that he may not have gotten any Lidocaine patch as they did not have any in the house. On February 19, 2025 at 9:54 AM, V2 (Director of Nursing) stated that the Lidocaine adhesive patch are house stock and that V9 (Central Supply) orders it. V2 stated that if not available, the nurse's should call the doctor and order another medication. V2 stated that previously the facility would get doctors order to change to Biofreeze topical cream until Lidocaine patch available. On February 19, 2025 at 1:24 PM, V9 (Central Supply Staff) stated that he orders Lidocaine adhesive patch weekly and that he places the order on Thursday and the order comes in on Thursday unless there is a deficit in supply. V9 stated that the nurses usually call the doctors and switch to a cream and there must have been a miscommunication. V9 stated I wasn't made aware that they were running short. V9 added that he went and picked up Lidocaine adhesive patch from their supply chain when it was brought to his attention on February 18, 2025. R203's pain care plan initiated February 12, 2025 showed that R203 has diagnoses of spinal stenosis, cervical region, arthritis due to other bacteria, right ankle and foot (septic- arthritis, right foot) and has complaints of chronic pain on neck, lower back and right lower extremity. Intervention for the same included to administer medications: see MAR (medication administration sheet) / ORDERS for details. Administer Lidocaine [OTC/over the counter] adhesive patch,medicated; 4 %; amount: 1 patch; topical Special Instructions: Apply to the neck for pain. Apply at 6:00 AM and remove at 6:00 PM.

Based on interview and record review, the facility failed to protect residents by immediately suspending an employee accused of abuse, pending the outcome of an investigation. The facility also failed to thoroughly investigate an allegation of abuse. This applies to all 54 residents residing in the facility. As a result of this failure, all facility residents were exposed to an alleged abuser, V3 (Social Services Director), while V3 was under investigation for abuse. Also as a result of this failure, all facility residents were at risk for abuse due to abuse investigations not being thoroughly conducted. The IJ (Immediate Jeopardy) began on 4/7/22 at 12:30 PM when R10 alleged she was abused by V3. The IJ was identified on 6/8/22. V16 (Consultant) and V2 (Director of Nursing) were notified of the IJ on 6/9/22 at 10:31 AM. V1 was provided with the IJ Template outlining the failures. The surveyor confirmed by interview and record review that IJ was removed on 6/10/22 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: Facility Census, dated 5/31/22, shows the facility census was 54 residents. Preliminary Incident Investigation Report, faxed to IDPH (Illinois Department of Public Health) on 4/7/22, shows on 4/7/22 R10 alleged a staff member covered R10's ears. The report shows the facility will continue to conduct a complete and thorough investigation until a conclusion is reached. Final Incident Investigation Report, faxed to IDPH on 4/11/22, shows R10 alleged V3 (Social Services Director) put her hands over R10's ears and V3 screamed at R10. The abuse investigation concluded on 4/10/22 and the allegation was not founded. 1. Face sheet, printed on 6/1/22, shows R10 was admitted to the facility on [DATE]. R10's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set), dated 4/20/22, shows R10's cognition was moderately impaired. On 6/2/21 at 1:07 PM, R10 stated on 4/7/22 she began discussing a problem regarding her wheelchair with V1 (Administrator) when V3 (Social Services Specialist) involved herself in the discussion after R10 told V1, I'll believe it when I see it. R10 stated V3 began arguing with R10 accusing R10 of calling V1 a liar. R10 stated she became upset, removed herself from the office, and went to her room. R10 stated when she got to her room, she received a call from her daughter asking why she called V1 a liar. R10 stated V3 called her daughter and accused R10 of calling V1 a liar. R10 stated she never called V1 a liar and R10 became very upset at V3 for calling her daughter. R10 stated V3 then came to her room as R10 was sitting on her bed facing the window. R10 stated V3 stood in front of R10 and R10 told V3 she didn't want to talk to her. R10 stated she told V3 to get out of her room and R10 put her hands over her ears because she did not want to hear or speak to V3. R10 stated V3 then put her hands over R10's hands and squeezed R10's hands onto her head. R10 stated she removed her hands and then put her fingers in her ears so she could not hear what V3 was saying. R10 stated she then grabbed her purse and threw it back toward the door. V3 continued to try to talk to R10, so R10 got up from the bed, put her Bible in her wheelchair, grabbed her purse, and pushed her wheelchair out of the room. R10 stated V3 continued to yell at her as she left the room. R10 stated she had a signed statement from R12 stating R12 saw V3 go into R10's room and heard V3 yelling at R10. R10 produced a spiral notebook that included an entry from R12 which showed, I [R12] witnessed Social Worker [V3] go into [R10's] room then heard them yelling back and forth. [V3] was yelling at [R10] for reasons unknown. The statement was signed by R12 and dated 4/7/22. On 6/7/22 at 3:18 PM, R10 stated V3 went on and on yelling after R10 told V3 she did not want to talk to her. R10 stated V3 told R10 to shut up. R10 stated V3 kept yelling at R10, so R10 decided to leave her room. R10 stated V3 kept yelling, Stop! I'm not finished talking to you! R10 stated V3 was too loud and R10 felt scared when V3 put her hands over R10's hands and squeezed her ears. R10 stated she told V3 to, 'stop, I got my glasses on! R10 stated V3 was pushing the frame of her glasses into her temples. R10 stated there was nobody around and R10 did not want to be around V3 by herself. R10 stated she was uncomfortable around V3, and she was concerned what would happen when she was alone with V3. R10 stated V3 can come down hard. R10 stated, I was definitely scared. R10 stated, I'm [AGE] years old in a wheelchair and I don't know what can go on. You don't know what will happen when I am alone with her. R10 stated she told V1 (Administrator) she was afraid of V3 and R10 was told to go directly to V1 with any of her concerns. On 6/2/22 at 9:41 AM, V3 stated R10 became very upset during an earlier discussion with V1 and V3 when R10 called V1 a liar. V3 stated she stepped and told R10 it was not nice to call V1 a liar and R10 responded, I'm done f______ with you! R10 then left the area and went to her room. V3 stated she gave R10 approximately an hour (during which time she called R10's daughter) and then walked to R10's room to speak to her again. V3 stated when she spoke to R10 in her room she was standing in the doorway leaning against the back of the wall to the door. V3 stated when she arrived in R10's room, R10 was very angry with V3 for calling her daughter, told V3 to get the f___ away from me, and threw items in her wheelchair. V3 stated she was telling R10 not to act that way and stood in her room as R10 exited the room. V3 stated afterward R10's daughter called and asked why she put her hands on R10 and V3 stated she never put her hands on R10. V3 stated R10 became angry with her because V3 called her daughter first and told her daughter R10 was calling V1 a liar. V3's progress notes, dated 4/7/22, show, Writer approached resident room door and resident was sitting on the bed. Writer stated to resident 'can I explain to you somethings before you get t[too] upset for nothing?' Resident [then] stated 'you call my f______ daughter who are you to call my f______ daughter on me get the f___ out of my room.' Writer stated to resident 'I called your daughter because your daughter is your POA (Power of Attorney) and to make her aware of the conversation that just took place in my office.' Resident continue with the inappropriate tone and language and begin throwing items into her wheelchair that was sitting by the end of her bed. Writer stepped aside and allowed the resident to come out her room Preliminary Incident Investigation Report and Final Incident Investigation Report both fail to show V3 was suspended during the abuse investigation between 4/7/22 and 4/11/22. On 6/2/22 at 4:20 PM, V1 (Administrator) stated he did not suspend V3 during his investigation of alleged abuse toward R10 by V3. Time sheet, dated 4/5/22 - 4/13/22, shows V3 (Social Services Director) was present and working daily at the facility from 4/8/22 - 4/11/22 during the duration of the abuse investigation of R10. On 6/9/22 at 10:31 AM, V16 (Consultant) stated V3 was responsible for social services provided to all residents residing in the facility. On 6/8/22 at 10:10 AM, V15 (Physician) stated his expectation for the facility was that any staff alleged to have perpetrated abuse should be suspended during the abuse investigation until the investigation is concluded. Facility Abuse Prevention Program, dated 2/2017, shows .Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee will not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property is unsubstantiated 2. On 6/2/22 at 1:07 PM, R10 stated she told V1 that she had a written witness statement from R12 in her notebook in her room, but she did not think V1 interviewed R12 during his abuse investigation. R10 produced a notebook with a signed witness statement from R12 stating he saw V3 walk into R10's room and heard V3 and R10 yelling while they were in the room. R10 stated she informed V1 that R12 witnessed the argument and alleged abuse between V3 and R10. MDS, dated [DATE], shows R12's cognition was moderately impaired. On 6/2/22, R12 stated he saw V3 walk into R10's room but was unsure how far into the room V3 walked. R12 stated R10 and V3 were bickering and loud talking. R12 stated he could not see if V3 touched R10. Preliminary Incident Investigation Report and Final Incident Investigation Report both fail to show V1 interviewed R12 as a potential witness to the alleged abuse being investigated. On 6/1/22 at 4:20 PM, V1 (Administrator) stated he could not recall why he did not interview R12 during his abuse investigation. V1 stated he was aware R10 stated R12 witnessed the alleged abuse incident, however V1 failed to interview R12 for reasons he could not remember. On 6/8/22 at 10:10 AM, V15 (Physician) stated his expectation was that all known witnesses to an abuse allegation should be interviewed during an abuse investigation. Abuse Prevention Program, dated 2/2017, shows .4. Investigation Procedures. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable The IJ that began on 4/7/22 was removed on 6/10/22 when the facility took the following actions to remove the immediacy: 1. All allegations of abuse will be investigated in accordance with the Facility Abuse Investigation Policy. The facility will follow its abuse investigation policy. Any person who is accused of perpetrating abuse will be immediately suspended from the schedule and will remain suspended from the schedule throughout the duration of the investigation. All allegations of abuse will be reported immediately in accordance with facility policy. All witnesses to the alleged abuse will be identified as soon as possible and interviewed in accordance with facility policy 2. The administrator who conducted the investigation no longer works at the facility. 3. On 6/9/22 inservices were held with facility staff. All staff will be inserviced prior to working their shift. Vice President of Quality Assurance / RN (Registered Nurse) or her designee will conduct inservices. Inservices will include: a. A review of the requirement that all residents are to be free from abuse, neglect or misappropriation of property b. A review of the facility's policies on abuse investigation and each staff member's role (All staff must report all allegations of abuse immediately to the Administrator whose number is posted at the time clock and the front office. In the event the Administrator is not available, the Director of Nursing must be informed of any allegations of abuse. For allegations of abuse that occur during the 2-11 or 11-7 shifts, the charge nurse must send the staff who is accused of perpetrating abuse home immediately and inform the Administrator and/or DON.) c. All agency staff and volunteers will be inserviced by the DON and/or designee on the Facility Abuse Policy prior to working a shift and must sign that the inservice was conducted. 4. The DON and/or designee will perform a QA (Quality Assurance) study including random spot checks on 2 staff per shift weekly for three months and based on QA results. The random QA study will include at a minimum a Charge Nurse and Agency staff weekly. Follow up will be determined for further need for a continued QA study and additional inservice training. 5. A QA study will be conducted after each allegation of Abuse. The QA Committee will meet weekly for the next three months to review interim Administrator's action with respect to such allegations and/or reports. 6. An Emergency QAPI (Quality Assurance and Performance Improvement) was conducted on 6/9/22 at 4:00 PM. 7. The interim Abuse Coordinator's and DON's phone numbers were posted on a sign at the time clock and front office in the event of the administrator's absence.

