Every finding on record at Arc at Dwight

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 89 residents in the facility.Findings:On 6/14/2026 at 8:43 a.m., V7, Dietary Manager (DM), was actively supervising dietary services in the facility's kitchen. At this time, V7 stated that V7 serves as the full-time manager of the facility's food service department. V7 further stated that V7 had not yet obtained the qualifications of a Certified Dietary Manager (CDM) or Certified Food Protection Professional (CFPP), nor had V7 completed equivalent training. V7 reported that V7 enrolled in a certification program in April 2026 and was currently working on the first lesson.On 6/16/26 at 10:24 a.m., V7, Dietary Manager (DM) denied:being a dieticianbeing a certified dietary managerhaving an associate's or higher degree in food service management or in hospitalityhaving two or more years of experience in the position of director of food and nutrition services in a nursing facility settingbeing a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course On 6/16/26 at 10:33 a.m., V13, Human Resources Director, provided employment records for V7, DM. These records indicated that V7 was hired on 12/03/25 and was promoted to the position of Dietary Manager on 2/16/26.On 6/16/26 at 10:49 a.m., V1, Administrator, stated that V1 was aware of the regulatory requirements and qualifications for the facility's Dietary Manager position. V1 confirmed that the facility was not currently in compliance with those requirements.On 6/16/26 at 10:52 a.m., V7, DM stated that the facility's dietitian visits the facility approximately every two to three months. V7 further stated that V7 discusses residents' diets and weight-related concerns with the dietitian by telephone on a monthly basis. V7 confirmed that food prepared in the facility's kitchen is available to all residents.The facility's Dietary Manager Job Description dated May 2026 documents that the qualifications to perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements below are representative of the knowledge, skill, and/or ability required:must have, as a minimum three years' experience in a supervisory capacity in a hospital, nursing care facility, or other related medical facility.must be knowledgeable of dietary practices and procedures as well as the laws, regulations, and guidelines governing dietary functions in nursing care facilities.The facility Long-Term Care Facility Application for Medicare and Medicaid dated 6/14/26 documents 89 residents reside in the facility.

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to notify residents of potential financial liability when Medicare covered services ended for three of three residents (R38, R67, and R97) reviewed for Medicare notification requirements on the sample list of 36.Findings include:R38's Beneficiary Protection Notification Review, provided by V14, Social Service Director, documents that R38 began a Medicare Part A covered stay on 3/4/26, with a last covered date of 5/15/26. The facility provided a SNF ABN for R38 signed and dated 3/5/26 but did not provide evidence that a SNF ABN was issued when Medicare Part A coverage ended.R67's Beneficiary Protection Notification Review, provided by V14, documents that R67 began a Medicare Part A covered stay on 11/12/25, with a last covered date of 2/9/26. The facility provided a SNF ABN signed and dated 11/26/25 but did not provide evidence that a SNF ABN was issued when Medicare Part A coverage ended.R97's Beneficiary Protection Notification Review, provided by V14, documents that R97 began a Medicare Part A covered stay on 4/21/26, with a last covered date of 5/7/26. The facility provided a SNF ABN signed and dated 5/2/25 but did not provide evidence that a SNF ABN was issued when Medicare Part A coverage ended.On 6/16/26 at 11:52am, V14 stated residents receive a Notice of Medicare Non Coverage (NOMNC) but do not receive a SNF ABN when Medicare Part A coverage ends. V14 stated the SNF ABN is included in the admission packet and completed only upon admission.On 6/16/26 at 12:04pm, V15, Admissions Coordinator, stated the SNF ABN is included in the admission packet and is only completed on admission. V15 confirmed the facility does not issue the SNF ABN to residents when Medicare Part A coverage ends.On 6/16/26 at 12:10pm, V16, Business Office Manager, confirmed that all residents sign a SNF ABN upon admission and that is the only time the SNF ABN is completed.On 6/16/26 at 12:22pm, V17, Regional Financial Coordinator, confirmed that the SNF ABN should be issued to residents when Medicare-covered services are ending and the resident is remaining in the facility.

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse by another resident. This failure affected two (R23 and R71) of three residents reviewed for abuse in the sample list of 36 residents. Findings:The facility's Abuse Prevention and Reporting - Illinois Policy, dated November 2016 and revised March 2026, states that the facility affirms each resident's right to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment. Accordingly, the facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.The policy further states that the facility strives to establish and maintain a resident-sensitive and resident-secure environment. The purpose of the policy is to ensure that the facility takes all reasonable measures within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and resident mistreatment.This policy defines sexual abuse as including, but not limited to, sexual harassment, sexual coercion, or sexual assault, including non-consensual sexual activity or sexual activity involving an individual who lacks the capacity to consent.On 6/14/2026 at 9:24 a.m., R71 was sitting in R71's wheelchair. R71 stated that a few weeks prior, R23 was kicking the back of R71's wheelchair. R71 stated when R71 turned around to ask R23 to stop, R71 observed R23 holding or grabbing R23's genital area. R71 stated that it appeared to R71 that R23 was scratching R23's self.R71 stated that R71 was bothered by R23 deliberately bumping and kicking the wheels of R71's wheelchair to get R71's attention. R71 pointed to the doorway of R71's room and stated that the incident occurred in that location. R71 also stated that V8, Certified Nursing Assistant (CNA), witnessed the incident.R71's Minimum Data Set (MDS) dated [DATE] documents that R71 is cognitively intact.R71's Care Plan, dated 9/26/24, documents R71 as being at low risk for abuse and neglect. This Care Plan included a goal initiated on 7/1/25 stating that R71 will feel safe and secure in the facility through the next review period.On 6/14/2026 at 10:13 a.m., R23 was sitting in R23's wheelchair in R23's room watching television. R23 stated they accused R23 of being a bad boy and that someone reported R23 for exposing R23's private areas in public. R23 denied the allegation and stated that R23 respects women.R23's MDS dated [DATE] documents that R23 is cognitively intact.R23's Care Plan dated 4/22/24, with a revision on 2/18/26, documents that R23 is an older adult male with multiple medical conditions and cognitive deficits, including Dementia. This Care Plan documents a history of impaired boundaries and sexually inappropriate behavioral symptoms toward others.This Care Plan also documents that R23 demonstrates poor impulse control and has limited self-regulation skills. It also documents that R23 has been reported to make inappropriate, sexually oriented, and suggestive remarks to others. Interventions include staff being direct with R23 and, in a calm and professional manner, informing R23 that inappropriate sexual behavior is not acceptable and must stop. Additional interventions include continued staff monitoring of R23's behavior.R23's Electronic Health Record (EHR) contains a progress note dated 6/10/26 that documents a failed Gradual Dose Reduction (GDR) of Prozac (antidepressant), in which the dosage was reduced from 40 milligrams (mg) to 20 mg. The documentation indicates that following the dose reduction, R23 exhibited sexually inappropriate behaviors.A Preliminary 24-Hour Abuse Investigation Report dated 5/30/26, provided by V1 Administrator, documents that an allegation was reported on that date indicating that R23 made an inappropriate gesture toward R71.According to the investigation details documented in the report, R23 was positioned behind R71 and was pushing R71's wheelchair toward R71's room with R23's foot. The report further documents that, while doing so, R23 had R23's genital area exposed and was holding it in R23's hand.R71's Electronic Health Record (EHR) contains an Incident Note dated 5/30/26 documenting that a male resident was observed blocking R71's doorway, preventing R71 from entering R71's room, and making an inappropriate sexual gesture toward R71. The male resident was identified as R23.R71's Electronic Health Record (EHR) contains a Social Services Note dated 5/30/26 that documents a psychosocial assessment completed in response to a resident-to-resident sexual allegation reported by R71. As a result of the assessment, an intervention was implemented that included providing R71 with one-to-one staff supervision and support.On 6/14/2026 at 9:32 a.m., V8, Certified Nursing Assistant (CNA), stated that on the day of the incident involving R23 and R71, V8 was walking down the hall looking for a plunger when V8 observed R23 in R23's wheelchair following R71 down the hallway. V8 stated R23 had R23's right foot on the back of R71's wheelchair and was holding R23's exposed penis in R23's right hand. V8 stated V8 immediately separated R23 and R71. V8, CNA stated R23 was not aware that anyone was observing the interaction.On 6/16/26 at 9:29 a.m., V10, CNA, stated V10 is familiar with R23 and has provided care to R23. V10 stated V10 has not personally witnessed R23 behaving inappropriately toward other residents; however, V10 has heard reports that such behavior has occurred. V10 stated R23 is known to exhibit inappropriate behavior toward staff members and has made inappropriate comments to V10, including stating, You are very well preserved. V10 stated staff routinely provide care in pairs due to R23's history of inappropriate behavior toward staff.On 6/16/2026 at 3:07 p.m., V18, Registered Nurse (RN) stated R23 has a long history of inappropriate behavior toward staff and other residents. V18 stated due to R23's history of inappropriate behaviors, staff currently provide care in pairs when assisting R23. V18 stated that R23's behavior had improved for an extended period until the most recent incident. V18 also stated R23 is able to independently propel R23's self in a wheelchair throughout the facility.On 6/16/26 at 3:30 p.m., V2, Director of Nursing (DON), stated that 15-minute checks were implemented following the most recent allegation of sexual abuse. V2 stated that R23 has a history of inappropriate sexual behavior, including incidents involving his wife. V2 further stated that providing care in pairs is an intervention implemented in response to R23's inappropriate sexual behaviors.On 6/16/26 at 3:40 p.m., V1, Administrator stated 15-minute checks remain in place and were initiated following the recent allegation. V1, Administrator stated that R23 and the resident involved (R71) denied sexual contact, while staff reported observing R23 with exposed genitalia. V1 acknowledged that R23 is independently mobile in R23's wheelchair and moves freely throughout the facility.

