Every finding on record at All American Vlge NRSG & RHB

Based on interview and record review, the facility failed to affirm the right of their residents to be free from verbal and physical abuse. This failure affected two (R2, R4) out of six residents reviewed for abuse. The deficient practice resulted in actual harm when R4 sustained a left eye injury. Findings Include:R4's clinical records show an admission date of 9/26/24 and discharged on 3/18/26, with included diagnoses but not limited to bipolar disorder and anxiety disorder. R4's Minimum Data Set (MDS) assessment, dated 1/1/26, shows a BIMS (Brief Interview for Mental Status) of 15, which means R4 was cognitively intact and required setup help to supervision with activities of daily living (ADLs).R4's progress notes, dated 3/12/26 at 3:21 PM documented by V8 (Licensed Practical Nurse/LPN), reads: The writer was informed that [R4] had a verbal aggression towards co-peer at 1:35 PM at the Lobby. R4's progress notes, dated 3/18/26 at 1:55 PM documented by V8, reads: The writer was informed that [R4] had a physical altercation with a co-peer. Both residents were immediately separated and placed on one-to-one close monitoring with staff. Head to toe assessment was conducted. [R4] was observed with a small opening area to the left eyebrow. R4's progress notes dated 3/18/26 at 3:33 PM documented by V23 (Registered Nurse/RN), reads: It was noted that resident expressed to leave facility AMA [Against Medical Advice]. Writer educated resident on risks of leaving against medical advice. Resident verbalized understanding of risks and continued to request discharging AMA. Resident was educated to wait and go to the hospital first as he was awaiting (sic) for EMT [Emergency Medical Technician] but he declined stating that he had the right to leave as he chose to. Resident advised medical assistance may be required if conditions worsens (sic) and instructed to call 911 or go to nearest Emergency room. Resident was noted earlier with an superficial open and first aid was rendered. Two steri-strips applied. Steri strips intact. No bleeding noted. Charge nurse assessed resident, area clean and dry, skin intact, resident denied having any pain and/or discomfort. Resident verbalized he felt fine and alright. Resident alert and oriented x 3. Resident took all his belongings. Physician made aware. [V22 (R4's Family Member)] contacted, no response as resident stated she may be at work, so voicemail was left. Resident left the facility with his items, properly dressed for the weather and was informed to seek medical assistance by contacting 911 for help if needed. Resident verbalized understanding and he departed from the facility. Law enforcement was notified of this as well.R2's clinical records show an admission date of 9/18/25 with included diagnoses but not limited to bipolar disorder, unspecified psychosis, and major depressive disorder. R2's MDS assessment dated [DATE] shows a BIMS of 15, cognitively intact and requires setup help to supervision with ADLs.R2's progress notes, dated 3/18/26 at 1:50 PM documented by V20 (LPN), reads: [R2] was involved in an altercation with a peer and immediately separated by staff and placed on one and one observation with staff. Full body assessment was conducted and resident noted with redness to forehead. R2's progress notes dated 3/12/26 at 1:30 PM reads: The writer was informed that [R2] had a verbal aggression towards another resident at 1:30 PM at the Lobby.The facility's first incident report related to R2 and R4 sent to Illinois Department of Public Health (IDPH) documents: Date of incident 3/12/26 at 5:02 PM. [R4] reported that [R2] had allegedly spat on him by the corridor of the first-floor elevator. [R2] denied spitting. Witnesses present in the area did not observe the alleged incident.The facility's second incident report related to R2 and R4's incident sent to IDPH documents: Date of incident 3/18/26 at 1:12 PM. An incident occurred involving [R2 and R4] near the elevator area. According to witness statements, the incident happened suddenly and without prior warning. Witnesses reported that [R4] approached [R2] without any verbal exchange and attempted to make contact with [R2]. Both residents were places om close monitoring to ensure safety. [R4] was noted to have a small open area above the left eyebrow.On 4/26/26 at 9:37 AM, a phone interview was conducted with R4. R4 stated he left the facility AMA and is currently residing at another facility because he no longer felt safe. R4 stated he was fearful for his life due to another resident [R2] residing in the facility. R4 stated the first incident occurred around March 6 or 7 during activity time in the common area on the first floor. R4 stated R2 was making gestures indicating he wanted to fight; however, R4 did not engage and laughed it off. Later that day, at approximately 3:30 PM while R4 was smoking outside, R2 approached and spat on R4's face. R4 stated V19 (Security) was present and intervened, separating both R2 and R4. R4 stated they were both sent to the hospital for a mental evaluation. R4 stated he did not instigate any physical altercation and did not understand the reason for being sent to the hospital. R4 further stated that after a few days, R4 returned to the facility after being reassured that the situation had been resolved. However, around March 17 or 18, R4 said another incident occurred. R4 stated upon exiting the elevator on the first floor, R4 saw R2 approaching and felt threatened, prompting R4 to swing at R2. R2 then punched R4 repeatedly, resulting in an injury to R4's left eye, which began bleeding. R4 stated V18 (Security), and a kitchen staff intervened. R4 stated the kitchen staff member restrained R4 while another staff member separated R2. R4 stated his wound was cleaned, and the situation was de-escalated. R4 stated ongoing fear for his safety, noting that although he did not reside on the same floor as R2, R4 frequently encountered R2 in common areas. R4 stated that due to continued fear and feeling unsafe within the facility, R4 chose to leave AMA.On 4/26/26 at 10:43 AM, R2 was interviewed. R2 stated he does not remember specific times and dates of the incidents that happened with R4. R2 stated since being admitted in the facility, R4 kept bullying him. R2 stated being called derogatory names by R4, including coo (interpreted as being called [NAME] or goofy). R2 stated a verbal altercation occurred, but R2 does not remember the exact date. R2 denied spitting at R4. R2 stated there was no physical fight that occurred at that time. R2 stated R4 were cursing and calling him names, but staff intervened, and they were both sent to the hospital. R2 stated R4 continued to provoke him on multiple occasions, including attempting to initiate fights when they passed each other. Staff reportedly intervened and separated them each time. R2 indicated R4 would come down to his floor and provoke R2. R2 stated following discharge from the hospital in March, R2 returned to the facility (R2 does not remember exact date) and was in the lobby near the elevator retrieving personal belongings. R2 stated at that time, R4 exited the elevator and swung at R2, striking him in the face and causing a minor bruise on the forehead. R2 stated he defended himself by striking R4 multiple times in the face, resulting in a cut near R4's left eye. R2 stated staff intervened, though R2 could not recall specific staff members involved. R2 stated staff physically separated them both. R2 stated R4 was taken to the social services office, while R2 was taken to the patio area. R2 stated he was sent to the hospital for evaluation. R2 believed R4 left AMA and refused hospital care. R2 reported feeling safe in the facility at the time of the interview.On 4/26/26 at 11:25 AM, V6 (Activity Aide) stated she does not remember the exact date of the incident between R2 and R4, as she was new at the facility at the time. V6 stated being stationed at the front desk and covering for security after lunch when the incident occurred. V6 stated she buzzed the front door open for an individual entering the building, and when she looked back towards the lobby, V6 observed R2 and R4 engaging in a physical altercation. V6 stated R2 and R4 were swinging at each other but could not recall who struck first. V6 stated after staff separated R2 and R4, V6 observed R4 was bleeding from one eye. V6 stated no one else was near her at the front desk, and she called for assistance. V6 stated male staff members responded and intervened.On 4/26/26 at 11:38 AM, V7 (Dietary Aide) stated he could not recall the exact date of the incident involving R2 and R4 but remembered it occurred at approximately 1:15 PM. V7 stated he was going upstairs to retrieve food carts and was near the elevator in the first-floor lobby when the incident occurred. V7 stated R2 was walking towards the lobby while R4 appeared to be exiting the elevator. V7 stated R2 and R4 approached each other face-to-face. R4 punched R2 in the face without saying anything. V7 stated R2 then defended himself and punched R4 back. V7 stated he observed R4 sustained an open wound above his eye, which began bleeding. V7 stated residents and staff were yelling for the altercation to stop. V7 stated he intervened by grabbing R4 and pulling him away from R2. Shortly thereafter, V18 arrived and assisted in separating R2 and R4. V7 stated they restrained R4 to prevent him from striking R2 again until additional staff arrived to assist.On 4/26/26 at 12:50 PM, a phone interview was conducted with V18 (Security). V18 stated the incident occurred at approximately 1:00 PM during the second week of March, though the exact date was unknown. V18 stated being stationed at the desk when R2 returned from the hospital carrying multiple personal belongings in a cart. V18 stated he was assisting with transporting R2's belongings to the elevator. V18 stated he was talking with R2 by the elevator when R4 approached unexpectedly and began swinging at R2. V18 stated R4 struck R2 in the face, causing a bruise to R2's forehead. V18 stated R2 then defended himself and struck R4 in the face. V18 stated he attempted to intervene and stood between R2 and R4 while they were still swinging at each other. V18 stated another staff member (V7) came and assisted in separating R2 and R4. V18 stated he observed that R4 sustained multiple bruises and significant facial bleeding, though the exact source of the injury was not identified. V18 stated both residents were placed on one-to-one supervision. V18 stated R2 was sent to the hospital, and R4 also left for the hospital. V18 stated residents involved in altercations are routinely sent to the hospital for the safety of all residents.On 4/26/26 at 11:49 AM, V8 (Licensed Practical Nurse/LPN) stated the incident occurred on March 18 at approximately after lunch while assigned to the floor. V8 stated not witnessing the altercation directly and could not recall who initially notified her. V8 stated she was informed that R2 and R4 had been involved in an altercation. V8 stated she was the nurse assigned to take care of R4. V8 stated when she was called on the first floor to assess R4, both residents had already been separated. V8 stated she observed a small open area to R4's left eyebrow. V8 stated a head-to-toe assessment was completed, first aid was rendered, and vital signs were obtained. V8 stated R2 and R4 were placed on one-to-one monitoring. V8 stated arrangements had been made to send R4 to the hospital; however, he refused treatment and left against medical advice (AMA). V8 reported notifying V13 (Nurse Practitioner).On 4/26/26 at 2:26 PM, a phone interview was conducted with V20 (Licensed Practical Nurse/LPN). V20 stated she did not remember the exact date of the incident but believed it occurred shortly after lunch. V20 stated she was informed that R2 and R4 had been involved in an altercation and was told they had a fight. V20 stated she was R2's nurse at the time. V20 stated R2 reported he had a fight with R4 and punched him in the face. V20 stated R2 was assessed with redness to his forehead with no other noted injuries. V20 stated R2 was sent to the hospital for further evaluation.On 4/26/26 at 1:05 PM, V19 (Security) was interviewed regarding the verbal altercation between R2 and R4 that happened prior to the March 18 physical altercation. V19 stated the incident occurred around 12:00 PM or 1:00 PM but could not recall the exact date, estimating it was in early March. V19 stated R2 and R4 had a verbal altercation. V19 stated R2 was exiting the elevator while R4 was near the patio door, and V19 was positioned on the patio behind R4. When R2 exited, R2 and R4 became aggressive toward each other. V19 immediately intervened and separated them. V19 then remained outside with R4 to calm him down. V19 stated R2 and R4 were later sent to the hospital. According to V19, R2 and R4 came close to each other but no physical contact occurred. V19 did not witness any spitting. V19 stated R4 alleged R2 spat on him, but V19 did not observe this. V19 stated R2 and R4 were calling each other derogatory names, making threats, cursing, and provoking one another to initiate a fight. V19 stated no physical altercation occurred in his presence. V19 identified the incident as verbal abuse due to the use of aggressive language, derogatory names, and cursing between the residents. V19 stated R2 and R4 were verbally abusing each other that's why V19 separated them so it won't escalate.On 4/26/26 at 1:22 PM, V1 (Administrator) stated she serves as the Abuse Coordinator. V1 stated abuse is any intentional act that causes harm to another person. V1 stated the types of abuse include physical, verbal, mental, sexual, misappropriation of funds, involuntary seclusion, theft, neglect, and injuries of unknown origin. V1 stated physical abuse includes punching, kicking, pushing to the ground, and wrestling. V1 stated verbal abuse includes threats of bodily harm, racial slurs, discrimination, name-calling, and cursing. V1 stated mental abuse includes statements or actions that cause emotional distress, fear, anxiety, or psychological harm. V1 stated that the person experiencing abuse can potentially cause them to feel anxious and fearful. V1 stated that with any abuse or abuse allegations, staff are expected to immediately intervene, separate involved residents, and ensure safety. V1 stated that all residents residing in the facility have the right to speak freely, participate in their plan of care, remain free from abuse, and live in a safe and comfortable environment. The facility's ABUSE PREVENTION PROGRAM (1/2026) documents: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation or property, deprivations of goods and services by staff or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability.