Based on interview and record review, the facility failed ensure a resident was free from mental/verbal abuse. These failures resulted in psychosocial harm expressed as fearfulness when discussing an incident when staff yelled at her (R10). This applies to 1 of 4 residents (R10) reviewed for abuse in a sample of 15. The findings include: Face sheet, printed on 6/1/22, shows R10 was admitted to the facility on [DATE]. R10's diagnoses included acute [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)] with exacerbation, acute diastolic congestive heart failure, hypertension, Type 2 diabetes mellitus, anxiety disorder, [CONDITION(S)], peripheral vascular disease, [CONDITION(S)], and history of falling. MDS (Minimum Data Set), dated 4/20/22, shows R10's cognition was moderately impaired. On 6/2/21 at 1:07 PM, R10 stated on 4/7/22 she began discussing a problem regarding her wheelchair with V1 (Administrator) when V3 (Social Services Director) involved herself in the discussion after R10 told V1, I'll believe it when I see it. R10 stated V3 began arguing with R10 accusing R10 of calling V1 a liar. R10 stated she became upset, removed herself from the office, and went to her room. R10 stated when she got to her room, she received a call from her daughter asking why she called V1 a liar. R10 stated V3 called her daughter and accused R10 of calling V1 a liar. R10 stated she never called V1 a liar and R10 became very upset at V3 for calling her daughter. R10 stated V3 then came to her room as R10 was sitting on her bed facing the window. R10 stated V3 stood in front of R10 and R10 told V3 she didn't want to talk to her. R10 stated she told V3 to get out of her room and R10 put her hands over her ears because she did not want to hear or speak to V3. R10 stated V3 then put her hands over R10's hands and squeezed R10's hands onto her head. R10 stated she removed her hands and then put her fingers in her ears so she could not hear what V3 was saying. R10 stated she then grabbed her purse and threw it back toward the door. V3 continued to try to talk to R10 so R10 got up from the bed, put her Bible in her wheelchair, grabbed her purse, and pushed her wheelchair out of the room. R10 stated V3 continued to yell at her as she left the room. R10 stated she had a signed statement from R12 stating R12 saw V3 go into R10's room and heard V3 yelling at R10. R10 produced a spiral notebook that included an entry from R12 which showed, I [R12] witnessed Social Worker [V3] go into [R10's] room then heard them yelling back and forth. [V3] was yelling at [R10] for reasons unknown. The statement was signed by R12 and dated 4/7/22. MDS, dated [DATE], shows R12's cognition was moderately impaired. On 6/2/22, R12 stated he saw V3 walk into R10's room but was unsure how far into the room V3 walked. R12 stated R10 and V3 were bickering and loud talking. R12 stated he could not see if V3 touched R10. On 6/7/22 at 3:18 PM, R10 stated V3 went on and on yelling after R10 told V3 she did not want to talk to her. R10 stated V3 told R10 to shut up. R10 stated V3 kept yelling at R10, so R10 decided to leave her room. R10 stated V3 kept yelling, Stop! I'm not finished talking to you! R10 stated V3 was too loud and R10 felt scared when V3 put her hands over R10's hands and squeezed her ears. R10 stated she told V3 to, 'stop, I got my glasses on! R10 stated V3 was pushing the frame of her glasses into her temples. R10 stated there was nobody around and R10 did not want to be around V3 by herself. R10 stated she was uncomfortable around V3 and she was concerned what would happen when she was alone with V3. R10 stated V3 can come down hard. R10 stated, I was definitely scared. R10 stated, I'm [AGE] years old in a wheelchair and I don't know what can go on. You don't know what will happen when I am alone with her. R10 stated she told V1 (Administrator) she was afraid of V3 and R10 was told to go directly to V1 with any of her concerns. On 6/2/22 at 9:41 AM, V3 stated R10 became very upset during an earlier discussion with V1 and V3 when R10 called V1 a liar. V3 stated she stepped and told R10 it was not nice to call V1 a liar and R10 responded, I'm done f______ with you! R10 then left the area and went to her room. V3 stated she gave R10 approximately an hour (during which time she called R10's daughter) and then walked to R10's room to speak to her again. V3 stated when she spoke to R10 in her room she was standing in the doorway leaning against the back of the wall to the door. V3 stated when she arrived in R10's room, R10 was very angry with V3 for calling her daughter, told V3 to get the f___ away from me, and threw items in her wheelchair. V3 stated she was telling R10 not to act that way and stood in her room as R10 exited the room. V3 stated afterward R10's daughter called and asked why she put her hands on R10 and V3 stated she never put her hands on R10. V3 stated R10 became angry with her because V3 called her daughter first and told her daughter R10 was calling V1 a liar. V3's progress notes, dated 4/7/22, show, Writer approached resident room door and resident was sitting on the bed. Writer stated to resident 'can I explain to you somethings before you get t[too] upset for nothing?' Resident [then] stated 'you call my f______ daughter who are you to call my f______ daughter on me get the f___ out of my room.' Writer stated to resident ' I called your daughter because your daughter is your POA (Power of Attorney) and to make her aware of the conversation that just took place in my office.' Resident continue with the inappropriate tone and language and begin throwing items into her wheelchair that was sitting by the end of her bed. Writer stepped aside and allowed the resident to come out her room . Preliminary Incident Investigation Report, faxed to IDPH (Illinois Department of Public Health) on 4/7/22, shows on 4/7/22 R10 alleged a staff member covered R10's ears. The report shows the facility will continue to conduct a complete and thorough investigation until a conclusion is reached. Final Incident Investigation Report, faxed to IDPH on 4/11/22, shows R10 alleged V3 (Social Services Director) put her hands over R10's ears and V3 screamed at R10. The statement shows R10 stated R12 heard the interaction between V3 and R10. During the investigation, R12 was not interviewed. The abuse investigation concluded on 4/10/22 and the allegation was not founded. The final abuse investigation included an interview with R10, dated 4/8/22, which shows R10 reported she did not want anything to do with V3. R10 stated V3 entered her room yelling she wanted to talk to R10. R10 stated V3 kept yelling so R10 covered her ears with her hands. The statement shows V3 then placed her hands over R10's hands and V3 asked, 'Now can you hear?' The statement shows R10 threw her purse toward the door of her room, got up and put the Bible, coffee, and then purse in her wheelchair. The final abuse investigation included a statement from V3, dated 4/8/22, stating after R10 became angry and left V3's office, V3 called R10's daughter and then reapproached R10 in R10's room. The statement by V3 shows V3 was telling R10 not to be upset because there was nothing to be upset about. The statement shows R10 then placed her hands over her ears so she could not hear V3 and V3 stated she replied, [R10] take your hands off your ears, you know we don't do that. V3's statement then shows R10 told V3 to, .get the f___ out of my room. The statement shows V3 continued to engage with R10 attempting to discuss her interaction with R10's daughter. The statement shows R10 then began to throw items in her wheelchair and exited the room with V3 standing in the room. The investigation included a statement signed by V1 and V3 showing V3 has been educated when resident does not want to talk to her, then not to approach resident at the time. On 6/2/22 at 1:07 PM, R10 stated she told V1 that she had a written witness statement from R12 in her notebook in her room, but she did not think V1 interviewed R12 during his abuse investigation. R10 produced a notebook with a signed witness statement from R12 stating he saw V3 walk into R10's room and heard V3 and R10 yelling while they were in the room. R10 stated she informed V1 that R12 witnessed the argument and alleged abuse between V3 and R10. Care plan initiated and effective 4/11/22 after R10's allegation of abuse on 4/7/22, shows Manipulative Behavior - Resident exhibits manipulative behavior rt (related to) mental illness and maladaptive personality traits. Evidence by making false allegation towards other and involving peer into matters of hers. Advanced Practitioner Nurse progress note, dated 5/19/22, shows no diagnoses of maladaptive personality disorder for R10. R10's psychiatric diagnoses include only [CONDITION(S)] and depression/anxiety. Psychiatrist progress notes, dated 1/7/22, show R10's diagnoses include Major Depressive Disorder and anxiety. No diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility Abuse Prevention Program Policy, dated 2/2017, shows, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to notify the physician