Based on interview and record review the facility failed to protect resident's right to be free from resident-to-resident verbal abuse. This failure affected three of four residents (R1, R2, R3) reviewed for abuse on the sample list of four.Findings Include: The facility's Abuse and Prevention Reporting - Illinois Policy dated March 2026 documents each resident has the right to be free from abuse including but not limited to verbal abuse. Verbal abuse is the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families or within their hearing distance. 1. R3's Medical Diagnoses list dated April 2026 documents R3 is diagnosed with Major Depressive Disorder. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact and had verbal behavioral symptoms at four to six times during the review period. R3's Care Plan initiated 11/24/25 documents R3 has a history of behavior problems related to poor impulse control. R3 also has a mood problem and is easily angered and will threaten others, lashing out both physically and verbally. R1's Medical Diagnoses List dated April 2026 documents R1 is diagnosed with Major Depressive Disorder, Anxiety, and Dementia. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately cognitively impaired. The Final Abuse Investigation Report dated 3/18/26 documents on 3/11/26, R3 became upset with R1 for attempting to sit at a spot he believed was for his friend. R3 yelled at R1 and called her a F****** (expletive) B**** (expletive) and shoved a chair towards R1's wheelchair. When R3 was interviewed about the incident On 4/26/26 at 12:53 PM V7 Dietary Manager stated she heard a commotion and walked out of the kitchen to find R3 yelling to get that F****** (expletive) B**** (expletive) out of that spot. R3 yelled that same phrase repeatedly and shoved a nearby chair at R1. The chair hit R1's wheelchair. On 4/26/26 at 2:30 PM V1 Administrator confirmed R3 has a problem with becoming verbally aggressive with other residents. V1 confirmed R3 was verbally abusive towards R1. 2. On 4/26/2026 at 11:43 AM, V4 Activity Aide stated during the incident between R1 and R2, she was pushing another resident to the dining room when she heard R2 yelled ouch, that hurts! V4 stated she checked on R2 and R2 stated that R1 kicked her in her feet. R1 was sitting next to R2 at that time. V4 stated she told R1 not to kick R2 and R1 stated she (R2) was on my way. V4 stated R2 responded and called R1 a B*** (expletive). V4 stated residents were separated immediately and V4 reported this information to the V1 Administrator. V4 stated she did not witness R1 kicked R2 because she was at the back end, but she confirmed R2 called R1 a B*** (expletive). On 4/26/2026 at 12:47 PM, V8 Licensed Practical Nurse (LPN) stated she is very familiar with R2 and has taken care of her regularly. V8 stated R2 uses curse words a lot especially when she is frustrated. On 4/26/2026 at 10:56 AM, V1 Administrator stated she was aware of the incident between R1 and R2. V1 stated R2 calling R1 a B*** (expletive) was a form of verbal abuse and should be reported. V1 stated R2 is known for her potty (cursing) mouth and has heard R2 say curse words in the past. R1's Incident Note dated 3/16/2026 documents R1 exchanged rude remarks and came in contact with another resident. R1' Care Plan (undated) documents R1 has issues with verbal/aggressive behaviors. R1 doesn't get along with other residents and doesn't like having roommates. R1 tends to be mean to others and doesn't enjoy big crowds. R1 tends to try and get into the dining room before others at mealtimes. Staff should offer R1 the option to sit in the dining room at a table by herself to avoid conflict with others. R2's Minimum Data Set (MDS) dated [DATE] R2 is cognitively intact. R2's Incident Note dated 3/16/2026 documents R2 exchanged rude remarks and came in contact with another resident. R2's Care Plan dated 3/25/2026 documents R2 has a potential for aggressive verbal behavior. Sometimes R2 can lash out at other residents if she is bothered or annoyed. Staff should remove R2 from the area when R2 shows increased aggression.