Based on observation, interview, and record review, the facility failed to ensure walk-in cooler, refrigerator (Reach In cooler) and freezer maintained a daily log tracking of temperatures; failed to maintain refrigerated foods within normal ranges; failed to label foods with open and use by dates; and failed to discard foods with expired dates. This has the potential to affect all residents residing in the facility. Upon initial kitchen observation at 9:15 am, refrigerator, freezer, and walk-in cooler (walk-in cooler tracking log on a clip board) had a January Tracking log affixed to the outside doors; refrigerated foods with no open or use by date; refrigerated foods with expired use by dates; walk-in cooler with an out of range temperature; and foods temperature measuring at warmer temperatures than normal range. On 2/1/2026 at 9:18 am, V7 (Dietary Cook) verified with surveyor the temperature tracking log on the freezer, Reach in Cooler, and Walk in Cooler was dated January 2026 and the last documented temperature tracking date was 1/31/2026. V7 stated the Dietary Supervisor reloads the new tracking log monthly, but today is Saturday. V7 stated she checked the temperature of the freezer, Reach in Cooler, and Walk in Cooler, and all three were within normal temperature ranges. Surveyor verified with V7 there was no February temperature tracking log affixed to the refrigerator. Thermometer reading was 38 degrees Fahrenheit; the freezer with a temperature reading was -9 degrees Fahrenheit; and the Walk in cooler with a temperature reading of 48 degrees Fahrenheit. V7 verified cheese partially wrapped in saran wrap with no open label date and no expiration date; large roast beef in a metal pan with soaking in a brown liquid covered with saran wrap with an open date of 1/28/2026 and a use by date 1/30/2026; hamburger buns with no open or use by date; and turkey breast sandwich meat wrapped covered with saran wrap and an open date of 1/28/2026 expiration date of 1/30/2026. V7 verified the milk temperature was 46 degrees Fahrenheit; turkey sandwich meat temperature was 48 degrees Fahrenheit; and the roast beef temperature was 47 degrees Fahrenheit. V7 stated the Walk in Coolers temperature had dropped because dietary staff are in and out of the Walk in Cooler frequently. V7 verified the cooling fan in the Walk in Cooler was blowing warm air. V7 stated the safe temperature in the Walk in Cooler should be about 40 degrees Fahrenheit. V7 stated the purpose of maintaining cold foods Walk in Cooler temperature at 40 degrees Fahrenheit is to prevent spoilage of the food and prevent foodborne illnesses. V7 stated she (V7) will discard all of the food in the Walk in Cooler. On 2/1/2026 at 12:06 pm, V10 (Dietary Supervisor) verified the Walk in Cooler thermometer temperature reading was 48 degrees Fahrenheit. V10 stated the dietary cook is responsible for affixing new temperature tracking logs monthly to the Walk in Cooler, Reach-In Cooler (refrigerator), and the Freezer. V10 stated the temperatures are tracked twice a day, and if they are out of temperature range, the Dietary staff should notify the Dietary supervisor and Maintenance immediately. V10 stated the Dietary staff did not notify her the Walk in Cooler temperature was out of range. V10 verified the temperature of the milk was 46 degrees Fahrenheit; turkey sandwich meat temperature was 48 degrees Fahrenheit with open date of 1/28/2026 and use by date of 1/30/2026; and the roast beef temperature was 47 degrees Fahrenheit with open date of 1/28/2026 and use by date of 1/30/2026. V10 stated all Dietary cooks, and Dietary Aides are responsible for applying open and use by dates on foods stored by them. V10 stated cold foods should be held at 32 degrees Fahrenheit and hot foods should be held at 165 degrees Fahrenheit to prevent food borne illnesses. V10 stated she (V10) will contact an outside HVAC company for maintenance to the Walk in Cooler.On 2/1/2026 at 1:24 pm, Walk in Cooler and all food and beverages had been discarded. V10 stated she was purchasing milk from the local grocery store and ordering food to replace discarded food from Walk in Cooler. HVAC repairman had just arrived to repair the walk-in cooler. On 2/4/2026 at 1:13 pm, V20 (Acting Maintenance Director) stated, The Dietary Director must check refrigerator temperatures twice daily and report any out-of-range readings to Maintenance; Refrigerators should be at 40 F or below, and freezers at 0 F; if temperatures fall below normal ranges a plan b is to add ice to the cooler until repairs are made by maintenance typically within an hour. This is why the company had the walk-in cooler was serviced on Sunday. Proper temperature control is critical to protect residents' health.On 2/4/2026 at 2:21 pm, V1 (Administrator) stated monthly temperature log must be maintained for all refrigerator, cooler, and freezers in the kitchen. The cook is required to check and record the temperatures at the start of each shift. The walk-in cooler temperature should read 41 degrees Fahrenheit or below; If temperature is out of range, notify manager immediately. The manager contacts HVAC for service and informs Maintenance. An improper temperature can cause food spoilage and health risks (e.g., upset stomach from milk) to the residents.On 2/4/2026 at 2:25 pm, V1 (Administrator) stated Dietary staff must label all food items and discard any expired or spoiled products. V1 stated consuming outdated food poses health risks and must be avoided to prevent foodborne illnesses.HVAC repair work order invoice, dated 2/1/2026, documents walk-in cooler running warm topped of system with 1.5 pounds of R-404A verified operation. Head pressure was high cleaned condenser. Temperature is 38 degrees Fahrenheit. HVAC repair work order invoice, dated 2/2/2026, documents [NAME] Cooler not working and upon inspection a new junction box and contactor was added along with a power switch was only cutting out 1 leg on 208V. Proper 208V switch was installed.HVAC repair work order invoice, dated 2/3/2026, documents warm walk-in cooler picked up parts replaced 1 breaker with proper 2 pole 20-amp breaker, tested breaker and found good.On 2/4/2026 at 2:15 pm, walk-in cooler temperature is 34 degrees Fahrenheit.Facility Food Service Supervisor Job Description undated documents, qualifications and essential functions include. Supervise and direct all food service components. This includes, but is not limited to, sanitation procedures, proper food and chemical storage procedures, proper operation of facility equipment (dishwasher, stove, oven, etc.), . monitoring of refrigerator and freezer temperatures. Facility policy titled Storage of Refrigerated Foods, dated 2015 revised 2017, documents Policy: Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quantity.Refrigerated foods are stored at 41 degrees Fahrenheit or below. Air temperature inside the refrigerator is checked and recorded twice daily. The reading on both the external and internal thermometers is recorded.The temperature of a PHF/TCS food is taken and recorded each day.