and monitor a resident for complications after having to reschedule/postpone hemodialysis due to not being able to set up transportation. This failure resulted in R50 requiring hospitalization and medical interventions including emergent hemodialysis. This applies to 1 of 1 (R50) resident reviewed for hemodialysis. The findings include: R50's EMR (Electronic Medical Record) showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R50's MDS (Minimum Data Set) dated February 26, 2022, showed R50 had moderate cognitive impairment. On April 4, 2022 at 11:33 AM, R50 said the facility arranges transportation for R50 to go to hemodialysis, but reported the facility failed to set up transportation during this past December due to the holiday. On April 6, 2022 at 1:13 PM, V15 (physician) said V15 was not made aware by facility staff that R50's hemodialysis would be delayed six days. V15 said he (V15) was rounding on R50 on December 27, 2021, and noticed R50 did not look well. V15 ordered for R50 to be sent to the hospital. V15 said R50 was hospitalized because of missing hemodialysis. A Consultation Report dated December 28, 2021, by V18 (Nephrologist) showed R50 went to the emergency room because R50 wasn't feeling well and was found to have [CONDITION(S)] (elevated potassium level) and fluid overload. The report showed R50's hemodialysis schedule was Tuesdays, Thursdays, and Saturdays, but R50 missed R50 regular Saturday hemodialysis because of the holiday. R50 was rescheduled for hemodialysis on Sunday, but the facility was unable to provide transportation so R50 missed hemodialysis. R50 started developing a worsening headache and generalized weakness prior to going to the emergency room . The report continued to show that in the emergency room , R50 had low oxygen levels, a potassium level of 7.5 (normal is range 3.5 to 5.5), and had to undergo emergent hemodialysis. After the emergent hemodialysis, R50 was still requiring oxygen and still had an elevated blood pressure of 200/70. R50 required an additional hemodialysis session on December 28, 2021. A Nursing Progress Note dated December 26, 2021 at 10:59 AM, by V14 (RN/Registered Nurse) showed R50's hemodialysis appointment had to be canceled and rescheduled due to transportation issues. V14 spoke with the [CONDITION(S)] center and rescheduled R50's hemodialysis appointment for Wednesday, December 29, 2021. R50 was made aware of the rescheduled hemodialysis appointment and the front office was notified to set up R50's transportation. A Nursing Progress Note dated December 27, 2021 at 3:56 PM, by V14 (RN) showed R50 reported to V14 that R50 wasn't feeling well. V14 responded by telling R50 to go to R50 room to remove one of R50 tops (a fleece jacket and a fleece sweatshirt) as they are too warm to be worn indoors. R50 said to V14 it's probably because I missed [CONDITION(S)]. The progress note did not show V14 assessed R50 or notified a physician. A Nursing Progress Note Dated December 27, 2021 at 11:02 PM, by V3 (LPN/Licensed Practical Nurse) showed R50 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On April 6, 2022 at 2:11 PM, V16 (Receptionist) said V16 is in charge of arranging transportation for residents. V16 said the transportation company used for R50 does not work on Sundays. V16 was not aware of any transportation services available on Sundays. Facility provided documentation regarding R50's hemodialysis schedule which showed R50 receives hemodialysis on Tuesdays, Thursdays, and Saturdays. The document also showed the transportation company does not work on Sundays.

Based on interview and record review the facility failed to prevent misappropriation of a Residents funds, by a staff member, (E5), in June of 2012. This is for one of one resident (R14) reviewed for financial exploitation in a sample of 15. As a result of the facility's failures, R14 suffered added financial exploitation by E5 from June 2012 until August 31, 2012. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on November 29, 2012 and the Immediate Jeopardy was removed on November 29, 2012 while the facility remains out of compliance at a severity level 2. Additional time is needed to monitor the effectiveness of the removal plan. Findings include: E23, (RN/Registered Nurse) signed statement dated August 31, 2012 at 3AM stated " (R14) stated she loaned money to a Certified Nursing Assistant, (CNA/E5). That same CNA, (E5) also used (R14's) debit card, without (R14's) permission. In May 2012 (E5) came to (R14) and asked to borrow money, because she, (E5) was moving and needed money to stay in a hotel. (R14) said she gave (E5) $300.00. (R14) said (E5) was going to pay it back when (E5) got her income tax check. E23 asked (R14) if anyone else knew about this. (R14) said yes, (E6/CNA). (R14) said (E6) was in her bedroom with (E5) when (R14) gave (E5) the money. (R14) said the only reason this is coming to light is because her bank notified her of an unusual purchase and overage fees, (from R14's debit card). (R14) said two other people, (E6/CNA and R41), knew about transactions on her debit card. (R14) said (E5) confessed to her, (about using her debit card). (R14) wished (E5) would have told her sooner, because now (R14) is incurring over draft fees in excess of $200.00. (R14) said (E6) knew about this because (E6) told (E5) to admit what she had done to (R14). (R14) said she was worried she would never see the money again. (R14) was also worried that (E5) would be fired. E23, asked (R14) if she had given (E5) permission to use her debit card for personal purchases and (R14) said no. (R14) said (E5) used it, (Debit card) without asking or informing her of what (E5) had done. (R14) said she wouldn't have known about it if the bank didn't make her aware. " On 11-29-2012 at 1:25pm., E23, (RN/Registered Nurse) stated, (R14) couldn't get out. (R14) told (E22/SSD/Social Service Director) in June. E23 reported that she knew this bothered (R14) very much. E23 knew (R14) was very upset; she avoided eye contact, was fumbling with her fingers, and said she was upset, and was afraid that (E5) would be fired and wouldn't pay her back. (R14) and the other residents are on fixed incomes. E23 stated "I was angry. (E5) had taken advantage of (R14). It's despicable. I reported it immediately, (August 31, 2012). " The Preliminary 24-Hour Incident Investigation Report dated, August 31, 2012 contains documentation that R14 is alleging " Financial Exploitation, " by a facility employee, (E5/CNA) in May 2012. This is against Facility and Union Policy. The facility has initiated an investigation. " (The report does not include allegations of the unauthorized employee's use of R14's debit card). E22, (Social Service Director) investigation note dated 8-31-2012 contains documentation that (E5/CNA) "borrowed $500.00 on May 15," from R14. E6, (CNA) ' s 9-5-2012 signed statement documents, " I was on the patio in June, (2012) and (R14) said (E5) owed her money. I told Social Service, (E22) and we both went to talk with (R14) and asked her about what (R14) said. (R14) denied that." On 11-29-2012 at 9:50am., E6, (CNA) stated, " I've worked at the facility, as a CNA, for six years. " E6 affirmed she was trained, at time of hire and in-serviced twice a year, on abuse and neglect. Affirming financial exploitation, of a resident, was abuse. E6 then stated, " (E5/CNA) and I worked together on the same floor of the facility. In June of 2012 (R14) said (E5/CNA) owes me $500.00. (R16 and R41), alert residents, were there. I told (E22/SSD). That day, we went to (R14) and asked about it. (R14) denied it. No concern form or investigation was done. We, as staff, cannot borrow money from residents or family members, it's in the Handbook, Code of Conduct, and is a Union Rule". E6 reported that she, confronted (E5) in June and told her she had to tell (R14) she was using her debit card, without her permission. E6 reported that she told (E5) its grounds for termination." E5 reportedly used (R14 ' s) debit card, for gas, in July 2012 and didn't let (R14) know. E6 further stated, "the facility practice is for resident's, that want to purchase personal items, to let the Activity Director, (E7) know. (E7) goes twice a month to the store, for residents. " E2, (DON/Director of Nursing) ' s August 31, 2012 Investigation signed statement is, " (R14) reported that (E5/CNA) owes her approximately $800.00. This amount was a sum of multiple transactions that (E5) acquired using (R14 ' s) debit card, without her knowledge, as well as $300.00 in overdrafts, as a result of those transactions. " E25, (Administrator/Retired) ' s 9-10-2012 signed investigation report, of R14's second allegation of financial exploitation on 8-31-2012, includes documentation that E6, (CNA) and E22, (SSD) knew about R14's allegation in June of 2012. " 1. (E5/CNA) admitted to taking $235.00 from (R14), in direct violation of Union Rule #15, Resident Rights, and Facility Code of Conduct. 2. Additional witness statements indicate that (E5), also had access to (R14's) debit card. Review of bank statements indicate several questionable purchases on this card including seven in (Name of Town, different from the town facility is in), (E5's) place of residence. 