Every finding on record at Aperion Care West Chicago

Based on interview and record review, the facility failed to protect a resident's right to be free from mental and physical abuse by a facility resident. This failure resulted in R4 experiencing psychosocial harm including flashbacks of prior abuse, sadness/crying, panic, fear of individuals walking into her room, and shame.This applies to 1 of 4 residents (R4) reviewed for abuse in a sample of 4. The findings include:Care plan, provided 6/17/26, showed R4's diagnoses included major depression, anxiety, bipolar disorder, depression, dissociative and conversion disorder, The care plan showed R4 was at risk for abuse due to a history of abuse, poor insight and judgement. The care plan showed R4 was at risk for suicidal issues and had a history of voicing suicidal thoughts and/or intentions and had a history of a suicide attempt.MDS (Minimum Data Set), dated 4/6/26, showed R4's cognition was intact.Facility Final Abuse Investigation Report, dated 6/9/26, showed, On 6/3/26 resident [R4] reported that at times while interacting with peer resident [R3] he would sometimes take hold of her hand. The report showed R4 stated R3 would sometimes grab hold of her hand and R4 would prefer being separated from him before his behavior escalated. The document showed R3 would sometimes take hold of R4's hand but only in a playful manner.On 6/17/26 at 2:45 PM with V7 (Social Services) present, R4 stated her friend saw R3 hit R4's hand and her friend encouraged her to report the incident to V7. V7 and R4 both stated they reported the allegation to V1 (Administrator) immediately. R4 demonstrated the hit she experienced by R3 as her hand resting flat on a hard surface and R3's closed fist pounding down on the top back of R4's hand. V7 stated after R3 was sent to the hospital for his behaviors, R4 began to disclose more allegations of abuse by R3 because R4 was less afraid with R3 being out of the building. V7 stated R4 reported R3 slapped R4 in the face, R3 put an umbrella up to R4's forehead and pushed the button to automatically open the umbrella hitting R4's forehead, R3 was verbally abusive to R4 (calling her multiple cuss words), R3 belittled R4, and R3 bent R4's friend's fingers backward. R4 and V7 both stated they reported the more recent allegations immediately to V1 and V2 (Administrator in Training). V7 stated she was shown the facility abuse investigation final report and stated there were bits and pieces of information that she reported that were not in the report, including R4 being hit in the face. V7 stated R4 came to her office frequently after the allegation for counseling because R4 became fearful of R3. R4 stated she cried frequently for several days after her initial allegations including when people would come into her room through the door. R4 said she was afraid it was R3 walking into her room. R4 stated she still became afraid, startled, panicked, and shocked every time the door opened to her room. R4 stated, That triggers me. V7 stated R4 frequently visited V7's office for assistance processing the shameful feelings she experienced.On 6/17/26 at 1:25 PM, V3 (Psychiatric Nurse Practitioner) stated she was told R4 alleged R3 was rough with R4 and R3 slapped R4's face and R4 became upset and scared of R3. V3 stated R4 told a female peer who told R4 to tell facility staff about the abuse. V3 stated R4 alleged the rough handling by R3 had happened for some time and was escalating with R4 becoming fearful of R3. V3 also stated R4 reported R3 could be rough during intercourse and R3 would verbally make statements toward R4 that R4 did not like.Review of R4's clinical record showed a Psychiatric Nurse Practitioner progress notes written by V3, dated 6/3/26, showed, [R4] is seen today had a stressful event recently with a male peer with whom she was having a long-term relationship. She states the male is physically too aggressive and when she told him to stop, he continued. She has past trauma from prior relationship abuse. She told another peer and that peer disclosed the incident to the staff. The two are now separated and [R4] is seen in the dining area. She is tearful but feeling safe at the moment. She does not want to see or speak to this peer again. Psychiatric Nurse Practitioner notes dated 6/10/26, showed R4 was still having some intrusive thoughts and ongoing anxiety from the most recent events. Patient had a consensual relationship with another male peer at the facility which is now done. She is having residual anxiety form the separation but knows she did the right thing. R4's psychotherapy counseling notes, dated 6/8/26, showed R4 recently reported flashback of abuse by her male peer. R4 was tearful, sad, and angry at male peer whom she had a relationship with until he became abusive. Psychotherapy notes, dated 6/11/26 and 6/13/26, show R4 was experiencing labile mood and depression. The 6/11/26 note shows R4 experienced increased flashbacks of previous abuse and has been retraumatized. The 6/13/26 note shows R4 reported her flashbacks continued and were lessening slowly. Psychotherapy counseling note, dated 6/16/26, showed R4 was less tearful sad and angry at her male peer. Review of R3's clinical record showed a Psychiatric Nurse Practitioner progress note, dated 6/3/26, written by V3 showed, It is reported by a fellow peer that [R3] grabbed her forcefully and slapped her on the face. Patient is denying that this occurred did admitted to playing with her aggressively but said he was not trying to hurt her. He feels remorse and is upset when she told on him. [R3] then verbally threatened to end her life and his life. R3 was then placed on 1:1 monitoring and sent to the psychiatric hospital.Facility Abuse Prevention and Reporting - Illinois, revised 10/25/20, showed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interviews and record reviews the facility failed to report resident allegations of abuse.This applies to 1 of 4 residents (R4) reviewed for abuse in a sample of 4.The findings include:Care plan, provided 6/17/26, showed R4's diagnoses included major depression, anxiety, bipolar disorder, depression, dissociative and conversion disorder. The care plan showed R4 was at risk for abuse due to a history of abuse, poor insight and judgement. The care plan showed R4 was at risk for suicidal issues and had a history of voicing suicidal thoughts and/or intentions and had a history of a suicide attempt.MDS (Minimum Data Set), dated 4/6/26, showed R4's cognition was intact.On 6/17/26 at 2:45 PM with V7 (Social Services) present, R4 and V7 both stated between 6/3/26 and 6/8/26, they reported allegations R3 hit R4's hand, slapped R4's face, opened an umbrella toward R4's forehead hitting R4, was verbally abusive to R4, and bent R4's friend's fingers backward to V1 (Administrator) and V2 (Administrator in Training). V7 stated R4 demonstrated to V1 how R3 hit R4's hand to V1 and V2 at the time of the report. V7 stated she was shown the facility abuse investigation final report and stated there were bits and pieces of information that she reported that were not included in the report, including R4 being hit in the face. On 6/17/26 at 1:25 PM, V3 (Psychiatric Nurse Practitioner) stated she was told R4 alleged R3 was rough with R4 and R3 slapped R4's face and R4 became upset and scared of R3. V3 stated R4 told a female peer who told R4 to tell facility staff about the abuse. V3 stated R4 alleged the rough handling by R3 had happened for some time and was escalating with R4 becoming fearful of R3. V3 also stated R4 reported R3 could be rough during intercourse and R3 would verbally make statements toward R4 that R4 did not like. Psychiatric nursing notes, dated 6/8/26, showed R4 was tearful, sad and angry at male peer whom she had a relationship with until he became abusive. Facility Final Abuse Investigation Report, dated 6/9/26, showed, On 6/3/26 resident [R4] reported that at times while interacting with peer resident [R3] he would sometimes take hold of her hand. The report showed R4 stated R3 would sometimes grab hold of her hand and R4 would prefer being separated from him before his behavior escalated. The document showed R3 would sometimes take hold of R4's hand but only in a playful manner. On 6/17/26 at 3:29 PM, V1 stated there were no other facility abuse investigation reports for R3 and R4 other than the initial report submitted to the regional office on 6/3/26 and final report submitted to the regional office on 6/9/26.On 6/17/26 at 2:00 PM, V1 (Administrator) stated he and V2 (Administrator in Training) interviewed R4. V1 said he was not aware of R4's allegation that she was slapped or was hit by R3 or his umbrella. V1 stated R4 told V1 that R3 would grab her hand and put her hand flat on a table, but V1 stated R4 did not mention R3 hitting her on her hand. V1 stated, I must have missed it.As of 6/17/26, the facility failed to show documentation they reported R4's allegations that R4 was slapped by R3, was hit by R3's umbrella, was called derogatory names by R3, and R3 hit R4's hand. Facility Abuse Prevention and Reporting - Illinois, revised 10/25/20, showed, All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on interviews and record reviews the facility failed to investigate resident allegations of abuse.This applies to 1 of 4 residents (R4) reviewed for abuse in a sample of 4.The findings include:Care plan, provided 6/17/26, showed R4's diagnoses included major depression, anxiety, bipolar disorder, depression, dissociative and conversion disorder. The care plan showed R4 was at risk for abuse due to a history of abuse, poor insight and judgement. The care plan showed R4 was at risk for suicidal issues and had a history of voicing suicidal thoughts and/or intentions and had a history of a suicide attempt.MDS (Minimum Data Set), dated 4/6/26, showed R4's cognition was intact.On 6/17/26 at 2:45 PM with V7 (Social Services) present, R4 and V7 both stated between 6/3/26 and 6/8/26, they reported the following allegations to V1 (Administrator) and V2 (Administrator in Training): R3 hit R4's hand, slapped R4's face, opened an umbrella toward R4's forehead hitting R4, R3 was verbally abusive to R4, and R3 bent R4's friends fingers backward. V7 stated R4 demonstrated to V1 how R3 hit R4's hand to V1 and V2 at the time of the report. V7 stated she was shown the facility abuse investigation final report and stated there were bits and pieces of information that she reported that were not included in the report, including R4 being hit in the face. On 6/17/26 at 1:25 PM, V3 (Psychiatric Nurse Practitioner) stated she was told R4 alleged R3 was rough with R4 and R3 slapped R4's face and R4 became upset and scared of R3. V3 stated R4 told a female peer who told R4 to tell facility staff about the abuse. V3 stated R4 alleged the rough handling by R3 had happened for some time and was escalating with R4 becoming fearful of R3. V3 also stated R4 reported that R3 could be rough during intercourse and R3 would verbally make statements toward R4 that R4 did not like.Facility Final Abuse Investigation Report, dated 6/9/26, showed, On 6/3/26 resident [R4] reported that at times while interacting with peer resident [R3] he would sometimes take hold of her hand. The report showed R4 stated R3 would sometimes grab hold of her hand and R4 would prefer being separated from him before his behavior escalated. The document showed R3 would sometimes take hold of R4's hand but only in a playful manner. On 6/17/26 at 3:29 PM, V1 stated there were no other facility abuse investigation reports for R3 and R4 other than the initial report submitted to the regional office on 6/3/26 and final report submitted to the regional office on 6/9/26.On 6/17/26 at 2:00 PM, V1 (Administrator) stated he and V2 (Administrator in Training) interviewed R4 and V1 was not aware of R4's allegation that she was slapped or was hit by R3 or his umbrella. V1 stated, I must have missed it.As of 6/17/26, the facility failed to show documentation they investigated R4's allegations that R4 was slapped by R3, was hit by R3's umbrella, was called derogatory names by R3, and R3 hit R4's hand.Facility Abuse Prevention and Reporting - Illinois, revised 10/25/20, showed, Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.

Based on interview and record review, the facility failed to keep residents free from verbal and mental abuse. This failure applies to 2 of 6 residents (R1 and R2) reviewed for abuse in a sample of 8 residents. The findings include: R1's EMR (Electronic Medical Record) shows R1 is a [AGE] year-old male with diagnoses that include a single episode of major depressive disorder, alcohol dependence in remission, insomnia, and peripheral vascular disease. R1's current care plan-initiated September 12, 2025, shows he has a history of verbal aggression and poor impulse control. R2's EMR shows R2 is a [AGE] year-old male with diagnoses that include anxiety disorder and problems related to social environment. On May 26, 2026, at 11:10 AM, R2 said there was altercation between him and R1 on May 14, 2026, at approximately 8:00 AM, in the dining room. R2 said R1 was teasing R5. He was making fun of his name by mispronouncing it. R2 said he could see that R5 was getting upset, so R2 asked R1 to stop it and pronounce his name correctly. A few minutes later, another resident, R6, jumped into the conversation and told R2 he heard R1 say he was going to get out of his chair and fight him. R2 said his response to R6 was that he would like to see R1 try it. R1 heard the comment and became angry and told R2 to bring it on you [profane derogatory name]. R2 stated R1 stood up and headed towards R2 to attack him. R2 said R1's words were verbally abusive and R1 was threatening to kill him. R2 said he was shaking and moving away when R1 attempted to attack him. R2 said R1 had threatened residents before, and he has seen R1 yelling and threatening other residents. R2 said he becomes nervous when R1 comes around during smoke breaks and he would be uncomfortable with R1 moving back to the floor he is located on. On May 26, 2026, at 12:32 PM, R1 said he and R2 had an altercation because R2 was up in his business. R1 said on May 14, 2026, in the dining room, R2 commented about R1 mispronouncing R5's name and this led to an argument. R1 said he was sitting across from V5 (Restorative Aide) talking and R2 was at another table staring him down. R1 said he stood up, threw off his jacket and lunged toward R2 and R2 said, C'mon I'm not afraid of you. R1 said he was going after R2. R1 said R2 fled, and he screamed out at R2 come back you little (profane derogatory name), I'll kick your ass. R1 said during the incident he went after R2 to throw a punch. On May 26, 2026, at 3:40 PM, R2 said since their altercation on May 14, he still gets paranoid each time R1 comes down for smoke breaks. R6 said she was present during R1 and R2's altercation and she heard R1 threaten to kill R2. On May 26, 2026, at 2:25 PM, V5 (Restorative Aide) said on May 14, 2026, he was sitting at a table with R1 in the dining area, facing and talking with R1. R2 was sitting at another table behind him when V5 said suddenly R1 stood up and threw off his jacket and moved towards R2 who was then standing behind him. V5 said he held R1 back from approaching R2 and R1 said to R2 I'll kill you. On May 26, 2026, at 11:59 AM, V3 (Psychosocial Rehabilitation Services Director) said on May 14, 2026, R1 and R2 had an altercation in the 1st floor common area. V3 said he responded to a code yellow (behavior code) that was called over the speaker system for an incident happening on the first floor. V3 when he arrived the staff had separated the residents. V3 went to R1's room where R1 was saying, someone needs to beat him up, he needs to learn. V4 (Psychosocial Rehabilitation Services Coordinator) was present during interview with V3 and said she was present during the incident between R1 and R2. V4 said R1 was verbally aggressive to R2, saying I'm going to (profane language) kill you or kick your ass. V3 said V5 and V7 (Restorative Aides) had to physically block R1 from attacking R2. R1 was attempting to push past staff. On May 26, 2026, at 3:01 PM, V1 (Administrator) said staff reported that R1 and R2 had a disagreement and that R1 became more escalated than R2. V1 said staff reported R1 and R2 were arguing over another resident. R2 didn't like what R1 said about R5, and they began arguing. V1 said staff stated the argument became heated. The facility's Abuse and Retaliation Prevention and Reporting Policy received May 26, 2026, shows: This facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse. Verbal Abuse is the use of oral or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident.

Based on interview and record review, the facility failed to report an incident of abuse to the State Agency. This failure applies to 2 of 6 residents (R1 and R2) reviewed for abuse in a sample of 8 residents. The findings include: R1's EMR (Electronic Medical Record) shows R1 is a [AGE] year-old male with diagnoses that included a single episode of major depressive disorder, alcohol dependence in remission, insomnia, and peripheral vascular disease who was admitted to the facility August 1, 2025. R1's current care plan-initiated September 12, 2025, shows he has a history of verbal aggression and poor impulse control. R2's EMR shows R2 is a [AGE] year-old male with diagnoses that included anxiety disorder and problems related to social environment who was admitted to the facility March 28, 2024. On May 26, 2026, at 11:10 AM, R2 said on May 14, 2026, at approximately 8:00 AM while in the dining room, R1 was teasing R5 by mispronouncing his name. R2 said you could see it was bothering R5, so R2 said he asked R1 to stop the behavior and state R5's name correctly. R2 said awhile later, R6 informed him R1 was going to get out of his chair and fight him. R2 said his response to R6 was that he would like to see R1 try it. R2 said R1 heard the comment and became angry saying to R2 bring it on you (profane derogatory name). R1 stood up and headed towards R2 to attack him. R2 said R1's words were verbally abusive and R1 was threatening to him. R2 said he was shaking and moving away when R1 attempted to attack him. R2 said R1 has threatened residents before, and he has seen R1 yelling and threatening other residents. R2 said he becomes nervous when R1 comes around during smoke breaks and he would be uncomfortable with R1 moving back to the floor he is located on. R2 said the incident was reported to V1 (Administrator) and V1 is aware of the whole situation. On May 26, 2026, at 12:32 PM, R1 said he and R2 had an altercation because R2 was in his business. R1 said on May 14, 2026, in the dining room, R2 made a comment about R1 mispronouncing R5's name and this led to an argument between them. R1 said he was sitting across from V5 (Restorative Aide) talking and R2 was at another table staring him down. R1 said he stood up, threw off his jacket and lunged toward R2 and R2 said, C'mon I'm not afraid of you. R1 said he was going after R2. R1 said R2 fled, and he screamed out at R2 come back you little (profane derogatory name), I'll kick your ass. R1 said he was out of line and outrageous during the incident. R1 said during the incident he went after R2 to throw a punch. On May 26, 2026, at 3:45 PM, R5 said on May 14, 2026, R1 was mispronouncing his name. R2 told R1 to stop and R1 replied he would call R5 whatever he wishes to. On May 26, 2026, at 3:40 PM, R2 said since their altercation on May 14, he still gets paranoid each time R1 comes down for smoke breaks. R6 said she was present during R1 and R2's altercation and she heard R1 threaten to kill R2. R6 said she was not interviewed by any staff or the administrator about the incident. On May 26, 2026, at 11:59 AM, V3 (Psychosocial Rehabilitation Services Director) said on May 14, 2026, R1 and R2 had an altercation in the first-floor common area, and a code yellow was called (behavior code). V4 (Psychosocial Rehabilitation Services Coordinator) said she was present during the incident and R1 was verbally aggressive to R2, saying I'm going to (profane language) kill you or kick your ass. V4 said R1 was attempting to go through staff to get to R2. On May 26, 2026, at 2:25 PM, V5 (Restorative Aide) said on May 14, 2026, he was sitting at a table with R1 in the dining area, facing and talking with R1, and R2 was sitting at another table behind him. V5 said suddenly R1 stood up and threw off his jacket then moved towards R2 who was then standing behind V5. V5 said he held R1 back from approaching R2 and R1 said to R2 I'll kill you. On May 26, 2026, at 3:01 PM, V1 (Administrator) said he interviewed V5 (Restorative Aide), V6 (Registered Nurse), V8 (Behavior Health Aide), V9 (Admissions Director), and V3 [NAME] (Psychosocial Rehabilitation Services Director) regarding the disagreement between R1 and R2 on May 14, 2026. V1 said staff reported that R1 and R2 had a disagreement, that R1 became more escalated than R2. V1 said he did not type these staff interviews. V1 said staff reported R1 and R2 were arguing over another resident, R2 didn't like what R1 said about R5, and they began arguing. V1 said staff did not report any swearing between the residents, just that the argument became heated. V1 said staff did not report any verbal threats were made during the incident, he did not receive any information about any attempts by R1 to swing at R2. Facility abuse investigation logs and reports from May 2026 were reviewed and did not include a report regarding an altercation between R1 and R2. On May 26, 2026, at 1:50 PM, V1 (Administrator) said he did not report the incident between R1 and R2 to the State Agency. On May 26, 2026, the facility provided their policy titled, Abuse and Retaliation Prevention and Reporting- Illinois that showed The facility affirms the right of our residents to be free from abuse. This facility is committed to protecting out residents from abuse. and mistreatment by anyone. Abuse: Abuse means any physical or mental injury. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents.regardless of an individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident. Mental Abuse includes, but is not limited to.threats of punishment.Any allegation of abuse. will be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Based on interviews and record review, the facility failed to investigate an incident of verbal and mental abuse. This failure applies to 2 of 6 residents (R1 and R2) reviewed for abuse in the sample of 8.The findings include:R1's EMR (Electronic Medical Record) shows R1 is a [AGE] year-old male with diagnoses that included a single episode of major depressive disorder, alcohol dependence in remission, insomnia, and peripheral vascular disease who was admitted to the facility August 1, 2025.R1's current care plan-initiated September 12, 2025, shows he has a history of verbal aggression and poor impulse control.R2's EMR shows R2 is a [AGE] year-old male with diagnoses that included anxiety disorder and problems related to social environment who was admitted to the facility March 28, 2024.On May 26, 2026, at 2:25 PM, V5 (Restorative Aide) said on May 14, 2026, he was sitting at a table with R1 in the dining area, facing and talking with R1. R2 was sitting at another table behind him when V5 said suddenly R1 stood up and threw off his jacket and moved towards R2 who was then standing behind him. V5 said he held R1 back from approaching R2 and R1 threatened to kill R2. On May 26, 2026, at 11:59 AM, V3 (Psychosocial Rehabilitation Services Director) said on May 14, 2026, R1 and R2 had an altercation in the first-floor common area. V3 said he responded to a code yellow (behavior code) that was called over the speaker system for an incident happening on the first floor. V3 when he arrived the staff had separated the residents. V3 went to R1's room where R1 was saying, someone needs to beat him up, he needs to learn. V4 (Psychosocial Rehabilitation Services Coordinator) was present during interview with V3 and said she was present during the incident between R1 and R2. V4 said R1 was verbally aggressive to R2, saying I'm going to (profane language) kill you or kick your ass. V3 said V5 and V7 (Restorative Aides) had to physically block R1 from attacking R2. R1 was attempting to push past staff.On May 26, 2026, at 11:10 AM, R2 said there was altercation between him and R1 on May 14, 2026, at approximately 8:00 AM, in the dining room. R2 said R1 was teasing R5. He was making fun of his name by mispronouncing it. R2 said he could see that R5 was getting upset, so R2 asked R1 to stop it and pronounce his name correctly. A few minutes later, another resident, R6, jumped into the conversation and told R2 he heard R1 say he was going to get out of his chair and fight him. R2 said his response to R6 was that he would like to see R1 try it. R1 heard the comment and became angry and told R2 to bring it on you (profane derogatory name). R1 stood up and headed towards R2 to attack him. R2 said R1's words were verbally abusive and R1 was threatening to kill him. R2 said he was shaking and moving away when R1 attempted to attack him. R2 said R1 had threatened residents before, and he has seen R1 yelling and threatening other residents. R2 said he becomes nervous when R1 comes around during smoke breaks and he would be uncomfortable with R1 moving back to the floor he is located on.On May 26, 2026, at 12:32 PM, R1 said he and R2 had an altercation because R2 was up in his business. R1 said on May 14, 2026, in the dining room, R2 made a comment about R1 mispronouncing R5's name and this led to an argument between them. R1 said he was sitting across from V5 (Restorative Aide) talking and R2 was at another table staring him down. R1 said he stood up, threw off his jacket and lunged toward R2 and R2 said, C'mon I'm not afraid of you. R1 said he was going after R2. R1 said R2 fled, and he screamed out at R2 come back you little (profane derogatory name), I'll kick your ass. R1 said during the incident he went after R2 to throw a punch.On May 26, 2026, at 3:40 PM, R6 said she was present during R1 and R2's altercation and she heard R1 threaten to kill R2. The facility provided their abuse investigation logs for May 2026 and there was no investigation including R1 and R2's altercation from May 14, 2026.On May 26, 2026, at 3:01 PM, V1 (Administrator) said the staff reported that R1 and R2 had a disagreement and that R1 became more escalated than R2. V1 said he did not type up interviews. V1 said the staff reported to him that R1 and R2 were arguing over another resident and R2 did not like what R1 said about R5 and they began arguing. V1 said the staff did not report swearing between the residents, just that the argument became heated. On May 26, 2026, the facility provided their policy titled, Abuse and Retaliation Prevention and Reporting- Illinois that showed The facility affirms the right of our residents to be free from abuse.This will be done by: implementing systems to promptly and aggressively investigate all reports and allegations of abuse.VII. Internal investigation 1. All incidents will be documents, whether or not abuse.2. Any incident or allegation involving abuse. will result in a proper investigation.