Based on observation, interview, and record review, the facility failed to discard expired medications for four residents (R61, R87, R96 and R124), failed to label multiuse medications for six residents (R9, R23, R55, R106, R132, and R133),and failed to monitor the temperature of the medication refrigerator that included medications for three residents (R30, R102 and R12. This failure affected 13 residents in a total sample of 50 residents reviewed. Findings include: 1.On 02/02/25 at 8:45am, V19 (Licensed Practical Nurse) reviewed the fourth-floor medication cart, noted the following observations with R23,R61,R87,R96,R132 : R132: No open date on the eye drops listed. Brimonidine Tartrate 0.15% ophthalmic solution , manufacture exp date of 2/28.No open date and No discard date. Prednisolone Acetate ophthalmic suspension 1%, manufacture exp date of 8/28.No open date and No discard date. Timolol maleate ophthalmic solution 0.5% ,manufacture exp date of 3/27.No open date and No discard date. Moxifloxacin solution hcl 0.5%, manufacture dispense date of 1/8/18/26 manufacture label states last for 30 days no open date on medication. No open date and No discard date. Latanoprost solution 005%, manufacture instructions on label states to discard medication after 6 weeks of use. No open date and No discard date. R96: Fluphenazine decanoate 125mg/5ml, medication vial observed in medication in top drawer with date on medication box of 6/7/25.Manufacture instructions to discard medication after 30 days. No open date and No discard date. R87: Fluphenazine decanoate 125mg/5ml, medication vial observed in medication in top drawer with date on medication box of 12/18/25.Manufacture instructions to discard medication after 30 days. No open date and No discard date. R61: Fluphenazine decanoate 125mg/5ml, medication vial observed in medication in top drawer with date on medication box of 8/4/25.Manufacture instructions to discard medication after 30 days. No open date and No discard date. R23: Breo Ellipta inhaler 100-25,manufacture label reads to discard medication after 6 weeks .No open date and No discard date. On 02/02/2026 at 9:33 am, V19 stated R23 is no longer a resident on the fourth floor and she is not sure why R23's medication was still on the cart.V19 stated medications should have an open date written on the medication box or bottle so that all nurses who are administering the medication would know when the medication should no longer be used and discarded. Administering expired medication may not have the same effect as unexpired medication. 2.On 02/02/2026 at 9:38 am, the 4th floor medication storage room was reviewed with V19. Upon opening the refrigerator, V19 observed there was no thermometer present in the refrigerator. There were medications inside the refrigerator including unopened insulin, tubersol , and a med pass supplement drink. V19 stated the refrigerator temperature should be kept below 46F to ensure the potency of the medication is maintained. V19 stated there is no thermometer in the refrigerator at this time because the refrigerator was just replaced, and she was not aware where they put the old thermometer.V19 recorded the temperature on the refrigerator temperature log as 40F time 7-3 shift, and stated she did this because she just followed the previous temperature reading from the day before. On 2/2/26 at 9:42 am, V2 (Director of Nursing) stated, Eye drops should have open dates on them. The nurses need to know when the medications expire to ensure medications are not administered after discard date. This is to decrease risk of administering expired medication because it may decrease the effectiveness of the medication. The nurses are aware to make sure the temperature and fridge logs are accurately checked on their shifts. The thermometer is not present in fridge because we just replaced the fridge, and they must have forgot to put the thermometer back in. 3.On 02/02/26 at 9:54am, R9's ophthalmic solution had no open date, R124's haloperidol injection had an expiration date of 01/2026, R55's, R106's, and R133's albuterol sulfate inhalation had no open date. Medication refrigerator had no temperature log for February 2026 and multiple missing temperature dates for January 2026. R9's R102's and R121's ophthalmic solution were in the medication refrigerator that stated refrigerate until open label and R30's pneumovax 23 injection. On 02/02/26 at 9:54am, V24 (Licensed Practical Nurse/LPN) stated R9's medication is expired and should not be used. V24 stated expired medication can be harmful to the residents. V24 stated there is no open date on the albuterol inhalation medications for R55, R106 and R133, but there should be. V24 stated the facility has not started a February refrigerator log. V24 stated it is important to check the refrigerator temperature to make sure that the refrigerator is at the right temperature. V24 stated if the refrigerator is not the right temperature, the medication can spoil. On 02/02/26 at 11:55am, V2 (Director of Nursing/DON) stated the medication refrigerator should be checked daily to make sure the medication is at the right temperature. V2 stated, If the medication is not at the right temperature, the medication can go bad. Multidose medication should have an open date because the medication has a certain lifespan. Expired medication has the potential to lose its potency and should be discarded. Facility's policy titled Storage of Medications, revision date 02/2025, documents, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. Temperature: A. Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges. C. Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 degrees Celsius (59 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) with a thermometer to allow temperature monitoring. E. The Facility should maintain a temperature log in the storage area to record temperatures at least once a day. F. The Facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC Guidelines. Expiration Dating: A. Expiration dates of dispensed medications shall be determined by the pharmacist at the time of dispensing. B. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. C. Certain medications or package types, such as IV (intravenous) solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solution and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. E. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.

Based on observation, interview, and record review, the facility failed to ensure the linen chute was secured to prevent unauthorized access. This failure has the potential to affect all 47 residents on the third-floor unit.Findings include:On 2/1/26 at 10:27 am, residents were walking throughout the third-floor unit. The third-floor laundry chute unlocked and accessible.On 2/1/26 at 10:34 am, V18 (Registered Nurse), stated the laundry chute should be locked at all times so the residents do not fall down the chute. V18 further explained if a resident falls down the laundry chute, it could cause death to the resident. V18 stated she does not have a key to lock the third-floor laundry chute. V18 stated she does not know who has a key to lock the laundry chute.On 2/2/26 at 12:22 pm, V20 (Building Engineer Consultant) observed the third-floor laundry chute remain unlocked and accessible. V20 stated all the laundry chutes should be kept locked at all times to prevent the risk of residents from throwing themselves done the laundry chute and causing an injury or death. V20 stated the third-floor laundry chute lock was broken and V20 does not know how long the third-floor laundry chute lock has been broken. The facility document, dated February 2025, and titled Equipment Reporting- Failures and Malfunctions documents: Policy: To provide a mechanism for reporting medical equipment failures malfunctions. Policy Specifications: 2. A reporting form to identify and document medical equipment failures and uses errors that may have an adverse effect on resident safety is completed by the department who owns/maintains the equipment. This report, forwarded to the Maintenance Department, includes the problems identified and the actions taken to resolve these problems.The facility document, dated February 2025, and titled General Safety Precautions documents, Policy: To assure that all personnel are aware of necessary and appropriate safety expectations when performing tasks associated with their positional responsibilities. Policy Specifications: 21. Report all unsafe acts or conditions to your supervisor as soon as practical . 34. Follow established safety precautions as well as those that may become necessary and appropriate.

Based on observation, interview, and record review, the facility failed to develop a discharge plan that reflects the residents post discharge needs, goals, and treatment preferences. This failure effected one (R70) in a sample size of 50 residents reviewed for discharges. Findings include: R70's face sheet, dated 2/4/2026, documents R70 was admitted to the facility on [DATE], with diagnoses of Diabetes mellitus, multiple myeloma, paroxysmal atrial fibrillation, hypertensive heart disease with heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, hyperlipidemia, and gastro esophageal reflux disease. R70's minimal data set section C cognitive patterns, dated 12/11/2025, documents R70 has a score of 15, which means R70 is cognitively intact; section GG functional abilities documents R70 has a score of 02 for shower/bathe self, meaning R70 requires staff substantial/maximal assistance to complete the task. R70's care plan, dated 12/06/2025, documents R70's discharge planning: R70's discharge plan is to return to community after completion of skilled treatment; Goal: R70 will be transitioned to home/community after completion of skilled treatment; Interventions: staff to assess availability support system for discharge to community. R70's care plan, dated 02/02/2026, documents; return to community referral; discharge planning: R70 plan is to return to the community/assisted living. Goal: R70 will discharge to the community/assisted living; Intervention: assess available support system for safe discharge back into the community. On 02/01/2026 at 10am, R70 was alert and responsive; able to make needs known to staff; no acute distress or pain expressed; she can transfer herself from bed to wheelchair; and reports that she is here from Arkansas. R70 states this placement in the nursing facility was supposed to be temporary but the last Social Worker she spoke to informed her she did not qualify to be transferred to another facility such as senior living because she was unable to walk. She stated it's not that she is unable to walk, but she is afraid to walk because she has had falls in the past prior to admission and she utilizes a mobility device for ambulation. She states she spoke to one Social Worker when she admitted that informed her that she would be able to transition back into the community when appropriate, but I'm being informed that the person is no longer working here and no one else has spoken to me about being discharged even though I ask frequently. R70 stated she is in her right state of mind and should be allowed to leave because she desires to have her own space. R70's resident progress notes, dated 12/05/2025 at 4:06pm, documents; resident's goal includes eventually transitioning back into the community when appropriate. On 02/02/2026 at 11:35 am, V6, Social Service Director stated, I was not aware (R70) wanted to discharge to senior living because the Social Worker who was working with (R70) no longer works here and never informed me prior to leaving there was a discharge discussion for (R70). I did meet with (R70) one time but cannot remember the conversation and did not document the meeting. V6 stated she is the Social Service Director and responsible for all the Social Workers in the facility, and it should have been reported to her that R70 desired to discharge. After interviewing V6, she stated she will now start making calls and sending out referrals to various agencies for R70 to be screened and evaluated for assistive living facilities. R70's resident progress notes, dated 02/02/2025 at 3:43pm, documents; R70 expressed interest in assisted living facility. V6 reached out to a facility and the representative was able to come out and complete and in person interview with R70 at 1:00 pm, tour of the assistive living facility has been scheduled at 11:00 am on 02/02/2026. R70's resident progress notes, dated 02/04/2025 at 12:05 pm, documents; R70 has returned from her tour of assistive living facility. On 02/04/2026 at 2:11 pm, V1 (Administrator) stated, When a resident admits to the facility, upon initial assessment, staff ask the resident do they have a place to discharge when the time comes, and if they have been working with any agency. We continue with the process and set up care plan meetings. If the resident has a team that they are working with we collaborate with the outside vendor to ensure the resident receives whatever care, equipment or supplies they may need for a smooth transition. V1 stated she was made aware on 02/03/2026 by V6 that R70 desired to transition to an assistive living facility and V6 sent out referrals to agencies. (R70) went out to one facility today to tour, but (V6) informed me that the resident did not qualify because (R70) demonstrated profound behaviors that the facility was unable to redirect at time of the tour. If (R70) wants a staff member to escort her on the tours, then the facility will assign her with an escort to accompany her. V1 stated she never spoke with R70's family regarding her inability to transfer to an assistive living facility. On 02/04/2026 at 2:29 pm, V6 (Social Service Director) stated, The discharge discussion starts at the beginning with admission process. When a resident wants to be discharged , a care plan meeting is scheduled that includes the vendors and resident, a discharge date is given, and the needs are set up if the resident requires equipment. V6 stated the last care plan for R70 was 12/16/25 and progress notes were written about the meeting. There is only an attendance sheet with staff names that V6 states attended the meeting. V6 states the care plan admission meeting topics that are discussed are orientation to the facility and discharge plan goals. V6 stated the boxes for agree/disagree with plan of care were not checked and she is not sure why, but V6 doesn't check any of those boxes ever. V6 stated the care plan meeting discussion was not documented because it is optional to document because if there is an attendance sheet that displays proof that the care plan was done that is all that is required. V6 stated, (R70) went out today to tour an assistive living facility but returned because (R70) did not like the facility. When asked where the documentation was for the visit, V6 stated she normally does her charting at the end of the day. V6 stated R70 requested for her to search for other facilities that she could tour for possible transition to assistive living. When V6 was asked why a facility escort or Social Service worker did not accompany R70, V6 stated, It's up to the resident if they ask staff to accompany them to an appointment. V6 stated she suggested it to R70, and she said she will think about it for next tour visit.Job description titled Social Service Director; direct service and programming: assist as a liaison with outside agencies as needed to facilitate communication and services ;assist in coordination of discharge planning services, job training and employment services and housing; 2) Record keeping: Maintains concise comprehensive case records by following established agency policies and procedures.Facility's policy titled Discharge summary and plan, with revised dated of February 2025, documents: Policy statement: when a resident's discharge is anticipated ,a discharge summary and post discharge plan will be developed to assist the residents to adjust to his/her new living environment; Policy interpretation and implementation:1) when the facility anticipates a residents discharge to a private residence or another nursing care facility, a discharge summary and a post discharge plan will be developed which will assist the resident to adjust his or her new living environment,4) social service department will review the plan with the resident and family before the discharge is to take place.