Based on observation, interview, and record review the facility failed to protect a resident's (R14) right to be free from sexual abuse by another resident (R15), protect a resident's (R12) right to be free from verbal/mental abuse by another resident (R11), protect a resident's (R8) right to be free from physical abuse by another resident (R3), and protect residents' (R2, R3) right to be free from physical abuse by another resident (R3, R2). These failures affect seven residents (R2, R3, R8, R11, R12, R14, R15) of 12 residents reviewed for abuse in the sample list of 15. Findings include: The facility's Abuse Prevention and Reporting policy dated December 2025 documents the facility affirms the residents' right to be free from abuse, including physical abuse, sexual abuse, and verbal abuse. This policy documents physical abuse is the infliction of injury on a resident that does not occur by accidental means, sexual abuse includes unwanted intimate touching of any kind including the breasts, and verbal/mental abuse includes yelling, mocking, insulting, and ridiculing.1.) The facility's Preliminary 24 Hour Abuse Investigation Report documents on 2/26/26 at 6:30 PM it was reported that R14 was in R15's room holding up her gown and R15 touched R14's breasts. V14 Certified Nursing Assistant (CNA) Staff Interview form dated 2/16/26 documents V14 walked past R15's room and noticed R14 was in R15's room, as V14 entered R15's room V14 witnessed R14 holding up her gown and R15 had his hand on R14's breast. R14's Minimum Data Set (MDS) dated [DATE] documents R14 has severe cognitive impairment, has hallucinations, and wandering behavior noted 1-3 days during the 7 day look back period. R14's Capacity for Sexual Consent assessment dated [DATE] documents R14 has no awareness of who is initiating sexual contact, R14 does not have the capacity to consent to sexual relationships, and R14 did not recall the incident with R15. R15's MDS dated [DATE] documents R15 has moderate cognitive impairment. R15's Care Plan initiated on 4/22/24 and revised on 2/18/26, documents R15 has a history of displaying a lack of boundaries including sexually inappropriate behavioral symptoms towards others, including inappropriate, sexually oriented and suggestive remarks. Due to dementia R15 displays poor internal control and self regulation skills. R15's Capacity for Sexual Consent assessment dated [DATE] documents R15 has the capacity to consent to sexual relationships but did not recall touching R14. On 3/4/26 at 10:55 AM R15 stated R15 does not recall this, but staff told R15 that a female resident came into R15's room, put her feet on his bed and lifted her gown. R15 denied touching R14 but did not recall this incident. On 3/4/26 at 11:15 AM R14 was interviewed but did not recall the incident with R15. On 3/4/26 at 10:48 AM V14 CNA stated at approximately 6:30 PM V14 came out of another resident room and saw R14 in R15's room with her feet on the edge of R15's bed and R14 was holding up her night gown. V14 stated R14 was not wearing a bra and R15 was touching R14's bare breast with R15's hand. V14 stated V14 asked R14 and R15 what they were doing and neither resident replied. V14 stated R15 has grabbed staff's buttocks before. V14 stated both R14 and R15 have memory impairment. On 3/4/26 at 11:04 AM V13 Licensed Practical Nurse stated at approximately 7:00 PM V14 CNA reported R14's/R15's abuse allegation. V13 stated R15 has a history of inappropriate sexual touching of other residents, but it has been about a year and half ago since the last incident. V13 stated R15 has intermittent confusion and R15's cognition varies between being alert and oriented to person, place, time and situation to just person and place. V13 stated R14 is alert and oriented to person only and did not recall the incident with R15.On 3/4/26 at 12:25 PM V21 Social Services Director stated V21 completes the capacity for sexual consent assessments and R14 does not have the capacity to consent. V21 stated R15 has the capacity to consent. V21 stated R14 did not recall the incident with R15. 2.) On 3/3/26 at 11:35 AM V6 Housekeeper stated V6 has witnessed R11 and R12 curse at each other a couple times and V6 witnessed them saying f*** (expletive) you to each other at approximately 7:00 AM today. V6 stated R11 does not like R12 since R12 has Alzheimer's and forgets things. On 3/3/26 at 11:57 AM V7 CNA stated R11 and R12 [NAME] back and forth, R11 gets upset with R12 being confused and forgetful. V7 stated V7 has heard R11 call R12 a f****** (expletive) dummy. V7 stated this has been going on for a couple of weeks, V7 has reported this to the nurses and mentioned that a room change should be considered. On 3/4/26 at 8:48 AM V17 Housekeeper stated R11 yells a lot at R12 saying things like you (R12) just asked that God d*** (expletive) it. R11's MDS dated [DATE] documents R11 has moderate cognitive impairment. R12's MDS dated [DATE] documents R12 has severe cognitive impairment. On 3/3/26 at 12:16 PM R11 and R12 were sharing a room. R12 stated R11 and R12 have been roommates for about a month and they [NAME] back and forth and curse at each other at times. R12 did not feel that this was abuse. On 3/4/26 at 8:44 AM R12 did not recall any yelling or cursing from R11. 3.) The facility's Preliminary 24 hour Abuse Investigation Report documents on 11/28/25 at approximately 10:00 AM it was reported that a resident (R3) had touched R8's nose. The facility's Final Report dated 12/4/25 documents R8 pushed R3's wheelchair. R3 told R8 not to push R3. R8 told R3 I'll (R8) do what I (R8) want. R3 then grabbed R8's nose and R8 grabbed R3's arm and pushed R3 away. R3's Abuse Allegation Interview dated 11/28/25 documents R3 reported R8 pushed R3's wheelchair so R3 grabbed R8's nose and then R8 grabbed R3's hand to push R3 away. R8's Abuse Allegation Interview dated 11/28/25 documents R8 reported trying to help R3 and R3 grabbed R8's nose so R8 pushed R3's hand away. R8 reported it hurt at first, but R8 was fine. V18 CNA undated Interview documents V18 heard R8 yell out for help, R8 was sitting in the hallway near the nurse's station and R3 was pedaling her wheelchair away. V18 asked R8 to show V18 what happened and R8 reached out and grabbed/twisted V18's nose. V19 Registered Nurse was also present. R3's MDS dated [DATE] documents R3 as cognitively intact and R3 had verbal behaviors towards others 1-3 days out of the 7 day review. R8's MDS dated [DATE] documents R8 has moderate cognitive impairment. On 3/3/26 at 1:02 PM R8 was interviewed but did not recall the incident with R3. On 3/4/26 at 10:30 AM R3 stated several months ago R8 bumped R3's wheelchair in the hallway near the dining room, so R3 touched R8's nose and told R8 not to do that. R3 stated R8 then told R3 not to do that and R3 went on her way. On 3/4/26 at 9:00 AM V19 stated V19 heard yelling and R3 and R8 had already separated themselves from each other. V19 stated R3 said R8 tried to push R3's wheelchair from behind so R3 grabbed R8's nose. V19 stated R8 is confused but reenacted the nose grab to the CNA. V19 stated R3 is alert and oriented to person, place and time.4.) The facility's Preliminary 24 Hour Abuse Investigation Report documents on 1/17/26 at 12:40 PM it was reported that R2 was observed in the front lobby yelling that someone was trying to kill R2's son and R2 made contact with R3.R7's Abuse Allegation Interview dated 1/23/26 documents R7 was present in the lobby when R2's/R3's incident occurred, R2 bumped R3's wheelchair, R3 bumped R2 back and then R2 grabbed R3's arm. R7's MDS dated [DATE] documents R7 as cognitively intact. R3's Abuse Allegation Interview dated 1/19/26 documents R2 was anxious and grabbed R3's wrist without causing injury. On 3/3/26 at 8:53 AM R3 stated about a month ago R2 was trying to slap at R3, so R3 grabbed R2's wrist, and then R2 grabbed R3's wrist. R3 stated R3 didn't get hurt.On 3/3/26 at 10:28 AM R7 stated he witnessed R2's/R3's altercation and there was no staff present. R7 stated R2 seemed upset prior, R2 bumped into R3's wheelchair, R3 yelled at R2, and R2 yelled at R3. R7 stated R3 grabbed R2's wrist then R2 grabbed R3's wrist. R7 stated R3 gets upset with staff and yells at them.