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from resident-to-resident physical abuse. This failure resulted in a resident experiencing severe shoulder pain with a possible fracture, and subsequent psychosocial harm. This applies to 1 of 2 residents (R131) reviewed for abuse in a sample of 38. The findings include: R131's Electronic Medical Record (EMR) indicated that progress notes, dated 1/18/2026, documents at approximately 10:15 PM, R131 was suddenly attacked by another male resident (R200) without provocation when R200 attempted to place his arm around R131's neck. V9 (RN) documented that he and another resident (R37) intervened and were able to separate the two residents, and that R200 stated, I'm not on for the 3rd floor (secure unit), adding, I'm here for murder, which was also heard by R131. On 1/20/2026 at 6:11 AM, V12 (LPN) documented that R131 reported 8/10 left shoulder pain, for which PRN Acetaminophen-Codeine was administered; assessment revealed stinging pain with upward shoulder movement. R131's Minimum Data Set (MDS) dated [DATE] reflects that his cognition was intact. R200's Orders-Administration Note by V9, dated 1/18/2026 at 11:33 PM, states R200 was agitated, impulsive, and aggressive toward another male resident. On 1/27/2026 at 10:37 AM, R131 was observed sitting in bed, holding his left shoulder and wincing in pain. R131 reported a history of chronic cervical and back pain from a decades-old accident but stated his left shoulder pain was new and began after the incident on 1/18/2026. R131 described his pain as severe, rating it as 8 to 10 out of 10 on the pain scale (with 10 being the worst pain he had ever experienced). R131 said he was holding a cup and standing in front of the ice machine when R200 suddenly charged at him, grabbed him, placed both arms around his upper torso, and put him in a headlock. R131 reported being caught off guard and unable to defend himself. He stated the pain in his left shoulder had not been relieved by his current pain medications and he had been requesting an X-ray and to be sent to the hospital to assess the injury. On 1/27/2026 at 10:48 AM, R145 (R131's Roommate) confirmed the events of the night of R131's attack. R145 said R37, another resident in their hallway, was the first to intervene to separate R200 from R131. R145 reported the incident was unprovoked and noted R131 appeared to be in significant pain and distress following the event. The staffing assignment sheet for 1/18/2026 indicated V8 (RN-Registered Nurse) was assigned as R200's nurse. V9 (RN) was assigned as R131's nurse, and V10 (CNA-Certified Nursing Assistant) was the CNA assigned to the unit that evening. On 1/28/2026 at 11:42 AM, V8 (RN) said on the evening shift of 1/18/2026, she heard screaming and observed R200 physically holding R131's neck area. V8 stated R200 had to be moved to the facility's secure unit due to his aggressive, unprovoked behavior towards R131. V8 classified the incident as physical abuse. On 1/28/2026 at 1:48 PM, V10 (CNA) said she saw R200 approach R131 and attack him. V10 stated R131 was screaming as R200 aggressively put his arms around R131's upper torso and shoulder area. V10 described the altercation as physical abuse. An X-ray was ordered, and the result was reported to facility on 1/28/2026. The result showed an acute or subacute glenoid fracture of the left shoulder. On 1/28/2026 at 10:48 AM, V13 (ADON-Assistant Director of Nursing) documented radiology results showing linear bone density inferior to the glenoid consistent with an inferior glenoid fracture fragment, prompting a physician order to send R131 to the hospital. V1 (Administrator) and V2 (DON-Director of Nursing) stated R131 returned to the facility without hospital paperwork and were unable to provide R131's hospital discharge paperwork prior to the end of the survey. On 1/29/2026 at 12:05 PM, R131 reported continued pain, rating it 8 out of 10 (severe), increasing to 10 out of 10 with sideward shoulder extension. R131 described the pain as unbearable. On 1/29/2026 at 12:27 PM, V36 (RN) assessed R131 and confirmed compromised ROM (Range of Motion) to his left shoulder and severe pain. On 1/29/2026 at 12:45 PM, R131 stated since the incident on 1/18/2026, he had been feeling on edge, anxious, and preoccupied with what had happened. R131 reported he remained deeply disturbed by R200's statement of I'm here for murder, which he had heard R200 say during the altercation. R131 stated R200's remark plays over and over in his mind and causes fear and distress. R131 state he was afraid of encountering R200 again and he was now hesitant to use common areas of the facility, including the ice machine and hallway where the abuse occurred. During the interview, R131 was observed pacing back and forth in his room, appearing restless and visibly tense when recounting the event. He stated his pain and fear made it difficult for him to sleep, he had been waking frequently at night, and he felt more depressed and withdrawn than usual. R131 reported he no longer felt safe in the facility and expressed concern a similar incident could happen again. On 1/29/2026 at 10:46 AM, an interview was conducted with V14 (In-house NP - Nurse Practitioner), and on 1/30/2026 at 9:37 AM, an interview was conducted with V34 (Psychiatric NP). Both stated pain is a subjective experience, meaning it is based on the resident's personal perception and report rather than solely on observable or objective findings. They emphasized regardless of a resident's mental or psychiatric status, if a resident reports pain, it must be taken seriously, appropriately assessed, and treated as real pain. V34 further explained that the symptoms reported to her regarding R131 following the 1/18/2026 altercation - including heightened anxiety, hypervigilance, disrupted sleep, and worsening mood - were not consistent with his baseline presentation. V34 explained that these symptoms are characteristic of an acute traumatic response to a threatening event, particularly when the resident continues to experience ongoing physical pain and fear of recurrence. V34 stated such a response can manifest as rumination about the incident, avoidance of common areas, sleep disturbance, emotional withdrawal, and increased distress, and may warrant additional psychiatric support, monitoring, or interventions. V34 further emphasized psychological distress, like pain, is a subjective experience, and clinicians must take a resident's report of distress seriously rather than discount it based solely on objective findings. On 1/28/2026 at 3:12 PM, V1 (Administrator) stated he reviewed the facility's security camera footage from 1/18/2026 and observed R200 making contact with R131. Per V1, the video showed R200 with his arms around R131 after approaching him from behind. V1 also confirmed he is the facility's Abuse Coordinator, and he was made aware of the incident on the night it occurred. V1 stated if a staff member had attacked a resident in the same manner as R200 attacked R131, he would consider that to be physical abuse and a reportable event. The facility's policy titled Abuse and Retaliation Prevention and Reporting (effective 1/8/2026) states, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish to a resident. The policy also showed Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment

Based on observation, interview, and record review, the facility failed to serve meals at palatable temperatures.This applies to all residents who receive food from the kitchen.The findings include:The CMS (Centers for Medicare and Medicaid Services) shows the survey start date of 1/27/26 and a resident census of 211. On 01/30/2026 at 2:39 PM, V2, DON (Director of Nursing), confirmed all residents residing in the facility at the time of survey start on 01/27/26 receive services from the Dietary department.On 01/27/2026 at 12:19 PM during the dining observation, R118 stated the food isn't always served to them while it is hot.R207 stated the food served is usually barely warm.R100 stated the meals are usually not served hot.On 01/27/2026 at 12:51 PM, R40 stated the food isn't usually served hot. R40 stated she will request staff to reheat her food, but she is told they can't reheat if for her. R40 stated staff will not get her a new tray from the kitchen, so she must eat it cold.On 01/28/2026 at 12:23 PM, food holding temperatures were done with V4, Dietary Director and V39 Cook. The following foods were noted held in degrees Fahrenheit (F): Broccoli- 100 degrees FSweet and Sour Pork carbohydrate-controlled Low Concentrated Sweets- 95 degrees FPlain Rice- 100 degrees FGrilled Cheese Sandwiches- 90 degrees FPureed Grilled Cheese- 120 degrees FCarrots- 120 degrees FPureed Broccoli- 120 degrees F On 01/27/2026 at 1:05 PM, the test tray sent to the conference room had two cookies, chili in a bowl, carrots, and crumbly corn bread on a Styrofoam plate.On 01/28/2026 at 12:23 PM, V4, Dietary Director, stated because of budget constraints, he is unable to purchase real plates, so the residents' meals are served on Styrofoam. V4 stated Styrofoam impacts how food temperatures are maintained. V4 stated there is no plate warmer and the delivery carts are not insulated, which also makes it difficult to maintain food temperatures. V4 stated there have been occasions he has gone to the units and meal trays are left unpassed up 20 minutes after being sent from the kitchen.The facility provided an undated policy which stated foods that are meant to be served and displayed for a long time require elevated temperatures for storage. Foods are held at 135 degrees F or above to stop the growth of harmful microorganisms and preserve food safety

Based on observation, interview and record review, the facility failed to store refrigerated resident food safely in the refrigerators on the units. This has the potential to apply to all 211 residents residing in the facility.Findings include:On 01/29/2026 at 2:59 PM, the second-floor small refrigerator (identified by V32 and V33 CNAs [Certified Nursing Assistants] as the supplement refrigerator) had no thermometer or temperature log. The supplement refrigerator contained:An opened 20 oz (Ounce) bottle of colaTwo opened cans of citrus sodaa clear plastic bag containing a bun wrapped in a paper towel with white crystal powdered substancea green apple with two brown bite marks wrapped in paper towels.A small plastic cup with vanilla pudding covered in plastic wrap without any dates or label.A 32oz (Ounce) carton of nutritional supplement without an open on or use by date.The larger refrigerator (identified by V32 and V33 as a staff and resident shared refrigerator) had no thermometer or temperature log. The refrigerator contained:A 15.4 oz cup of homestyle chicken noodle soup expired on 10/21/25.A pint of dried-up blueberriesAn unlabeled undated personal food container with rice and meat.An undated unlabeled take-out container with a noodle dish.An undated unlabeled personal container with vegetable pizza.An unlabeled undated personal container of asparagusAn unlabeled undated take-out container with bread, fettuccini [NAME] and shrimp. The container had a strong sour spoiled smell.A15.2 oz bottle of strawberry/banana no-sugar-added smoothie, expired on 1/24/25An unlabeled undated pizza sliced in a plastic zippered bag.V33 CNA. stated she was unaware of who is responsible for keeping the refrigerator clean and throwing out spoiled outdated food. The staff member that receives the food is responsible for labeling and dating the food item. V33 stated maintenance is responsible for updating the temperature log.On 01/29/2026 at 2:40 PM, V32 CNA. stated she did not know who is responsible for maintaining the refrigerator log or throwing out expired spoiled food items.On 01/30/2026 at 9:28 AM, V3 Maintenance Director stated everyone that uses the refrigerator is responsible for keeping it clean. V3 stated he did not know who was responsible for monitoring the refrigerator and the log or where they were kept once completed.On 01/30/2026 at 9:51 AM, V2 DON (Director of Nursing) the nursing staff are responsible for the refrigerators on the unit. Nursing staff are responsible for labeling and dating food items and completing the temperature log. If the thermometer is missing the nursing staff should have notified maintenance. Temperatures can't be logged without a thermometer. V2 stated she was unable to provide the requested twelve months of refrigerator temperature logs for any of the facilities unit refrigerators.On 01/30/2026 10:35 AM tested the unit refrigerators with a temperature gun. The 1st floor supplement refrigerator did have a thermometer. The temperature was 44 degrees F (Fahrenheit). The 2nd floor supplement refrigerator did not have a thermometer or temperature log was 45 degrees F. The larger refrigerator was 46 degrees F. The 3rd floor supplement refrigerator was 45 degrees F.On 01/30/2026 at 11:06 AM, V1 Administrator stated he did not have the last twelve months of temperature logs for refrigerators located on the nursing units.The facility policy Food from Family, Visitors, Community dated 2020 states food stored for residents should be labeled and dated appropriately and discarded per safe food storage guidelines. A facility may choose to utilize a specific refrigerator or area of cooler for resident food.The facility policy Food -Resident Pantry - Safe Storage dated 6/13/19 states to ensure that resident food items are stored in a manner that is sanitary and safe for consumption and to prevent contamination and spoilage refrigerators shall be maintained between 33 and 41 degrees. All resident foods and beverages, including alcoholic beverages shall be labeled with the resident's name and dated. If food or beverages are used for multiple residents, the date open shall be written on the container. Food items, condiments and liquids that are in the original container shall follow the expiration date on the container. Foods which are outdated or are not labeled and dated shall be discarded daily when cleaning. Employee food shall be placed in the employee refrigerator.

Based on observation, interview, and record review, the facility failed to administer and record individualized supplemental nutritional interventions for residents being treated for weight loss. This applies to 4 of 4 (R51, R8, R10, and R121) residents reviewed for nutrition in a sample of 38.The findings include:1. On 1/27/2026 at 10:10 AM, R51 was in bed and unable to recall if he had eaten breakfast. R51 was thin and frail. At 11:50 AM, V37 (Certified Nurse Assistant/CNA) said R51 skipped breakfast, and she was now going to inform the nurse.On 1/28/2026 at 9 AM, V38 (CNA) said she supervised R51 for breakfast, and he only ate his served scrambled eggs, which was approximately less than 50% of his meal.On 1/29/2026 at 8:35 AM, R51 was in bed, sleeping. R51 was fatigued and unsure if he had eaten breakfast. V32 (CNA) said R51 did not eat breakfast and had a history of refusing meals. V32 said she informed V18 (Licensed Practical Nurse/LPN). On 1/29/2026 at 8:40 AM, V18 (LPN) said R51 received an ordered nutritional supplement for his nutrition management. V18 said she administered the facility's house stock nutritional supplement and used the 5-oz (ounce) medication cup (which was approximately 148 ml/milliliters). V18 said the supplement order did not indicate the amount, and it was unclear what the serving volume should be. V18 said all the residents with orders for oral nutritional supplements did not indicate the amount that should be administered, it only indicated frequency instructions. V18 said the oral nutritional supplements were ordered by V19 (Dietitian). V18 continued to say she also administered R8, R10 and R121's nutritional supplements in the same 5-oz medication cup.R51's Nutrition Progress Note dated 9/17/2025, said R51 was assessed for significant weight loss, and was to continue with his nutritional interventions, including house stock nutritional supplement four times a day to supplement his oral intake.R51's Order Summary Report had an active order for House Nutrition Supplement four times a day 1 serving. R51's EMAR (Electronic Medication Administration Record) for January 2026 did not indicate the total amount administered and consumed of his ordered nutritional supplement.R51's care plan said he had a nutritional problem related to being underweight, a history of significant weight loss, dementia with mental health illness, and dysphagia. The interventions included Monitor intake and record.Provide supplements as ordered. 90 ml house supplements [twice daily]. 2. On 1/29/2026, R8 said he was losing weight and received a small medication cup filled with an oral nutritional supplement from the nurses. R8's Nutrition Progress Note, dated 1/15/2026, said R8 was assessed for significant weight loss, and was to continue with his nutritional supplement daily to supplement his oral intake. R8's Order Summary Report had an active order for House Nutrition Supplement in the morning one serving. R8's EMAR for January 2026 did not indicate the total amount administered and consumed of his ordered nutritional supplement.R8's care plan said he had a nutritional problem related to his recently identified significant weight loss and mental health disorders. There were no interventions regarding an oral nutritional supplement. 3. On 1/27/2026 at 12:30 PM, R10 was in the dining room for lunch. R10 was thin and frail. R10 was confused and unable to be interviewed regarding her nutrition.R10's Nutrition Progress Note, dated 1/06/2026, said she was assessed for her ongoing underweight status and recently downgraded diet, which had resulted in a diminished oral intake. The note said she was to continue with her nutritional supplement three times a day to supplement her oral intake. R10's Order Summary Report had an active order for House Nutrition Supplement three times a day one serving. R10's EMAR for January 2026 did not indicate the total amount administered and consumed of her ordered nutritional supplement.R10's care plan said she had a nutritional problem related to being underweight, a history of significant weight loss, severe mental health illnesses, and dysphagia. The interventions included Monitor intake and record.Provide and serve supplement as ordered 240 ml house supplement [twice daily]. 4. On 1/27/2026 at 12:15 PM, R121 was in the dining room for lunch. R121 was thin and frail. R121 was confused and unable to be interviewed regarding her nutrition.R121's Nutrition Progress Note, dated 10/17/2025, said she was assessed for additional nutritional support related to her new pressure injuries to promote wound healing.R121's Order Summary Report had an active order for House Nutrition Supplement one time a day. R121's EMAR for January 2026 did not indicate the total amount administered and consumed of her ordered nutritional supplement.R121's care plan said she had a nutritional problem related to being underweight, a history of significant weight loss, dementia, and dysphagia. The interventions included Give the resident supplement as ordered.120 ml house supplement [three times daily]. On 1/29/2026 12 PM, V2 (Director of Nursing/DON) said the facility's house stock oral nutritional supplement container that was used for all the residents, indicated a serving was 8 oz (which was approximately 236 ml). V2 said the nurses recorded the administration of the supplement in the residents' EMAR, but not the amount consumed. On 1/29/2026 at 12:05 PM, V19 (Dietitian) said R51, R8, R10, and R121 were monitored for weight loss and had standard orders for the facility's oral house stock supplement. V19 said the supplement order did not indicate the amount because at times, the available supplement product changed, but the order indicated instructions to administer a serving. V19 said the serving to be administered was based on the facility's container product instructions. V19 said nurses had to administer the ordered oral nutritional supplements to ensure the residents' nutritional interventions were being followed as ordered. V19 said it was also important that the amount consumed be recorded to ensure an accurate review of the residents' nutritional assessments.The facility's policy titled Fortified Foods, Supplements, and Snacks, dated 2020, said residents who cannot consume adequate amounts of regular foods at meals to meet their nutritional needs may be considered for oral nutritional supplements in order to increase their nutritional intake. Commercially prepared supplements and nutritional interventions may be ordered by the dietician or nursing staff and shall include specifications. Then the Registered Dietitian will then evaluate if the resident requires further nutritional interventions and if needed, will make additional recommendations. After the physician's approval, the individualized residents' care plans will be updated with their nutritional interventions and written in their MAR (Medication Administration Record). Additionally, the resident's tolerance of the supplement will be monitored, and the data will be collected in the resident's medical record.