Based on observation, interview, and record review, the facility failed to ensure the development of a care plan focused on a serious mental health illness to maintain proper disease management and continuance of care. This failure affected 1 of 1 resident (R12) in the sample of 50. R12's Face Sheet, dated 2/4/2026, documents a diagnosis of but not limited to for schizoaffective disorder on 3/2020.R12's Minimum Data Set Section C documents a BIMS (Brief Mental Interview Status) Score of a 15, which is indicative of an intact cognition. R12's care plan, dated 11/18/2025, does not document a focus for a severe mental illness of schizoaffective disorder.On 2/4/2026 at 11:51 am, V6 (Social Services Director) stated, (R12) should have a care plan for schizoaffective disorders to manage the condition effectively. Social Services is responsible for ensuring this care plan exists and without a care plan, we cannot properly monitor or manage the diagnosis.On 2/4/2026 at 2:27 pm, V1 (Administrator) stated R12 and other residents with schizoaffective disorder must have a care plan outlining behavioral history and interventions because this ensures proper management and continuity of care.Facility Policy titled Care Plan, with an effective date of April 2015- Updated October 2025, documents, an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and /or psychological needs is developed for each resident:#3. Each resident's Comprehensive Care Plan has been designed to:Incorporate identified problem areasIncorporated risk factors associated with identified problemsBuild on the residents' strengthsReflect treatment goals and objectives in measurable outcomesIdentify the professional services that are responsible for each element of care.

Based on observation, interview, and record review, the facility failed to ensure a residents had a privacy curtain that extended around the bed. This failure affected one resident (R77) in the total sample of 50 residents. Findings include: R77's face sheet documents R77 has diagnoses which include but not limited to anxiety, cerebral infarction, bipolar disorder, hemiplegia, paroxysmal atrial fibrillation, benign prostatic hyperplasia, syphilis, and headaches.R77's Brief Mental Status Interview (BIMS), dated 01/13/26, indicates R77 is cognitively intact. On 2/1/26 at 10:18 am, R77's room was without a privacy curtain that extended around R77's bed. R77 was out on pass from the facility during this observation.On 2/2/26 at 2:28 pm, R77's room was without a privacy curtain that extended around R77's bed. V20 (Building Engineer Consultant) explained all residents should have a privacy curtain, so the residents are not exposed. V20 stated, The privacy curtains are to give the residents privacy.On 2/2/26 at 2:28 pm, R77's room was without a privacy curtain that extended around R77's bed. R77 was out on a pass at a doctor's appointment during this observation.The facility's undated document titled Residents Rights Protocol for All Nursing Procedures documents: Purpose: To provide guidelines for residents rights while caring for the resident. Preparation: 1. b. Resident dignity and respect . General Guidelines: 1. f. close the room entrance door and provide for the resident's privacy.

Based on observation, record review, and interview, the facility failed to provide necessary foot care, treatment, or professional referrals to maintain skin integrity on the foot. This failure affects one resident(R70) in a sample size of 50 reviewed for podiatric/foot care. R70's face sheet, dated 2/4/2026, documents R70 was admitted to the facility on [DATE] with diagnoses of Diabetes mellitus, multiple myeloma, paroxysmal atrial fibrillation, hypertensive heart disease with heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, hyperlipidemia, and gastro esophageal reflux disease. R70's Minimal Data Set section C cognitive patterns, dated 12/11/2025, documents R70 has a Brief Interview for Mental Status score of 15, which means R70 is cognitively intact; section GG functional abilities documents R70 has a score of 02 for shower/bathe self, meaning R70 requires staff substantial/maximal assistance to complete the task. R70's physician order report, dated 01/04/2026- 02/04/2026 with a start date of 12/05/2025, documents R70 may receive services from podiatrist. On 02/01/2026 at 10:00 am, R70 was observed in her room sitting at bedside. She can make her needs known to staff. R70 stated, My toenails have not been cut since August 2025, and my toenails are so long and bending over they are uncomfortable in my shoes. I told the nurse, but nothing happened. On 02/01/2026 at 10:03 am, R70's toenails were observed to be long and curled over towards her toes. On 02/04/2026 at 1:06pm, V25 (Medical records) stated, (V2, Director of Nursing) just gave me the task a few seconds ago to record and maintain the list of residents who will need to be seen by the podiatrist. The facility just started with this new group in December 2025. The task was previously assigned to Social Service, but Social Service did not seem to know about the podiatrist list. V25 stated she will have the nurses to create a list of which patients need to be seen by the podiatrist. V25 stated she took the appointment request sheet forms to each nursing unit for nurses to be able to place resident's names on the sheet who need to be seen also for better tracking. V25 stated the podiatry group will begin evaluating residents on 02/12/2026.On 02/04/2026 at 1:23pm, V8 (Wound care/IP nurse) assessed R70's toenails. V8 stated R70's toenails definitely need to be cut. V8 stated R70's feet should be assessed by podiatry because she is a diabetic and nurses should be assessing the nail care and feet three times a week during showers. R70 receives showers on Monday-Wednesday-Friday on 11-7am shift. V8 stated she was not made aware R70 had any concerns with her toenails. On 02/04/2026 at 1:29pm, V12 ( Licensed practical Nurse) stated, The shower report sheet is for body assessments and open areas after completion of shower or bed baths, and the toenail care box was not checked on the sheet so that means the staff did not check the toenails. The nurse should be reviewing the whole skin report sheet to assess if there are any opening skin concerns or nail care concerns that need to be further assessed and addressed with our wound care nurse or call placed to the physician.On 02/04/2026 at 1:33pm, V29 (Certified nursing assistant/CNA) stated she supervised R70 with her shower on 02/03/2026.V29 stated she did not check the box for toenail care and was not aware of how R70's toenails appeared. V29 stated, (R70) prefers to give herself a shower but I stand close by shower room to give her supplies and assistance if required, and after (R70) completed her shower I completed the skin check but forgot to check her toenails and feet. On 02/04/2026 at 1:40 pm, V2 (Director of Nursing) stated, The podiatrist comes in for toenail care monthly. The list is kept with Social Service Director. The staff should place residents on the list to be seen by podiatrist. V2 expectations of the nursing staff is for the CNA and nurse to check, inspect, and assess the toenails during showers or baths, and if any concerns, this needs to be brought to the attention of the wound care nurse and the physician for further orders.V2 stated she was not made aware R70 had any concerns with her toenails. On 02/04/2026 at 3:00 pm, V25 submitted a list of residents that were to be seen by the podiatrist on these dates 12/10/2025,12/12/2025,12/18/2025, R70's name was not on any of the residents list and V25 stated she was never given R70's name to be added. Facility document, dated 02/04/2026 titled Skin report sheet, documents R70 received a shower on 02/03/2026 and skin was reviewed by V29 (Certified Nursing Assistant), and toenail care was left blank with no documentation for yes or no. Facility's policy titled care of Fingernails/Toenails, with revised dated of February 2025, documents, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections; General guidelines:2).proper nail care can aid in the prevention of skin problems around the nail bed,3).Unless otherwise permitted, do not trim the toe nails of diabetic residents or residents with circulatory impairments,4).trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin,6) stop and report to the nurse supervisor if there is evidence of ingrown nails, pain, or if nails are too hard or thick to cut with ease; Documentation: the following information should be recorded in the resident's medical record,3)the condition of the residents nails and nail bed including pain, breaks or cracks especially between toes, corns or calluses, ingrown nails, any problems or complaints made by the resident with his/her feet,6).if the resident refuses treatment, the reason why and the intervention taken,7)the signature and title of the person recording the data.