Based on observation, interview and record review the facility failed to report allegations of resident-to-resident abuse to the administrator for four (R9, R10, R11, R12) of 12 residents reviewed for abuse in the sample list of 15. Findings include:The facility's Abuse Prevention and Reporting policy dated December 2025 documents verbal abuse includes oral and gestured communication towards residents, verbal abuse can be considered mental abuse and includes yelling, mocking, insulting, and ridiculing. This policy documents to consider resident to resident altercations as potential situations of abuse that should be investigated. This policy documents employees are required to report any incidents, allegations or suspicions of abuse immediately to the administrator or to an immediate supervisor who must immediately report to the administrator.1.) On 3/3/26 at 11:35 AM V6 Housekeeper stated V6 has witnessed R11 and R12 curse at each other a couple times and V6 witnessed them saying f*** (expletive) you to each other at approximately 7:00 AM today. V6 stated R11 does not like R12 since R12 has Alzheimer's and forgets things. V6 stated V6 had not reported this to V1 Administrator since nursing staff were aware of this, including V7 Certified Nursing Assistant (CNA). V6 stated abuse is reviewed in the monthly meetings and staff are to report suspected abuse immediately to V1. V6 was asked if V6 would consider R11 and R12 cursing at each other as abuse. V6 stated I (V6) guess but was unsure since these residents are prone to it due to their illnesses. On 3/3/26 at 11:57 AM V7 CNA stated R11 and R12 [NAME] back and forth, R11 gets upset with R12 being confused and forgetful. V7 stated V7 has heard R11 call R12 a f****** (expletive) dummy. V7 stated this has been going on for a couple of weeks, V7 has reported this to the nurses and mentioned that a room change should be considered. V7 stated V7 would consider this as verbal abuse and had not reported this to V1 or V2 Director of Nursing since the nurses were aware. On 3/4/26 at 8:48 AM V17 Housekeeper stated R11 yells a lot at R12 saying things like you (R12) just asked that God d*** (expletive) it. V17 stated V17 did not report this to V1 since the CNAs were aware. On 3/3/26 at 12:16 PM R11 and R12 were sharing a room. R12 stated R11 and R12 have been roommates for about a month and they [NAME] back and forth and curse at each other at times. The facility's abuse log does not include an allegation of abuse between R11 and R12. On 3/3/26 at 12:22 PM V1 was not present in the facility. V2 Director of Nursing stated no one has reported any concerns between R11 and R12, and V2 would consider the yelling/cursing as abuse. V2 stated staff should report this so that it can be investigated. V2 stated V2 will report this to V1 and will follow up to look into a room change. On 3/4/26 at 9:33 AM V1 stated staff should have reported R11's/R12's yelling and cursing to V1, and V1 was not made aware until notified yesterday by V2. 2.) On 3/3/26 at 11:35 AM V6 Housekeeper stated a couple months ago V6 heard yelling between R9 and R9's roommate (R10), V6 witnessed R9 give R9's roommate (R10) the middle finger, and their rooms were changed. V6 stated V6 did not report this as there was an unidentified CNA in the room at the time. V6 was asked if V6 would consider this to be abuse. V6 stated I (V6) guess but was unsure since these residents are prone to it due to their illnesses. R9's Minimum Data Set, dated [DATE] documents R9 has moderate cognitive impairment. The facility's abuse log does not include an allegation of abuse involving R9. On 3/3/26 at 12:22 PM V2 stated there have been no abuse allegations involving R9 or roommate. V2 stated R9's former roommate, R10, asked for a room change due to R9 getting in R10's personal space. V2 stated V2 was aware of R9 giving staff the middle finger, but not residents. V2 stated V2 will report this to V1.On 3/4/26 at 9:33 AM V1 confirmed staff should have reported the allegation of R9 giving R10 the middle finger. V1 stated this was just reported to V1 yesterday by V2.

Based on interview and record review the facility failed to implement measures to prevent further abuse during an abuse investigation for three (R2, R3, R8) of 12 residents reviewed for abuse in the sample list of 15. Findings include: The facility's Abuse Prevention and Reporting policy dated December 2025 documents the facility will take steps to prevent potential abuse during the investigation and residents who allegedly abuse another resident will be assessed to determine the most suitable therapy, care approaches, and placement while considering the resident's safety and the safety of other residents. This policy documents the facility will take all necessary steps to ensure the safety of residents, including but not limited to separating the residents involved. 1.) The facility's Preliminary 24 hour Abuse Investigation Report documents on 11/28/25 at approximately 10:00 AM it was reported that a resident (R3) had touched R8's nose. The facility's Final Report dated 12/4/25 documents R8 pushed R3's wheelchair. R3 told R8 not to push R3. R8 told R3 I'll (R8) do what I (R8) want. R3 then grabbed R8's nose and R8 grabbed R3's arm and pushed R3 away. R3's Abuse Allegation Interview dated 11/28/25 documents R3 reported R8 pushed R3's wheelchair so R3 grabbed R8's nose and then R8 grabbed R3's hand to push R3 away. This incident happened near the nurse's station. R8's Abuse Allegation Interview dated 11/28/25 documents R8 reported trying to help R3 and R3 grabbed R8's nose so R8 pushed R3's hand away. R8 reported it hurt at first, but R8 was fine. V18 Certified Nursing Assistant undated Interview documents V18 heard R8 yell out for help, R8 was sitting in the hallway near the nurse's station and R3 was pedaling her wheelchair away. V18 asked R8 to show V18 what happened and R8 reached out and grabbed/twisted V18's nose. V19 Registered Nurse was also present. There is no documentation that the facility implemented 15 minute checks or one to one supervision of R3 and R8 during the investigation of this abuse allegation.On 3/4/26 at 9:00 AM V19 stated V19 heard yelling and R3 and R8 had already separated themselves from each other. V19 stated R3 said R8 tried to push R3's wheelchair from behind so R3 grabbed R8's nose. V19 stated R8 is confused but reenacted the nose grab to the CNA. V19 stated R3 is alert and oriented to person, place and time. V19 stated sometimes 15 minute checks are done for abuse allegations, but that is based on directive from V1 Administrator and V19 could not recall if 15 minute checks were implemented after the incident. V19 stated 15 minute checks are documented on a paper form that is uploaded into the resident's electronic medical record. On 3/4/26 at 12:20 PM V1 stated 15 minute checks or one to one monitoring was not implemented during the investigation of R3's/R8's altercation. V1 stated staff were just checking on these residents every two hours and monitoring their behaviors. 2.) The facility's Preliminary 24 Hour Abuse Investigation Report documents on 1/17/26 at 12:40 PM it was reported that R2 was observed in the front lobby yelling that someone was trying to kill R2's son and R2 made contact with R3. The facility's Final Abuse Investigation Report for this allegation is dated 12/4/25. R7's Abuse Allegation Interview dated 1/23/26 documents R7 was present in the lobby when R2's/R3's incident occurred, R2 bumped R3's wheelchair, R3 bumped R2 back and then R2 grabbed R3's arm. R3's Abuse Allegation Interview dated 1/19/26 documents R2 was anxious and grabbed R3's wrist without causing injury. There is no documentation in R2's or R3's medical records that 15 minute checks or one to one supervision was implemented during the investigation of this abuse allegation.On 3/4/26 at 12:20 PM V1 stated 15 minute checks or one to one monitoring was not implemented during the investigation of R2's/R3's altercation. V1 stated staff were just checking on these residents every two hours and monitoring their behaviors.