3. (R14' s) family is considering possible legal and/or criminal action regarding the issue. 4. (E5), CNA has been terminated based on investigation results and her own statement of 8-31-2012. " R14's 9-5-2012 Final Investigation Report includes R14's May and June 2012 bank statements. These same bank statements contain documentation that R14 ' s debit card was used 57 times for gasoline purchases, in various Chicago area locations, and not in the city R14 resided in. Additionally, R14 ' s debit card was used for Illinois tolls, game stores, home improvement stores, and restaurants, which do not correspond with R14's documented absences from the facility. E1, (Administrator) on 11-29-2012 at 4:36pm., stated, " We do not allow employees, other than (E7/Activity Director), to shop for residents. So there is a record of the purchase and money spent. This has been the practice of the Facility for the six years I've been here. We did not report (R14 ' s) abuse investigation results to the local authorities. (R14's) family did not want to pursue criminal charges. " SSD, (E22)'s Progress Note of August 31, 2012 is, " (R14) told another aide, (E6) about it. When (E6) told SSD, about it in June, (R14) was approached and stated (E5/CNA) did not borrow any money. " This is the first, and only documented entry, in R14's file, of R14's June 2012 allegation of financial exploitation. On 11-29-2012 at 10:35am., E22, (SSD) affirmed financial exploitation of a resident was abuse, needed to be investigated, and reported to the proper authorities. E22 then stated, " In June (E6/CNA) stated (R14) told her (E5/CNA) owed (R14) money. We, (E6 and E22) did not investigate this or fill out any Concern Forms. I didn ' t hear about (R14's) debit card until August 31, 2012. I guess that's when I first documented it. I did not ask the other residents, (R16 and R41) that were on the patio, in June when (E6) overheard (R14) talking about it. I, (E22) didn ' t ask (E5/CNA) about it. I, (E22) assisted with (R14's) August 31, 2012 Investigation. " E22 verbalized that the local authorities were not notified of (R14's) financial exploitation allegation because, " (R14 ' s) family member did not want to press charges. " In-Service Record of April 6, 2012 contains documentation that E22, (SSD) assisted in the training of facility staff on " Reporting Suspicion of a Crime Policy. " On 11-29-2012 at 12:10pm., R41 stated, " (R14) told me (E5/CNA) borrowed money from her. (R14) didn ' t know what to do, because if (R14) told administration (E5) might be fired, and might not be able to pay her back. (E14) told me everything. I know (R14) was upset because it's all she talked about. (E6/CNA) and (E5/CNA) were best friends. I heard (R14) ask (E6) to call (E5) from her cell phone, several times, because (E5) wouldn ' t answer her phone to (R14 ' s) number. (E6) would call (E5) and hand her phone to (R14). I saw this happen. (R14) told (E5) she needed the money. I never talked to the Administrator about it, just (E22/SSD). (E5) didn't have (R14's) permission to use her debit card. Other residents knew about it. I know (R31) did. (R14) was upset and talked about it all the time and how she couldn't buy stuff. (E5) was always doing stuff in (R14's) room, like straightening out her closet. I knew about it for awhile, a couple of months. " On 11-29-2012, at 12:56pm. R31, stated, " A lot of residents knew (E5/CNA) owed (R14) money. (E6/CNA) knew. (R14) was upset because she trusted (E5). (E5) used (R14 ' s) debit card. In July (R14) told me (E5) owed her money. I know (R30) knows about it. " On 11-29-2012 at 1:05pm., R30 stated, " (R14) told me (E5/CNA) owed her $706.00 from (E5) borrowing and debit use, with charges. I knew it for half a year. (R14) talked about it a lot and worried about it. (R14) didn ' t know what to do. " E5, (CNA)'s personnel file includes signed affirmation that E5 " received, read, and understood the " Abuse Prevention, Employee Code of Conduct, and Resident Rights Policies and Procedures." As a result of the facility's failure an Immediate Jeopardy was identified to have begun on May 15th, 2012 when the first documented incidents of R14's financial exploitation by E5, (CNA) occurred. Financial exploitation of R14, by E5, continued through August 31, 2012. On 11-29-2012 at 4:36pm., E1, (Administrator) was informed of the Immediate Jeopardy. The facility took the following actions to remove the Immediate Jeopardy: " Removal of Immediacy Plan: Initiated on 11-29-2012 " 1." Corrective Action for Residents identified in Deficiency: Allegations investigated and reported to local authorities. " 2." Identify other residents with potential for being affected and corrective actions: The Administrator will review and revise, with input from the Quality Assurance committee, its policies and procedures annually on abuse and neglect. Alert and orientated residents will be interviewed monthly. " 3." Systemic changes to reasonably assure the deficiency does not recur: In-service staff on prevention of abuse, neglect, misappropriation of property will be initiated with all staff on 11-29-2012." 4." How corrective action will be monitored: The administrator or director of nursing will review all reports of unusual occurrences, abuse, neglect, and misappropriation of property."

A. Based on interview and record review the facility failed to operationalize their policy to thoroughly and immediately investigate all allegations of possible misappropriation of resident's finance and failed to protect residents from further misappropriation of their personal finances for one of one residents (R14) reviewed for financial exploitation in the sample of 15. The facility failed to investigate R14's allegation that E5/Certified Nursing Assistant (CNA) "owed" her $500. R14 suffered emotional distress and continued financial exploitation from May 15, 2012-August 31, 2012. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 11/30/12, the facility remains out of compliance at a severity level two as additional time is needed to monitor the effectiveness of the inservices provided to staff and the implementation of policies and procedures related to investigation of misappropriation of resident finances. Findings include: On 11/28/12 at 9:10 a.m. E1 (Administrator) and E3 (Quality Assurance Vice President) provided the facility's entire Abuse Prevention Program Policy and Procedures dated 1999. Both E1 and E3 affirmed that this was the facility's entire Policy and Procedure for Abuse. This policy directs staff to "Follow the Resident Protection Investigation Procedures." These investigation procedures repeatedly, in bold print, direct staff members to implement this procedure "where there is reasonable cause to suspect that willful abuse, neglect, or theft may have occurred." The policy further directs staff to determine whether "willful abuse, neglect, or theft" has occurred and "if it is determined the allegation was because of accidental improper handling, refer the employee for supervisory counseling on the proper care delivery techniques and proceed to the Final Investigation Report." On 11/29/12 at 9:50 a.m., E6 (CNA) stated, "In June 2012 (R14) said that (E5/CNA) owes me $500. Alert residents (R16 and R41) were there. I told (E22/Social Service Director/SSD). that day we went to (R14) and asked about it (the allegation). (R14) denied it. No Concern Form or investigation was done. I confronted (E5/CNA) in June and told her she had to tell (R14) that she (E5) was using (R14's) debit card without her permission." E23/Registered Nurse (RN) stated on 11/29/12 at 1:25 p.m., "On August 31, 2012 (R14) stated she borrowed money to (E5/CNA) in May 2012 and (E5) used (R14's) debit card without her permission. (R14) told (E22/SSD) in June. I know this bothered (R14) very much. I knew (R14) was upset; she avoided eye contact, was fumbling with her fingers, and said she was upset, and was afraid (E5) would be fired and wouldn't pay her back. I reported it immediately (same day)." Final Investigation Report for R14 dated 9/5/12 includes R14's bank statements for May and June 2012. These bank statements document that R14's debit card was used 57 times for gasoline purchases in various Chicago area locations there were not R14's residence city. These statements also document that R14's debit card was used for Illinois tolls, game store, home improvement stores, and restaurant purchases. The purchase dates on these debits do not correspond with R14's documented absences from the facility. Social Service Progress Note dated 8/31/12 documents "(R14) told another aide (E6) about it. When (E6) told SSD about it (money not paid back) in June, (R14) was approached and stated (E5) did not borrow any money." E22/SSD's Progress Note dated 8/31/12 is the first and only documented entry in R14's file for the June 2012 allegation of financial exploitation. On 11/29/12 at 10:35 a.m., E22 affirmed that financial exploitation of a resident was abuse, that it needed to be investigated and reported to the proper authorities. E22 then stated "In June (E6/CNA) stated that (R14) told her that (E5/CNA) owed (R14) money. We (E6 and E22) did not investigate this or fill out any Concern Forms. I didn't hear about (R14's) debit card until August 31, 2012. I guess that's when I first documented it. I did not ask the other residents (R16 and R41) who were on the patio in June when (E6) overheard (R14) talking about it. I didn't ask E5 (alleged perpetrator) about it. I assisted with (R14's) August 31,2012 investigation." During this same interview, E22 verbalized that the local authorities were not notified of (R14's) financial exploitation allegation because "(R14's) family member did not want to press charges." In-Service Record dated 4/6/2012 contains documentation that E22/SSD assisted in the training of facility staff on "Reporting Suspicion of a Crime Policy." The Immediate Jeopardy was identified on 11/29/12. The Immediate Jeopardy was determined to have begun on May 15, 2012 when facility staff (E5) made the first unauthorized debit on R14's debit card account. E1/Administrator was informed of the Immediate Jeopardy on 11/29/12 at 4:30 p.m. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Corrective Action for Residents identified in Deficiency--allegations investigated and reported to local authorities. 2. The Administrator will review and revise, with input from the Quality Assurance committee, its policies and procedures annually on abuse and neglect. Alert and oriented residents will be interviewed monthly. 3. In-service staff on prevention of abuse, neglect, misappropriation of property will be initiated with all staff on 11/29/12. 4. Administrator or Director of Nursing will review all reports of unusual occurrences, abuse, neglect, and misappropriation of property. B. Second Area of Noncompliance--Not cited at Immediate Jeopardy Level Based on interview and record review, the facility failed to thoroughly investigate and immediately report all allegations of staff mistreatment of [REDACTED]. These failures affected two of fifteen residents (R14, R17) reviewed for abuse in the sample of fifteen and eight residents in the supplemental sample. Findings include: 1. During the resident group interview on 11/27/12 at 10:40 a.m., R28 reported an allegation of staff mistreatment by E27/Licensed Practical Nurse/LPN. According to R28, the incident occurred "a couple of weeks ago" and was reported to E23/LPN. R28 alleged that E27 threatened to withhold medication and cursed at R28. According to R28, "(E23) didn't do anything about it. (E23) said for me to talk to (E27) about it. I just avoid (E27). R31 stated during this same meeting "(E27) thinks all ambulatory residents should come to him for their medications." E23/LPN stated on 11/28/12 at 2:25 p.m. (R28) came to me "alleging staff mistreatment by (E27) on 11/19/2012. I did not make any notes. I did not fill out a Concern Form. I didn't report it to anyone. I didn't ask (R28) about it again. I didn't realize I had to report it." 2. E26/LPN's signed statement dated 7/20/12 at 4 a.m. documents "(E10/CNA) started to position (R70) but became aggressive to resident. Nurse stopped (E10) and told him to calm down. (E10's) behavior became out of control and inappropriate." The 7/20/12 Final Incident Investigation Report for this incident includes statement that "Nurse (E26) felt threatened by E10. Abuse did occur. CNA (E10) terminated. The initial and the final notification of the above abuse allegation was not faxed to the State Survey Agency until 1:48 p.m. on 7/20/12. E1/Administrator and E3/Quality Assurance Vice President stated on 11/27/12 at 2:10 p.m. "(E10/CNA) was sent home on 7/20/12." E10's time card for 7/20/12 documents that E10 completed his shift and went home at 6:56 a.m. E1 and E3 could not explain the delay in reporting the incident to the State Agency or why E10 was not immediately removed from providing direct care. 3. Preliminary 24-hour Incident Investigation Report for R55 contains documentation that R55 "on 10/30/12 at 7:05 p.m. reported to the nurse (E20) that another resident slapped (R55) in the face." Final Incident Investigation Report dated 11/15/12 consisted of interviews with two Certified Nursing Assistants (E18 and E28). E18 was not on the same floor of the facility when the incident occurred. No further investigation information could be provided. E1/Administrator stated on 11/27/12 at 2:30 p.m., "This was prior to my administration. You have (R55's) complete allegation of abuse investigation." On 11/27/12 at 3:40 p.m. E1/Administrator and E3/Quality Assurance Vice President were informed of the above information. An investigation was initiated. 4. Document entitled "Description of Skin Tear/Bruise" for R54 dated 4/27/12 at 2:30 p.m. documents "right inner thigh measured 3 cm (centimeters) by 1 cm." "Description of Skin Tear/Bruise" for R53 on 6/22/12 notes "is ecchymotic (black and blue area resulting from a bruise), area to inner aspect of right eye." R67's "Description of Skin Tear/Bruise" is "Left shoulder abrasion measures 2 cm by 2 cm. Left forehead bump is 8 cm by 8 cm." "Description of Skin Tear/Bruise" for R27 documents on 4/9/12 at 10 a.m. "abrasion to right parietal side of head." On 12/5/12 at 9:45 a.m. E2/Director of Nursing stated, "We did not do an investigation of potential abuse and therefore did not report to the State Survey Agency injuries of unknown origin for (R27, R53, R54, and R67). The Abuse Program Policy dated 1999 does not include information regarding the investigation of suspicious injures which are not witnessed and cannot be explained by the resident. These policies do not direct employees to report all allegations to the Administrator and do not document that all allegations will be investigated. 5. Portions of The Abuse Program Policy dated 1999 also document: "Reporting Requirements and Identification of Allegations: Employees are required to report any occurrences...to a Supervisor or the Administrator... Internal Investigation of Allegations and Response: Appointing an Investigator: Once the Administrator or designee determines that there is a reasonable cause for possible mistreatment, the Administrator or designee will appoint a person to take charge of the investigation. External Reporting of Potential Abuse: Initial, Reporting of Allegations: If during the course of an incident investigation, the administrator or designee has determined that there is reasonable cause to suspect mistreatment has occurred, the resident's representative and the Department of Public Health shall be informed immediately. Five Day Final Investigation Report: For the protection of individuals involved, copies of any internal reports, interviews and witness statements during the course of the investigation shall be released only with the permission of the administrator or the facility attorney. Informing Law Enforcement Authorities: If there is clear evidence of abuse by an employee...The Department of Public Health will also notify the State Police, for further investigation of the employee. Depending on the seriousness of the incident and the present evidence, the administrator may also notify the local police. Pre-Employment Screening of Potential Employees: File an Illinois State Police healthcare Worker Background Check application, )live-scan fingerprint check) for a Certified Nurse Aide Position." The facility failed to follow this policy for several residents. The Preliminary 24 hour Incident Investigation Report documents that on 4/22/12 at 11 p.m., R71 stated "male staff member (E29/CNA) kissed her on the lips, forehead, and cheek. Staff member (E29) has been suspended and local police department called. This Investigation Report was faxed to the State Survey Agency on 4/23/12 at 11:20 a.m. (a delay of 12 hours after the incident was reported). On 11/27/12 at 2:10 p.m. E1/Administrator and E3/Quality Assurance Vice President could not provide any information regarding the delay in notification of the State. The Preliminary 24 hour Incident Investigation Report for R17 documents that R17 reported on 3/21/12 at 8 p.m. that "she had been hit by someone." The Final Incident Investigation Report dated 3/26/12 states "According to (R17's) family, (R17) has a previous history of multiple accusations, which are found to be false accusations. There were no witnesses ' to the accusation." No further investigation information was provided. E5/CNA's undated Employee Report documents "Discharge. Date of incident 8/31/12. (E5) took money from (R14)." E22/SSD and E6/CNA were aware of R14's allegations of financial exploitation in May, yet E5 continued to be allowed to work until 8/31/12. On 11/28/12 at 4 p.m. E2/Director of Nursing stated E27/LPN was being suspended, pending R28's abuse allegation investigation. On 11/28/12 at 2:25 p.m., E23/LPN affirmed R28 has alleged mistreatment by E27 on 11/19/12 ( nine days earlier). E1/Administrator signed statement dated 12/12/12 at 10:54 a.m. documents "(E5/CNA's) date of hire was 1/19/10. An Illinois State Police live-scan fingerprint check was not completed on (E5)."