Based on interview and record review, the facility failed to refer one resident (R71) who has a serious mental illness was referred to the appropriate state agency for a Level 1 PASRR (Pre-admission Screening and Resident Review) evaluation and failed to refer one resident (R12) to the appropriate State Agency for evaluation after being diagnosed with a serious mental illness. This deficient practice affected two residents (R12 and R71) in a total sample size of 50 residents.Findings Include: 1.On 2/2/2026 at 10:43 am, R12's Preadmission Screening and Resident Review (PASRR) I and II were not noted in R12's electronic health record. R12's PASRR Level I and Level II were requested from V4 (Admissions Director/Business Office Manager). On 2/4/2026 at 11:38 am, V4 (Admissio. Director/Business Office Manager) stated R12 has a serious mental health condition of schizoaffective disorder; has a Preadmission Screening and Resident Review (PASRR) Level I with a determination to refer for a PASRR Level II onsite; and was referred to the referral agency for level II but the referral agency cancelled the level II. V4 stated she is responsible for PASRR's during admission and if a required level II is triggered, Social Services is responsible; R12 should have had a PASRR Level I and Level II on admission and when the required PASRR Level II is not completed, a resident may not receive the needed services. V4 stated R12's PASRR Level II was completed today, 2/4/2026. On 2/4/2026 at 11:49 am, V6 (Social Services Director-(SSD) stated currently, the admission Director handles Preadmission Screening and Resident Review screenings (PASRR). The facility is behind on several tasks; another SSD from a sister facility will be training her soon on PASRR screenings. PASRR screenings ensure residents with mental health diagnoses are appropriate for the facility and the facility can provide appropriate care according to the resident's diagnosis. On 2/4/2026 at 2:17 pm, V1 (Administrator) stated R12 should have both a Preadmission Screening and Resident Review (PASRR) Level I and Level II for his diagnosis of Schizoaffective Disorder. PASRR Level I is completed by the Business Office Manager to identify mental health needs before admission or a few days after admission; PASRR Level II is completed by the Social Service worker or Director. If level I triggers it is based on diagnosis and behavioral history. The purpose is to ensure appropriate care and services for residents with serious mental illness. 2.R71's medical diagnoses include but are not limited to schizoaffective disorder, depression, generalized anxiety disorder, cocaine abuse, and hypertensive heart disease with heart failure. R71's admission date to the facility is documented as 02/28/19. R71's PASSR I provided by the facility is dated 02/02/26. R71's PASSR II provided by the facility is dated 02/02/26. On 02/04/26 at 10:41am, V4 (Business Office Manager/Admissions Director) stated R71's PASRR was submitted on 02/02/26 after surveyor requested to review R71's PASRR. V4 stated she is responsible for making sure that residents have a PASRR done prior to or on admission. V4 stated the PASRR evaluation is important because it tells the facility how to assess and treat the resident. On 02/02/26 at 11:55am, V2 (Director of Nursing/DON) stated every resident should have a PASRR done to make sure the resident is appropriate for the facility. V2 stated PASRR's give the facility direction on how to care for the residents. Facility's policy titled Pre-admission Screening and Resident Review), revised date 12/2023, documents, Background: In accordance with Federal and State of Illinois regulatory standards and recommended practices, this organization requires each resident to be screened for Level I prior to or shortly thereafter admission. The facility will expect Maximus to properly complete the Level 2 is a PASRR condition (SMI (Serious Mental Illness)/ID (Intellectual Disability) exists. The facility works to obtain Pre-admission Screening documents prior to the individual's arrival at the facility. Facility staff, as indicated, will provide information to help Maximus complete the Level 2 interview/screen. Policy: it is the policy of this facility to: 1. Comply with Federal, State and the appointed screening agency, maximus, in standards addressing the PASRR assessment/screening process. 2. Request full and complete PASRR materials (Level 1 and 2) from each referral source prior to or soon following admission. Procedure: 1. A facility representative shall request the complete screening from the referral source. 3. The hospital/screening agency/referral source may be contacted, as indicated and asked to provide any missing or incomplete documents.

Based on observation, interview, and record review, the facility failed to ensure the call light for two residents (R7, R85) was within reach. This failure affected 2 residents out of a sample size of 50.Findings include:1.R7 has a diagnosis of but not limited to Bilateral primary Osteoarthritis of Hip, Hemiplegia and Hemiparesis, Type 2 Diabetes Mellitus, Cerebral Infarction, and Hypertensive Heart Disease.R7 has a Brief Interview of Mental Status score of 15, indicating cognition is intact.R7's Minimum Data Set, dated 1/1/2026, documents, Roll left and Right: 02 Substantial/maximal assistance-helper does MORE THAN HALF the effort.R7's care plan focus: Falls, dated 10/01/2025, documents, keep call light in reach at all times.2.R85 has a diagnosis of but not limited to Chronic Obstructive Pulmonary disease, Schizophrenia, Hypertensive Heart Disease, Dementia, and Major Depressive disorder.R85 has a Brief Interview of Mental Status score of 07, indicating severe cognition impairment.R85's R7's Minimum Data Set, dated [DATE], documents, roll left and Right: 05-Setup or clean-up assistance: Helper sets up or cleans up.R85's care plan focus: Falls, dated 09/22/2025, documents, keep call light in reach at all times.On 2/01/2026 at 10:12am, R7's and R85's call light strings were hanging behind the bed on the wall where the residents could not reach it.On 2/01/2026 at 10:41am, V22 (Licensed Practical Nurse-LPN) stated call lights should be within reach of the resident.On 2/04/2026 at 9:34am, V2 (Director of Nursing) stated, Call light should be within reach of the resident so they can let us know if they need assistance.Policy titled Answering the Call Light, with a revised date of October 2025, documents, the purpose of this procedure is to respond to the resident's requests and needs, and when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.Undated Job description titled Certified Nursing Assistant documents, Ensure that all residents have access to call lights throughout each shift.

Based on observation, interview, and record review, the facility failed to include the required elements (date and census) on the daily nursing staffing post. This failure affected all the 134 residents residing in the facility.Findings include:On 2/1/26 at 9:18 am, surveyor observed the facility daily staff posting displayed in a clear case, on the wall, with no date and census.On 2/04/2026 at 11:04am, V28 (Licensed Practical Nurse) stated he s responsible for completing and posting the daily staff posting daily. V28 stated it should include the date and the census. V28 stated on the weekends, no one posts it because he doesn't work on the weekends. Policy Posting Direct Care Daily Staffing Numbers, with a revised date of February 2025, documents, our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents and at the beginning of each shift facility shall post the nurse staffing data as required by state and federal regulations, and Staff staffing information shall be recorded on the form provided by the facility's Administrative for each shift. The information recorded on the form shall include: b. the date for which the information is posted, and c. the resident census at the beginning of the shift for which the information is posted.