Based on interview and record review the facility failed to develop a care plan with problem, goals, and interventions to address behaviors of disrobing for one (R14) of 12 residents reviewed for abuse in the sample list of 15. Findings include: R14's Minimum Data Set, dated [DATE] documents R14 has severe cognitive impairment. R14's Behavior Tracking dated 2/3/26-3/4/26 documents R14 had behaviors of disrobing on 2/3/26, 2/5/26, 2/19/26, 2/20/26, 2/23/26 and 2/24/26. The facility's Preliminary 24 Hour Abuse Investigation Report documents on 2/26/26 at 6:30 PM it was reported that R14 was in R15's room holding up her gown and R15 touched R14's breasts. V14 Certified Nursing Assistant Staff Interview form dated 2/16/26 documents V14 walked past R15's room and noticed R14 was in R15's room, as V14 entered R15's room V14 witnessed R14 holding up her gown and R15 had his hand on R14's breast. R14's Nursing Note dated 2/24/2026 at 10:24 PM documents R14 had increased confusion with hallucinations and R14 took her gown off while sitting in the hallway with incontinence brief halfway off. R14 was assisted with dressing. R14's Care Plan dated as revised 2/25/26 documents R14 wanders into other resident rooms and has pulled her top up in a male resident's room. This care plan does not include a problem, goals and interventions to address R14's behaviors of disrobing in public areas. On 3/4/26 at 1:43 PM V2 Director of Nursing stated R14 is not aware of R14's surroundings, R14 will change R14's gown in the hallway or comes out of R14's room while putting R14's top on. V2 stated this is not a new behavior for R14. At 1:51 PM V2 confirmed R14's care plan does not include a problem, goal, and interventions to address R14's public disrobing behaviors, only the incident involving R15. The facility's Abuse Prevention and Reporting policy dated December 2025 documents staff will identify residents with increased vulnerability for abuse, including residents who have needs, triggers and behaviors that might lead to conflict. This policy documents staff will identify problems, goals, and interventions that will be care planned to reduce the chances of abuse.

Based on observation, interview, and record review the facility failed to implement fall interventions and thoroughly investigate falls for two (R5, R6) of three residents reviewed for falls in the sample list of 15. Findings include: The facility's Fall Prevention Program dated January 2026 documents nursing staff are responsible for implementing and maintaining resident safety precautions, residents will be observed every two hours and provided care as care planned, residents will be transferred according to their care plan and fall interventions will be documented on the care plan. The facility's Transfers- Manual Gait Belt and Mechanical Lifts policy dated December 2025 documents to use a gait belt for one and two person transfers and the use of a gait belt is mandatory for all physical assisted transfers. 1.) R5's Minimum Data Set (MDS) dated [DATE] documents R5 has severe cognitive impairment and requires substantial/maximal staff assistance for bed mobility and transfers. R5's Care Plan documents an intervention dated 1/6/26 that R5 requires one assist for transfers. R5's Fall Report dated 2/18/26 at 6:30 PM documents R5 was lowered to the floor by a Certified Nursing Assistant (V16 CNA) and R5 bumped her head on the trash can. The facility's fall investigation for this fall does not include an interview or statement from V16 regarding this fall or documentation if a gait belt was utilized for this transfer. The documented root cause is weakness due to recent COVID-19 illness, and the post fall intervention is to encourage fluids for three days and physical therapy. On 3/3/26 at 6:11 PM V16 stated V16 was transferring R5 from the wheelchair to the bed, R5 became weak and lost balance, and V16 had to grab the waist band of R5's pants and lower R5 to the floor. V16 stated R5 landed on her bottom and bumped R5's head on the trash can. V16 stated R5 had COVID-19 and was a one assist for transfers at that time. V16 stated V16 did not use a gait belt for this transfer but should have since gait belts should be used for one person transfers. On 3/4/26 at 1:06 PM V2 Director of Nursing stated a gait belt should be used for all non-mechanical lift transfers, including one assist transfers. V2 was not aware that a gait belt was not used during R5's staff assisted transfer and fall. At 1:43 PM V2 confirmed all of R5's fall investigation documentation was provided and does not include whether a gait belt was used.2.) R6's MDS dated [DATE] documents R6 has severe cognitive impairment, R6 requires partial/moderate staff assistance for chair/bed/toilet transfers, R6 is always incontinent of urine and frequently incontinent of bowel. R6's Care Plan dated 10/25/24 documents interventions for bed in low position with landing strip (mat) 1/5/26 and revised toileting plan 2/23/26. R6's Care Plan dated 12/12/24 documents R6 is incontinent of urine and to remind/cue R6 to go to the bathroom. New intervention added 2/23/26 to toilet ever two hours and as needed. R6's Unwitnessed Fall Report dated 1/4/26 at 9:30 PM documents R6 was found on the floor of her room lying on her left side at the foot of the bed. R6 had a large skin tear to her left arm. R6 stated R6 thought she saw a dog, went to look for it and tripped over the floor mat. The facility's fall investigation for this fall does not document when R6 was last checked on or provided toileting/incontinence cares. R6's Unwitnessed Fall Report dated 2/22/26 at 3:15 PM documents R6 was sitting on the floor between the foot pedals of her wheelchair. R6 stated R6 was trying to put pants on. The facility's investigation for this fall does not document when R6 was last checked on or provided toileting/incontinence cares. The root cause is listed as attempted to self-toilet and R6 was on isolation for COVID-19. The intervention is listed as revised toileting plan to include toileting at 3:15 PM. On 3/3/26 at 10:04 AM R6 was sitting in her wheelchair in her room. There was no fall mat noted in R6's room. R6 did not recall having any falls or what fall interventions are used. On 3/3/26 at 2:38 PM R6 was in bed with bed low to the floor. There was no fall mat beside R6's bed. At 2:40 PM V2 stated a landing strip is a fall mat placed beside the bed. V2 confirmed R6 did not have a fall mat beside her bed. V2 stated V2 would have to check R6's care plan. At 3:25 PM V2 confirmed R6 should have a fall mat on the floor when R6 is in bed. On 3/3/26 at 11:57 AM V7 CNA was working on R6's hallway. V7 stated R6 had a fall recently, R6's door was closed due to COVID-19, and V7 had been in another resident room. V7 stated V7 heard yelling, R6 was trying to put her pants on or off, R6 slid down to the floor onto her knees, and R6 was incontinent at that time. V7 stated R6 was in the wheelchair prior to the fall, V7 had just changed R6 prior and dressed R6 in a clean gown because R6 wanted to go to bed. V7 stated R6 attempts to self-transfer. V7 was unsure of R6's specific fall interventions and stated V7 refers to the resident care plans for fall interventions. On 3/3/26 3:09 PM V22 Registered Nurse stated a CNA came to report that R6 was on the floor and R6 had a skin tear on her arm. V2 stated R6 said R6 was looking for a dog, lost balance and fell. V22 stated R6 is checked on every couple of hours at night and would have been toileted around 8:00-8:30 PM. V22 stated R6 does not usually try to self-transfer during the night. On 3/4/26 at 1:43 PM V2 confirmed R6's fall investigations do not include staff interviews or statements documenting when R6 was last toileted or checked on prior to the falls. V2 stated R6 was on a standard every two-hour toileting schedule prior to the fall which was changed to add toileting at 3:15 PM.