Based on observation, interview, and record review, the facility failed to monitor, identify, and document side effects of medications, and failed to monitor for the therapeutic blood level of a medication.This applies to 4 of 5 (R82, R93, R182, and R51) residents reviewed for medications in a sample of 38.The findings include:1. R82 was admitted to facility on 11/13/23. Diagnoses include anxiety disorder, psychosis, schizophrenia, depression and extrapyramidal and movement disorder. R82's MDS (Minimum Data Sheet) dated 12/22/25 documents that he has intact cognitive functions.On 1/27/26 at 10:54 AM, 1/28/26 at 9:24 AM and 10/29/26 at 9:30 AM, R82 was observed drooling excessively while talking. He was observed constantly wiping his mouth and there were moisture marks on his shirt below his mouth. He said he cannot control it and feels embarrassed by his drooling.R82's POS (Physician Order Sheet) documents R82 was receiving Clozapine 50 mg, three tablets by mouth in the morning and Clozapine 50 mg, five tablets by mouth at bedtime. An order to monitor for side effects for antipsychotic medication was also documented. R82's care plan for use of psychotropic includes interventions to administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. R82's TAR (Treatment Administration Record) show that R82 did not manifest any side effects for the whole month of January 2026.On 1/29/26 at 8:30 AM, V27 (RN-Registered Nurse) said common side effects from antipsychotic medication are drowsiness, dizziness, drooling. She said if any of these symptoms are observed, she informs the Psychotropic Nurse (V11) and the psychiatrist is informed and new orders for medications like scopolamine are ordered. She said side effects from psych meds are monitored every shift and documented on TAR. On 1/29/26 at 10:15 AM, V11 said if side effects from antipsychotic medications are noted, staff should call physician right away.On 1/30/26 at 9:55 AM V2 (DON-Director of Nursing) said nurses are responsible for assessing and documenting side effects from psychotropic medication. She said nurses are also responsible to make the Psychotropic nurse aware so he can inform the psychiatrist and have a recommendation for treatment, or if the resident is already on a medication for side effects, maybe the medication can be adjusted.Facility's Policy on Psychotropic Medication- Gradual Dosage Reduction dated 11/28/12 and revised on 2/1/18 documents the following: Monitoring: Staff will monitor residents for side effects, withdrawal symptoms and/or changes in behavior and report to physician and/or psychiatrist. Documentation of observed side effects by nursing staff will occur as indicated in the nurse's Notes and/or on the EMAR.2. R93 was admitted to facility on 4/19/23. Diagnoses include dementia, depressive disorder, severe intellectual disabilities and schizoaffective disorder, bipolar type. R93's MDS dated [DATE] documents he has short- and long-term memory problem. And he needs extensive assist of one person with grooming related to dementia.On 1/27/26 at 9:55 AM, R93 was observed pacing the hallways of the unit. He was repeatedly saying he was going to the gas station and asking everybody what he needs to buy. He was observed excessively drooling and his shirt had moisture marks under his mouth by his collar. On 1/28/26 at 9:30 AM and 1/29/26 at 9:20 AM, R93 was standing close to the nurse's station and was drooling excessively.R93's POS documents he receives Clozapine 50 mg, 1 tablet at bedtime for schizoaffective disorder and Olanzapine 20 mg, give half tablet by mouth two times a day for schizoaffective disorder, bipolar type. An order for Benztropine Mesylate 0.5 mg, give 1 tablet by mouth twice a day to prevent drug-induced extrapyramidal symptoms was ordered and started on 10/25/2023. An order to monitor for side effects for antipsychotic medication was also documented. R93's care plan for use of psychotropic includes interventions to administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. R93's TAR show that R93 did not manifest any side effects for the whole month of January 2026.3. R182 was admitted to facility on 11/25/23. Diagnoses include depressive disorder, anxiety disorder, extrapyramidal and movement disorder, schizophrenia and schizoaffective disorder. R182's MDS dated [DATE] documents he has intact cognitive functions.On 1/27/26 at 10:59 AM, R182 was standing by his doorway. He was observed with excessive drooling and was constantly wiping his mouth while talking. He said he is embarrassed by his excessive drooling and stated his appearance matters to him.R182's POS documents he receives Clozapine 100 mg, one tablet by mouth every morning for schizophrenia and Clozapine 100 mg, two tablets by mouth at bedtime for schizophrenia. An order for Benztropine Mesylate 1 mg, by mouth two times daily related to extrapyramidal and movement disorder was ordered and started on 1/14/2022. An order to monitor for side effects for antipsychotic medication was also documented. R182's care plan for use of psychotropic includes interventions to administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. R182's TAR show that R182 did not manifest any side effects for the whole month of January 2026. 4. On 1/29/2026 at 8:25 AM, R51 was in bed. R51 was weak and frail, unable to be interviewed regarding his seizure disorder and treatment. At 8:40 AM, V18 (Licensed Practical Nurse/LPN) said R51 had a seizure disorder with a history of convulsions. V18 said R51 was receiving Dilantin (antiseizure) oral medication for management of his disorder. V18 reviewed R51's EMR (Electronic Medical Record) and said his last Dilantin medication blood level was done on 11/20/2025. V18 said the level was 4, which was too low because the normal reference range is between 10 and 20. V18 continued to say that R51's physician gave an order on 11/21/2025 to increase his Dilantin dosage and repeat a blood level check in two weeks. V18 said R51 did not get his medication drug blood level checked as ordered. V18 said lab orders should be followed as instructed to ensure residents receiving antiseizure medications are monitored appropriately with the goal to prevent seizures. V18 said checking blood levels for antiseizure medication is needed to determine proper medication dosage and ensure residents had therapeutic levels.R51's laboratory report dated 11/20/2025 showed his Dilantin level was 4.0 L and the reference range was 10.0-20.0. The report also showed a written physician's order to increase the medication dosage and repeat the medication level in two weeks. R51's EMR showed that as of 1/29/2026, R51's lab order from 11/20/2025 was not completed. R51's care plan said he required the use of an anticonvulsant medication because he was at risk for seizures related to convulsions. The interventions included Monitor lab values for therapeutic levels of anticonvulsant medications and report to MD.On 1/29/2026 at 9:40 AM, V2 (Director of Nursing/DON) said she expected nurses to follow lab orders for medication drug levels as ordered by the physician to ensure residents at risk for seizures be safely monitored.The facility's policy titled Physician Orders- Entering and Processing, dated 1/31/2018, said the facility followed general guidelines when receiving, entering, and confirming physician orders. Orders would be confirmed by the nurse to ensure the order instructions were followed. All orders will be documented in the Electronic Medical Record.

Based on observation, interview, and record review, the facility failed to have thermometers, keep temperature logs, remove expired items, and maintain resident refrigerators. This applies to 5 of 5 residents (R66, R118, R119, R168, R207) reviewed for refrigerators in a sample of 38.The findings include:1.On 1/27/26 at 11:05 AM, R119's refrigerator did not have a thermometer inside. R119 was not in her room. R119's roommate stated the staff was supposed to bring a thermometer, but they never did.2.On 1/27/26 at 11:19 AM, R207's refrigerator did not have a thermometer inside. Inside, there was a package of chicken salad and container of apple sauce. R207 said she's never seen a thermometer inside her fridge.3.On 1/27/26 at 11:22 AM, R168's refrigerator had ice built up in her freezer and the door's hinge was broken, causing difficulty in opening and closing it. R168 stated it has been like that for some time. She told staff, but nobody came to fix it.4.On 1/27/26 at 11:41 AM, R118's refrigerator had no thermometer inside. Inside, there was a 1/2 pint of 2% milk with a best by date of 1/26/2026. There were two 1/2 pint fat free milk with a best by date of 1/21/26. There was one 1/2 pint of fat free milk with a best by date of 1/26/26. She stated she never had a thermometer in her fridge. 5.On 1/27/26 at 11:44 AM, R66 was not in his room. The fridge was heavily stained and dirty on the inside.There were no temperature logs for the above residents' refrigerators inside their room, and the facility was unable to provide any temperature logs.On 1/28/2026 at 9:21 AM, V2 (DON-Director of Nursing) stated, There are supposed to be thermometers in resident refrigerators. Usually, the Social Workers are supposed to check in with the residents regarding the refrigerator. Housekeeping should clean the refrigerators.On 1/28/26 at 3:51 PM, V3 (Maintenance/Environmental Services Director) stated residents should have a thermometer in their refrigerators. He stated Social Services gives the residents a temperature log sheet where they can record their own temperatures for their refrigerators. If the fridges freeze, then maintenance would go and defrost them. He stated all staff are supposed to remove expired items from resident refrigerators. Staff, including managers, nurses, and CNA's (Certified Nursing Assistants), and/or housekeeping are responsible for cleaning the refrigerators.Facility's policy titled Refrigerators in Resident Rooms (2020) shows: 2. Each refrigerator shall have a temperature log with daily entry. Each refrigerator will have an inside thermometer. 3. The housekeeper will enter the temperature once daily. 6. All food will be monitored when daily temperature check is performed. Any food item past its use by date will be discarded by staff or resident. The resident and/or the resident's responsible party will be educated on food safety and leftover food to be discarded after three days. 8. The housekeeping department will clean and sanitize the refrigerators at least once a month or as required. 9. Housekeeping supervisor will conduct at least monthly quality assurance audit of refrigerators to monitor adherence to procedures.

Based on observation, interview, and record review, the facility failed to ensure the call light system was working in resident rooms. This applies to 28 of 28 (R102, R6, R156, R103, R77, R47, R202, R4, R206, R13, R209, R171, R96, R108, R177, R52, R24, R25, R31, R44, R8, R19, R109, R183, R10, R90, R113, and R210) residents reviewed for call lights.On 1/27/2026 at 10:05 AM, R113 was in bed. R113 said he was extremely upset because his call light had not worked since yesterday. R113 said the facility reported they fixed the call system problem, but it frequently continued to malfunction, causing the call lights for his entire hall to stop working for extended periods of time. R113 pressed his call light, but it was not sending a call signal outside his door and to the nurses' station main panel. R113 said it was very upsetting because he had no way of getting assistance with his care needs and for emergency situations. R113's MDS (Minimum Data Set), dated 11/17/2025, said he was cognitively intact and required moderate to maximal staff assistance with his ADLs (Activities of Daily Living).On 1/27/2026 at 10:10 AM, R90 was in her wheelchair, upset. R90 said it was horrible trying to get assistance with her toileting needs because her call light was not working. R90 said the call lights stopped working yesterday and were yet to be fixed. R90 said the call lights in the hallway where she resided had frequently stopped working in the past month. R90 said it was a recurrent problem because the facility failed to fix it properly. R90 said it was difficult to request assistance, and she frequently had to resort to yelling or banging on the wall to get the staff's attention. R90's MDS, dated [DATE], said she was cognitively intact and required touch to substantial staff assistance with her ADLs.On 1/27/2026 at 10:20 AM, R19 was sitting on the bed, yelling for assistance. R19 was visually impaired. R19 continued to yell out louder for staff to assist him with his hydration. R19 became more upset because the staff was not responding to his call for help. R19's MDS, dated [DATE], said he had cognitive impairment and required moderate to maximal staff assistance with his ADLs.On 1/27/2026 at 10:15 AM, V17 (Certified Nurse Assistant/CNA) said she was assigned to the unit hall. V17 said when she started her morning shift, the room call lights for the unit were not working. V17 said they stopped working yesterday, and she was informed a company was scheduled to come today to fix the call light panel. V17 said residents in the unit were upset because it had also occurred a few weeks prior. V17 said she was not given further instructions on the facility's plan regarding monitoring residents while the call light system was not working.On 1/27/2026 at 10:30 AM, V15 and V16 (Maintenance Staff) said they had just fixed the main call light panel located at the nurses' station. They said the panel had a missing wiring connection, causing the call lights for some rooms to not work. They said V3 (Maintenance Director) informed them an outside company was coming to assess the panel because it was a recurrent problem. They continued to say there was no work order created but were informed the call lights stopped working yesterday at approximately 4:30 PM.On 1/29/2026 at 9:40 AM, V2 (Director of Nursing/DON) said the call lights for the hall would frequently stop working. V2 said she was unsure when they stopped working on 1/26/2026 but was informed an outside company came to assess the panel that evening but was unsure when they stopped working again that evening. V2 said the call light system needed to be working properly to ensure residents could be assisted with their care needs and for safety emergencies.On 1/29/2026 at 11 AM, V3 (Maintenance Director) said on 1/26/2026 at approximately 3 PM, the call lights on the unit for some rooms stopped working, and an outside vendor came at 6 PM to fix the panel. V3 said he was going to place another call on 1/27/2026, but the facility maintenance staff was able to rewire the panel at approximately 10:30 AM. V3 said the panel wiring had become faulty at a minimum of three times in the past month. V3 said he had no work order request logs for the call lights. The facility's untitled document, dated 1/26/2026, said staff rounded every 30 minutes on 1/26/2026 from 3 PM-6 PM. The document does not provide information regarding the type of rounds completed and for which residents. The document also does not show further entry logs from when the call light system stopped working again on the evening of 1/26/2026 through the morning of 1/27/2026.The facility's Daily Census report, dated 1/27/2026, showed R102, R6, R156, R103, R77, R47, R202, R4, R206, R13, R209, R171, R96, R108, R177, R52, R24, R25, R31, R44, R8, R19, R109, R183, R10, R90, R113, and R210 resided in the hall with the faulty call light system.The facility's policy titled Call Light, dated 2/2/2018, said the facility was to respond to residents' requests and needs in a timely and courteous manner. If needed, hand bells will be provided for alert dependent residents when positioned out of reach of the permanent call light when needed. Call bell system defects will be reported promptly to the Maintenance Department for servicing, and room checks will be done until the system is repaired.

Based on observation, interview, and record review, the facility failed to honor a resident's wishes to have food warmed in a microwave at their preferred time.This applies to 1 resident (R37) reviewed for accommodation of needs.On 01/27/2026 at 12:43 PM, R37 stated there use to be a microwave available for residents' use, but it was taken away. The only microwave available is at the nursing station and is not accessible to the residents. R37 stated if residents want any food reheated, they must request the facility staff do it for them, but the time for reheating food is limited. If he wants any food reheated after 9:30 PM, staff will not heat his food. On 01/28/2026 at 4:10 PM, V8 RN (Registered Nurse) stated residents are not allowed behind the nursing station to use the microwave. Staff will reheat food for residents, but only during the posted specified times (8:30 AM to 9:30 AM, and 8:45 PM to 9:15 PM). V8 stated it's to prevent the residents from interrupting staff while they are working and because the residents need to go to sleep at night. V8 stated if there isn't a cut off time, the residents will stay up all night heating up food.On 01/29/2026 at 2:06 PM, V30 Behavioral Aide stated she is not allowed to reheat residents' food outside the posted time frames.On 01/29/2026 at 2:12 PM, V31 Behavioral Aide stated there are time restrictions for reheating residents' food. V31 stated the times for heating up resident food are posted, and staff stick to those times.On 01/29/2026 at 2:40 PM, V32 CNA (Certified Nursing Assistant) stated staff will reheat resident food items only during the specified times and not after bedtime.The facility's documented microwave use hours are 8:30 AM to 9:30 AM, and 8:45 PM to 9:15 PM.On 01/29/2026 at 12:33 PM, V1 Administrator stated there are set times for residents to reheat food items so staff aren't reheating food all day. V1 stated there is no facility policy specifying times that food may be reheated.

Based on observation, interview, and record review, the facility failed to identify abuse, investigate an incident of resident-to-resident abuse, implement interventions to prevent further recurrence, and report the incident. This applies to 2 of 2 residents (R131 and R200) reviewed for abuse in a sample of 38. The findings include: On 1/27/2026 at 10:37 AM, R131 was observed sitting in bed, holding his left shoulder and wincing in pain. R131 stated he was experiencing severe left shoulder pain that began on 1/18/2026 when he was physically attacked by R200. According to R131, R200 suddenly charged at him, grabbed him, and placed both arms around his upper torso, putting him in a headlock. On 1/28/2026 at 3:12 PM, V1 (Administrator/Abuse Coordinator) stated he had reviewed the facility's security camera footage from 1/18/2026 and confirmed he was made aware of the incident that night. V1 described the footage showed R200 approaching R131 from behind and placing both arms around his upper torso. V1 stated he did not report the incident to the Illinois Department of Public Health (IDPH) at that time because he did not believe it met the facility's definition of abuse, reasoning there was no serious injury, bodily harm, or psychosocial effects. V1 further acknowledged the incident was not reported to IDPH until 1/27/2026, nine days later. He indicated an internal investigation had not yet been conducted but would be initiated. Requests for staff statements, interviews and/or any other documentation related to the incident (including incident reports), had been made; however, the facility was not able to provide any of these records prior to the end of the survey. Review of R131's EMR (Electronic Medical Record) shows following the 1/18/2026 incident, R131 did not have new care plan interventions or protective measures initiated to address the outcomes of the incident, including severe left shoulder pain and psychosocial distress (which he verbalized experiencing on 1/29/2026 at 12:45 PM). R131's care plan had not been updated following the incident. Care plan sections related to abuse (created 1/29/2026) and psychosocial wellbeing, including mood triggers (created 1/27/2026), were added only during the survey. Review of R200's EMR shows diagnoses including anxiety disorder, insomnia, schizophrenia, and schizoaffective disorder. R200's care plan had not been updated after the incident involving R131. Care plan sections related to mood triggers (created 1/30/2026), abuse (created 1/28/2026), behaviors (created 1/28/2026), and physical and verbal aggression (created 1/28/2026) were added during the survey. The facility's policy titled Abuse and Retaliation Prevention and Reporting (effective 1/8/2026) states The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse.and mistreatment of residents This will be done by: identifying occurrences and patterns of potential mistreatment immediately protecting residents involved in identified reports of possible abuse .implementing systems to promptly and aggressively investigate all reports and allegations of abuse .and making necessary changes to prevent future occurrences .filing accurate and timely investigative reports The policy further states: Any allegation of abuse, retaliation, or any accident resulting in serious bodily injury be reported to IDPH immediately, but no more than two hours after the allegation, [and that] any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents.

Based on observation, interview, and record review, the facility failed to conduct a thorough investigation of physical abuse between 2 residents. This applies to 2 of 2 residents (R131 and R200) reviewed for abuse in a sample of 38. The findings include: On 1/27/2026 at 10:37 AM, R131 was observed sitting in bed, holding his left shoulder and wincing in pain. R131 stated he was experiencing severe left shoulder pain that began on 1/18/2026 when he was physically attacked by R200. According to R131, R200 suddenly charged at him, grabbed him, and placed both arms around his upper torso, putting him in a headlock. On 1/28/2026 at 3:12 PM, V1 (Administrator/Abuse Coordinator) stated he reviewed security camera footage from 1/18/2026 and confirmed awareness of the incident that night. V1 stated he did not report the incident to IDPH (Illinois Department of Public Health) at that time because he did not believe it met the definition of abuse, reasoning there was no serious injury, bodily harm, or psychosocial effects. V1 further acknowledged the incident was not reported to IDPH until 1/27/2026. Review of V1's Initial Report to IDPH regarding the physical altercation involving R131 and R200 included a fax confirmation sheet indicating it was sent on 1/27/2026 at 2:59 PM. The report confirmed a date of occurrence of 1/18/2026 and stated the incident category as Resident Abuse. The reported also stated, Facility will conduct a thorough investigation with complete report to follow, indicating an investigation had been initiated 9 days later. The facility's policy titled Abuse and Retaliation Prevention and Reporting (effective 1/8/2026) states, The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse.and mistreatment of residents. The policy also states: All incidents will be documented, whether or not abuse, neglect.was alleged or suspected as any incident or allegation involving abuse. will result in an investigation and that upon learning of the report, the administrator or designee shall initiate an incident investigation. Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical record or other documents.