Based on interview and record review, the facility failed to keep three residents (R2, R3, R4) free from abuse for three of four residents reviewed for abuse. This failure resulted in R2 losing a dental implant and a tooth, R3 sustaining an upper lip laceration, and R4 complaining of headache after being kicked to the head. Findings include: 1. R1's Resident Face Sheet documents diagnoses of schizoaffective disorder, bipolar type; anxiety disorder; and bipolar disorder. R1's Care Plan documents R1 experiences delusions (8/22/2024). V12's (Psychiatric Rehabilitation Services Coordinator) progress note for R1, dated 1/16/2025 10:31 PM, documents R1 was involved in a physical altercation with co-peer. R1 displayed agitated and aggressive behavior with delusions. Facility's Incident Report Form, dated 1/21/2025, documents an incident between R1 and R2 that occurred on 1/16/2025 at 9:10 PM. During facility's investigation, R2 stated R1 came into R2's room and hit R2 in the face, causing an implant tooth to fall off. R2 stated R1 was deeply delusional. On 5/21/2025 at 11:21 AM, R1 stated, [R2] instigated the fight. R1 stated R2 entered R1's room first trying to look for R5. R1 was unclear as to what happened next, but stated getting angry and following R2 back to R2's room. R1 stated, Whatever compelled me to do it, I punched [R2] in the mouth, and I guess [R2's] tooth fell out. On 5/21/2025 at 11:52 AM and during a follow-up interview at 1:45 PM, R5 stated R5 was hanging out with R1 earlier in the evening in the lobby. R1 and R5 were sitting at a table near the elevator talking about religious, magical, and spiritual stuff. R2 was sitting at a nearby table and told R5 to come sit with R2 instead. R5 stated R1 felt emotional that day and was upset that R5 was spending more time with R2 instead of R1. R5 stated R1 got up and left to go upstairs. R2 and R5 then went to R2's room to hang out. R5 stated, That's when [R1] came into [R2's] room and said something like 'you don't pay kindness with evilness.' Then [R1] punched [R2] in the face. R5 stated R1 punched R2 with a closed fist. On 5/21/2025 at 2:09 PM, V4 (Certified Nurse Aide) stated V4 was sitting in a chair near the nurses station when R2 stated, [R1] punched me, and I lost my tooth. V4 stated R2 had a little blood near the mouth. V4 recalls providing R2 with paper towel for R2's bleeding mouth and helping R2 locate missing teeth. V4 described R2 being a a little bit in distress. On 5/21/2025 at 3:15 PM, V8 (Nurse) stated V8 was at the nurses station when R2 reported lying in bed talking to another resident when R1 came in and hit R2 in the mouth. V8 stated R2 lost the top front tooth and had a bloody mouth. V8's associated progress note, dated 1/16/2025 10:38 PM, documents R2 had bleeding to oral cavity. V8 stated facility sent R1 to the hospital for psychiatric evaluation, and R2 for medical evaluation. R1's hospital papers for service date of 1/17/2025 documents aggressive behavior. R1 endorsed feeling possessed. R2's hospital discharge instructions, dated 1/17/2025, documents diagnoses of dental injury. R2 received new order for chlorhexidine topical orally two times a day and dental referral. V17's (Psychiatric Rehabilitation Services Coordinator) well-being progress note for R2, dated 1/18/2025 8:10 PM (post hospitalization ), documents R2 at times felt self-conscious about R2's own physical appearance due to missing two of R2's teeth. During a telephone interview with V14 (Previous Administrator/Abuse Coordinator) on 5/22/2025 at 12:42 PM, V14 stated R1 was having delusional moments that morning. Just before the incident, R1 heard internal commands and that's when R2 sustained the hit in the mouth that caused the implant to fall out. V14 stated facility is assisting R2 with dental follow-ups. R2's dental paperwork, dated 2/05/2025, documents broken implant to tooth #9. During a telephone interview on 5/23/2025 at 10:03 AM, V16 (Dentist) stated R2 reported getting punched in the face and sustaining dental injury. V16 stated R2 was missing an implant that was in the front, upper mouth (tooth location #9) and a normal tooth next to it (tooth #10). V16 stated R2 has solid bone and gum health. V16 stated it will take quite a bit of force and some pretty serious impact to cause R2's teeth (implant and regular tooth) to come out like that. V16 referred R2 to a periodontist for further evaluation. Once cleared, V16 stated R2 will need a bridge and crown to replace the teeth. 2. Facility's Incident Report Form, dated 5/09/2025, documents R3 and R4 reporting abuse on 5/04/2025 at around 1:20 PM. R3 had small redness to mouth area. On 5/21/2025 at 11:44 AM, R4 stated roommate was R3. R4 returned to the bedroom and found R3 on R4's side of the room holding R4's TV remote control. R3 went back to R3's bed and laid in the bed with R4's remote in hand. R4 came over to R3's side and tried to snatch the remote control off R3's hand, but it fell on the floor. R4 stated, I tried to grab it but [R3] kicked me in the face, so I punched [R3] in the head. I hit [R3] in the head three times for kicking me in my face. R4 stated R4 hitt R3 with a closed fist. On 5/21/2025 at 11:56 AM, R3 stated R4 liked leaving the TV on even when R4 wasn't in the room. R3 stated the incident started because R3 turned off R4's TV. R4 got mad and punched R3 in the mouth with a closed fist multiple times. R3 pushed R4 off with foot to get R4 away. Once R4 stopped punching, R3 left and told the nurse. R3 stated R3 sustained a bloody lip to the top right side. On 5/22/2025 at 10:06 AM, V6 (Certified Nurse Aide) stated V6 interviewed R3 after the incident. R3 reported R4's TV was loud, so R3 took R4's remote and turned it down. R3 said R4 came into the room shortly after, got mad, and started punching R3 in the face. R3 told V6 R3 kicked R4 during the incident. V6 stated R3 was shook up and mostly scared. During a telephone interview with V10 (Nurse) on 5/22/2025 at 10:37 AM, V10 stated V10 was at the nurses' station when R3 complained R4 struck R3 on the face around the mouth. Upon assessment, V10 noted redness to the upper part of R3's lip. R3's hospital records from 5/04/2025 document small laceration on the mucosal aspect of the upper lip. R4's hospital records from 5/04/2025 document R4 reported being kicked to the right side of the head. R4 complained of a little headache on the right side. On 5/22/2025 at 11:22 AM, V2 (Director of Nursing) stated the facility is responsible for each residents safety in the building. Staff are to prevent abuse through close monitoring and knowing where the residents are and their behaviors. Facility's Resident Rights Guideline (last revised 10/2024) documents residents have the right to be from abuse. Facility's Abuse Prevention Program (01/2025) documents the facility affirms the right of their residents to be free from abuse. The facility therefore prohibits abuse and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on observation, interview, and record review, the facility failed to establish an environment that promotes resident sensitivity and safety and prevention of mistreatment for one resident (R3) out of four residents reviewed for abuse. Findings include: R3 is [AGE] years old, initially admitted in the facility on 10/08/2015. R3 medical diagnosis includes schizoaffective disorder, bipolar, psychosis. Per Minimum data Set (MDS) assessment, dated 04/02/2025, R3 has a score of 12; R3 has moderate impairment of his cognition. R4 is [AGE] years old, initially admitted in the facility on 07/12/2024. R4 medical diagnosis includes schizoaffective disorder, bipolar type, anxiety disorder, psychosis. Per Minimum Data Set (MDS) assessment; dated 04/11/2025, R4 has a score of 7; R4 has severe impairment of his cognition. Per clinical notes, R4 had multiple behavioral concern involving staff and other residents. R4 was given antipsychotic medication Haloperidol injection multiple times to manage behavior. Review of R4's notes for the month of March and April 2025, it documents as follows: - Dated 04/24/2025 by V4 (Licensed Practical Nurse) documents, R4 agitated and yelling to himself. - Dated 04/19/2025 by V9 (Licensed Practical Nurse) documents, R4 noted with increased aggression, screaming and pacing the hallway, unable to redirect. - Dated 03/28/2025 by V10 (Licensed Practical Nurse) documents, R4 physically aggressive towards members of the staff during breakfast. R4 was sent to the hospital due to his behavior. - Dated 03/17/2025 by V4 documents, R4 has increased in aggression towards the members of staff and peers during breakfast. He was observed screaming, yelling and tried to have a physical fight with a member of staff. - Dated 03/09/2025 by V9 documents, R4 noted with increased agitation, screaming, singing very loud and attempted taking food off other resident's plates at lunch in the lobby. V13 (Former Social Service) document, R4 taking food from other residents. - Dated 03/04/2025 by V12 (Former Director of Nursing) documents, R4 has behavior of snatching food off other residents' plates and tampering with the fire alarms. - Dated 03/02/2025 by V4 documents, R4 was agitated towards peers during breakfast. - Dated 03/02/2025 by V14 (Psychiatric Nurse Practitioner) documents, The staff reported that R4 continues to intermittently displays verbal aggression and agitation towards peers without provocation, remains in need of Haldol (antipsychotic medication) for agitation. On 04/10/2025 per census history, R3 was transferred in the same room with R4. On 04/30/2025, an abuse incident happened between R3 and R4. Incident document an allegation of abuse involving R3 and R4 was noted. Per V4 (Licensed Practical Nurse) clinical notes, dated 04/30/2025, R3 had physical incident with R4. Facility's investigation includes interview log/written statement by facility staff, it documents as follows: - R3 stated he was laying when R4 came at him. R3 stated, I didn't do nothing. I mean (R4) has never been like this. I am okay though, what's wrong with him? - R4 unintelligible things was noted on R4's interview. - V5 (Social Service Director) stated, I was walking the hall when I heard something and got to the room and found (R4) stripped and out of it. It was around 03:00 PM shift change. V2, Director of Nursing, stated, I was on the floor when I saw (V5 )run towards the room. I followed and we immediately intervened when we got to the room. V4 (Licensed Practical Nurse) stated, I saw everyone rush towards the room and (R4) came out naked, we redirected him, and he got dressed and was on close monitoring. On 05/06/2025 at 1:40 PM, R3 was able to express his thoughts clearly within topic during conversation. R3 stated R4 tried to put up a fight. Then R4 started hitting him on the back of his head, also on his ribs. R3 was asked if he got injuries because he was hit by R4. R3 replied, yes, on my ribs. R3 lift his shirt showing his ribs. R3 said, I don't know if you can see any injury. I don't know what started it at all. We have been roommates for weeks or less than a month. I did not hit him back. I tried to push him away. R3 was asked if he feels safe? R3 replied, I feel safe, for now. R3 was asked what he means for now. R3 did not elaborate. R3 was asked how he feels if R4 is around. R3 did not answer. On 05/07/2025 at 9:13 AM, V5 (Social Service Director) stated R4 has had behavioral problems in the past, including aggressive behavior towards staff and other residents. Per V5, R3 did not say R4 hit him. V5 stated R3's cognition is intact and able to describe what happened; R4 has severe impairment of his cognition. V5 was asked the reason why R3 was transferred in the same room with R4? V5 said, I do not know the reason why he was placed into the same room with (R4). V5 stated staff monitors residents, but incidents that happened between R3 and R4 happened fast. V5 stated placing himself to R3's situation, being with a person who have aggressive behavior, will make him feel indifferent. V5 was asked what are interventions placed by facility for R3 and R4 to prevent incident of abuse from happening? V5 reviewed R3's full care plan, then stated there is no care plan or intervention seen related to abuse prevention. V5 then reviewed R4's care plan and pointed to the care plan for behavioral symptoms, dated 03/28/2025. When R4 displays physical behavior directed towards others (staff) resulting to R4's involuntary hospitalization . On the care plan interventions, it documents R4 needs to be separated from other person as needed due to his behavior. V5 was asked why R3 brought into the same room with R4 since care plan intervention documents R4 needs separation as needed due to his behavior? V5 stated he does not know the answer. Another care plan intervention for R4's behavior was for social service to assess R4 for aggression. V5 stated, I think he (R4) was assessed. Per Aggression Risk Review, dated 04/30/2025, R4 was assessed to have physical aggression. Although R4 has multiple documentation of aggression, R4 was assessed without aggressive combative incidents. There was no aggression assessment done from the date of care plan intervention, dated 03/28/2025, to actual abuse incident when R4 hit R3 on 04/30/2025. On 05/07/2025 at 09:41 AM, V1 (Administrator) stated during the incident, she was talking to V5 (Social Service Director). V1 stated R3 told her R4 hit him on his right shoulder. V1 stated incident happened quick. V1 said, It was so quick that next second (V5) said 'I had to go'. Next thing I know, it happened. It was really quick. V1 stated R3 and R4 room was placed near the nurse station for nursing staff to monitor. V1 was made aware the room was not close to nurse station. It is located near the elevator far from the nurse station. V1 stated, Is it not close to the nurse station? But they (R3 and R4) need to be monitored. V1 was asked why R3 was placed on the same room with R4? V1 stated, No, I don't know the background why they became roommates. V1 was asked if there were interventions in place to prevent incidents of abuse when R3 was transferred in the same room with R4? V1 stated, We usually go over those things in the meeting. V1 stated she wants to verify if R3 was transferred due to room change, which is facility-initiated or during readmission. V1 said, (R3) may be in the same room with (R4) not by facility-initiated room change. It may be due to direct re-admission from the hospital. Upon checking R3's record, transfer was initiated by facility due to bed change, not hospital readmission. V1 said, Oh, it was room change, not re-admission. Abuse Prevention Program Policy and Procedure, dated 01/2025, reads: This facility affirms the right of our residents to be free from abuse. This facility prohibits abuse; to do so, the facility has attempted to establish a resident sensitive and resident secure environment. This will be done by establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, identifying occurrences and patterns of potential mistreatment.