Based on interview and record review, the facility failed to perform a mechanical lift transfer safely for one (R1) of three residents reviewed for transfers.Findings include:The facility Transfers-Manual Gait Belt and Mechanical Lifts Policy dated 12/2025 documents mechanical lift equipment shall undergo routine maintenance checks by the nursing and maintenance staff to ensure that the equipment remains in good working order.The Mechanical Lift User Instruction Manual dated 2020 documents the following: Safety Precautions: Please read and follow the safety precautions listed below. The operation and use of mechanical patient lifts is simple and straightforward. Following these few basic safety precautions will make lifting operations easy and trouble free. ALWAYS carry out the DAILY CHECK LIST before using the lift. Maintenance Schedule: All mechanical lift products are designed for minimum maintenance; however, some safety checks and procedures are required. A schedule of DAILY tasks is detailed below. The manufacture strongly recommends the following checks be carried out on a daily basis and before using lift including- EXAMINE the sling hooks on the spreader bar and side suspenders for excessive wear. If in doubt - do not use.R1's Minimum Data Set/Quarterly assessment dated [DATE] documents R1 is severely cognitively impaired with bilateral upper and lower extremity impairments and is dependent on staff for all transfers.R1's Care Plan (current) documents R1 transfers via full body mechanical lift with assist of two persons.On 1/3/26 at 12:19pm, V9 Certified Nursing Assistant (CNA) stated the full circle piece on the one end of the lift spreader bar where the sling straps slide into was broken in half. V9 stated the side R1's sling came off that day (12/11/25) was the side that had the broken plastic circle piece. V9 stated this circle piece is what kept the sling straps from coming out of the spreader bar.On 1/3/26 at 1:53pm, V11 Maintenance Director stated the mechanical lift that was used on R1 on the day of the incident had a broken piece on the spreader bar where the sling straps go. V11 stated it was a round plastic piece and half of it was missing.On 1/3/26 at 1:58pm, V1 Administrator stated staff should have taken the mechanical lift out of service due to the broken piece and reported the broken piece immediately.

Based on observation, interview, and record review, the facility failed to provide a clinically qualified director of food and nutrition services. This failure has the potential to affect all 87 residents residing in the facility. Findings include: On 4/15/25 at 9:20 AM, V9, Dietary Manager, introduced herself as the dietary manager. During the ensuing tour of the facility kitchen, V9 was actively managing and directing kitchen support personnel and their food preparation and food storage activities. V9's food service certificate, issued 8/27/21, documents V9 was certified as a Food Service Manager. V9 stated the requirements for this certificate were to review course material for approximately eight hours in a single day and take a test. V9 stated the certificate course was directed for cooking sanitation. V9 further stated there was not any clinical information such as how nutrition is involved with healing pressure ulcers, reducing weight loss, gastrostomy tube feeding requirements, or for residents receiving dialysis. V9 then stated she had been told by the facility administration that she needs to get signed up for the CDM (Certified Dietary Manager) course ASAP (as soon as possible). V9 stated she understands the CDM course is 6 months to a year long and includes the clinical aspects of nutrition, not simply cooking sanitation. V9 then stated the facility Registered Dietician (V13) would only work on a consultant basis. V9 concluded by confirming she did not meet the State requirements for a Director of Food Services, or definition of a Dietetic Service Supervisor, by stating she was not a Registered Dietician, had not graduated from an authorized dietetic and nutrition program, had no food service experience prior to 1990, had not completed the course study as a CDM and was not a CDM, and had no military service. The facility's Resident Roster and Form 802 Resident Matrix, both dated 4/15/25, document 87 residents reside in the facility, all of whom receive nutritional services in the facility. R11 was one resident who receives no food by mouth but rather receives gastrostomy feedings.

Based on interview and record review, the facility failed to provide certified food handlers for the meal service and food preparation operations. This failure has the potential to affect all 87 residents residing in the facility. Findings include: On 4/15/25 at 9:20 AM, V9, Dietary Manager, stated there were three Dietary Aides (V10, V11, and V12) who did not yet have a Food Handler's certificate. The Illinois Public Act [PHONE NUMBER], documents a food handler or food employee is defined as any individual working with unpackaged food, food equipment, utensils, or food contact surfaces. This Act documents all food handlers working in non-restaurants such as nursing homes, must have the food handler's training by 7/1/2016 with enforcement beginning 1/1/2017. On 4/16/25 at 11:47 AM, V9 confirmed V10, V11, and V12 had been working in the facility kitchen and dining room and did engage in meal service activities serving food trays and plates to residents, rolled service utensils into napkins for resident meal preparations, and V11 also operated the dishwasher. The facility's Resident Roster and Form 802 Resident Matrix, both dated 4/15/25, document 87 residents residing in the facility, all of whom, with the exception of R11 who receives no food by mouth, consume food prepared and served from the facility kitchen.

Based on observation, interview, and record review, the facility failed to provide meal service in the posted service times. This failure affects six residents (R14, R15, R21, R47, R59, and R195) of six residents who received meal trays in their rooms, on the sample list of 34. Findings include: On 4/15/25 between 11:00 AM and 12:45 PM, R14, R15, R21, R47, and R195, were identified as waiting in their rooms for meal service on the facility's A Hall. Each of the identified residents stated the food is consistently late for the hall trays delivered to rooms. Each resident identified that breakfast is due around 7:30 AM, lunch around 11:30 AM, and supper around 4:30 PM. Each resident stated the meals actually arrive around 9:00 AM, lunch around 1:00 PM, and supper around 6:00 PM. On 4/15/25 at 1:10 PM, the cart containing the meal trays arrived on the facility's A Hall. On 4/15/25 at 1:14 PM, V8, Certified Nursing Assistant, stated the meals are often served late because there weren't enough kitchen staff. V8 stated at least three days per week the breakfast goes out for the hall trays around 9:00 AM and lunch is right around this time (1:10 to 1:15 PM). V8 stated she did not work the evening shift and could not speak as to when supper was delivered to the residents eating in their rooms. On 4/16/25 at 8:25 AM, V9, Dietary Manager, stated the kitchen serves any resident who comes to the dining room between 6:30 AM and 8:30 AM, then they can determine which residents need a hall tray. V9 stated for lunch, the kitchen serves the A and D Halls in the dining room starting at 11:30 AM, then the B and C Halls in the dining room starting at 12:15 PM. V9 stated after the dining room is finished serving, they start preparing the meal carts that go out to the residents eating in their rooms. V9 stated a similar routine happens during the supper meal service with A and D Hall starting in the dining room at 4:30 PM, then the B and C Halls at 5:15 PM, then determine which residents did not come to the dining room and prepare to serve the trays to the residents eating in their rooms. The facility's posted signs in the hallway leading to the dining room, on the Care Plan Coordinator's office door, and in the central rotunda, all document meal service times for breakfast for all halls 6:30 AM through 8:30 AM, lunch for A and D Hall at 11:30 AM, B and C Halls at 12:15 PM, and dinner A and D Hall at 4:30 PM, and B and C Hall at 5:15 PM. On 4/16/25 at 12:20 PM, V29, Dietary Aide, was able to identify the residents who were requesting to eat in their rooms and would need to be provided a hall tray. On 4/16/25 at 12:57 PM, in addition to the aforementioned five residents, R59 (A Hall) also stated she had not yet been served lunch and the meals have been coming late routinely.