A. Based on interview and record review the facility failed to operationalize their policy to thoroughly and immediately investigate all allegations of possible misappropriation of resident's finance and failed to protect residents from further misappropriation of their personal finances for one of one residents (R14) reviewed for financial exploitation in the sample of 15. The facility failed to investigate R14's allegation that E5/Certified Nursing Assistant (CNA) "owed" her $500. R14 suffered emotional distress and continued financial exploitation from May 15, 2012-August 31, 2012. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 11/30/12, the facility remains out of compliance at a severity level two as additional time is needed to monitor the effectiveness of the inservices provided to staff and the implementation of policies and procedures related to investigation of misappropriation of resident finances. Findings include: On 11/28/12 at 9:10 a.m. E1 (Administrator) and E3 (Quality Assurance Vice President) provided the facility's entire Abuse Prevention Program Policy and Procedures dated 1999. Both E1 and E3 affirmed that this was the facility's entire Policy and Procedure for Abuse. This policy directs staff to "Follow the Resident Protection Investigation Procedures." These investigation procedures repeatedly, in bold print, direct staff members to implement this procedure "where there is reasonable cause to suspect that willful abuse, neglect, or theft may have occurred." The policy further directs staff to determine whether "willful abuse, neglect, or theft" has occurred and "if it is determined the allegation was because of accidental improper handling, refer the employee for supervisory counseling on the proper care delivery techniques and proceed to the Final Investigation Report." On 11/29/12 at 9:50 a.m., E6 (CNA) stated, "In June 2012 (R14) said that (E5/CNA) owes me $500. Alert residents (R16 and R41) were there. I told (E22/Social Service Director/SSD). that day we went to (R14) and asked about it (the allegation). (R14) denied it. No Concern Form or investigation was done. I confronted (E5/CNA) in June and told her she had to tell (R14) that she (E5) was using (R14's) debit card without her permission." E23/Registered Nurse (RN) stated on 11/29/12 at 1:25 p.m., "On August 31, 2012 (R14) stated she borrowed money to (E5/CNA) in May 2012 and (E5) used (R14's) debit card without her permission. (R14) told (E22/SSD) in June. I know this bothered (R14) very much. I knew (R14) was upset; she avoided eye contact, was fumbling with her fingers, and said she was upset, and was afraid (E5) would be fired and wouldn't pay her back. I reported it immediately (same day)." Final Investigation Report for R14 dated 9/5/12 includes R14's bank statements for May and June 2012. These bank statements document that R14's debit card was used 57 times for gasoline purchases in various Chicago area locations there were not R14's residence city. These statements also document that R14's debit card was used for Illinois tolls, game store, home improvement stores, and restaurant purchases. The purchase dates on these debits do not correspond with R14's documented absences from the facility. Social Service Progress Note dated 8/31/12 documents "(R14) told another aide (E6) about it. When (E6) told SSD about it (money not paid back) in June, (R14) was approached and stated (E5) did not borrow any money." E22/SSD's Progress Note dated 8/31/12 is the first and only documented entry in R14's file for the June 2012 allegation of financial exploitation. On 11/29/12 at 10:35 a.m., E22 affirmed that financial exploitation of a resident was abuse, that it needed to be investigated and reported to the proper authorities. E22 then stated "In June (E6/CNA) stated that (R14) told her that (E5/CNA) owed (R14) money. We (E6 and E22) did not investigate this or fill out any Concern Forms. I didn't hear about (R14's) debit card until August 31, 2012. I guess that's when I first documented it. I did not ask the other residents (R16 and R41) who were on the patio in June when (E6) overheard (R14) talking about it. I didn't ask E5 (alleged perpetrator) about it. I assisted with (R14's) August 31,2012 investigation." During this same interview, E22 verbalized that the local authorities were not notified of (R14's) financial exploitation allegation because "(R14's) family member did not want to press charges." In-Service Record dated 4/6/2012 contains documentation that E22/SSD assisted in the training of facility staff on "Reporting Suspicion of a Crime Policy." The Immediate Jeopardy was identified on 11/29/12. The Immediate Jeopardy was determined to have begun on May 15, 2012 when facility staff (E5) made the first unauthorized debit on R14's debit card account. E1/Administrator was informed of the Immediate Jeopardy on 11/29/12 at 4:30 p.m. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Corrective Action for Residents identified in Deficiency--allegations investigated and reported to local authorities. 2. The Administrator will review and revise, with input from the Quality Assurance committee, its policies and procedures annually on abuse and neglect. Alert and oriented residents will be interviewed monthly. 3. In-service staff on prevention of abuse, neglect, misappropriation of property will be initiated with all staff on 11/29/12. 4. Administrator or Director of Nursing will review all reports of unusual occurrences, abuse, neglect, and misappropriation of property. B. Second Area of Noncompliance--Not cited at Immediate Jeopardy Level Based on interview and record review, the facility failed to thoroughly investigate and immediately report all allegations of staff mistreatment of [REDACTED]. These failures affected two of fifteen residents (R14, R17) reviewed for abuse in the sample of fifteen and eight residents in the supplemental sample. Findings include: 1. During the resident group interview on 11/27/12 at 10:40 a.m., R28 reported an allegation of staff mistreatment by E27/Licensed Practical Nurse/LPN. According to R28, the incident occurred "a couple of weeks ago" and was reported to E23/LPN. R28 alleged that E27 threatened to withhold medication and cursed at R28. According to R28, "(E23) didn't do anything about it. (E23) said for me to talk to (E27) about it. I just avoid (E27). R31 stated during this same meeting "(E27) thinks all ambulatory residents should come to him for their medications." E23/LPN stated on 11/28/12 at 2:25 p.m. (R28) came to me "alleging staff mistreatment by (E27) on 11/19/2012. I did not make any notes. I did not fill out a Concern Form. I didn't report it to anyone. I didn't ask (R28) about it again. I didn't realize I had to report it." 2. E26/LPN's signed statement dated 7/20/12 at 4 a.m. documents "(E10/CNA) started to position (R70) but became aggressive to resident. Nurse stopped (E10) and told him to calm down. (E10's) behavior became out of control and inappropriate." The 7/20/12 Final Incident Investigation Report for this incident includes statement that "Nurse (E26) felt threatened by E10. Abuse did occur. CNA (E10) terminated. The initial and the final notification of the above abuse allegation was not faxed to the State Survey Agency until 1:48 p.m. on 7/20/12. E1/Administrator and E3/Quality Assurance Vice President stated on 11/27/12 at 2:10 p.m. "(E10/CNA) was sent home on 7/20/12." E10's time card for 7/20/12 documents that E10 completed his shift and went home at 6:56 a.m. E1 and E3 could not explain the delay in reporting the incident to the State Agency or why E10 was not immediately removed from providing direct care. 3. Preliminary 24-hour Incident Investigation Report for R55 contains documentation that R55 "on 10/30/12 at 7:05 p.m. reported to the nurse (E20) that another resident slapped (R55) in the face." Final Incident Investigation Report dated 11/15/12 consisted of interviews with two Certified Nursing Assistants (E18 and E28). E18 was not on the same floor of the facility when the incident occurred. No further investigation information could be provided. E1/Administrator stated on 11/27/12 at 2:30 p.m., "This was prior to my administration. You have (R55's) complete allegation of abuse investigation." On 11/27/12 at 3:40 p.m. E1/Administrator and E3/Quality Assurance Vice President were informed of the above information. An investigation was initiated. 4. Document entitled "Description of Skin Tear/Bruise" for R54 dated 4/27/12 at 2:30 p.m. documents "right inner thigh measured 3 cm (centimeters) by 1 cm." "Description of Skin Tear/Bruise" for R53 on 6/22/12 notes "is ecchymotic (black and blue area resulting from a bruise), area to inner aspect of right eye." R67's "Description of Skin Tear/Bruise" is "Left shoulder abrasion measures 2 cm by 2 cm. Left forehead bump is 8 cm by 8 cm." "Description of Skin Tear/Bruise" for R27 documents on 4/9/12 at 10 a.m. "abrasion to right parietal side of head." On 12/5/12 at 9:45 a.m. E2/Director of Nursing stated, "We did not do an investigation of potential abuse and therefore did not report to the State Survey Agency injuries of unknown origin for (R27, R53, R54, and R67). The Abuse Program Policy dated 1999 does not include information regarding the investigation of suspicious injures which are not witnessed and cannot be explained by the resident. These policies do not direct employees to report all allegations to the Administrator and do not document that all allegations will be investigated. 5. Portions of The Abuse Program Policy dated 1999 also document: "Reporting Requirements and Identification of Allegations: Employees are required to report any occurrences...to a Supervisor or the Administrator... Internal Investigation of Allegations and Response: Appointing an Investigator: Once the Administrator or designee determines that there is a reasonable cause for possible mistreatment, the Administrator or designee will appoint a person to take charge of the investigation. External Reporting of Potential Abuse: Initial, Reporting of Allegations: If during the course of an incident investigation, the administrator or designee has determined that there is reasonable cause to suspect mistreatment has occurred, the resident's representative and the Department of Public Health shall be informed immediately. Five Day Final Investigation Report: For the protection of individuals involved, copies of any internal reports, interviews and witness statements during the course of the investigation shall be released only with the permission of the administrator or the facility attorney. Informing Law Enforcement Authorities: If there is clear evidence of abuse by an employee...The Department of Public Health will also notify the State Police, for further investigation of the employee. Depending on the seriousness of the incident and the present evidence, the administrator may also notify the local police. Pre-Employment Screening of Potential Employees: File an Illinois State Police healthcare Worker Background Check application, )live-scan fingerprint check) for a Certified Nurse Aide Position." The facility failed to follow this policy for several residents. The Preliminary 24 hour Incident Investigation Report documents that on 4/22/12 at 11 p.m., R71 stated "male staff member (E29/CNA) kissed her on the lips, forehead, and cheek. Staff member (E29) has been suspended and local police department called. This Investigation Report was faxed to the State Survey Agency on 4/23/12 at 11:20 a.m. (a delay of 12 hours after the incident was reported). On 11/27/12 at 2:10 p.m. E1/Administrator and E3/Quality Assurance Vice President could not provide any information regarding the delay in notification of the State. The Preliminary 24 hour Incident Investigation Report for R17 documents that R17 reported on 3/21/12 at 8 p.m. that "she had been hit by someone." The Final Incident Investigation Report dated 3/26/12 states "According to (R17's) family, (R17) has a previous history of multiple accusations, which are found to be false accusations. There were no witnesses ' to the accusation." No further investigation information was provided. E5/CNA's undated Employee Report documents "Discharge. Date of incident 8/31/12. (E5) took money from (R14)." E22/SSD and E6/CNA were aware of R14's allegations of financial exploitation in May, yet E5 continued to be allowed to work until 8/31/12. On 11/28/12 at 4 p.m. E2/Director of Nursing stated E27/LPN was being suspended, pending R28's abuse allegation investigation. On 11/28/12 at 2:25 p.m., E23/LPN affirmed R28 has alleged mistreatment by E27 on 11/19/12 ( nine days earlier). E1/Administrator signed statement dated 12/12/12 at 10:54 a.m. documents "(E5/CNA's) date of hire was 1/19/10. An Illinois State Police live-scan fingerprint check was not completed on (E5)."