Based on observation, interview, and record review, the facility failed to ensure pain assessment and management was provided for a resident's new onset of pain. This applies to 1of 1 resident (R131) reviewed for pain management in a sample of 38. The findings include: On 1/27/2026 at 10:37 AM, R131 was observed sitting in bed holding his left shoulder and wincing in pain. R131 reported his shoulder pain began ten days earlier on 1/18/2026 following a physical altercation with another resident. R131 described his left shoulder pain as severe, rating it 8-10/10, with 10 being the worst pain he has ever experienced. R131 stated his current pain medication was not relieving his left shoulder pain and he had been requesting an X-ray and transfer to the hospital to have the injury evaluated. Review of R131's N Adv - Long Term Care Evaluation documented a pain level of 8, categorizing it as severe, with indicators including vocal complaints of left anterior shoulder pain and facial expressions consistent with pain. The assessment identified this as a new issue and further documented the pain as sharp and non-radiating. Additionally, R131's MDS (Minimum Data Set) dated 10/23/2025 documented that prior to the incident, his pain had been mild, occasional, and did not affect sleep. The MDS also noted that R131's cognition was intact, with no behavioral issues or limitations in bilateral upper extremity Range of Motion (ROM). R131's Physician Order Sheet (POS) and Medication Administration Record (MAR) showed:Acetaminophen-Codeine Oral Tablet 300-30 mg - Give 1 tablet every 9 hours as needed for pain (ordered 11/26/2025). The January 2026 MAR documented 11 administrations after the 1/18/2026 incident, on the following dates: 1/18/2026, twice on 1/20/2026, 1/21/2026, 1/22/2026, twice on 1/23/2026, 1/26/2026, 1/28/2026, and twice on 1/29/2026; andTylenol Extra Strength 500 mg (Acetaminophen) - Give 2 tablets by mouth every 6 hours as needed for back pain. The January 2026 MAR showed 3 administrations after the incident, on 1/26/2026 and twice on 1/27/2026. R131's Pain Level Summary from 1/18/2026 to 1/30/2026 showed R131's pain levels were documented as severe (7 to 10 out of 10 on pain scale) on 1/22/2026, 1/24/2026, 1/26/2026, 1/28/2026, and twice on 1/29/2026, and were documented as moderate (4-6 out of 10 on pain scale) on 1/18/2026, 1/20/2026, 1/21/2026, 1/23/2026, 1/25/2026, 1/26/2026, and twice on 1/27/2026. On 1/29/2026 at 12:05 PM, R131 stated that although medications were being administered, he still experienced severe left shoulder pain since the 1/18/2026 incident. On 1/27/2026, an X-ray was scheduled after V2 (DON-Director of Nursing) was asked about the plan to address R131's ongoing left shoulder pain. R131's 1/28/2026 X-ray results showed findings consistent with a left glenoid fracture and R131 was sent to the Emergency Department. On 1/29/2026 at 10:46 AM, an interview was conducted with V14 (In-house NP-Nurse Practitioner) and on 1/30/2026 at 9:37 AM, an interview was conducted with V34 (Psychiatric NP). Both stated pain is a subjective experience, meaning it is based on the resident's personal perception and report rather than solely on observable or objective findings. They emphasized regardless of a resident's mental or psychiatric status, if a resident reports pain, it must be taken seriously, appropriately assessed, and treated as real pain. V34 explained for residents with psychiatric diagnoses, such as R131, uncontrolled pain can act as a trigger that exacerbates anxiety, agitation, or emotional distress, and therefore must be promptly assessed and addressed. V34 stated failing to adequately evaluate or manage a resident's reported pain could contribute to worsening psychological symptoms and an overall decline in wellbeing. On 1/29/2026 at 12:27 PM, R131 continued to report ongoing left shoulder pain, rating it 8/10 (severe), which increased to 10/10 with sideward shoulder extension. R131 again stated his current pain medication that he had been receiving prior to the 1/18/2026 incident, was not effective in relieving his left shoulder pain. V36 (RN) assessed R131, acknowledged his severe left shoulder pain, confirmed compromised range of motion (ROM) to his left shoulder, and stated she would notify the provider that the pain was not relieved by R131's current pain regimen, adding she would ask about an Occupational Therapy (OT) evaluation. On 1/30/2026 at 10:14 AM, V2 (DON) stated her expectation is for nursing staff to assess residents' pain levels, including determining whether the pain is new and whether it is relieved by current interventions. V2 further stated any pain rated above 6 out of 10 on the pain scale is considered severe and requires immediate action. She explained if the current medications are insufficient, nursing staff are expected to offer available PRN (as needed) medications as appropriate and notify the provider. The facility's policy titled Pain Management Program (Revised 7/6/2018) states the purpose of the policy is to establish a plan to manage pain in order to reduce adverse physiologic and psychological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. The policy further outlines that the pain management program includes the following components:Documentation of pain assessment and ongoing monitoring;Informed resident participation in care decisions, including decisions related to pain management;Recognition of pain as the fifth vital sign, along with temperature, pulse, respiration, and blood pressure. The facility's policy also specifies that the pain assessment protocol must be initiated whenever there is a change in the resident's condition that requires pain control or when there is a change in the identification of pain. Per policy, care plans must be reviewed and updated whenever the resident's pain management plan is found to be ineffective and at least during each quarterly care conference. Lastly, the policy requires documentation of the resident's response to the pain management plan to ensure ongoing evaluation and effectiveness.

Based on interview and record review, the facility failed to provide physical therapy that was ordered by the physician.This applies to 1 of 1 resident (R151) reviewed for rehab services in a sample of 38. Findings Include:R151's diagnosis list includes Parkinsonism, idiopathic progressive neuropathy, recurrent major depressive disorder, and drug-induced subacute dyskinesia.R151's current care plan includes limited range of motion in bilateral upper and lower extremities related to pain and limited mobility; interventions include to demonstrate exercises and have resident return-demonstrate the exercises.On 01/27/2026 at 11:02 AM, R151 stated for two years he's had numbness and tingling in both legs and his fingers. R151 stated his Neurologist wrote orders for him to have PT (Physical Therapy) that was never set up for him. R151 stated he provides his after-visit summary from his doctor's office visit to the floor nurse on duty and to V29, Scheduler.On 01/28/2026 at 2:59 PM, V8, RN (Registered Nurse), stated R151 had not recently received any physical therapy services.On 01/28/2026 at 3:10 PM, V29, Scheduler, stated she arranges residents' follow up appointments and referrals. V29 stated R151 has been followed by the in-house PT department. V29 stated the referral was given to V25, Physical Therapist.On 01/28/2026 at 3:22 PM, V25, Physical Therapy Director, stated the PT department was not seeing R151 and had not seen him since 2022. R151's last PT evaluation was 8/8/22, and he received eight sessions before being discharged from PT. On 01/28/2026 at 3:38 PM, V2, DON (Director of Nursing), stated when a resident returns from a community physician's office visit with PT referral, V25 is notified during the morning meeting. V2 stated if the floor nurse provides her with the referral, she will notify V25 directly. V2 stated she did not know how the order therapy order was overlooked.R151's community Neurologist after-visit summary, dated 4/23/25, included a referral for Physical Therapy to evaluate and treat for the diagnosis of sensory ataxia.The facility had no documentation of R151 receiving the physician-ordered Physical Therapy services. The facility policy Therapy - Specialized Rehabilitative Services Guidelines dated 7/16/24 states, the facility shall provide specialized and supportive rehabilitative services either directly or through arrangements with services provider. Services shall be provided in accordance with the assessment results, the written comprehensive plan of care in accordance with physician's orders. Specialized rehabilitative service may include but not limited to physical therapy, speech / language audiology, speech pathology, respiratory therapy, occupational therapy. Such services are utilized to restore, maintain or improve the resident's optimal level of functioning, self-care, independence, and quality of life.

Based on observation, interview, and record review, the facility failed to maintain hot water temperatures at a comfortable range for residents in bathrooms and showers. This applies to all 206 residents residing in the facility.The findings include:On December 16, 2025 at 10:30 AM, R3 said the water at the facility had been freezing for the last three weeks. R3 said he had a doctor's appointment earlier in the day and he had to take a freezing cold shower. R3 said a lot of residents had been complaining about the temperature and it was making the residents angry. R3 said it was the water everywhere in the building including the bathrooms and the showers. R3 said administration was not doing anything about it, based on what he could see. On December 16, 2025, the water was tested in the facility. At 11:12 AM, V3 (Maintenance Director) tested the hot water in a resident's bathroom sink, which showed it was 68 degrees. V3 said the hot water temperature should be between 102 to 110 degrees. V3 said he found out on Friday, December 12, 2025 there was an issue with the hot water. At 11:22 AM, the water was tested in the men's shower rooms on the first floor, and the hot water was 72 degrees. At 11:28 AM, the water was tested in the women's shower rooms on the first floor, and the hot water was 72 degrees. At 12:59 PM, the water was tested in the men's shower room on the second floor and the hot water was 84 degrees. At 1:08 PM, the water was tested in the women's shower room on the second floor and the hot water was 67 degrees. At 1:22 PM, the water was tested in the men's shower room on the third floor and the hot water was 75.2 degrees. At 1:25 PM, the water was tested in the women's shower room on the third floor and the hot water was 65.2 degrees. On December 16, 2025 at 11:35 AM, R6 said she was the resident council president and there had not been hot water in the facility for over a week. R6 said taking a shower was brutal and inhumane. R6 said the water started being cold on December 8, 2025 in the shower room. R6 said the waters were not fluctuating, they remained cold. R6 said she wrote on the maintenance sheet three different times and highlighted it to let them know the water was cold. R6 said the sink went out a few days later. R6 said it was super frustrating since they were not allowed to go outside to smoke if it was less than 10 degrees, but they had to take freezing cold showers for over a week. R6 said she tried showering at different times of the day to see if it depended on the time and when she took a shower at 4 AM, the water was still cold. R6 said there were lots of residents complaining about the cold water and multiple residents wrote their concerns on the maintenance logs. On December 16, 2025 at 11 AM, R12 said they did not have hot water to take a shower since last Monday. R12 said the water temperature was tepid. R12 said she was told the regulator was broken but the issue had been going on for a week. R12 said the water in the sinks were ice cold and it hurt to wash her hands. At 2:17 PM, R12 said they were complaining and nothing was happening for about a week, and it was miserable. R12 said she hoped it got fixed soon as she used to shower at least once a week. On December 16, 2025 at 1:52 PM, R9 said the cold water issue had been going on for at least two weeks. R9 said the cold water was consistent, but for one day there was hot water. R9 said the residents were just avoiding taking showers altogether. On December 16, 2025 at 1:55 PM, R10 said he had to take a shower when it was freezing cold. R10 said he did not want to take any more showers since it was so uncomfortable. On December 16, 2025 at 2:35 PM, R5 said she used to shower every other day, but she has been avoiding it since it has been cold water for about a month. On December 16, 2025 at 11:10 AM, V3 said he found out yesterday (December 15, 2025) there was an issue with the mixing valve. V3 said he found out on Friday there was an issue altogether by V4 (Maintenance). At 1:05 PM, V3 said the maintenance logs were checked daily. V3 said there was water on Monday, but the temperatures kept changing. V3 said he did not do anything about it because with a facility of this size, you had to wait and see how the mixing valve was working. V3 said he should have tested the water more frequently instead of just on Monday & Friday. On December 16, 2025 at 11:14 AM, V4 said he normally checked the water temperature twice a week, on Mondays and Fridays. V4 said he was not sure when the water became cold but found out about it on Thursday. V4 said they had someone come out to check the water heater. V4 said he tested the water, and it showed around 90 degrees. On December 16, 2025 at 2:49 PM, V9 (CNA/Certified Nurse Assistant) said the residents had been complaining about the temperature of the water for at least a week. V9 said the water started out lukewarm, but then became cold. V9 said the maintenance staff had been addressing it the last two days. On December 17, 2025 at 11:34 AM, V11 (RN/Registered Nurse) said he started to hear complaints about the cold water from last Monday. V11 said the residents complained there was no hot water. V11 said many of the residents wrote it in the maintenance request and he had called maintenance several times regarding the issues. The Maintenance Logs showed the following: On December 2, 2025, someone wrote Everyone: When will we be able to take a hot shower?????? with a response in the Fixed section showing There is hot water 12/8. On December 4, 2025, someone wrote, Everyone: No hot water. On December 8, 2025, R12 wrote shower water keeps switching from warm- not hot- just barely warm to cool. 1st floor shower room for women 2nd stall. On December 10, 2025, R6 wrote, NO HOT WATER IN SHOWER with a response in the Fixed section showing The first stall was hot. On December 10, 2025, No hot water in room [ROOM NUMBER]. On December 12, 2025 at 4:30 AM, someone wrote, NO HOT WATER WOMEN SHOWER.On December 14, 2025 at 2 AM, someone wrote STILL NO HOT WATER- CALLING STATE. On December 16, 2025, V4 provided temperature logs for the water testing, which showed the water was tested on [DATE], December 5, 2025, December 8, 2025, and December 12, 2025. The facility's Resident Council Meeting Minutes were reviewed from October 2025 to present. On December 5, 2025, the Resident Council Meeting Minutes showed Water temperature for the showers in the men & women's shower rooms appear to not be hot enough or taking a while to warm up. The facility's Bathing- Shower and Tub Bath policy, revised on January 31, 2018, showed Turn on water and ensure that the water is at a comfortable and safe temperature. Temperature should be 100-110 degrees F (Fahrenheit).

Based on interview and record review, the facility failed to report an abuse allegation. This applies to 1 of 3 (R1) residents reviewed for reporting abuse allegations. The findings include:On October 17, 2025, multiple requests were made for abuse allegations for October 2025 to V1 (Administrator) and V2 (DON/Director of Nursing), with none provided. On October 17, 2025 at 1:50 PM, R1 said she was in pain a lot and it hurt her when she was changed, especially when V3 (CNA/Certified Nurse Assistant) would change her. V3 said she told the staff she was in pain because she felt they pull and hurt her when they change her. R1 said when V3 changed her, she would lift her leg high up, and when she would say she was in pain, V3 would apologize. R1 said she told the nurse she did not want V3 to care for her anymore. The EHR (Electronic Health Record) shows R1 was admitted to the facility with diagnoses including hemiplegia and hemiparesis, major depressive disorder, seizures, persistent mood (affective) disorder, generalized osteoarthritis, contracture of the left hand and left ankle, and schizophrenia. R1's MDS (Minimum Data Set) dated October 2, 2025 showed R1 was cognitively intact and was dependent on staff for showers/bathing. On October 17, 2025 at 3:46 PM, V3 (CNA) said she was the CNA on duty on October 11, 2025. V3 said she gave R1 a shower and after the shower, was approached by V9 (Nurse) saying R1 complained about the care. V3 said she was called by V10 (Psychotropic Nurse/Manager on Duty). V3 said she was sent home because when someone reports you, they send the staff home because of the investigation. On October 17, 2025 at 4 PM, V10 said he was the manager on call on October 11, 2025. V10 said there was an incident where the nurse called and said V3 had an issue with R1. V10 said she notified V2 (DON/Director of Nursing) and she called the consultant, who advised him to suspend the CNA. V10 said they got a statement from R1, and a body check was completed. V10 said the nurse filled out a grievance form with R1 and the plan was for management to do a further investigation. V10 said he was not sure what happened after regarding the investigation. On October 17, 2025 at 3:05 PM, V7 (CNA) said he was the second assist for R1's shower on October 11, 2025. V7 said he heard V3 was told to leave the shift pending the investigation. On October 21, 2025 at 9:45 AM, V9 (Nurse) said she was R1's nurse on October 11, 2025. V9 said she was passing medications when she heard R1 crying and when asked what happened, R1 told her she was given a shower in the shower stretcher and the CNA was rough with her. V9 said she reported it to the supervisor right away and the supervisor sent her home, and they would start an investigation. V9 said she was not interviewed by anyone, including V1 (Administrator) or V2 (DON) regarding the allegation by R1. On October 17, 2025 at 2 PM, V4 (CNA) said she worked on October 11, 2025, and R1 complained to her that V3 put cold water on her and pulled her arms and legs. V4 said she thinks V3 was trying to wash her face and maneuver her on the shower bed but did not take into account R1's painful sides. On October 17, 2025 at 2:06 PM, V5 (CNA) said she worked on Saturday, October 11, 2025, and she heard R1 crying and yelling loudly in the shower room. V5 said R1 told her V3 pulled her arms and legs and put cold water on her face. V5 said she knew the nurse started the investigation. V5 said she gave a statement to the administrator about the incident. On October 21, 2025 at 11:16 AM, V5 said she wrote a statement about the incident. On October 21, 2025 at 11:11 AM, V6 (CNA) said she wrote a statement and put it in V1's mailbox, which was what they did when an incident happened. V6 said the incident should be reported. V6 said she felt the situation was abnormal because of the way R1 was crying after coming from the shower. V6 said V3 was sent home. On October 17, 2025 at 2:17 PM, V2 (DON) said she did not work on October 11, 2025, but was called by V10 and notified of the incident. V2 said she was told R1 received a shower in the shower bed but wanted it in the shower chair. V2 said V10 said R1 complained of pain, and she instructed the nurse to do an assessment to check for bodily injury. V2 said she contacted the consultant, and a grievance form was written regarding the shower. V2 said V1 (Administrator) was notified and did not respond to the allegation until Monday. V2 said V1 spoke with R1 and interviewed the staff. V2 said to ask V1 for the information regarding the investigation. V2 said if there was an issue with the staff and residents, their protocol was to suspend the staff and investigate what happened. V2 said it was not really an abuse investigation. V2 said she had not received any written statements from the staff. On October 21, 2025 at 2:45 PM, V1 (Administrator) said he was not working on October 11, 2025 and saw the messages regarding the incident late on Saturday night. V1 said R1 had a history of pain and complaining about pain. V1 said the staff told him R1 screamed of pain, especially in the leg, and more recently complained about pain in the abdomen and back. V1 said he was told V3 and V7 were giving R1 a shower and she was screaming about the pain in her leg in the shower. V1 said R1 reported to V9 about the shower and V9 confronted V3 about the incident. V1 said V3 got defensive and was sent home. V1 said some of the staff complained about V3's care. V1 said he did not recall if the staff had given written statements, and he did not report this to IDPH (Illinois Department of Public Health). The facility's Abuse Prevention and Reporting-Illinois policy, revised on October 24, 2022, showed Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but no more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. The administrator or person designated to act as administrator in the administrator's absence will review the report. The administrator or designee is then responsible for forwarding a final written report of results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated.