Based on observation, interview, and record review, the facility failed to procure proper written authorization to manage resident's trust funds for 2 residents (R1 and R4) out of 5 residents reviewed for financial management. This failure resulted in R1 displaying aggressive behavior due to lack of consent for the facility to manage personal trust fund, and R1 being hospitalized for aggressive behavior. Findings include: 1. R1 is [AGE] years old, initially admitted in the facility on 07/19/2024. R1 medical diagnoses includes major depression, bipolar disorder, anxiety disorder and post-traumatic stress disorder. R1 is cognitively intact with Brief Interview for Mental Status (BIMS) score of 15, dated 04/03/2025. On 05/06/2025 at 1:15 PM, R1 can clearly express her thoughts within topic during conversation. R1stated the facility was asking her to sign paperwork, but she refused, and the facility forged her signature that will make her check go to the facility. R1 stated she refused to sign the paperwork because she can manage her own money. R1 stated when she called Social Security, she was informed the payee is now the facility, and a bank was added into it. R1 stated she was very agitated because of what happened. R1 stated R1 saw an envelope on V3 (Business Office Manager) that has R1's name. When she tried to get it, V3 covered it. R1 said, I was angry and called her a liar. They had me out to the hospital. Clinical notes, dated 04/17/2025 by V8 (Licensed Practical Nurse), documents per clinical staff, R1 was noted with physical aggression towards staff, with increase agitation and crying spells, and loud disruptive behavior. R1 was unable to be redirected per staff. On 05/07/2025 at 10:10 AM, V3 (Business Office Manager/BOM) stated it is not necessary, or there is no need for authorization coming from resident for the facility manage resident funds. V3 said, When Social Security got information that the resident resided in the facility, they deposit the funds to the facility. V3 stated in R1's case, there was no authorization coming from R1 for facility to manage her personal fund. V3 stated roughly 98% of residents do not have authorization. V3 stated there is a form called rep payee. V6 (Administrative Consultant), who was inside the room during conversation with V3, stated it means representative payee. V3 was asked to present representative payee or any authorization form R1 consented in favor of the facility to manage her personal fund. V3 presented a form titled Authorization and Agreement to Handle Resident Funds by V7 (Outside Vendor/Managing Resident Funds) on the line where resident needs to sign was left blank. Under the line on the right side was written refused to sign. 2. On 05/07/25 at 10:10 AM, V3 did not present R4's written authorization form. Per V3, R4 does not have written authorization. V3 stated R4's fund is being managed by the facility receiving physical checks instead of electronic checks, and R4 did not sign the authorization form yet. Resident Personal Trust Fund Policy and Procedure, dated 05/15/2024, reads: Residents/Guardians or Residents' Persons of Authority desiring to have a personal funds account must authorize service by signing an authorization form. This form will be maintained in their Business Office file.

Based on observation, interview, and record review, the facility failed to ensure food is labeled, dated, and discarded after use by date/expiration date and failed to ensure reach-in refrigerator temperature, walk in refrigerator temperature and walk-in freezer temperatures were monitored 2 times per day. These failures have the potential to affect 138 residents living in the facility. The findings include: On 04/08/2025 at 9:22 AM, the reach-in refrigerator was inspected, and the following food items were found inside the refrigerator: *A container of nacho jalapeno peppers (1 gallon) with an open date of 02/08/25, and expiration date of 03/20/2025. V10, Dietary Service Director, said it should have been discarded. *A container of giardiniera mild pepper mix (1 gallon) with no open date and expiration date of 10/08/2025. *A container of sweet relish (1 gallon) marked with an open date of 04/07/2025, and no use by date. *A jar of creamy peanut butter (5lb) with no open date and the use by date was not readable. *A container of red western dressing (1 gallon) with an open date of 04/06/2025, and the use by date was not readable. *A container of silver source salad dressing (1 gallon) with an open date of 04/07/2025, and no use by date. *A container of yellow mustard (1 gallon) with an open date of 04/07/2025, and no use by date. *A jar of grape jelly (4 lb.) with no open date and no use by date. *A jar of red [NAME] (24 oz.) with the open date and the use by date smeared and not readable. Inspection of the dry foods/spice pantry was conducted with V10 (Dietary Service Director). The following food items were found: *A container of Cajun Chef Louisiana Hot Sauce (1 gallon) with the open date of 03/25/2025, and no use by date. *A container of Liquid Smoke Concentrated Sensory Hickory Sauce (1 gallon) with the open date of 02/18/2025, and no use by date. *A bottle of [NAME] Vinegar (1 gallon) with the opened date of 02/11/2025, and no use by date. *A bottle of Liquid Smoke Concentrated Sensory Hickory Sauce (1 gallon) with an open date of 10/02/2024, and no use by date. *A container of Black Pepper Ground (5 lbs.) with an open date of 03/25/2025, and no use by date. *A container of Parsley Flakes (1 lb.) with the open date of 10/29/2024, and no use by date. *A container of Light Chili Powder (80 oz.) with the open date of 09/03/2024, and no use by date. *A container of Italian Seasoning (2 lbs.) with the open date of 02/18/2025, and no use by date. *A container of Ground Nutmeg (16 oz.) with the open date of 03/18/2025, and no use by date. Inspection of the reach-in refrigerator temperature logs for the month of April 2025 documented no entries on evening temperature on days 04/01/2025 to 04/08/2025. The temperature log had no entries for the morning temperature for the date of 04/09/2025. Inspection of the walk-in refrigerator temperature logs for the month of April 2025 documented no entries on evening temperature on days 04/01/2025 to 04/08/2025. The temperature log had no entries for the morning temperature for the date of 04/09/2025. Inspection of the walk-in freezer temperature logs for the month of April 2025 documented no entries on evening temperature on days 04/01/2025 to 04/08/2025. The temperature log had no entries for the morning temperature for the date of 04/09/2025. On 04/08/2025 at 10:21 AM, V10 stated the cooks check the temperatures of the refrigerators and the freezers once per day, in the morning at the start of shift. V10 stated the cook documents the temperatures on the log only for the morning temperatures. V10 stated the cooks should be checking the temperatures 3 times per day, and not only once per day. Labeling and Dating Foods Policy (dated 2021) states: To decrease the risk of food borne illness and to provide the highest quality, food is labeled with the date received, the date opened and the date by which the item should be discarded. Refrigerated Foods Policy (revised 2017) states: Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by. Storage of Refrigerated Foods Policy (revised 2017) states: Air temperature inside the refrigerator is checked and recorded twice daily. The reading on both the external and internal thermometers is recorded.

Based on observation, interview, and record review, the facility failed to implement a plan to prevent Legionella (a bacteria that can cause a serious type of pneumonia/lung infection) growth in the facility's water system. This failure has the potential to affect all 137 residents residing in the facility. Findings include: On 04/08/2025 at 1:56 PM, V21 (Maintenance Director/Housekeeping Director) stated he has been working at the facility for approximately 5 months. V21 stated he does not have a plan in place to check the facility's water system for Legionella. V21 stated he does not have any documentation to show the facility has a plan in place to prevent Legionella in the facility. V21 stated he has been searching, and is unable to find any previous documentation to show the facility's water system has been tested for Legionella. V21 stated at his previous employment, he implemented Legionella water testing, but has not implemented Legionella testing and prevention at the facility. Facility census, dated 04/08/2025, documents a total of 137 residents reside in the facility. Facility policy, dated 2023, titled Prevention of Legionella and Other Waterborne Pathogen Outbreak documents, It is the policy of this facility to reduce Legionella Risk in the facility water systems to prevent cases and outbreaks of Legionnaires' Disease and other Waterborne Pathogens. Legionella can grow in parts of building water systems that are continually wet Facilities must be able to demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program. To reduce cases of Legionnaires' disease in health care facilities, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare certified healthcare facilities must develop and maintain water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. The directive has an immediate effective date. (https://www.ashrae.org/about/news/2017/cms-issues-directive-requiring-medicare-certified-healthcare-facilities-to-implement-and-maintain-legionella-prevention-policies)Legionella, the bacterium that causes Legionnaires' disease, .Legionella can pose a health risk when it gets into building water systems. Legionella first must grow (increase in numbers). Then it has to spread through small water droplets (aerosolization) that people can breathe in. (https://www.cdc.gov/legionella/wmp/overview/growth-and-spread.html) Seven key elements of a Legionella water management program are to: Establish a water management program team, describe the building water systems using text and flow diagrams; identify areas where Legionella could grow and spread; decide where control measures should be applied and how to monitor them; establish ways to intervene when control limits are not met; make sure the program is running as designed (verification) and is effective (validation) and document and communicate all the activities. (https://www.cdc.gov/legionella/wmp/overview.html) 45111