Based on observation, interview and record review, the facility failed to implement interventions to prevent development of pressure ulcer. The facility also failed to apply appropriate pressure ulcer treatment as ordered by the physician. This resulted in 1 resident (R11) developing a stage II pressure ulcer to the left buttocks. This applies to 3 of 3 residents (R11, R3, R7) reviewed for pressure ulcers in the sample of 15. Findings include: 1. During initial tour on 11/26/12 at 9:45 AM, R11 was observed sitting up on the specialty high back chair in the bedroom. R11 stated that her "behind" (coccyx) is sore. R11 said that she has been up since breakfast. At 12:00 PM, R11 was observed still sitting up in the chair by the dining room hallway waiting for lunch meal. There was no attempt from the staff to reposition R11 while in the chair. On 11/27/12, R11 was observed up in the chair from 8:30 AM for breakfast. At 10:00 AM, R11 was observed sleeping in the chair outside of the bedroom. There was no attempt from staff to reposition R11. At 11:15 AM, R11 was observed in the dining room hallway sitting in the chair waiting for lunch. R11 said that she has up in the chair since breakfast. On 11/28/12 at 10:15 AM, while E13 (Certified Nursing Assistant) was providing incontinence care to R11, a round yellowish opened wound was observed at the left buttock. E13 did not see the open sore until asked by the surveyor. E13 stated she has not seen that wound before. At 10:30 AM, E21 (Treatment Nurse) came after being informed of the observation. E21 said that the left buttock sore healed on 11/7/12 but now reopened. E21 further said that the wound has slough and will call the Wound Specialist for treatment order. A review of R11's nurses notes dated 11/28/12, no time documented, stated the dimensions of the stage II pressure ulcer on R11's left buttocks was 1.0 X 0.8 X 0.1 centimeters. The review of the record indicated that R11 was admitted on [DATE] with [DIAGNOSES REDACTED]. The initial Braden Scale score indicated high risk for skin breakdown. R11 was alert & oriented X 3. Nursing Admission Record reflected the following : 1) Stage II Left buttock with open area but healed on 11/7/12; 2) Stage II Right buttock open sore; 3) Stage II Right elbow; 4) Right inner thigh sore. The current care plan documented the following interventions: 1) Positioning/ Turning every 2 hours; 2) Daily skin check and document weekly . These interventions were not followed according to observations made on 11/26/12 and 11/27/12, and as evidenced by reopening of the healed left buttock sore. 2. On 11/28/12 at 10:30 AM during pressure wound dressing observation, E14 (Licensed Practical Nurse) removed the old rolled gauze dressing from R7's right foot. There were 2 open areas (upper lateral aspect & distal plantar) observed but only the upper lateral aspect had the dressing on. E14 cleansed and applied treatment to the upper sore and proceeded to wrap the foot. When asked if the distal sore was supposed to be treated, E14 proceeded to cleanse the area and applied santyl ointment and covered with foam dressing. E14 then wrapped the right foot with rolled gauze. E14 was not sure what treatment was ordered for the right distal plantar sore during interview on 11/28/12 at 10:40 AM. Review of the current POS (Physician order [REDACTED]. 3. R3 is a [AGE] year old resident admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of facility records, including physician orders [REDACTED]. A physician's orders [REDACTED]. On 11/27/12 at approximately 2:30 PM, R3 was observed while incontinence care was being provided by one of the facility's Certified Nurse's Aides ( E6). During incontinence care it was noted that there was no wound dressing covering R3's wound. On 11/28/12 at between 11:00 and 12:00 PM the facility's Quality Assurance nurse (E21) was accompanied to observed R3's left buttock wound. Upon observation it was again noted that there was no dressing covering R3's wound. E21 stated that she wasn't sure why R3 had no dressing on his wound. She stated that maybe it came off during an episode of incontinence or that it may have never been put on. On 11/28/12 at approximately 12:00 PM, E6 stated that she was assigned to care for R3 for the day (11/28/12), but did not see any evidence of a dressing when she performed incontinence care earlier in the shift. E6 stated that she didn't notice that R3 was missing a dressing or she would have informed the nurse. The facility's Incontinence Care policy states that staff are to inspect the resident's skin during incontinence care.

Based on observation, record review and interview the facility failed to ensure that 1 resident identified as high risk for wandering/elopement (R2) was provided with adequate supervision when he eloped from the facility and the alarm system failed to activate. This failure affected R2, with the potential to affect 2 other residents identified by the facility as wanderers, R1 and R3. On 07/13/11 R2 left the building without the alarm system being activated. He was hit and killed by a train a short time later while crossing nearby train tracks. The facility was unaware that R2 had eloped from the facility or why the alarm system failed to activate. This resulted in an Immediate Jeopardy. Although the Immediacy of the situation was removed on 07/19/11 at 4:15 PM the facility remains out of compliance at a level 2 until the effectiveness of the facility's plan of correction can be evaluated. E1 (administrator) was notified by phone of the Immediate Jeopardy on 07/19/11 at 10:00 AM. Findings include: According to the medical record R2 was a [AGE] year old, ambulatory male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Upon admission R2 was assigned a room on the 2nd floor of the 2 story building. A nurses note of 05/08/11 at 6:50 am by E 5, RN (registered nurse night shift) documents that (after admission)R2 was oriented to the smoking rules of the facility, and the time breakfast is served. E 3, (1st floor nurse 3-11 shift) documents on 05/09/11 at 10:15pm, "needs re-direction at all times as resident is forgetful." E5's nurses end of shift note of 05/11/11 at 7:00 am documents the following: Resident wanted to smoke during shift." (night shift)) Nurse explained again regarding-smoking rules, regulation & schedule. Easily re-directed, however forgetful. At 4:20 am front door alarm went off. CNA immediately checked and saw res. (R2) smoking outside. Staff stayed and supervised res. Res was told not to go outside unsupervised. Nurse again explained regarding - smoking rules & regulation. Resident verbalized understanding but resident seemed to be forgetful. E5's end of shift note of 05/14/11 at 7:05 am documents: Resident was seen wandering 3 times during shift. Re-directed several times but seemed forgetful. Needs constant cueing. Resident wants to smoke but was reminded about smoking rules & regulations. E5's end of shift note of 05/17/11 at 7:30am documents : Res was seen wandering on 1st floor several times holding cigarette & lighter. Res was re-directed several times. Res got very mad. At 2:30 am alarm-door was heard by the patio. Staff checked & res attempted to open door to smoke. Res was re-directed per CNA." On 05/19/11 according to Z1's (psychiatrist) evaluation progress note R2 was alert and oriented x 3 with some periods of forgetfulness. R2 told Z1 that he feels helpless, hopeless, no motivation, no interest and sometimes wishes to die. Z1 also noted that R2's judgement and insight were "fair." R2 was diagnosed with [REDACTED]. (milligrams) a day (at bedtime). Z1 also ordered psychotherapy for R2. Z1 was interviewed by phone on 07/15/11 and stated that he comes to the facility on ce a week. When he last saw R2 during rounds he was out socializing with others per usual and did not show any signs of suicidal ideation. Z1 also stated that although R2 wished to be more independent, he was not showing signs of hurting himself. E5's end of shift note on 05/20/11 at 7:15 am documents: "At 2:30 am loud thud several times was heard. Nurses checked where the sound is coming from. Res. (R2) was seen outside patio. Nurse let him in and asked how did he get out & why? Res replied, "I went out for smoke." Nurse asked, "how did he know the code?" Res replied, I have a good memory." Res won't tell how he got the code." The note further documents that R2 was counseled about leaving the building unsupervised. E5 also documents that she informed E2( social worker) of the issue. E2 stated on 08/09/11 that she remembers counceling R2 regarding smoking rules and that the code to the patio was probably changed. E2 also stated that there were no changes to R2's careplan after the incident and R2 was not restricted, placed on checks or monitored more closely. 5/22/11, 6:55 am E5 documents that earlier in the shift a smell of cigarette smoke was noted in the hallway by R2's room. R2 denies smoking in his room. E5 told CNA to supervise R2 closely regarding smoking in his room. At 7 am R2 is again observed on his way out the patio door. E1(administrator) stated on 08/09/11that E5 went over the smoking policy again with R2 after the incident and he was re-directed when he tried to go out to the patio at 7AM. No other interventions were initiated at this time to supervise R2 more closely. 