Based on interview and record review, the facility failed to ensure a resident was supervised to prevent the resident from leaving the grounds of the facility, and failed to ensure nursing staff were aware R1 was out of the building resulting in a 6 hour delay in identifying R1 was missing. This failure resulted in R1 leaving the facility grounds at 5:57 PM on [DATE], and being found deceased about 600 feet from the facility's main entrance at 7:50AM on [DATE]. The Immediate Jeopardy began on [DATE] when R1 signed out of the facility, left unsupervised, and failed to return at the expected time. The receptionist failed to notify the nurse R1 had not returned to the facility by the 8:00 PM curfew and nursing staff was therefore unaware R1 was not in the facility until after 11:00 PM, when police were finally notified. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 2:30 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on [DATE], prior to the start of the survey on [DATE] and was therefore Past Noncompliance. This past non-compliance occurred from [DATE]-[DATE]. The findings include: R1's care plan, dated [DATE], states, Community Access/ Supervised - The resident required the support, care and services of a long term care facility and has been determined by community assess assessment to be able to access the community with supervision. On [DATE] I was assessed as appropriate for Level 2. I was assessed as appropriate for level 3. Interventions include: I am on supervised access to the community. R1's Elopement Risk and Community Survival Skills Assessment, dated [DATE], shows: The resident appears to be capable of outside independent pass privileges at this time. A care plan for outside pass privileges including risk factors for non-compliance for adhering to pass policies and parameters as indicated. This area is marked with a No. R1's Physician's Order Sheet, dated [DATE], shows R1 has diagnoses including schizophrenia, delusional disorders, paranoid personality disorder, Attention Deficit Hyperactivity Disorder, and cannabis and nicotine dependence. R1's Psychiatric Note, dated [DATE], states, + (positive for) baseline paranoia, No (SI) Suicidal Ideation, HI (Homicidal Ideation), AH (Auditory Hallucinations), VH (Visual Hallucinations), no other delusions were elicited. R1's EMR (Electronic Medical Record) shows a form titled, Level 2 Pass Privileges Acknowledgement, dated [DATE], that states, I understand that I have earned a level 2 pass privilege, which allows me to sign out of the facility two times per day for 1 hour maximum, between the hours of 9 AM and 6 PM Monday- Friday and between the hours of 10 AM and 7 PM on Saturday and Sunday with a fell ow level 2 or 3 peer. I agree to remain with level 2 or 3 peer while out of the facility. The facility Resident sign in and out log, dated [DATE], shows R1 signed out with a destination of Bench at 12:15 PM, with a time expected of 1:15 PM, and an actual time in of 12:29 PM. R1 then signed out with a destination of Bench at 2:38 PM, with a time expected of 3:38 PM, and an actual time in of 2:47 PM. Finally, R1 signed out at with a destination of Bench at 5:57 PM, with a time expected of 6:57 PM. R1 did not return to the facility following this sign out. The Facility Reported Incident, dated [DATE], states, On [DATE], resident was out on pass and was reported deceased . Resident went out on pass on [DATE] and was observed to not return to the facility. On [DATE] at 1:57 PM, V8 (Receptionist) said he has worked at the facility for about two months. There are red and blue cards at the front desk. Residents with a red pass can leave the facility three times a day, an hour at a time. (R1) was a red pass; he was allowed to leave for one hour, if they don't return, I should notify the nurse. On [DATE], (R1) left at 5:57 PM, he went outside to smoke and came back to give me his lighter, and told me he was going outside for a little longer. I left at 8:00 PM, at end of my shift, there was a random rush of things that I was busy with. Normally, I check the sign in sheet, and I forgot to notify the nurse (R1) did not return from his pass. On [DATE] at 2:09 PM, V11, Registered Nurse (RN), said she was R1's nurse from 3:00 to 11:00 PM. She saw R1 last around 4:30 PM to 5:00 PM in the big dining room. Around 8:00 PM, she asked V9, Certified Nursing Assistant (CNA), if R1 ate dinner, she said she did not know. During her evening med pass, she asked R3 (R1's roommate) if he had seen R1. R3 said to check another resident's room. She continued passing her medications because residents were insisting on getting their medications. About 10:30 PM, she was searching for R1, but did not call a code pink (missing resident). During shift change, she reported to V9 (CNA) R1 was missing, and she started searching for him. V11 said she was not aware R1 left to go out on pass at 5:57 PM. V8 did not report to her R1 did not return to the facility. R1 had a red pass; he was able to go out unsupervised for two hours at a time, up to three times a day. She reported off to V12, Licensed Practical Nurse (LPN), that R1 was missing, and they could not locate him. On [DATE] at 4:36 PM, V12 (Licensed Practical Nurse/LPN) said she came in at 11:00 PM. V12 said, (V11) was at the medication cart and endorsed to me (R1) did not receive his medications because he was not in his room and the staff searched for him, but could not locate him. She (V11) called (R1's) family and they had not seen (R1). She called and the police and reported (R1) as a missing person. (R1) had a red pass and could go out on pass unsupervised for two hours. Nursing is not notified when a resident signs out on pass. The receptionist should notify nursing if a resident does not return. On [DATE] at 11:40 AM, R2 said she and R1 were friends. They were both smokers, and he was an angel. R1 has a red pass, which is now a green pass. Red passes could leave the facility up to three times a day two hours at a time without supervision. We would go out on walks together and would talk about life. That day on [DATE], we were outside at 4:15 PM for a smoke break, he mentioned he had this lucid dream about being on another planet seeing other beings and said the dream ended, he was at peace. After the smoke break it was dinner time, R2 saw R1 grab his tray, and after dinner, at 6:00 PM, she went outside to smoke in the front of the building. She saw R1 outside with his coat on and blanket on, and then saw him walk back inside of the building and walk back out. She didn't think anything of it, and went back inside the building. At 8:00 PM, the last smoke break outside, she went outside and R1 did not show up. R1 had never missed a smoke break. She continued her evening and got ready for bed. Sometime about 11:30 PM, she heard the door open and the staff said they were doing a room check. (V12-LPN) asked me if (R1) was in my room and told me (R1) was missing. R2 said she got dressed and went to look for R1. She told the staff he was outside about 6:00 PM, and did show up the 8:00 PM smoke break. R2 said V11 (RN) was in a panic because (R1) had not taken his medications and she started drilling me about his whereabouts. She told the staff to check the sign out sheet; we found the clipboard and (R1) was signed out at 5:57 PM and the sign in time was blank. The male receptionist who was at the desk was new, he knew (R1) did not return. Then I checked the red cards, when a resident leaves the front desk gives them a red pass they have to return when they come back. She checked the entire stack and did not find his red pass. R1 does not have a phone. R2 said she told the staff to call the police, this was unusual for R1, and it was cold outside. She called a mutual friend of theirs, who was a resident at the facility about 1:00 AM, and told him R1 was missing, and asked if he heard from him. R1 had not returned his emails the last couple of days. R2 said she spoke to the police when they arrived about his whereabouts. The next day about 8:30 AM, she was outside and saw several police cars race to the back of the building. After some time, she saw V6 get out of the police car and he was wreck. She knew R1 was found. R2 said the nurse did not know he was missing, the receptionist did not tell the nurse he did not come back, and no one knew how the sign out system worked. She was telling the staff how it works when someone signs out. Now they changed it all. On [DATE] at 12:46 PM, V7 (Behavioral Aide) said she worked a double shift on [DATE] from 6:30 AM to 10:00 PM. She saw R1 last about 4:15 PM, out on the patio during the smoke break. When she left at 10:00 PM, no one knew R1 was missing, there was no code pink called, the nurse did not ask her about or report to her that he was missing. R1 was friendly, liked to walk a lot, and had no behaviors. Residents are allowed to leave the facility for two hours. The receptionist gives them a red pass when they leave, and turn it when they return. The receptionist should notify the nurse if a resident does not return. On [DATE] at 10:50 AM, V9 (CNA) stated, I did my head count at the beginning of my shift just before 4:00 PM, and I saw him then. He eats in the unsupervised dining room and I was in the supervised dining room, so I did not see him at dinner time. It was the end of my shift and I heard the nurses (PM and Night shift) talking that the PM nurse (V11) was not able to give him his medications because she hadn't found him. I had already clocked out, but (V11) said she was going to go upstairs and look for him, and me and the other PM shift nurse left. I didn't know he was missing until the next day. An undated typewritten interview with V6 (Behavioral Aide) states, I came to work a little before 8:00 AM. Nursing staff told me (R1) was missing. I knew that (R1) usually walk in the direction of the golf club, so I went to look there and found him on the wooden path neatly covered with a blanket over him. I immediately called 911 and the dispatcher told me to perform CPR (Cardiopulmonary Resuscitation) if I can. I removed the bag and started CPR. The police came shortly after and took over. (V6 was called 6 times by Surveyors between [DATE] and [DATE]. V6 did not return any of the phone calls and was not able to be interviewed.) On [DATE] at 9:58 AM, V2, Director of Nursing (DON), said she was in the evening on [DATE] doing in-services with the staff. V11 (RN) notified her she could not find R1, she instructed staff to drive around the building and search the facility. She instructed V12 (LPN), the night shift nurse, to call the family and the police. The police were called around 11:15 PM. The police arrived before midnight and we verified with the video he left about 6:00 PM. She received a call the next day around 8:30 AM; R1 was found behind the facility in a wooded area, deceased . She believes R1 had a green community pass. On [DATE] at 9:27 AM, V1 (Administrator) said he was notified on [DATE] R1 was missing when he did not return back from his community pass. (R1) left the facility at 5:57 PM; (R1) had a green pass and could leave the facility unsupervised for two hours. About 11:00 PM, the police were notified and could not locate (R1) when they conducted their search. On [DATE], around 7:00 AM, (V6, Behavioral Aide) found (R1) behind the facility in the wooded area with a bag over his head and blanket over his body, deceased . (V6) called the police immediately. On [DATE] at 2:30 PM, V15 (Police Officer) stated, The (first) call came in somewhere after 12:00 AM. I responded with another officer, I was training. You will have to get the FOIA (Freedom of Information Act) form for any information because I don't want to give you wrong details about anything, but it is all in my report. We had several resources out there, dogs, [NAME], we were searching local businesses in case he went in somewhere to get warm. We didn't find him. That is all in my report. That may take a few days to get because everything has to be completed before they will release any of it. On [DATE] at 11:20 AM, V13 (Detective) stated, Behind the Assisted Living (building next to facility) to the northeast of the facility there is a wooded area. There is a driving area and a walking path back there. He was found ,d+[DATE] feet inside that wooded area. The body had already been removed by the time I got there. Another officer took the initial report that the medication pass was at 9:00 PM, and (R1) wasn't there for the medications at 9:00 PM. They called the police at 1:00 AM, per the police report. According to one of the staff, when a resident has a Level 3 he has the most amount of freedom, and they are required to be back by 6:45 PM. On [DATE] at 2:40 PM V14 (Psych Nurse Practitioner) stated, I had no concerns at all about him. He was very stable. Alert and oriented, very sweet, and involved with many of his peers. I don't think he was ready to live out in the community on his own, but he could go out. I don't know all the facility policies, but I would want to make sure all the residents were supervised because they do have a mental illness diagnosis. R1's Death Certificate was requested on [DATE] and again on [DATE], but it was not available at the time of survey exit. The undated facility policy (at the time of this incident) titled Behavior Management Level Program states, Level 2 Expectations (Pass with staff only) This pass level will be for a minimum of 30 days prior to being considered for Level 3 Level 2 Privileges- Eligible to participate in 2 additional smoke breaks with supervision in the front of the building. In small level 2 groups. May participate in Level 2 gatherings with activity department. The facility policy titled Therapeutic Leave of Absence dated [DATE] states, .2. Psychiatric Facilities Only: Resident will apply for pass privileges. This will be reviewed by the IDT and the physician and will be signed by all participants. 3. Each resident leaving the premises should be signed out on leave of absence. 4. Establish an agreed upon time frame for return to the facility with the resident and/or the accompanying party. 7. Resident should be signed back in upon return to the facility from leave of absence 8. If a resident does not return to the facility within ,d+[DATE] hours of the agreed upon time without communication from the resident or family representative, the following will be initiated: Family, Physician and Police will be notified. The Immediate Jeopardy that began on [DATE] was removed, and the deficient practice was corrected on [DATE], prior to the survey starting on [DATE]. The facility had taken the following action to correct the noncompliance: 1. R1 is no longer a resident at the facility. Completed [DATE] 2. All Community survival risk assessments were reviewed for accuracy, updated accordingly and all Care plans were reviewed to validate they match. Assessments were reviewed by IDT team composed of Administrator, DON, and Social Service designee. Completed [DATE] 3. All staff have been re-educated on the facilities therapeutic leave of absence policy. Any staff on leave or unavailable staff were educated via phone and again before next scheduled shift. Administrator, Assistant Administrator, DON, and Assistant Director of Nursing/ADON conducted the training. Policy details that all residents leaving the premises should be signed out, establish an agreed upon time frame for return to the facility, sign back in upon return to the facility, and what to do if a resident does not return at the agreed upon time. All new hires and agency staff (if utilized in the future) will be educated on this policy prior to working their first shift. Completed [DATE] 4. Facility receptionists were educated by their supervisor on the pass return protocol; Protocol states Only residents with green pass can leave the facility unsupervised, all residents leaving must sign out and establish an agreed upon time for return. Residents must sign back in upon return from pass. If resident fails to return at the agreed upon time, the 1st floor nurses station will be notified before their next scheduled shift. Competed [DATE] 5. No resident goes out on independent pass without having a current Community survival/elopement risk assessment completed and CP updated. Completed [DATE] 6. The pass privilege list was reviewed by the facility IDT composed of Administrator, DON, and Social Service designee, and compared to the response report of current elopement risk/community survival assessments. Completed [DATE] 7. All residents identified as having exit seeking behaviors were reviewed by a Social Service designee and care plans were updated as appropriate. Completed [DATE] 8. All residents with a history of suicidal ideation/suicidal attempts have their independent pass privilege assessment signed by a physician/provider. Completed [DATE] 9. Updated Medical director on event and details. Medical director notified of incident on [DATE] by the facility DON and reviewed the facility's immediate action plan. He agreed with the immediate action plan. Completed [DATE] 10. Administrator and/or designee will audit 5 residents' 2X per week for 6 months to ensure resident's community skills assessment and care plan are accurate. Completed [DATE] 11. Director of Nursing and/or designee will audit the resident sign in/out log daily for 3 months then 2X per week for 3 months to ensure that all residents are accounted for. Completed [DATE] 12. Community pass policy reviewed with IDT and medical director Completed [DATE] 13. QAPI review with Medical Director to review incident and plan of action. IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. Action plan will be reviewed monthly at QAPI meeting. Completed [DATE].

Based on interview and record review, the facility failed to reassess and update R1's capacity for sexual consent after a significant decline in her cognition, failed to timely report an incident of sexual abuse as per facility guidance This failure resulted in the sexually inappropriate behavior between R1 and R2 in a public area. R1 is not able to consent to sexual activity due to her severe impairment in cognition and diagnosis of Dementia, and a reasonable person would not want to perform sexual acts without consent. This applies to 1 of 4 residents (R1) reviewed for sexual assault in the sample of 5. The Immediate Jeopardy began on June 25, 2024, when the facility failed to update the Capacity for Sexual Consent form when R1 was assessed to be severely impaired in cognition, and therefore unable to consent to sexual activity. V1, Administrator, and V2, Director of Nursing, were notified of the Immediate Jeopardy on July 15, 2024 at 10:37 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on July 15 2024 at 2:30 PM, but remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the measures taken. The findings include: Facility census report, dated July 9, 2024, showed R1, R2, R5-R9 resided on the secure behavioral unit. R1's EMR (Electronic Medical Records) showed R1 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, Schizoaffective disorder, depressive type, need for assistance with personal care, mood disturbance, and anxiety, mixed obsessional thoughts and acts, and difficulty in walking, not elsewhere classified, other lack of coordination. Social Service Assessment for Capacity for Sexual Consent, dated April 23, 2024, included R1 has capacity to consent to sexual relationship as she is able to describe what consent looks like, and states is able to spend time with anyone she would like. R1's quarterly MDS (Minimum Data Set), dated June 25, 2024, showed R1 was severely impaired in cognition. Social Service Assessment for Capacity for Sexual Consent, dated July 10, 2024, included R1 is unable to consent due to diagnosis of Dementia and BIMS (Brief Interview of Mental Status) score of 5/15, indicating severely impaired cognition. Nursing progress notes, dated July 9, 2024 at 6:45 PM, included R1's behavior noted at that shift was socially inappropriate, with R1 being sexually inappropriate with co-peer R2 in the dining room. On July 11,2024 at 10:07 AM, R1 stated she got in trouble as a man pretended to be a cop and took her to the back of the room and wanted her to have oral sex on him, and he wanted to feel her in her private parts. R1 stated R2 had his pants down and so did she, and he wanted to have sex with her in the middle of the dining room. R1 stated she was wearing a [NAME] shirt, blue jeans, and a [NAME] pink bra. R1 stated R2 kept touching her private parts as she performed oral sex on him. R1 stated, Two staff came in and said that I am in trouble. They were going to put me in jail as I did something obscene. I committed adultery. This man was married to some other black girl, and I cheated on his wife, and he got me involved in it. I consented to it, so unfortunately, it's my fault and I should go to jail. R1 continued to ramble about unrelated topics about a Rabbi and about diet cola and about the furniture in her room. R2's EMR included R2 is a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses of Bipolar disorder, current episode depressed, severe, with psychotic features, attention-deficit hyperactivity disorder, unspecified type. R2's quarterly MDS, dated [DATE], showed R2 was moderately impaired in cognition. Nurses progress notes, dated July 10, 2024, included R2 was seen by in house Psychiatric NP (Nurse Practitioner) related to sexually inappropriate behaviors and increased psychotic behaviors, and received new order for psychiatric hospitalization for psychiatric evaluation and treatment and R2 was discharged to affiliated hospital on the same day. Social Worker Biopsychosocial assessment dated [DATE] included that R2 has pressured speech flight of ideas loose associations, mood disturbance, interpersonal relationship issues and sporadic bouts of depression and mania. Residents (R5-R9) in the same unit were also interviewed on the above incident. On July 11, 2024 at 11:00 AM, R5 stated she was in the dining room and saw R1 and R2 in the corner Doing something they should not be doing in front of people. He (R2) had his zipper undone and he put it (his penis) in her (R1's) mouth and she was laughing. I was sitting right next to what happened. It was after dinner and two other residents were in the dining room. I notified the staff and told them about it. R5 identified one of the two witnesses as R6 and R7. R5 added no other staff including from Administration has talked to her about this incident after she reported it. On July 11, 2024 at 12:52 PM, R6 stated he saw, A black man and an old lady wearing glasses doing something embarrassing in the dining room. I did not tell anybody about it. On July 11, 2024 at 10:32 AM, R7 stated prior (about half hour) to the above incident, R7 saw R2 leaning towards R1 inappropriately and talking to R1. R7 she went up to V7 (Behavioral aide) and told him she thought it wasn't appropriate for R2 to talk to an elderly woman, because she knew about R2's history. R7 stated V7 just left and V6 (Behavioral Aide) was in the dining room. R7 stated R5 told her at a later time she saw R2 pull out his penis and R1 performed oral sex on him, and there were no behavioral aides in the dining room as they had left. R7 stated later that night, V7 told her R1 has had a wild sexual history and she was into it and it was consensual. R7 stated she told V7 that she disagrees because R1 has Dementia and she cannot consent. R7 added R2 was behaving in a bizarre manner for three days in a row in the dining room prior to the incident of R1 and R2. On July 11, 2024 at 12:44 AM, R8 stated she heard R5 talk to V7 about R2 talking inappropriately to R1 in the dining room right after dinner. On July 11, 2024 at 10:44 AM, R9 stated, [R2] had an incident with me a month ago and requested to use my bathroom and he went in there and later bragged to his friend that he was thinking of f***king me as he was jacking off. R9 stated she told the administration about it. R9 continued (R2) was living on the second floor before and doesn't understand why the facility moved him up to the 3rd floor. On July 11, 2024 at 3:20 PM, V4 (Registered Nurse) stated on July 9, 2024, R5 came up to the nurses station at around 6:45 PM after dinner and told the staff present R1 and R2 were being sexually inappropriate in the in the dining room. V4 stated she told the behavioral aides to check on them, and they separated them. V4 stated she assessed R1. V4 stated, I asked [R1] if she was consenting and she said 'yes'. I was concerned about the age gap as [R1] is around 70 and [R2] is 29 (years old). I felt that it is inappropriate to mingle with someone at a younger age. [R2] is hyper and has a behavior of grandiosity. On July 11, 2024 at 1:29 PM, V6 (Behavioral Aide) stated on July 9, 2024 after dinner time, he was at the nurses station, and R5 came and told the staff R1 is doing a hand job on R2 in the dining room. V6 stated =he saw that R2's pants were unbuttoned, and R1's hands on R2 and he separated them. V6 stated he and V4 talked to them and made it clear that what they did was not appropriate as it was a public space. V6 stated both R1 and R2 stated it was consensual. V6 added, I still think it was not okay. I don't think both of them are in the right mind. [R1] is one of our new patients. She could be mentally persuaded. On July 12, 2024 at 1:53 PM, V7 (Behavioral aide) stated he did see R2 taking to R1, who was seated at the next table in the dining room. V7 stated he believes R7 said something about the behavior being inappropriate, but he could not recall the conversation exactly. On July 11, 2024 at 11:32 AM, V1 (Administrator) stated after the above incident, both R1 and R2 were assessed by V8 (Psychiatric Nurse Practitioner) on July 10, 2024, and R2 was sent out to the hospital for Psychiatric evaluation as he was off in his behavior. V1 stated R1 was initially assessed after admission to have ability to consent to sexual relationships. V1 stated V8 was questioning R1's capacity to consent as R1 has Dementia and it's progressing. V1 stated V8 suggested to get her off the 3rd floor and to a memory care setting. V1 stated V3 (Social Service Director) re-did the assessment for Capacity for Sexual Consent and assessed R1 does not have the capacity to consent. On July 11, 2024 at 1:46 PM, on July 12, at 12:27 PM, and on July 16, at 12:33 PM, V3, Social Service Director, stated the facility's assessment tool to determine a Capacity for Sexual Consent is done initially when a resident shows interest in having sexual activity with another resident. V3 stated R1 was liking a resident sometime in April and on April 23, 2024 an assessment for Capacity for Sexual Consent was done that showed R1 had the capacity to say no to uninvited sexual contact. V3 stated R1's BIMS (Brief Interview for Mental Status) on admission was 11/15, which showed she was moderately impaired in cognition and able to give consent, as she knew that resident by name and room number. V3 also added, Having a high BIMS score does not necessarily mean they have good judgement. V3 stated on June 25, 2024, during R1's cognitive reassessment, R1 was found to have severe cognitive impairment, and therefore R1 would not be able to provide consent to sexual activity. V3 added when a resident is not able to give consent ,then they are identified at risk for sexual abuse On July 12, 2024 at 3:01 PM, V8 (Psychiatric Advanced Practice Nurse-ANP) stated R1 has Dementia, Schizophrenia, and Neurocognitive disorder, and was admitted to the 3rd floor (secure Behavioral unit). V8 stated she saw the facility video of the incident between R1 and R2, and it was evident R1 did not know what she was doing. V8 stated during consultation, R1 showed moderate to severe cognitive capacity as she was not able to recall the incident with R2, and did not seem to be upset or bothered as a reasonable person would. V8 stated R1 being able to give consent is questionable as she is unable to know and understand and can easily be taken advantage of. V8 stated R2 is a younger man who is hypersexual and thinks he is a [NAME]. V8 stated R2 has the capacity to make decisions, but was in a manic psychotic state, with erratic behavior with up and down cycles and was going in and out of resident's rooms. Facility policy and procedure titled 'Abuse Prevention and Reporting' (effective date November 28, 2016) included as follows: This facility has the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Sexual Abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault (42 CFR 483.12 Interpretive Guidelines) including non-consensual or non-competent to consent sexual activity . Generally, sexual contact is nonconsensual if the resident either: Appears to want the contact to occur, but lacks the cognitive ability to consent, OR does not want the contact to occur. Facility Policy titled 'Sexuality-Capacity to Consent Determination' (effective date January 7, 2019) Purpose: To establish criteria for determining the capacity to consent when resident to resident sexual activities occur. Capacity and Consent: Residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility shall ensure the resident is evaluated for capacity to consent. Residents without the capacity to consent to sexual activity may not engage in sexual activity . Capacity may be defined as an individual's physical or mental ability relative to a specific task, e.g., executing a will, consenting to medical treatment, or sexual consent Capacity to consent to sexual activity are not required to be completed on all resident, but rather on an as needed basis when circumstances arise that warrant the assessment. Any resident previously assessed will be re-assessed with a change in level of cognition. The facility submitted an acceptable plan to remove the immediacy on July 15, 2024, and took the following actions to remove the immediacy. - R1 has an updated capacity to consent for sex assessment completed on July 10, 2024. - R2 has been sent out to the hospital for a psychiatric evaluation. - An emergency Quality Assurance meeting has been conducted with facility medical director and IDT (Interdisciplinary Team) to review the incident and action plan. - Residents that have been identified being at risk from sexual exploitation have had their care plans updated to reflect interventions to prevent abuse. - All residents have been reassessed for capacity for sexual consent. - Residents that have been identified for being at risk from sexual exploitation were interviewed if they have been taken advantaged of or manipulated to perform sexual acts. None of them responded yes. -Residents who are identified as at risk to potentially be the perpetrator for sexual abuse or exploitation will be reassessed and placed closer to the nurse's station for increased monitoring, and have their care plans updated to reflect. - The capacity to consent policy has been revised and updated. - Social Service staff received an Inservice on updating the capacity for consent assessment whenever a significant change in a resident's cognition is noted. - Facility wide Inservice, initiated on July 11, 2024, and ongoing. Information included: How to recognize sexual abuse and the facility's abuse protocol to prevent it from happening to other residents. The Abuse prevention reporting policy, specifically the definition of abuse, sexual abuse, sexual assault and internal reporting requirements and identification of allegation and protection of residents. All staff were re-educated prior to their next scheduled shift including staff that are on leave and are on vacation. Staff acknowledged information via signature or via phone call. Administrator and Assistant administrator are conducting the training. Administrator/Managers will continue to monitor all staff for compliance by a competency questionnaire. - Facility administrator and/or designee will interview 5 staff members 2 times weekly for 2 months, then weekly for 2 months, then bi-weekly for 2 months to ensure staff is aware of the facility policy related to sexual abuse. (Audit Tool included). - Facility Administrator and/or designee will interview 5 residents 2 times weekly for 2 months, then weekly for 2 months, then bi-weekly for 2 months to ensure they are free from abuse.(Audit Tool included). The immediate jeopardy began on June 25, 2024 and removed on July 15 2024, after onsite verification of implementation of abatement plan to remove the immediacy.