Based on observation, interview, and record review the facility failed to follow pharmacy/hormone replacement medication guidance, for one of eight residents (R32) reviewed during medication administration observation. The facility had three medication errors out of 30 opportunities resulting in a 10 percent medication error rate. Findings include: R32's Medication Administration Record (MAR) dated 04/01/2025- 4/30/2025 documents the following: Levothyroxine Sodium (hormone replacement medication) Oral Tablet, 75 MCG (micrograms), give 75 mcg by mouth in the morning, related to Hypothyroidism. Unspecified, Omeprazole (proton-pump inhibitor medication) Oral Tablet, Delayed Release, 20 MG (milligrams), give 1 tablet by mouth in the morning for acid reflux, and Acetaminophen (pain medication) Oral Tablet, give 1000 mg by mouth every 8 hours as needed for pain rated 1-5. The same MAR documents V19's initial indicated document R32 was scheduled to receive both Levothyroxine and Omeprazole during Liberal AM, medication time frame of 4:00 am - 6:00 am. R32's same MAR documents V19 initials also document Acetaminophen was administered during the same Liberal AM medication time frame of 4:00 am - 6:00 am. On 4/17/25 at 5:00 am, V19, Licensed Practical Nurse (LPN) administered R32's Levothyroxine 75 mcg tablet, Omeprazole delayed release 20 mg tablet, and two tablets of Tylenol 500 mg (1000 mg). A detailed electronic medical record (EMR) report dated 4/17/205 at 12:02 pm, signed by V2, Director of Nursing, documents the following times the above medications were signed out as administered during the Liberal AM medication pass time frame: Omeprazole oral tablet, Delayed Release 20 MG (milligrams) was administered on 4/17/25 at 5:02 am, Levothyroxine Sodium oral, 75 mcg tablet was signed out as administered the same time at 4/17/25 at 5:02 am, and Acetaminophen Oral Tablet, 1000 mg was signed out as administered four minutes later, at 5:06 am. On 4/17/25 at 11:45 am V2, Director of Nursing stated Levothyroxine should not be administered with any other medication. Yes, those are medication errors. The facility Medication Error Report dated 4/17/25 documents: a physician (unidentified) was notified Omeprazole Oral Tablet Delayed Release 20 MG (milligrams), Levothyroxine Sodium Oral, 75 mcg and Acetaminophen Oral Tablet, 1000 mg were given together in error, and Synthroid (name brand for Levothyroxine) is to me given on an empty stomach, prior to other medication. The same report documents the type of error was medications given at the wrong time and caused by a transcription error (scheduled at the same time). The facility pharmacy pamphlet undated insert for Levothyroxine (thyroid hormone replacement) directs the administration of the medication to be administered once daily, preferably on an empty stomach, one-half to one hour before breakfast and at least four hours before or after other medication, that can interfere with absorption of the Levothyroxine medication.

Based on interview and record review, the facility failed to protect a residents (R2) right to be free from inappropriate touching by another resident (R1), for 1 (R2) out of three residents reviewed for abuse in the sample of five residents. Findings include: The facility policy titled 'Abuse Prevention and Reporting', reviewed 8/2023, documents 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. The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse: Abuse means any physical or mental abuse injury or sexual assault inflicted upon a resident other than by accidental means. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 13, cognitively intact. R1's Other/General Note dated 8/29/24 at 11:10pm documents R1 observed by CNA (Certified Nurses Assistant) in hallway with R2 with what appeared to be inappropriate touching of R2's pants/brief. R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnoses: Guillain-Barre Syndrome, Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Dysphagia, Hyperlipidemia, Syncope and Collapse, Major Depressive Disorder, Insomnia, Unsteadiness On Feet, Abnormalities of Gait and Mobility, Lack of Coordination, Need for Assistance with Personal Care, Edema, HTN (Hypertention), GERD, Muscle Weakness, Urinary Tract Infection, Dementia Moderate with Psychotic Disturbance, Mood (Affective) Disorder, Delusional Disorders, Acute Cough and Hypothyroidism. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 4, severe cognitive impairment. R2's Other General Note dated 8/29/24 at 10:30pm documents R1 noted at end of hall by CNA with what appeared to be another male R2 who may have been inappropriately touching R1, having his hand on her pants/brief On 9/6/24 at 10:53am V1 Administrator said, on 8/29/24 at 7:30pm V1 was in V1's office and V4 (CNA) knocked on V1's door telling V1 to come to the nurses station regarding an incident between R1 and R2. V1 said, V3 (CNA) stated that V3 and V4 just left R4's room and observed R1 and R2 at the end of the hallway. V1 said, V3 stated that V3 ran down the hall to see what was going on and observed R1 with R1's hand slightly down R2's brief, and that R2's shirt was up to R2's belly button. V1 said, when V3 asked R1 what R1 was doing R1 did not respond and removed R1's hand. On 9/6/24 at 11:49pm V3 (CNA) said, on 8/29/24 at 7:25pm V3 and V4 (CNAs) had just put R4 to bed and came out of R4's room. V3 stated V3 looked down hall and saw R1 very close to R2, R1 had R1's back to V3 and could not see what R1 and R2 were doing. V3 stated, V3 ran down the hallway to see what was going on and R1 had R1's right hand inside R2's left side of R2's brief and that R2's shirttail was pulled up to R2's belly button. V3 stated V3 asked R1 what R1 was doing and R1 did not respond and removed R1's hand from R2's brief.

Based on interview and record review the facility failed to report an allegation of sexual abuse to the state survey agency for two of three residents (R1, R2) reviewed for sexual abuse in the sample list of three. Findings include: The facility's Abuse Prevention and Reporting - Illinois policy with a revised date of October/2022 documents, Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. External Reporting Initial Reporting of Allegations: 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. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired. R2's MDS dated [DATE] documents R2 has moderately impaired cognition. On 7/29/24 at 9:10 AM, V1 (Administrator) stated that she got a call from V3 (Registered Nurse-RN) that said R2 was touching R1 inappropriately. V1 stated that she couldn't remember if it was last weekend or the weekend before but confirmed she did her own investigation and did not report it to the state survey agency. V1 stated that she did not think it was abuse so she did not report it. On 7/29/24 at 10:00 AM, V5 (Certified Nursing Assistant/CNA) stated on Saturday the 20th, V5 was in the bathroom next to R1's room assisting another resident and she heard R1 say No, No, No which V5 stated R1 often did if she was falling out of bed. V5 stated as soon as she could she went to R1's room and R2 was in his wheelchair next to R1's bed and appeared to have his hand between her legs and V5 asked him what he was doing. V5 stated that R2 told her he was trying to push her back into bed as she was falling out. V5 stated that R1 had to sleep without any clothing on as she has [NAME] and will eat her clothing and the briefs so she was naked. V5 stated that she reported it to her nurse V3. On 7/29/24 at 10:35 AM, V3 stated that on 7/20/24 V5 came to her and told her that she walked into R1's room and R2 appeared to have his hand between R1's legs. V3 stated that V3 called V1 and reported it to her. V3 stated that V1 told her not to document anything about it. On 7/29/24 at 11:11 AM, V8 (Hospice Social Worker) stated that one of the hospice Certified Nursing Assistants (CNA) reported to her that when the CNA was visiting R1 over the weekend that one of the facility CNAs reported to her that R2 (R1's husband and roommate) was touching R1 inappropriately. V8 stated that V8 went to the facility to follow up and V1 (Administrator) and V2 (Director of Nursing) told V8 that they were handling the investigation internally and that they had moved R1 to a different room. On 7/29/24 at 1:24 PM, V1 confirmed she did not report the allegation, she stated that she thought about reporting it but did not.