05/26/11 1:00 pm nurses note by E6, LPN (licensed practical nurse) documents that R2 left the facility without permission. After staff searched the building R2 was seen coming from the gas station (which is located on the other side of 2 sets of train tracks.) At this point the facility intervened and the use of a wandering device was implemented. Review of nursing progress notes documents that there were no incidents of attempted elopement throughout the month of June, 2011. However on 06/28/11 R2 was seen by the infectious disease physician at 10 am. At 11:30 am the doctor's office called stating that R2 was suicidal and he was sent to the hospital. R2 returned to the facility at 4:30 pm. E1stated that R2 was not monitored more closely after his return because his doctor at the clinic misunderstood R2 and that he wasn't actually suicidal at all. No further documentation was found in the record that the facility implemented any further interventions after R2 returned to the facility from the hospital. The only reference to the incident in the record after this occurred was a note by E8 (LPN) on 06/29/11 which stated, "Denies any suicidal plans." On 07/0711 R2's Elopement Risk Assessment form documented that his wandering device was discontinued on 07/07/11. E2 stated on 07/15/11 that R2's "out on pass privileges" were reinstated after R2 was re-assessed and noted to be following facility policies. On 07/11/11 a 10:30 PM nurses note by E3 documents that R2 left the building sometime before 7:50 PM. without signing out. He was seen by the receptionist at approximately 8:15 pm crossing the street heading towards the gas station. (across the railroad tracks). At approximately 9:55 pm R2 returned to the facility through the patio door. R2 was counceled by E2 after he returned and he was told he may have his pass revoked and he could not go out on his own anymore. The physician was notified and the wandering device was re-applied on 07/12/11. R2's order was changed to "can only go out with family". E3's (nurse on duty) note in the record dated 07/13/11 documents that R2 was given his medication at approximately 9 PM. After that he was observed by E3 leaving his room. During rounds (approximately 20 minutes later), R2 was not in his room or the patio. All staff were instructed to search the facility. At approximately 9:30 PM second floor nurse, E4 was asked to look for R2 at the gas station, (which is located across the street beyond two sets of railroad tracks). E4 returned a short time later stating that he could not get to the gas station because there was an accident. At 10:15 PM a police officer entered the building and asked if anyone was missing from the facility. The officer also stated that someone had been hit by a train. E1 (administrator) stated on 07/14/11 that she was called to the facility after the incident occurred. E1 was asked to go to the scene of the accident. E1 was allowed to get close enough to the scene to identify the body. R2's foot was visible and he was identified by E1 because his wandering device was still attached to his ankle. E1 also stated that there were no problems found with the facility's alarm system and their investigation was unable to determine how R2 was able to leave the building without triggering the alarm. R2's wandering device remained on his ankle and could not be tested by the facility. On 07/14/11 surveyor accompanied by E2 (social services director) checked all alarmed doors in the facility. The 2 remaining residents who wear wandering devices were assessed for the proper placement and function of their devices. Direct care staff were observed and interviewed as the alarms were activated. Staff acted quickly to disable the alarms after coming to the area. E2 explained that all of the alarms require a code to be input in order to stop the alarm from ringing after it is triggered. No problems were found with any of the alarms on 07/14/11. E2 stated that she personally tested R2's wandering device on 07/12/11 prior to attaching it to his ankle. E2's social service notes also reflect that the alarm was checked prior to it's application. E3 was interviewed on 07/15/11 and stated that she did not notice anything unusual with R2 on 07/13/11 and did not hear any alarms go off at the time of R2's elopement from the facility. E9, CNA was interviewed on 07/15/11 and stated that at the time of the elopement of 07/13/11 she was in a resident's room doing care and did not hear any alarms go off. E10, CNA was interviewed by phone on 08/14/11 and stated that she did not hear any alarms go off on 07/13/11 and if an alarm does go off you have to punch in the code to shut it off. The Immediate Jeopardy was determined to have begun on 07/13/11 shortly after 9:00 PM when staff became aware that R2 was not in the building, they did not know where he was, and the alarm did not trigger to indicate that he had left. It was confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The facility has reviewed and revised it's wandering device policies and procedures. Responsible for implementation : Director of Nursing 2. The facility will test all door alarms daily and keep a log. To be implemented by Maintenance Dept. 3. The wandering device system is being tested for functionality daily and a log will be kept. Responsible party- Maintenance 4. Visual checks for placement of wandering devices on residents will be done daily and a log will be kept. Charge nurse will be responsible. 5. Residents who wear wandering devices will not be allowed to go out on the patio without one on one supervision. charge nurse, direct care staff. 6. Residents' assessments will be reviewed to assure that all residents who need wandering devices will have them. Careplans will be updated to reflect assessments as appropriate. Careplan co-ordinator or social services. 7. On or before 07/19/11, inservices will be held with appropriate facility staff. Administrator or designee will conduct the inservices. Staff including: Supervisors, dietary, maintenance, housekeeping as well as direct care staff. The inservices will include: a) a review of the requirement that the facility reasonably assures that residents' environment remains as accident free as possible. b) a review of the allegations c) a review of the facility's revised policies and procedures for wandering devices. Corrective actions will be monitored by charge nurses for compliance through daily rounds and review of logs. Any trends in noncompliance and/or need for additional inservices will be addressed. The Director of Nursing will monitor for overall compliance through her supervision of staff. The facility's abatement plan was reviewed and accepted on 07/19/11 at 4:00 PM.

Based on observation, interview and record review the facility failed to assess whether or not a facility-acquired un-stageable pressure ulcer was avoidable or unavoidable, failed to have documentation of treatment for [REDACTED]. This is for 2 resident (R6 and R2) out of 6 reviewed for pressure ulcers in the sample of 15. This failure resulted in R6 developing an un-stageable facility acquired pressure ulcer to the midline [MEDICATION NAME] lower back and resulted in a worsening of the pressure ulcer on the left upper back. The examples include: R6 is at high risk for developing pressure ulcers according to the Braden Scale assessments completed on 8/1, 10/21 and 11/1/10. R6 has [MEDICAL CONDITION] and requires extensive assistance from staff for all activities of daily living according to documentation on the 9/17/10 Minimum Data Sets (MDS). R6 developed a facility-acquired un-stageable pressure ulcer on his midline, [MEDICATION NAME] lower back with thick adherent black necrotic tissue according to documentation on the 10/11/10 Wound Care Assessment. The assessment documents that this pressure ulcer developed less than 7 days ago. There is no documentation as to when this pressure ulcer was first identified per review of the medical record, physician's orders [REDACTED]. This was confirmed by E8 on 11/9/10 at 1:45 PM. E8 also confirmed that this was a facility-acquired pressure ulcer and that an assessment to determine whether or not this pressure ulcer was avoidable or unavoidable was not done. R6 was re-admitted to the facility on [DATE] with multiple decubitus ulcers, including a new stage II ulcer measuring 2 by 1.2 on the left upper back according to documentation on the Resident-Data Collection nursing assessment dated [DATE]. There is no documentation of treating this new ulcer until 11/8/10 according to review of the Treatment Administration Records (TAR) for October and November 2010. This was confirmed by E8 (Wound Care Nurse) on 11/10/10 at 12:20 PM. E8 stated that she did not know why treatment was not started until 11/8/10. E8 added, "that's when the order came through." The Wound Care Assessment notes dated 11/1 and 11/8/10 document that this upper back pressure ulcer now measures 2.0 by 2.0 and is un-stageable with 100% thick adherent yellow necrotic tissue. (The Weekly Pressure Sore Tracking Forms, Wound Care Assessment Notes dated 11/1 and 11/8/10 and the pressure ulcer care plan document "right" upper back. On 11/10/10 E8 confirmed that this was an error. E8 stated that R6's pressure sore is on the "left" upper back). The Pressure Sore Evaluation Form dated 10/22/10 and the Weekly Pressure Sore Tracking Form dated 10/25/10 do not document the presence of this new pressure ulcer site of the left upper back that was present on R6's 10/21/10 re-admission nursing assessment. On 11/10/10 E8 confirmed that this pressure ulcer was not assessed on the 10/25/10 Weekly Pressure Sore Tracking Form. A skin check was done on R6 on 11/91/0 at 1:30 PM. R6 had multiple dressings covering his buttocks, heels, ankles, sacrum, hip, midline lower back and left upper back. The facility's Pressure Ulcer Prevention and Guidelines policy dated 10/95 documents that residents assessed for high risk to develop pressure ulcers should have daily skin checks by the CNA and weekly skin checks by the nurse and that this check should be documented on the treatment records. R2 was admitted to hospice on 10/28/10. Prior to that date R2 had a history of [REDACTED]. There is no documentation of whether these pressure ulcers were avoidable or unavoidable.