Based on observation, interview, and record review, the facility failed to discard medication without an expiration date in a cart serving 42 residents on the third floor; failed to follow pharmacy instructions on medication administration while administering an inhaler for one (R31) resident; failed to document medications as given for one (R55) resident; and failed to contact provider while administering late medications to one (R84) resident in a sample of 27. Findings include: 1. On [DATE] at 10:10 AM, V3(Licensed Practical Nurse-LPN) residents eMAR (Electronic Medication Administration) profile showed red on R55's medication profile for medications: Furosemide 40 Mg, Finasteride 5mg, Lisinopril 5mg, Memantine 10mg. V3 stated she gave the medication earlier, but forgot to sign as given. V3 stated the nurse administering medications should sign as soon as it is given to prevent medication error because another nurse might give the resident medication thinking it was not given, and it can also confuse the nurse giving the medication and not know if she/he gave the resident medications. V3 stated this can affect the resident if given medications double. V3 stated signing the medication as given prevents confusion and medication error. 2. On [DATE] at 10:20 AM, V4 (Licensed Practical Nurse-LPN) was administering Symbicort inhaler-two puffs to R31 back-to-back, and did not wait between puffs. V4 read the instructions on the medication label that documented, wait ,d+[DATE] seconds between puffs. V4 stated she waited two seconds before giving the second puff, and stated she should have waited between puffs as noted on the medication instructions to let the medication get absorbed properly in R31's body, so R31 can get the full benefits of the medication. 3. [DATE] at 11:00 AM, V5 (Licensed Practical Nurse-LPN) was administering medications to R84: Biktavy 200mg oral, Olanzapine 200mg oral, Folic Acid 1 tablet oral, Amantadine 100mg oral, Vit B-1(Thiamine) one tablet. V5 stated R84's medications were being administered late because R84 refused to wake up this morning. V5 stated medications should be given on time so that the resident can have therapeutic levels to promote management of their illnesses. V5 stated he should have notified the doctor when R84 refused his medications so that new orders can be given, or new administrations times can be given. 4. On [DATE], at 10:45 AM, 3rd floor medication cart and medication room reviewed with V11(LPN), and V2 (Director of Nursing). Observed in the cart: -A bottle of Ferrous Sulfate with open date of [DATE] written on the bottle. No expiration date was observed on the bottle. V2 stated medications without expiration dates should be taken out of the medication cart because it is not known if they are expired, and might not be therapeutic if given to the residents and can cause bad side effects. On [DATE] at 12:00 PM, V2(Director of Nursing) stated if a resident refuses medication, the nurse is supposed to notify the doctor, so the doctor can give orders and/or adjust the medications time, so that the resident can maintain therapeutic levels. V2 further stated nurses should read the instructions by pharmacy on the inhalers so that they can administer the medications as instructed on the medications label, so that the medication can be therapeutic to the resident. Medication Administration Policy dated [DATE] documents: -Medications shall be administered one (1) hour before/after of the medication schedule unless specifically ordered otherwise. -Medications shall be recorded on the MAR (Medication Administration Record) promptly after each administration by the individual who administered the drug. -Clarifications and/or questions related to administering medications will be directed to the next highest authority in the nursing service, and if needed the attending physician or pharmacist.

Based on observation, interview, and record review, the facility failed to provide a functioning call light system for eleven (R14, R22, R34, R47, R59, R64, R112, R118, R119, R133, R139) residents of 27 reviewed for call light. Findings include: On 4/8/25 at 12:55 PM, R133 was asked to activate the call light. The light bulb above R133's door did not light up, and there was no audible sound heard. On 4/8/25 at 12:58 PM, V18 (Certified Nursing Assistant) stated, There is a call light in each resident room. When it is pulled, it should light above the resident's door, and you should hear a sound. It also lights up at the nursing station panel. The call light is for emergency purposes; for the assistance of the resident. V18 pull the call lights in three resident rooms. Writer verified with V18 that no light came on over the door of the resident rooms. There was no audible sound heard, and the panel at the nursing station did not light up. On 4/8/25 at 1:10 PM, V2 (Director of Nursing) stated, The purpose of the call light is so the patient can get assistance when needed, to accommodate the patient's needs. If the resident feels sick, they can get assistance. The call light is kept in reach for emergencies and non-emergency purposes. If the call light system is not operating, then the patient cannot call to get help. I was not aware the system is not working. There must be a glitch in the system. V2 pulled the call lights in (3 resident rooms). No light came on over the door of the resident rooms, and no audible sound was heard when the call light system was activated from each room. On 4/8/25 at 1:22 PM, the call light system was activated in (resident room). The light over the door did not light up, and no audible sound was heard. On 4/8/25 at 1:32 PM, the call light system was activated in (resident room). The light over the door and the nursing station panel lit up, however, no audible sound was heard. On 4/8/25 at 1:40 PM, V19 (Certified Nursing Assistant) stated, Somebody was here last week looking at the call light system. We noticed there were no lights coming on and there was no sound. Currently there still is no sound from the system. The purpose of the call light system is if the resident gets sick and needs assistance. The CNAs (Certified Nursing Assistants) round hourly. On 4/8/25 at 1:51 PM, V5 (Licensed Practical Nurse) stated, Last week they were working on the system. We only saw the light on, with no audible sound. The purpose of the call light system is if someone needs help, we assist. We have to go quick to answer the call light. On 4/9/25 at 9:48 AM, V1 (Administrator) stated, My expectation is that staff are to do continuous check-ins in those areas identified with call light issues, and immediately notify maintenance in order to resolve the issue. Facility Call Light policy, 5/2024, documents: Equipment: Functioning call light.

Based on observation, interview, and record review, the facility failed provide privacy and confidentiality of personal information for one (R33) resident reviewed in a total sample of 27. Findings include: R33's facesheet documents R33 is a [AGE] year-old male admitted to the facility on [DATE], with diagnoses not limited to: Hemiplegia, cerebral infarction, schizoaffective disorder, glaucoma, lack of coordination, unsteadiness on feet, heart failure, and malignant neoplasm of prostate. R33's MDS/Minimum Data Set, dated dated [DATE], documents R33 has a BIMS/Brief Interview for Mental Status of 11/15, indicating R33 is cognitively impaired. On 04/08/2025 at 11:53 AM, R33 was sitting in the dining room located on the second floor of the facility. R33 was sitting in a wheelchair wearing a white hospital wristband on his right wrist, which displayed R33's full name, date of birth, age, and medical record number. Record review of R33's electronic health record documents R33 was last admitted to the hospital on 03/18/2025, and returned to the facility on [DATE]. On 04/08/2025 at 12:31 PM, V2 (Director of Nursing/DON) observed the white hospital wristband on R33's right wrist. V2 was made aware of R33's full name, date of birth, age, and medical record number being displayed for anyone to see. V2 stated the wristband was placed on R33 in the hospital, and it should have been removed once R33 was admitted back to the facility. V2 stated R33 should not still be wearing the hospital wristband with his private health record information displayed. V2 stated this is a violation of HIPAA/Health Insurance Portability and Accountability Act, and V2 will get some scissors to cut R33's wristband off. Facility policy, undated, titled Health Information Management- Resident Information Privacy Protection documents, Policy: To assure that all resident-identifiable information maintained by the facility shall be confidential and disclosed only to authorized individuals. 45111

Based on interview and record review, the facility failed assert the right of the resident by searching a residents' room and personal property without the residents' knowledge and consent. This failure affects one (R33) resident in a total sample of 27 residents reviewed. Findings include: R33's facesheet documents R33 is a [AGE] year-old male admitted to the facility on [DATE], with diagnoses not limited to: Hemiplegia, cerebral infarction, schizoaffective disorder, glaucoma, lack of coordination, unsteadiness on feet, heart failure, and malignant neoplasm of prostate. R33's MDS/Minimum Data Set, dated dated [DATE], documents R33 has a BIMS/Brief Interview for Mental Status of 11/15, indicating R33 is cognitively impaired. On 04/08/2025 at 11:32 AM, V8 (Certified Nursing Assistant/CNA) was sitting on R33's bed, and V8's right hand inside of R33's nightstand located adjacent to R33's bed. V9 (CNA) was sitting in a chair at the foot of R33's bed, with a water container placed on R33's bedside table. R33's closet was open, and R33's clothing was exposed. R33 wass not located inside of his room at this time. V8 stated he is inside of R33's room because he is taking his lunch break. V8 was asked why his hand was located inside of R33's nightstand. V8 stated he was only looking, and stated he did not take any of R33's items. V9 stated this is her very first day working in the facility, and she is assigned to be trained by V8, and is shadowing V8's schedule. V9 stated R33's closet door was already open prior to V8 and V9 going inside of R33's room. V9 stated she was only drinking her water and sitting down waiting on further direction from V8. V8 stated he is aware that he should not be inside of any of the residents' rooms without their knowledge and while the residents are not located in their rooms. V8 stated he is not assigned to care for R33 today. V8 stated going inside of R33's nightstand is a violation of R33's rights. On 04/08/2025 at 11:53 AM, R33 was observed sitting in the dining room located on the second floor of the facility. On 04/08/2025 at 11:47 AM, V3 (Licensed Practical Nurse/LPN) stated all staff members have a designated break area located on the fourth floor of the facility. V3 stated staff should go to that break room whenever they take their assigned lunch breaks. On 04/10/2025 at 12:45 PM, V2 (Director of Nursing/DON) stated staff members should not be inside residents' rooms during their assigned breaks. V2 stated staff members should not be searching through residents' personal belongings without permission. V2 stated this is a violation of R33's resident rights. Facility policy, dated 10/2024, titled Resident Rights Guideline documents, Our facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each residents' individuality. The facility protects and promotes the rights of the residents.