Based on observation, interview, and record review, the facility failed to ensure a resident who required supervision and safe swallowing strategies while eating was provided supervision while eating. This failure resulted in R1 eating alone in her room and experiencing a choking incident requiring the Heimlich maneuver and CPR (Cardio-Pulmonary Resuscitation). R1was transported via emergency response and expired. The facility also failed to have a system in place to identify residents who require supervision with eating and ensure Speech Therapy recommendations are implemented. This applies to 48 of 48 residents (R1, R3, R4, R5, R6, R7, R8, R11-R51) reviewed for supervision while eating in the sample of 51. The Immediate Jeopardy began on [DATE] when V12 (BA-Behavioral Aide) served a meal tray to R1 in her room, and left R1 unattended with the meal tray. R1 was later found unresponsive in her room by facility staff. R1 was transported to the local hospital and expired at the hospital on [DATE] at 2:14 PM. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on February 1, 2024 at 1:45 PM. The facility presented an abatement plan to remove the immediacy on February 1, 2024. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on February 2, 2024 at 12:04 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on February 2, 2024 at 1:08 PM, and the survey team accepted the abatement plan on February 2, 2024 at 1:18 PM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on February 2, 2024 at 1:18 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was a [AGE] year-old resident, admitted to the facility on [DATE]. The EMR continues to show R1 expired on [DATE]. R1 had multiple diagnoses including, pneumonia, UTI (Urinary Tract Infection), schizophrenia, abnormal gait and mobility, lack of coordination, abnormal posture, need for assistance with personal care, cognitive communication deficit, mild intellectual disabilities, generalized anxiety disorder, history of breast and intestinal cancer, and chronic kidney disease. R1's MDS (Minimum Data Set), dated [DATE], shows R1 was rarely/never understood and had severe cognitive impairment. R1 required substantial/maximal assistance with toilet hygiene, showering, dressing, and personal hygiene, and supervision/touch assistance with bed mobility, transfers between surfaces, eating, and oral hygiene. R1 was frequently incontinent of bowel and bladder. Speech Therapy recommendations for R1, dated [DATE], show: Swallow strategies/positions: Continue meals in dining room; cue as needed for safe PO (Oral) intake. Slower pace of PO intake, upright and alert, smaller bites and single bites, smaller sips, and alternate solids and liquids. The facility did not have documentation to show care plan interventions for safe swallowing strategies were put in place following the [DATE] speech therapy recommendations. On [DATE] at 1:20 PM, V3 (RN) documented, CNA went into [R1's] room. Resident noted to have obstructed airway. Code blue initiated. Heimlich maneuver performed. Resident became unconscious, cyanotic. O2 (Oxygen) 49 percent RA (Room Air), no pulse. 911 called, and CPR initiated. Compressions provided and oxygenation. Resident placed on non-rebreather mask. [R1] suctioned. O2 at 63 percent on 3 LPM (Liters Per Minute). HR (Heart Rate) 67 BPM (Beats Per Minute). Paramedics arrived on unit and took over. Resident left the unit on a stretcher with paramedics. On [DATE], effective 2:25 PM, V3 (RN) documented: Notified [V16] (Physician) and [V19] (R1's POA-Power of Attorney) of resident's transfer to [local hospital]. Writer called [Local Hospital] to follow up on resident's health status. ER (emergency room ) receptionist notified writer that resident was deceased on arrival to the hospital. Writer spoke with ER nurse and stated that the resident was deceased on arrival to the hospital. EMS (Emergency Medical Services) documentation, dated [DATE], shows EMS personnel had their first contact with R1 on [DATE] at 1:35 PM. The EMS report shows: Upon medics arrival, [R1] found supine on the floor in the care of (fire department), in cardiac arrest. (Fire department) crew had started CPR upon their arrival. (Fire department) crew reports patient was found to be pulseless and in asystole. Facility staff reports finding [R1] unresponsive with food in their mouth prior 20 minutes prior to EMS arrival and had started CPR. (Fire department) made numerous attempts to open patient's airway and clear but were unsuccessful due to the presence of food in the airway. Crew was attempting to ventilate with BVM (Bag Valve Mask) Pulse and rhythm check showed patient to have no pulse and was asystole on the monitor, CPR continued with (mechanical chest compression device) . A second attempt was made to clear patient airway and was unsuccessful, airway could not be visualized due to food obstruction, numerous large pieces of food were removed from mouth with forceps and suction. Attempts at ventilation with BVM continued. Another pulse check was performed showing patient to still be pulseless and asystole . CPR continued. Patient moved to cot and loaded on to the ambulance where care and assessment continued. Surgical cricothyrotomy (incision through the skin and cricothyroid membrane to establish airway) was performed and was successful, tube secured with tape and gauze. The EMS report continues to show No ROSC (Return of Spontaneous Circulation) at any time. Hospital records dated [DATE] show R1 expired at the local hospital on [DATE] at 2:14 PM. The State of Illinois Certificate of Death Worksheet (Death Certificate), dated February 6, 2024, shows R1 expired on [DATE] at 2:14 PM at the local hospital. An autopsy was performed, and the autopsy findings were used to complete the cause of R1's death. The death certificate shows R1's cause of death was asphyxia due to aspiration of a food bolus. The death certificate continues to show the asphyxia due to aspiration of a food bolus occurred at the facility on [DATE] at 1:25 PM. The death certificate is certified and signed by V20 (Physician/Medical Examiner/Coroner). R1's diet card was provided by V1 (Administrator) on [DATE]. The diet card showed supervision. R1's diet card did not show the safe swallowing strategies recommended by speech therapy. On [DATE] at 1:13 PM, V5 (Speech Therapist) said, I started working at the facility a couple of months ago. [R1] was evaluated by the previous speech pathologist in [DATE]. I evaluated [R1] at the end of November and at the beginning of December I started caring for her related to her cognition. She was impulsive with eating. She needed supervision because she was impulsive. She also liked to stand up and try to walk while she was eating. Supervision means that someone is around in case something happens. [R1] should not have eaten alone in her room with the door closed because she was at risk for choking. Her speech therapy notes from early November showed she needed to eat in the dining room and needed cuing to ensure safe oral intake. She needed to be reminded to eat at a slower pace, to take small bites and alternate solid foods with liquids. On February 1, 2024 at 9:11 AM, V12 (BA-Behavioral Aide) said, I have worked as a Behavioral Aide at the facility for one and a half years. I help pass meal trays to residents. Behavioral Aides are not aware of any resident concerns like who needs help being fed or anything like that. All Behavioral Aides do is pass meal trays to residents; we do not help feed them. On [DATE], I delivered the lunch tray to [R1]. I went in and set the tray down on her bed around 12:30 PM, and went out and passed other meal trays to residents. From 1:00 PM to 1:30 PM, I was outside supervising other residents for their smoking break. I did not go back to check on [R1]. I never saw writing on [R1's] meal ticket that showed she needed supervision because I was never trained to look for that on the ticket. I just know the people who needed supervision with eating were sitting in the dining room, and [R1] was sitting on the chair in her room, so I gave her the lunch tray. I was outside on the smoking patio and a resident said they were calling a code blue inside. I came in and I went up to [R1's] floor and I saw it was her. After that happened, [V1] (Administrator) told me [R1] was supposed to be supervised. I explained to him I did not see the word supervision on the ticket because no one told me I had to read the tickets. On [DATE] at 9:55 AM, V9 (CNA-Certified Nursing Assistant) said, After lunch on [DATE], I was collecting the meal trays. I was done picking up all of the trays and went to [R1's] room. The door to her room was mostly closed, and only open about four inches. I could not see into her room from the hallway. I found [R1] unresponsive, lying across her bed, with her feet still on the floor. I called for help right away. We did the Heimlich maneuver. No food came out. I could see pieces of food in her mouth. The lunch served that day was chicken on a bun. [R1] was able to feed herself, but she had to be supervised because she ate too fast and needed reminders to slow down. We had Covid in the building and we were locked down, so some residents had to eat in their room. We passed the trays, and people who needed supervision were fed by us, or we watched them in their room. We do not have a list or binder anywhere to show which residents need supervision with eating. After the interview with V9, V9 was able to demonstrate how he found R1's door closed to within four inches of the door jamb, and how he was unable to see R1 sitting in her room from the nurse's station or from the hallway. On [DATE] at 10:04 AM, V4 (CNA) said, I was feeding a resident in the TV room. [V9] (CNA) approached me and said, Who gave the lunch tray to [R1]? Come on, let's go see her. We ran to [R1's] room and saw her lying across the bed. My initial reaction was to call the nurse and call a code blue. There was food in her mouth. When we found her she was pale and did not have a pulse but was warm. She was supposed to eat with someone watching her. [R1] needed to be supervised because she ate too fast. I have been working here since [DATE], and she has needed to be supervised while eating since I started working here. I never saw it in writing anywhere, I just knew that. I don't think we have a list or a posting anywhere that shows which residents need to be supervised. On February 1, 2024 at 9:49 AM, V14 (RN-Registered Nurse) said, The nurse assigned to [R1] was on her lunch break. I was organizing the medication cart because lunch was pretty much over. [V4] (CNA) came to me and said I should follow her to [R1's] room. [R1] was unresponsive and lying across her bed. I saw food coming from her mouth. [R1] was on a regular diet, but she needed supervision while she ate. She got anxious and did not sit still when she ate. She was supposed to be supervised. No one ever told me there were speech therapy recommendations for her. I tried to do a finger sweep because I could see visible food in her mouth. We called a code blue, and I started CPR. I tried the Heimlich maneuver, and she was not responding to me. We put a pulse oximeter on her while we were doing the compressions, but we did not get a reading. 2. On [DATE], multiple observations were made throughout the facility. No postings or lists of residents requiring supervision while eating or one-to-one assistance could be located. V3 (RN), V8 (RN), V9 (CNA), V4 (CNA), and V17 (Cook) said the facility does not have a list of residents who require supervision while eating. On [DATE] at 12:47 PM, V1 (Administrator) said, The meal tickets show the word supervision if the resident needs supervision while eating. After the choking incident with [R1], we changed meal tickets to red paper to flag the residents who need supervision while eating. At the time of the interview, V1 did not have a list to show which residents required supervision while eating. On [DATE] at 2:16 PM, V1 (Administrator) provided a list of residents who require supervision while eating and one-to-one feeding assistance. The list showed one resident (R3) required one-to-one supervision while eating. The list continued to show R3, R4, R5, R6, R7, R8, and R11-R39 required supervision while eating. On [DATE] at 2:25 PM, V17 (Cook) showed a stack of meal tickets to be used for the dinner meal on [DATE]. V17 said the facility has not had a Food Service Director for about eight months. V17 said she is running the kitchen, but does not have access to the computer and all meal tickets are updated by V1 (Administrator). Every meal ticket was reviewed with V17 (Cook) present and compared to the list of residents who require supervision while eating provided by V1 (Administrator) several minutes earlier. A discrepancy was found between the meal tickets and the list provided by V1. Twelve additional residents (R40-R51) had meal tickets showing supervision was required while eating, but did not show on the list provided by V1. On [DATE] at 2:46 PM, V1 (Administrator) said he is responsible for updating all meal tickets for residents to show if they need supervision while eating or other speech therapy recommendations. V1 said to his knowledge, only R3 required one-to-one supervision with eating. V1 said he was not aware Speech Therapy recommended R7 and R8 should have one-to-one supervision while eating. V1 could not say why the facility's list of residents of residents requiring supervision while eating did not include R40-R51. 3. The EMR shows R7 was admitted to the facility on [DATE]. R7 has multiple diagnoses including schizoaffective disorder, anxiety disorder, asthma, dyskinesia, dysphagia, tremor, lack of coordination, and difficulty walking. R7's MDS, dated [DATE], shows R7 has moderate cognitive impairment, requires partial/moderate assistance with eating and oral hygiene, substantial/maximal assistance with showering and personal hygiene, and is dependent on facility staff for toilet use, lower body dressing, bed mobility, and transfers between surfaces. R7 has an indwelling urinary catheter and is frequently incontinent. R7's Speech Therapy Recommended PO Intake Form, dated [DATE], and signed by V5 (Speech Therapist) shows R7 should receive mechanical soft diet, thin liquids, and eat in the general dining room with 1:1/supervision for all oral intake. The form continues to show the following Swallowing Compensatory Strategies: Slow rate, small bites/sips, alternate solids and liquids, upright position, upright 30 minutes after intake, double swallow. Intermittent 1:1 assist as needed. R7's care plan, initiated on [DATE], shows: I am risk for swallowing issue r/t (Related To) swallowing difficulty. Care plan interventions initiated on [DATE] show: Make sure resident is sitting in upright position when eating. Monitor for coughing, shortness of breath, choking, labored respiration. Observe closely during activities involving consumption of food/drink for any s/s (Signs/Symptoms) of choking, if noted, report to nurse immediately. On [DATE] at 5:23 PM, R7 was lying in bed in his room eating his dinner. R7 was eating a bowl of fruit while lying in his bed. No staff were present. R7's plate had a scant amount of uneaten food particles and appeared empty. R7 said he had eaten his dinner while lying in his bed with no staff present. At 5:28 PM, V10 (CNA) entered R7's room. V10 said the CNA assigned to R7 was in another room, feeding a resident. V10 said she was not assigned to care for R7, and was not aware R7 required one-to-one supervision when eating. V10 was unable to say what swallowing strategies were necessary for R7 to eat safely. R7's meal ticket, dated [DATE], showed R7 required supervision. R7's meal ticket did not show the speech therapy swallow strategies. On [DATE] at 1:13 PM, V5 (Speech Therapist) said, I want [R7] to eat in the dining room. He should never be lying in bed while eating. He needs one-to-one supervision at all times when he is eating, because he is at risk of choking. I also wrote on the Speech Therapy form to provide intermittent one-to-one assistance as needed. Assistance and supervision are two different things. The one-to-one intermittent assistance means if [R7] gets tired while eating or needs reminders to double swallow, or eat slow, or alternate solids with liquids while he is being supervised the entire time he is eating, then staff can intervene. We want him supervised at all times while eating and to be safe, but we don't want the resident to feel like he is not allowed to feed himself. 4. The EMR shows R8 was admitted to the facility on [DATE]. R8 has multiple diagnoses including encephalopathy, lack of coordination, abnormal gait, dysphagia, dementia, major depressive disorder, bipolar disorder, schizoaffective disorder, COPD, obsessive compulsive disorder, anxiety disorder, and epilepsy. R8's MDS, dated [DATE], shows R8 is rarely/never understood, has moderately impaired cognition, requires partial/moderate assistance with eating and oral hygiene, and substantial/maximal assistance with all other ADLs (Activities of Daily Living). R8's MDS continues to show R8 holds food in his mouth or cheeks. R8 is always incontinent of urine and frequently incontinent of stool. R8's Speech Therapy Recommended PO (oral) Intake Form, dated [DATE], shows R8 should receive mechanical soft diet, thin liquids, and eat in the general dining room with 1:1 assist. The form continues to show the following Swallowing Compensatory Strategies: Slow rate, small bites/sips, alternate solids and liquids, upright position, upright 30 minutes after intake, check for pocketing. The speech therapy notes also show R8 is edentulous (lacking teeth) and has moderate oral inefficiency with regular textures and is a choking/aspiration risk. R8's care plan, initiated on [DATE], shows: I am pocketing with regular texture foods during meals r/t dysphagia. Interventions dated [DATE] include: Monitor for any signs of choking and swallowing issues. On general diet, mechanical soft texture, thin consistency. Staff need to redirect him to eat small bites and give drink in between. On [DATE] at 5:19 PM, R8 was sitting in his bed feeding himself his dinner. V11 (CNA) was standing at the foot of R8's bed watching him eat. R8 was not alternating solids and liquids. V11 was not reminding R8 to take small bites or alternate solids and liquids. V11 did not check to ensure R8 was not pocketing food. V11 (CNA) said she was not aware of Speech Therapy swallowing strategies. R8's meal ticket did not show the Speech Therapy swallowing strategies. On February 1, 2024 at 2:34 PM, V5 (Speech Therapist) said, At the time [R8] was eating dinner in his room on [DATE], he should have had one-to-one assistance, and speech interventions should have been place for him, including checking for food pocketing. The Immediate Jeopardy that began on [DATE] was removed on February 2, 2024 at 1:18 PM when the facility took the following actions to remove the immediacy: The facility has implemented a system to identify residents who require supervision and ensure speech recommendations are being implemented. Speech Therapy, in conjunction with the Director of Rehab, has created a list of residents who require assistance and/or supervision with eating, individualized resident specific interventions along with their recommendations, including if resident needs a one-to-one, having a CNA or Nurse present during mealtimes, slow rate, small bites, sips, alternating solids and liquids, upright position, and check for food pocketing. That list has been shared with the Dietary Department, Restorative Department, clinical management team: DON (Director of Nursing), ADON (Assistant Director of Nursing), Psychotropic Nurse, Infection Control Nurse, administration, and a copy has been placed at each nurse's station and the Dietary Manager's office. Any updates will be discussed in the facility's morning meeting. CNAs and nurses have been in-serviced on where the list is located, and specific resident interventions required. Any new speech therapy recommendations will be communicated by hand delivering the new form to the charge nurse. The Director of Rehab will also send the new form via email to the DON, ADON, Restorative Nurse, Dietary Manager, and Administrator to update. All updates will be discussed in the facility morning meeting. The list of residents requiring supervision and the degree of supervision will be updated as needed and audited by the Director of Nursing and/or designee daily for three weeks, then three times a week for five weeks, then weekly for three months. If any errors are noticed there will be immediate corrective action along with in-service on what went wrong. All findings will be discussed during the facility QA (Quality Assurance) meetings. All residents who need supervision will be placed in the TV room on each floor to ensure adequate supervision during meals. Social Service will be made aware of residents who refuse to eat in the dining room, and will educate residents on the benefits of eating in a group setting. In the event residents who require supervision refuse to eat in the dining room, those trays will be separated and will only be served in the presence of a CNA or nurse. The facility will utilize restorative staff as well as nursing staff from other floors as needed. In the event of a Covid outbreak, the facility will designate a specific dining room for Covid positive residents requiring supervision. All residents who have been identified that they require supervision have their meal tickets being printed on red paper and have therapy recommendations printed on their ticket to be aware of specific instructions regarding compensatory swallowing strategies including slow rate, small bites, sips, alternating solids and liquids, upright position, and checking for food pocketing. All staff who deliver meal trays to residents have received an in-service on separating all trays with red tickets and those trays will only be served by nurses and CNAs. The in-service will be verified by their respective supervisor. Staff who are on leave or vacation will receive an in-service prior to their return date. All new hires will receive the in-service prior to working on the unit. In the event that the facility utilizes agency staff, the agency staff will be educated prior to working on the unit. The Restorative Nurse and MDS Nurse have updated the CNA's tasks in POC (Point of Care) so the CNAs can have access to see the recommendations in the EMR. The therapy recommendations have also been added to the notification ribbon on residents' EMR charts for those residents whom therapy has specific recommendations reflecting those recommendations. Therapy interventions will also be notated on the resident's individual care plan and updated when there is a change. Nursing staff received an in-service on the emergency response of the facility's obstructed airway policy. An emergency response drill has been completed on all shifts. Staff present on the day of the drill attended the drill. Residents who witnessed the choking incident have been offered counseling. The facility will complete emergency response drills every week for two months, then quarterly on all three shifts. The facility is actively looking to hire a Dietary Manager with several candidates already interviewed. In the interim, V21 (AIT-Administrator in Training) will assist with overseeing the Dietary Department. The Administrator and/or designee will audit the dining room daily for three weeks, then three times a week for five weeks, then once weekly for three months at random mealtimes to ensure nurse presence and appropriate residents are seated in dining observation area. The Director of Nursing and or designee will conduct audits daily for three weeks, then three times a week for five weeks, then weekly for three months to ensure all direct care staff can identify which residents are at risk for choking. The Administrator and or designee will conduct audits three times per week for six months to ensure that therapy's list of residents requiring supervision and their recommendations match the list by the nurse's station and the dietary tickets. In the event the Administrator is not working V21 (AIT) will be the backup up designee. An emergency QA meeting has been conducted with facility Medical Director and IDT (Inter-Disciplinary Team) to discuss survey concerns and findings. An additional QA meeting will be conducted once all evidence has been presented to the Department of Public Health.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect when the facility failed to provide services to support safe eating environment for R1 who was identified to need direct supervision and safe swallowing strategies to prevent choking and aspiration. The facility neglected to develop and implement a care plan with interventions for R1 to include the recommended eating plan and the facility neglected to train direct care staff on the services R1 needed to prevent aspiration. The facility also neglected to have a system in place to identify other residents with eating and swallowing precautions and train direct care staff on monitoring and supervising these residents and following speech therapy recommendations. As a result, R1 was served a meal tray in her room without supervision by an untrained staff member, aspirated and later expired. This applies to 1 of 48 residents (R1) reviewed for supervision while eating in the sample of 51. The facility's initial report to the State Agency, dated [DATE], shows R1 experienced choking and an obstructed airway episode at the facility on [DATE] at 1:20 PM. Staff initiated the Heimlich maneuver immediately, 911 was called for assistance, and R1 was sent to the local hospital and expired. The EMR (Electronic Medical Record) shows R1 was a [AGE] year-old resident, admitted to the facility on [DATE]. The EMR continues to show R1 expired on [DATE]. R1 had multiple diagnoses including, pneumonia, UTI (Urinary Tract Infection), schizophrenia, abnormal gait and mobility, lack of coordination, abnormal posture, need for assistance with personal care, cognitive communication deficit, mild intellectual disabilities, generalized anxiety disorder, history of breast and intestinal cancer, and chronic kidney disease. R1's MDS (Minimum Data Set), dated [DATE], shows R1 was rarely/never understood and had severe cognitive impairment. R1 required substantial/maximal assistance with toilet hygiene, showering, dressing, and personal hygiene, and supervision/touch assistance with bed mobility, transfers between surfaces, eating, and oral hygiene. Speech therapy recommendations for R1, dated [DATE], show: Swallow strategies/positions: Continue meals in dining room; cue as needed for safe PO (Oral) intake. Slower pace of PO intake, upright and alert, smaller bites and single bites, smaller sips, and alternate solids and liquids. The facility did not have documentation to show care plan interventions for safe swallowing strategies were put in place following the [DATE] speech therapy recommendations. On [DATE] at 1:20 PM, V3 (RN-Registered Nurse) documented, CNA (CNA-Certified Nursing Assistant) went into [R1's] room. Resident noted to have obstructed airway. Code blue initiated. Heimlich maneuver performed. Resident became unconscious, cyanotic. O2 (Oxygen) 49 percent RA (Room Air), no pulse. 911 called, and CPR initiated. Compressions provided and oxygenation. Resident placed on non-rebreather mask. [R1] suctioned. O2 at 63 percent on 3 LPM (Liters Per Minute). HR (Heart Rate) 67 BPM (Beats Per Minute). Paramedics arrived on unit and took over. Resident left the unit on a stretcher with paramedics. On [DATE] at 2:25 PM, V3 (RN) documented: Notified [V16] (Physician) and [V19] (R1's POA-Power of Attorney) of resident's transfer to [local hospital]. Writer called [Local Hospital] to follow up on resident's health status. ER (emergency room ) receptionist notified writer that resident was deceased on arrival to the hospital. Writer spoke with ER nurse and stated that the resident was deceased on arrival to the hospital. EMS (Emergency Medical Services) documentation, dated [DATE], shows EMS personnel had their first contact with R1 on [DATE] at 1:35 PM. The EMS report shows: Upon medics arrival, [R1] found supine on the floor in the care of (fire department), in cardiac arrest. (Fire department) crew had started CPR upon their arrival. (Fire deepartment) crew reports patient was found to be pulseless and in asystole. Facility staff reports finding [R1] unresponsive with food in their mouth prior 20 minutes prior to EMS arrival and had started CPR. Hospital records, dated [DATE], show R1 expired at the local hospital on [DATE] at 2:14 PM. The State of Illinois Certificate of Death Worksheet (Death Certificate), dated February 6, 2024, shows R1 expired on [DATE] at 2:14 PM at the local hospital. An autopsy was performed, and the autopsy findings were used to complete the cause of R1's death. The death certificate shows R1's cause of death was asphyxia due to aspiration of a food bolus. The death certificate continues to show the asphyxia due to aspiration of a food bolus occurred at the facility on [DATE] at 1:25 PM. The death certificate is certified and signed by V20 (Physician/Medical Examiner/Coroner). R1's diet card was provided by V1 (Administrator) on [DATE]. The diet card showed supervision. R1's diet card did not show the safe swallowing strategies recommended by speech therapy. On [DATE] at 1:13 PM, V5 (Speech Therapist) said, I started working at the facility a couple of months ago. [R1] was evaluated by the previous speech pathologist in [DATE]. I evaluated [R1] at the end of November, and at the beginning of December I started caring for her related to her cognition. She was impulsive with eating. She needed supervision because she was impulsive. She also liked to stand up and try to walk while she was eating. Supervision means that someone is around in case something happens. [R1] should not have eaten alone in her room with the door closed because she was at risk for choking. Her speech therapy notes from early November showed she needed to eat in the dining room and needed cuing to ensure safe oral intake. She needed to be reminded to eat at a slower pace, to take small bites, and alternate solid foods with liquids. On February 1, 2024 at 9:11 AM, V12 (BA-Behavioral Aide) said, I have worked as a Behavioral Aide at the facility for one and a half years. I help pass meal trays to residents. Behavioral aides are not aware of any resident concerns like who needs help being fed or anything like that. All Behavioral Aides do is pass meal trays to residents; we do not help feed them. On [DATE], I delivered the lunch tray to [R1]. I went in and set the tray down on her bed around 12:30 PM, and went out and passed other meal trays to residents. From 1:00 PM to 1:30 PM, I was outside supervising other residents for their smoking break. I did not go back to check on [R1]. I never saw writing on [R1's] meal ticket that showed she needed supervision because I was never trained to look for that on the ticket. I just know the people who needed supervision with eating were sitting in the dining room, and [R1] was sitting on the chair in her room, so I gave her the lunch tray. After that happened, [V1] (Administrator) told me [R1] was supposed to be supervised. I explained to him I did not see the word supervision on the ticket because no one told me I had to read the tickets. On [DATE], at 9:55 AM, V9 (CNA) said, After lunch on [DATE] I was collecting the meal trays. I was done picking up all of the trays and went to [R1's] room. The door to her room was mostly closed, and only open about four inches. I could not see into her room from the hallway. I found [R1] unresponsive, lying across her bed, with her feet still on the floor. I called for help right away. We did the Heimlich maneuver. No food came out. I could see pieces of food in her mouth. The lunch served that day was chicken on a bun. [R1] was able to feed herself, but she had to be supervised because she ate too fast and needed reminders to slow down. We do not have a list or binder anywhere to show which residents need supervision with eating. After the interview with V9, V9 was able to demonstrate how he found R1's door closed to within four inches of the door jamb, and how he was unable to see R1 sitting in her room from the nurse's station or from the hallway. On [DATE] at 10:04 AM, V4 (CNA) said, I was feeding a resident in the TV room. [V9] (CNA) approached me and said, Who gave the lunch tray to [R1]? Come on, let's go see her. We ran to [R1's] room and saw her lying across the bed. My initial reaction was to call the nurse and call a code blue. There was food in her mouth. When we found her she was pale and did not have a pulse, but was warm. She was supposed to eat with someone watching her. [R1] needed to be supervised because she ate too fast. I have been working here since [DATE], and she has needed to be supervised while eating since I started working here. I never saw it in writing anywhere, I just knew that. I don't think we have a list or a posting anywhere that shows which residents need to be supervised. On February 1, 2024 at 9:49 AM, V14 (RN) said, The nurse assigned to [R1] was on her lunch break. I was organizing the medication cart because lunch was pretty much over. [V4] (CNA) came to me and said I should follow her to [R1's] room. [R1] was unresponsive and lying across her bed. I saw food coming from her mouth. [R1] was on a regular diet, but she needed supervision while she ate. She got anxious and did not sit still when she ate. She was supposed to be supervised. No one ever told me there were Speech Therapy recommendations for her. On [DATE], multiple observations were made throughout the facility. No postings or lists of residents requiring supervision while eating or one-to-one feeding assistance could be located. V3 (RN), V8 (RN), V9 (CNA), V4 (CNA), and V17 (Cook) said the facility does not have a list of residents who require supervision while eating. On [DATE] at 12:47 PM, V1 (Administrator) said, The meal tickets show the word supervision if the resident needs supervision while eating. After the choking incident with [R1] we changed meal tickets to red paper to flag for residents who need supervision while eating. At the time of the interview, V1 did not have a list to show which residents required supervision while eating. On [DATE] at 2:16 PM, V1 (Administrator) provided a list of residents who require supervision while eating and one-to-one supervision while eating. The list showed one resident (R3) required one-to-one supervision while eating. The list continued to show R3, R4, R5, R6, R7, R8, and R11-R39 required supervision while eating. On [DATE] at 2:25 PM, V17 (Cook) showed a stack of meal tickets to be used for the dinner meal on [DATE]. V17 said the facility has not had a Food Service Director for about eight months. V17 said she is running the kitchen, but does not have access to the computer and all meal tickets are updated by V1 (Administrator). Every meal ticket was reviewed with V17 (Cook) present and compared to the list of residents who require supervision while eating provided by V1 (Administrator) several minutes earlier. A discrepancy was found between the meal tickets and the list provided by V1. Twelve additional residents (R40-R51) had meal tickets showing supervision was required while eating, but did not show on the list provided by V1. R7's Speech Therapy Recommended PO (Oral) Intake Form, dated [DATE], and signed by V5 (Speech Therapist) shows R7 should receive mechanical soft diet, thin liquids, and eat in the general dining room with 1:1/supervision for all oral intake. The form continues to show the following Swallowing Compensatory Strategies: Slow rate, small bites/sips, alternate solids and liquids, upright position, upright 30 minutes after intake, double swallow. Intermittent 1:1 assist as needed. R8's Speech Therapy Recommended PO Intake Form, dated [DATE], shows R8 should receive mechanical soft diet, thin liquids, and eat in the general dining room with 1:1 assist. The form continues to show the following Swallowing Compensatory Strategies: Slow rate, small bites/sips, alternate solids and liquids, upright position, upright 30 minutes after intake, check for pocketing. The speech therapy notes also show R8 is edentulous (lacking teeth) and has moderate oral inefficiency with regular textures and is a choking/aspiration risk. On [DATE] at 2:46 PM, V1 (Administrator) said he is responsible for updating all meal tickets for residents to show if they need supervision while eating or other Speech Therapy recommendations. V1 said to his knowledge, only R3 required one-to-one supervision with eating. V1 said he was not aware Speech Therapy recommended R7 and R8 should have one-to-one supervision while eating. V1 could not say why the facility's list of residents of residents requiring supervision while eating did not include R40-R51. The facility's policy entitled, Abuse Prevention and Reporting - Illinois, effective [DATE], and revised on [DATE] shows: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Definitions: Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish (42 CFR 483.5). Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident (201 ILCS ,d+[DATE]-117) including deprivation of goods and services by staff. Neglect may be the result of a pattern of failures or the result of one or more failures involving one resident and one staff member.

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse. This failure resulted in R108 receiving sutures after R304 hit him in the face two times. This applies to 2 of 35 residents (R108 & R304) reviewed for abuse in the sample of 35. The findings include: 1. R304's care plan, date initiated 8/24/23, shows, Focus: I am/have the potential to be physically aggressive. AEB (as evidenced by) I Punched a fell ow resident in the face on December 23, 2023 r/t (related to) dx of other schizophrenia, generalized anxiety disorder, and schizoaffective disorder, bipolar type. Interventions: .12/23/2023- res punched another resident after going into res room to hug them and fell ow res punched them. Res punched res back cutting them on the face . R108's nursing progress note, dated 12/23/23, shows, Call light activated and aide went to room to check on the light. Resident was at the doorway bleeding from a 2-3 inch laceration on his left eyebrow and 1/2 inch on middle of forehead . Resident stated that co-peer (R304) hit him twice. R304's nursing progress note, dated 12/23/23, shows, Resident was noted to be watching as staff was rendering first aide to co-peer (R108). Co-peer (R108) stated that resident had hit him twice. Resident stated co-peer (R108) hit him first . R108's local hospital after visit summary, dated 12/23/23, shows, Reason for visit: Close Head Injury; Diagnosis: Cut on face. Instructions: Please return to the emergency department or to primary care doctor in 7-10 days to have your sutures removed . R108's nursing progress notes, dated 12/24/23, shows, Per ER (emergency room ) nurse report, resident has a CT (computed tomography) scan- result is neg (negative). DX (diagnosis) cut on face . Noted 8 stitches to L (left) eyebrow and to forehead . The facility's incident log, dated 1/2/24, shows, On 12/23/2023, (R304) was calmly pacing the halls. He went into (R108's) room and got close to him (R108) did not like that, so he hit him, causing (R304) to experience an acute onset of agitation and poor impulse control and reflexively hit (R108) . On 1/8/24 at 10:30 AM, R108 had two sutures to the left side of his forehead. He stated, I got attacked by a black guy. He tried to kiss me. There was blood everywhere. He punched me. I hope he's in jail. At 11:23 AM, R108 was sitting at the nursing station. He had more sutures to his left eyebrow. V7, Registered Nurse (RN), stated, he was hit by another resident. On 1/10/24 at 10:13 AM, V8, Licensed Practical Nurse (LPN), stated he was working the night R304 hit R108 in the face. He was at the nursing station, and the call light for R108's room went off. He walked down there and saw R108 bleeding from the left eyebrow. He stated the laceration was pretty deep and he knew he needed stitches. (R108) said (R304) came in and hit him twice in the face. (R108) went to the hospital and came back with stitches to his left eyebrow and forehead. 2. R304's care plan, date initiated 8/24/23 shows, Focus: I am/have the potential to be physically aggressive.r/t (related to) dx of other schizophrenia, generalized anxiety disorder, and schizoaffective disorder, bipolar type. Interventions: .When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive staff to walk calmly away, and approach later . R304's nursing progress notes, dated 9/19/23shows, 3:30 PM Resident trying to leave the unit for smoke break, behavior aide trying to redirect resident by grabbing and applying inappropriate CPI (crisis prevention intervention) . The facility's Resident Abuse Investigation Form, dated 9/26/23, shows, (V4) Behavioral Aide (BA) mistakenly called the north hall to come down to smoke when she meant the west hall. (R304) who resided on the north hall went to the gate to go down for his smoke break. (V4) told him that is was not yet his turn, but he said they called my hall and walked past her. (V4) started to firmly guide (R304) back onto the unit and argument broke out between them . On 1/9/24 at 2:32 PM, V5, BA, stated she had problems with V4, BA, before this incident happened. She didn't like the way V4, BA, talked to the residents. She would snap at them and had a very rude tone. She was never calm and always yelling at them. On the day of the incident, V4, BA, and V5, BA, were working 3rd floor and getting ready to take the residents out for a cigarette. (V4, BA) accidentally called (R304's) hall. He heard it and started coming up to the gate. (V4, BA) was on the other side of the gate and told (R304) that it was not his turn and he had to wait. He said, 'I heard you call my hall.' She continued to tell him that it wasn't his turn and he had to go back. She was nasty about it. Her tone was rude. (R304) ended up going through the gate. He was asking her nicely to please let him go smoke. Then they got into each others faces. She pushed and shoved him towards the elevator door. (R304) took off his headphones and said, 'don't touch me! Don't put your hands on me!' (V4, BA) kept saying, 'why didn't you listen?' V5, BA, ended up getting between them and separating them. I was holding (V4, BA) back. We usually do that with the residents. She was causing more damage to this whole fight. If anything she was going to hurt him. On 1/9/24 at 3:11 PM, V4, BA, stated all she did was hold him back. I was defending myself. I had to grab him and hold him back. She admitted she got emotional in the moment and should have controlled her emotions. She stated the facility was accusing her of abuse and fired her. She stated R304 was attacking her and she was under a lot of stress, and didn't know what to do in that moment. On 1/9/24 at 12:11 PM, V1, Administrator, stated, (V4, BA) was terminated after the incident with (R304). She called the wrong hall by accident and (R304) came. She told (R304) it was the wrong hall and he couldn't go smoke. She grabbed him. Unprofessional really. V4's, BA, Human Resources notice of corrective action, dated 9/19/24 shows, Rule or Policy involved: inappropriate interaction with a resident. The form shows, this was a final warning resulting in discharge. The facility's abuse prevention policy (no date) shows, .The abuse, neglect, or other mistreatment of residents in the facility, physically, mentally, or emotionally, is unlawful and is prohibited . Definitions of Abuse and Neglect: Abuse and neglect exist in many forms and to varying degrees. A. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . iii. Physical abuse includes hitting, slapping, pinching, and kicking.

Based on interview and record review, the facility failed to provide one to one supervision to a resident that was involved in prior physical altercations. The facility failed to prevent R1 from attacking R3 and R2 in the third-floor dining room when R1 was under one-to-one supervision for an earlier incident. This failure resulted in R3 requiring emergency medical care and sustaining a fractured nose and laceration to the head that required sutures. This applies to 1 of 4 residents reviewed for supervision and behaviors. The findings include: R1 is a [AGE] year-old resident, first admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 did not return to the facility after discharge from the facility to the hospital for psychiatric care post incident of 5/30/22. On 5/29/22, R1 was involved in an incident on the third floor with R5, in which R5 reported R1 was physically aggressive with R5. R1 was placed on safety checks after this incident. R1 was also involved in an incident involving physical aggressive behavior with R6 on 4/19/22. R1's care plan, initiated 5/29/22, included R1was involved in altercation with peer, and placed on 30-minute safety checks. The same care plan also included R1 has potential to be physically aggressive related to poor impulse control, agitation, SMI (serious mental illness), poor coping skills. The facility reported an Incident, dated 5/30/22, to the department regarding R1's behavior on the smoking patio and third floor dining room. R1 and R2 were initially involved in a physical altercation on the outside smoking patio on 5/30/22. R1 and R2 were separated by staff when the verbal disagreement became physical, and R1 was escorted back to the third floor. According to the facility's incident report, R1 ran into the dining area and struck R3 and R4. R3 suffered bleeding from a laceration on her forehead and was transferred to the hospital for care. R3 was readmitted to the facility the next day with 7 sutures on her forehead and a fractured nose. Facility nurses' station on 3rd floor was observed to be in an enclosed area from the hallway that led to the dining room. The height of this enclosure was greater than 3 feet. On 6/23/22 at 10:31 AM, R3 stated, I was sitting on a wheelchair in the dining room and [R1] just came into the dining room and just hit me on my forehead and my nose got broken and split my forehead open with her fist. There were 2 staff in the nurses station, but they were just standing there and did not do anything to stop it. There was an altercation earlier that day, and she should have been removed from the facility and wasn't. She has been talking all day in an antagonistic way towards residents. I was sent out to the hospital. R3's quarterly MDS, dated [DATE], showed R3 was cognitively intact. On 6/23/22 at 10:40 AM, R4 stated, I was sitting in the dining room at the back table and [R1] came in and started yelling and then started to punch [R3]. [V4] was at the nursing station calling ambulance as she [R1] hit [R2] in the smoking area. After she hit [R3], [V4] came to check on [R3] and then went to the nursing station to call somebody. [R1] then started punching me too, and I got hit at the back of my head, and it was painful at first. R4's quarterly MDS, dated [DATE], showed R4 was cognitively intact. On 6/23/22 at 11:44 AM, V1 (Administrator) stated the altercation between R1 and R2 occurred on Memorial Day on the patio during smoking break. V1 stated he was not in the facility, but watched a video of the incident, and saw R1 and R2 were separated by behavioral aides. V1 stated R1 was placed on 1:1 monitoring, but staff were sporadic on that day, due to the Memorial Day Holiday. V1 stated V4 (Registered Nurse) on duty that day was supposed to have eye contact with her. V1 stated R1 ran into the dining room and punched another resident, and nurses went in to intervene. V1 stated one staff on one resident is 1:1 monitoring. V1 stated if there is a concern for resident to harm self or others, then the resident should be in the room by self with 1:1 monitoring. On 6/23/22 at 1:52 PM, V5 (Behavioral Aide) stated R1 and R2 were arguing during the last smoking break at the 1st floor patio. V5 stated R1 was threatening R2, and then punched R2. V5 stated he, with the help of his peer V6 (Behavioral Aide), separated both residents. V5 stated he took R1 up the elevator to the 3rd floor, and took her to her room and stayed with her for about 20 minutes, and left as he had to assist V6 to bring the residents up, as they were short staffed that day (related to the holiday). V6 stated V4 was at the nurse's station when he left the floor. V5 stated he heard R1 came out of the room and started attacking again. On 6/23/22 at around 2:00 PM, V4 (Registered Nurse) stated he worked the 3-11 shift on 5/30/22, and R1 was under his care. V4 stated he was behind the nurses station making a phone call to R1's medical doctor to send her out for psych evaluation following the altercation of R1 to R2. V4 stated R1 was under the supervision of V5 (Behavioral Aide) following this incident, but he had to leave the floor to assist with bringing residents up. V4 stated R1 was within his view, when she went past the nurse's station and went into the dining room and was aggressive towards R3 and then R4. V4 stated R4 was injured and was sent out via 911. On 6/24/22 at 11:37AM, V10 (Registered Nurse) stated she was the nurse on duty during the incident of R1 and R5 on 5/29/22. V10 stated R1 had pushed R5 down as she used her bathroom, and the Psychiatric doctor said just to separate them, which was done immediately. V10 stated during such resident-resident altercations, the facility protocol is to separate and then do 1:1 monitoring for every shift which is entered in the EMR. R7 and R8, who were witnesses to the resident-to-resident incident of R1 to R3 and R4, were also interviewed. On 6/23/22 at 11:06 AM, R7 stated he was standing before the desk (nurses' station) during the time of the incident between R1 to R3 and R4. R7 stated, I saw R1 punch R3 in the dining room and she was all bleeding. There was no staff in the dining room. V4 at the desk went to assist and told her [R1] to stay there but she went and started to punch another girl [R4] by the window. R7's Annual MDS, dated [DATE], showed R7 was cognitively intact. On 6/23/22 at 10:56 AM, R8 stated he was in the dining room during the incident between R1 to R3 and R4. R8 stated R1 hit R3, and she fell to the ground and was bleeding. R8 stated there was a couple of staff at the nurse's station during the time of the incident, which was at night around 7:00-8:00 PM. R8's Quarterly MDS, dated [DATE], showed R8 was mildly impaired in cognition. On 6/23/22 at 2:44 PM and on 6/24/22 at 9:38 AM, V3 (Social Service Director) stated R1 had an history of serving time in prison due to aggression with a police officer, and was at a mental health institute prior to being admitted to the facility. V3 stated the incident of R1to R2 happened on the last smoking break at 7:30 PM on 5/30/22. V3 stated R1 has had 2 prior incidents of resident-to-resident altercation with peers, one on 4/19/22 with R6, and another one on 5/29/22 with R5. V3 stated on 5/29/22, R1 had pushed R5 down as she used her bathroom, and was placed on 1:1 safety check for every 30 minutes for 72 hours. V3 stated =this safety check task is embedded in the EMR. Review of the BEHAVIOR-safety checks every 30 minutes physical alteration of 5/29/22 showed that checks were done every 30 minutes on 5/29/22, starting 1815 (6:15 PM) until 2245 (10:45 PM). No further checks were recorded after that. V3 verified the safety check monitoring was overlooked after last recorded check through 5/30/22, until the time R1 was discharged to the hospital. On 6/24/22 at 10:15 AM, R2 stated, She [R1] has not been nice. She is a [OBSCENITY] . She busted my roommate's [R3] face and has pushed older people to the floor. I don't want to talk about it. R2's quarterly MDS (Minimum Data Set), dated 4/01/22, showed R2 was cognitively intact. On 6/24/22 at 11:11 AM, V7 (Licensed Practical Nurse) stated he was the facility [CONDITION(S)] nurse and he verifies and follows up with orders from the psychiatrist. V7 stated he was not in the facility on 5/29/22 and 5/30/22 during the resident-to-resident altercations of R1 towards multiple residents. V7 stated 1:1 is an intervention the social services put in effect for safety of the patient and other residents around her. V7 stated the social services and medical doctor/psychiatrist determine how long the monitoring is needed. V7 stated during the time between the incident/altercation and sending the resident out to the hospital, there has to be direct 1:1 supervision, as the resident is in a heightened state. On 6/27/22 at 9:10 AM, V8 (Psychiatrist) stated she is on call for R1's Psychiatrist. V8 stated R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V8 stated R1 was seen on 5/18/22 with [MEDICATION(S)] Furamate[antipsychotic] 25 mg/milligrams added for increased anxiety. V8 stated the office was notified of the incident of 5/30/22 [R1 to R2], and orders were given to send R1 out to the hospital for evaluation by calling 911. V8 stated R1 should have direct 1:1 supervision between the time of incident and the ambulance arrival. V8 also stated the facility will have to follow their protocol for supervision for high-risk patients. Facility Policy and Procedure titled Behavior Crisis (effective 11/28/22) included as follows: Purpose: To initiate appropriate measures to control and secure the environment when a resident has a behavior crisis or catastrophic reaction. Definition: A behavior crisis is defined as a situation in which a resident is considered to be significant danger to self and others. The crisis may or may not have been exhibited in the past, however, is not an ongoing (day-day) observed behavior. Guidelines: 1. Implement measures to provide safety. 2. Summon additional staff as needed. 4. Assess need for additional intervention as indicated, including implementing Code Yellow Procedure. Remove resident from situation. Place resident in a safe environment. Remove offending stimuli from resident. Remove onlookers from area. Facility Policy and Procedure titled Abuse Prevention and Reporting-Illinois (revised 4/29/22) included as follows: Protection of Residents: Residents who allegedly abused another resident will be removed from contact with the other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility.

Based on observation, interview, and record review the facility failed to keep a resident safe from physical abuse by another resident (R2). As a result, R1 sustained a laceration that required sutures and emergency room treatment. This applies to one (R1) of four residents reviewed for abuse. The findings include: R1's EMR (Electronic Medical Record) shows R1 is a [AGE] year-old man who was admitted to the facility on [DATE]. He has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set), dated August 20, 2021, shows R1 is cognitively intact. On September 30, 2021 at 12:48 PM, R1 stated R1 was lying in bed asleep, when R2 jumped on R1 in the bed and started punching R1 in the face. R1 tried to get out of the room, and fell cutting R1's elbow. R1 stated R1 was able to get out of the room and into hallway, where R2 started to beat up on the nurse. R1 said R1 was sent to the hospital where they did an x-ray of R1's face and R1 has a broken nose. They had to put stitches in my arm too. R1 was observed to have a gauze dressing over the laceration R1 sustained during this altercation. R1's hospital record from September 19, 2021 at 3:45 AM, shows R1 was seen in the emergency room after R1's roommate attacked him and started jumping on (R1's) bed and punching (R1) in the face. The patient never lost consciousness .(R1) has some epistaxis (nosebleed) bilaterally. (R1) noted a laceration to (R1's) right elbow but has not had any pain at that point There is a 4 cm laceration at the posterior elbow .Slight [CONDITION(S)] (fast heart rate) now improved Will CT (Computed tomography) head and face given recent trauma, will x-ray right elbow given laceration and fall Will update [CONDITION(S)] shot laceration will be irrigated and likely need suture. CT of head negative CT if facial bones show acute fracture to anterior (near front) nasal bones and osseous nasal septum . no other fracture Given antibiotics. [CONDITION(S)] shot updated .Patient was discharged back to facility. Patient will follow with ENT (Ears Nose Throat) and primary care physician for removal if sutures in 10 to 14 days as it is overlying the joint. On September 27, 2021 at 4:43 PM, V3 (DON - Director of Nursing) created progress note, dated September 19, 2021 at 2:25 AM, (note from V28, LPN) (Licensed Practical Nurse) Heard a loud sound in the west hallway. (R1) came running out from room and suddenly (R2) came out from the same room to attack (R1). I redirected (R2). Both residents were immediately separated from each other. Psyche physician and family notified. Called 911 and residents transported to ER (emergency room ) per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R2's EMR shows R2 is a [AGE] year-old man and was admitted to the facility on [DATE]. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS, dated [DATE], shows R2 has moderate cognitive impairment. Reports hallucinations and delusions. R2's care plan, dated April 28, 2021, shows R2 has a history of noncompliance with medications, history of physical aggression, and threatening others. R2's progress note shows last visit from R2's psychiatrist was on June 25, 2021 at 2:06 PM. Progress note shows Resident seen. Sleeping in bed, no reports of agitation or non-compliance with medication no recent hospitalization . medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . PLAN: continue current medication. Possibly discontinue [MEDICATION(S)]. R2's June MAR (Medication Administration Record) and progress notes show on June 26, 27, and 30, R2 refused R2's medications. On June 20 and 28, they were not given because R2 was asleep. R2's progress note shows on July 1, R2 came out of room with pants down and refused to pull them up. When staff was redirecting R2, R2 became aggressive and hit and kicked staff. Code Yellow was called and R2 was sent to local hospital for evaluation. R2's July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's progress note on July 15, shows R2 was attempting to leave the floor, when staff intervened he became combative and started to hit, kick, and punch at staff. Code Yellow was called and R2 was sent to the hospital for evaluation. R2's August MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's September MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's progress note shows R2 attacked R1 on September 19 at 2:45 AM. R2's care plan was not updated to reflect the behaviors that occurred on the dates above. There was no documentation to show the facility had notified V35 (R2's psychiatrist) of any of R2's medication refusals. Facility provided undated policy titled Medication and Treatment Refusal shows the procedure 1. Should a resident refuse his or her medication and/or treatment, documentation must be recorded concerning the situation. 2. Documentation pertaining to a resident's refusal will include as a minimum . e.) documentation each time the resident refused his medication and/or treatment, f.) The date and time the physician was notified as well as the physician's response .3.Inquires concerning the resident's refusal of medications or treatment should be referred to the Director of Nursing Srevices. ****Note: Cardiac, [CONDITION(S)], oral glycemic, and insulin refusal must be reported to the physician each time refused. Facility provided Behavior Crisis revision date 11/20/20 shows the purpose is to initiate appropriate measures to control and secure the environment when a resident has a behavior crisis or catastrophic reaction. A behavior crisis is defined as a situation in which a resident is considered to be a significant danger to self or others. The crisis may or may not have been exhibited in the past, however, is not an ongoing (day-to-day) observed behavior. Guidelines: 1. Implement measures to provide safety. 2. Summon additional staff as needed. 3. Defuse crisis through calming communication. 4. Assess need for additional intervention as indicated, including implementing Code Yellow Procedure (refer to Code Yellow Procedure- Behavior Crisis): Remove resident from situation, remove offending stimuli from resident, place resident in a safe environment, remove onlookers from area. 5. Assess need for chemical restraint, 6. Assess need for physical restraint physician and facility on-call person for additional interventions. If restraint is required in an emergency situation to prevent resident from harming self or others, obtain an order and refer to Restraint Guidelines. 8. Contact the Local Police Department as indicated, if behavior crisis requires immediate removal from facility. 9. Follow disaster action plan procedures, when necessary. 10. Evaluate behavior crisis. Contact mental health or hospital for transfer and admission to the psychiatric care unit as indicated. Facility policy Code Yellow Procedure- Behavior Crisis with revision date January 11, 2021 shows the purpose it to initiate appropriate measures to control and secure the environment when a resident has a behavior crisis it catastrophic reaction .A behavior crisis is defined as a situation in which a resident is considered to be a significant danger to self or others . 1) call for help by using the intercom system to page a Code Yellow with location. 2) Implement measures to provide safety. 3) summon additional staff as needed. 4) diffuse crisis through calming communication 5) Assess need for additional interventions as indicated: remove resident from situation, remove offending stimuli form resident, place resident in a safe environment, and remove onlookers from area. 6) assess need for chemical restraint, 7) assess need for physical restraint, 8) contact physician, on-call person for additional interventions. If restraint is required in an emergency situation to prevent resident from harming self or others, obtain an order and refer to Restraint Guidelines, 9) contact local police department as indicated, if behavior crisis requires immediate removal from facility .12) Contact mental health or hospital for transfer and admission to the psychiatric care unit as indicated.

Based on interview and record review, the facility failed to keep residents safe from physical, mental, and verbal abuse by V19 (Certified Nurse Aide) and V18 (Licensed Practical Nurse - LPN). This resulted in R5 and R6 being physically abused by V19 when R5 and R6 were thrown into bed during transfers instead of using a mechanical lift. R5 was also abused by V19 when V19 applied tooth paste to R5 during incontinent care in place of peri-wash. This also resulted in R7, R8, R9, and R10 being verbally and mentally abused by V18 (Licensed Practical Nurse). R7, R8, R9, and R10 became fearful due to threats of unit changes to the locked unit when residents refused to follow V18's instructions. This applies to 6 of 6 (R5, R6, R7, R8, R9, R10) reviewed for abuse from a total sample of 10 The findings include: 1) R6 is a [AGE] year-old male admitted to facility on 3/12/18 with diagnosis [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Major Depressive disorder, and [CONDITION(S)]. R6's MDS showed R6 (3/16/21) to be cognitively intact and Social Service documentation notes R6 has no problem with memory and decision making. In addition, R6 is noted to need extensive assistance with all ADLs (Activities of Daily Living) and is dependent on staff for transfers and personal care. On 3/30/21, interview with V17 (Certified Nursing Aide), noted V17 was assisting V19 (Certified Nursing Aide) putting R6 back to bed. V17 stated, Due to R6's condition we are to use a mechanical lift on him, but V19 lifted him up under his armpits and threw him into bed. V17 asked V19 What are you doing, and V19 replied, Don't worry about it. V17 stated this appeared to be uncomfortable for R6. While repositioning and transferring R6, V19 was always rough. V17 reported this to V2 and V20 3 times over the last few months. V17 (Certified Nursing Aide) noted during another occasion during incontinent care, V19 (Certified Nursing Aide) was pulling R6's pubic hair, You could see it was painful on R6's face and I told V19 to stop. (V19) looked at me with an angry look. V17 saw this happen 2 times, and reported this to V2 (DON) a few days later. On 3/30/21, V14 (Certified Nursing Aide) noticed during meal time (V19) (Certified Nursing Aide) making fun of R6 and the way he communicates. R6 looked very sad, and after V19 was done assisting him with his meal, I went over to comfort him. I told R6 that I was going to inform V2 and V20 about the inappropriate behavior from V19. The next day I notified both V2 and V20 the above incident. On 3/30/21, during an interview with R6, he was able to communicate by shaking his head yes/no, and using soft mumble like words. R6 agreed V19 (Certified Nursing Aide) was rough and caused pain while transferring him into the bed. R6 also stated yes to the question of being belittled and mocked during dining due to his inability to speak. R6 answered yes when asked during his incontinent care if V19 would pull his pubic hair intentionally. During this course of time, R6 felt sad, humiliated, and unsafe at the facility. When told V19 was no long going to be working at the facility, he nodded his head yes and mumbled the word good. 2) R5 is a [AGE] year-old resident totally dependent upon staff for personal care, transfers and hygiene, and has been coded per the MDS (Minimum Data Sets) Assessment of 1/13/21) to be severely cognitively impaired. Face sheet, dated 6/19/20, showed R5 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission nursing progress note, dated on 6/23/20, noted R5 is alert orientated x2, anxious, disoriented, thumping fist on wall calling for son. Resident was placed on 30 minute safety checks for 24 hours. Initial Social service screening appeared anxious and disoriented, calling out for son, unable to give details about her home life situation. Nursing 72 hours admission noted R5 unable to bear weight, and is dependent upon staff for all ADL's (Activities of Daily Living) personal hygiene, dressing, toileting, eating, and transfer x2 assist with mechanical lift. R5 started Hospice with Unity Hospice on 9/29/20. Care plan, dated 7/10/20, noted under Social Service, documented R5 is at risk for abuse/neglect due to Dementia, and has history of abuse from family member. During a phone interview on 3/30/21 with V16 (Certified Nursing Aide), (V19) was extremely rough with (R5). V16 noted she and V17 (Certified Nurse's Aide) saw V19 (Certified Nurse's Aide) pick R5 up by one hand and one ankle and throw her into her bed. V16 continued to add she asked V19 to stop, and V19 ignored V16. While I was in the room, (V19) proceeded to do incontinent care on (R5) using toothpaste for instead of peri-wash. When questioned what he was doing, (V19) stated he wanted her to smell fresh. While (V19) was doing the incontinent care on (R5), she said ouch and no for him to stop, but (V19) continued. I did tell (V19) to stop so I could finish (R5's) care, but he refused and finished her care. V16 spoke to V2 (Director of Nursing), V3 (Assistant Director of Nursing), and V20 (Restorative Director) the next day. V16 noted V19 using toothpaste on R5 at least four timea over the last few months during incontinent care. On 3/30/31 phone interview with V17 (Certified Nurse Aide), noted he was in R5's room straightening up the room when V19 (Certified Nurse Aide) brought R5 back to her room for the night. Instead of using a mechanical lift he lifted her up under her arms and threw her into her bed. I asked (V19) what are you doing, and told me to leave the room if I didn't like it, I refused and we completed the care together. V17 proceeded to tell V2 (DON), and V20 (Restorative Director) about the way V19 was transferring R5 the day after the incident. V17 noted V19 transferring R5 in the same manner three more times in the past few months. 3) Residents R7, R8, R9 and R10 all voiced complaints about V18's conduct in the facility. V1 was notified of V18's behavior via anonymous complaint that V18 was abusive to residents. A final abuse investigation was filed with the department on 3-29-2021. V18 was terminated by the facility for failure to follow the facility's abuse policy. On 4/5/31 10:00am, R7 stated, (V18) (License Practical Nurse) speaks to me rudely even if I ask her for water. Not too long ago, V18 got so mad at me because I kept asking her for things, she threatened to move me to the 3rd floor if I didn't stop asking the questions. There also have been times when V18 is upset with me, she will totally ignore me when I ask for something. I feel that I can't speak the truth due to the repercussions that might happen. On 4/5/21 10:30am, R8 stated she has had situations with V18 (Licensed Practical Nurse) where V18 has been unkind to me by using loud yelling voice when I asked for medication. I don't think she likes me. There have been times she totally ignores me and will not answer my questions or requests for medicine. I feel disrespected from V18. On 4/5/21 11:00am, R9 stated, (V18) (Licensed Practical Nurse) and I have gotten into a few disagreements and the last one sent me to the 3rd floor locked unit. I was just telling her what I thought and V18 made such a big deal about it and exaggerated it that's when I was transferred to the 3rd floor. V18 has a loud voice and while I was on the floor she would yell at residents all day long. I feel that if you tell the truth you still get punished, I feel like I can't trust anyone. On 4/5/21 11:30am, R10 stated, I remember one time I asked for water from (V18) (Licensed Practical Nurse) and she yelled no and wouldn't give it to me. Then all of a sudden she gave me a few cups. I caught her sleeping at the desk, I woke her up because I needed my medication. (V18) told me if I said anything she would transfer me to the 3rd floor. Nurses like V18 make you feel belittled and sad about yourself. The facility's investigation, dated March 30, 2021, documents V19 was terminated for providing inappropriate resident care and not following the facility's abuse policy. On 3/30/21, during an interview with V1 (Administrator), V1 stated she was in the process of terminating the following staff members. V14, V15, V16, V17 V18 and V19, for not notifying the administrated staff of above allegation in a timely manner. The facility's policy entitled Abuse Prevention and Reporting, revised January 22, 2019, documents: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy defines as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physician harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that necessary to attain or maintain physical mental and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on interview and record review the facility failed to ensure that R21 was positioned safely prior to attempting to transfer him out of his bed, and failed to have transfer equipment in close proximity to the resident prior to attempting to transfer the resident. These failures resulted in R21 sustaining a laceration to his forehead when he fell from his bed to the floor. R21 was sent to the emergency room and received 7 sutures to his forehead. This is for 1 (R21) of 6 residents reviewed for falls in the total sample of 30. The findings include: R21 is an [AGE] year old resident with multiple [DIAGNOSES REDACTED]. R21 is at high risk for falls due to a history of falls prior to admission, a fall on the first day of admission, difficulty maintaining sitting balance, and impaired balance during transfers according to the Care Area Assessment (CAAs) completed with the 3/2/12 admission MDS. R21's Fall assessment dated [DATE] finds that R21 continues to be at high risk for falls. R21 requires extensive, 2 + persons physical assist with transferring from the bed according to Section G, B. of the MDS assessments dated 3/2/12, 5/31/12, and 8/26/12. R21's care plan titled "decreased ability to transfer self" dated 8/30/12 does not reflect that R21 requires a 2 person physical assist, and does not reflect that R21 requires a mechanical lift for transfers. On 9/20/12 at 7:00 AM, R21 "rolled out from his bed while the CNA set up the E-Z stand" and lacerated his forehead according to the facility's FAX to the Department dated 9/20/12. In the facility's investigation interview with E6 (Certified Nursing Assistant (CNA)), E6 stated that R21 was lying down in bed prior to the fall, according to the Investigation Interview from dated 9/20/12 2 PM. On 10/24/12 at 1:05 PM, E6 (CNA) stated that R21 was sitting on the edge of the bed prior to his fall on 9/20/12. E6 said that he had placed the (lift) sling around R21's back while R21 sat on the bed with his feet toward the floor. E6 demonstrated how he applied the sling which went around R21's back from this shoulders to his hips. E6 said that R21 was leaning forward so he placed his right hand on R21's right shoulder as he reached for the mechanical lift which was positioned approximately 3 feet behind him. E6 then demonstrated how he held R21's right shoulder with his right hand and outstretched his left hand to reach for the mechanical lift. E6 said that the lift was not next to the bed. E6 said that when he turned to reach for the lift, R6 fell forward head first, hitting his head on the floor. E6 said, "I couldn't hold him back because he was heavy." The facility's Mechanical Lifts Policy and Procedure states that the manufacturer's guidelines are to be followed for mechanical lifts. The mechanical lift manufacturer guidelines recommend that "2 assistants be used for ALL lifting preparations, transferring from and transferring to procedures" per page 10 of the manufacturer booklet provided by the facility. On 10/25/12 at 11:45 AM, R21 was in bed asleep with his wife at his bedside. R21 was noted to have a healed scar, measuring approximately 1 inch, on the middle of his forehead just above his eyebrows.