Based on observation, interview, and record review the facility failed to provide the services of a clinically qualified director of food and nutrition services. This failure has the potential to affect all 77 residents residing in the facility, with R18 being one exception. Findings Include: On 4/2/24 at 9:44 AM, V5 Dietary Manager stated, I am the Dietary Manager. I started here as the manager in 2019. I have an FSM (Food Service Manager, cooking sanitation certificate) certificate. The FSM took one day to get. It was a one day course of study and take a test. I also have a CFM (Certified Food Manager, cooking sanitation certificate) certificate which is basically the same course of study and take a test that also took one day. V5 continued and confirmed neither of these certificates is similar to a CDM (Certified Dietary Manager), nor CFPP (Certified Food Protection Professional) (nationally certified, 6 months or greater of clinical nutritional study followed by a certification exam). V5 then stated, I am enrolled in the CDM course through the University of North Dakota. This course has a set of 4 books for study and since I have these 2 sanitation certificates, I only have to complete 2 of the books, so I am about halfway through the course. V5 continued, We do have an RD (Registered Dietician) who is here several days per month but is not full time, she works as a consultant. V5 then confirmed she did not meet the state requirements as a Dietetic Service Supervisor (reference Illinois Admin Code 77, Section 300.330, Definitions) by stating, I am not an RD, I haven't graduated from any school or program, I have not completed the CDM course so I don't have the CDM certificate, and I don't have any military service. V5 concluded by stating, We have one resident (R18) who receives feedings through a G-tube (gastrostomy tube) who is NPO (nothing by mouth). On 4/2/24 at 9:44 AM and 11:55 AM, and on 4/3/24 at 12:08 PM through 1:47 PM, V5, Dietary Manager was actively directing and managing the food preparation and food service activities in the facility's kitchen. There were concerns with resident dignity identified during the survey with the daily use of disposable dish wares (reference F550). The facility's Form 802 Resident Matrix dated 4/2/24 documents 77 residents reside in the facility, all of whom, with one exception, R18, consume food prepared from the facility kitchen. This same Form 802 documents R18 receives all nutrition and hydration through a gastrostomy tube and takes nothing by mouth.

Based on observation, interview, and record review the facility failed to honor residents' right to dignity during dining by daily serving of meals on disposable dishware and by standing over residents while providing feeding assistance. This failure affects seven residents (R8, R13, R15, R17, R22, R37, and R61) out of 18 reviewed for dignity on the sample list of 47. Findings Include: 1. On 4/2/24 at 12:10 PM, V3 Dietary Manager stated, We are serving the foam plates due to the dishwasher being broken. The dishwasher has been broken since February (2024), it first started leaking and it got worse, and then it finally quit. The server today started serving on regular plates then realized she intended to use foam plates for everybody. On 4/3/24 at 12:42 PM, R37 stated, I don't like the foam plates. It is too easy to cut through the foam plates with the metal knives, and the foam cups are small at the bottom and large at the top so I am always afraid I am going to tip them over and spill them. It's easy to lose track of time in here but I would say they have been serving the foam plates for about 3 weeks straight or so. On 4/3/24 at 12:44 PM, R13 stated, Foam plates, yeah, the dishwasher must be broken, there's nothing like a regular plate. On 4/3/24 at 12:46 PM, R8 stated, The dishwasher is broken, that's why they are using foam plates. On 4/3/24 at 12:48 PM, R61 stated, The foam plates are easier to get rid of, they just throw them away. On 4/3/24 at 12:55 PM, V10 Cook stated, We are using the foam plates because the dishwasher is broken. They are supposed to get us a new one. The use of the foam plates has varied but we have been steady using them for about 3 weeks. Nobody wants to stand over the sink and do dishes by hand. On 4/4/24 at 9:45 AM, R15 unprompted, stated, For a couple of months we have been served meals on foam plates. The food gets cold a lot quicker because they can't use the plate warmers on foam plates like they do with regular plates. I hope they fix that dishwasher soon. 31642 2. R17's Minimum Data Set, dated dated dated [DATE] documents R17's staff assessment as R17 has memory problems with moderate cognitive impairment. R17's Care Plan dated 1/04/24 documents R17 is dependent on staff for assistance with eating. On 4/3/24 at 11:50 AM, during medication administration observation, V7 Registered Nurse entered R17 and R22's shared room. Both R17 and R22 were seated in partially reclined geriatric specialty wheelchairs. R17 and R22's geriatric specialty wheelchairs sat on opposite sides of their room. V8 Certified Nursing Assistant (CNA) was feeding R17 while in a standing positron, next to R17's reclined geriatric specialty wheelchair. There were no chairs in R17's room for V8 CNA to sit down in while feeding R17. On 4/3/24 at 11:59 AM, V8 CNA exited R17's room after R17 finished his meal. V8 CNA stated she did not know it was a dignity issue to feed R17 while she (V8) was standing next to R17's chair. 3. R22's Minimum Data Set, dated dated dated [DATE] documents R22's Brief Interview of Mental Status score as nine out of a possible 15, indicating moderate cognitive impairment. R22's Care Plan dated 3/06/24 documents R22 is dependent on staff for assistance with eating. On 4/3/24 at 11:50 AM, during medication administration observation, V7 Registered Nurse entered R17 and R22's shared room. Both R17 and R22 were seated in partially reclined geriatric specialty wheelchairs that sat on opposite sides of their room. V9 Licensed Practical Nurse (LPN) was feeding R22 while standing up beside R22's chair. There were no chairs in R22's room for V9 LPN to sit down on while feeding R22. On 4/3/24 at 11:55 AM, V9 LPN exited R22's room, after R22 finished his meal. V9 stated V9 recognized it is a dignity issue to feed a resident while standing up. On 4/3/24 at 12:01 PM, V1 Administrator acknowledged it is a dignity issue when staff feed residents while the staff member remains standing. The facility policy Dignity dated 03/2024 documents the following: Guidelines: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity, and respect in full recognition of his or her individuality. The facility shall consider the resident's life style and personal choices identified through the assessment processes to obtain a picture of his or her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Maintaining a resident's dignity should include but is not limited to the following: *Encouraging and assisting residents to dress in their own clothes, rather than hospital- type gowns, and appropriate footwear for the time of day and individual preferences; *Placing labels on each resident's clothing in a way that is inconspicuous and respects his or her dignity (for example, placing labeling on the inside of shoes and clothing or using a color coding system); *Promoting resident independence and dignity while dining, such as avoiding: *Daily use of disposable cutlery and dishware; *Bibs or clothing protectors instead of napkins (except by resident choice); *Staff standing over residents while assisting them to eat; *Staff interacting/conversing only with each other rather than with residents while assisting with meals.

Based on observation, interview, and record review the facility failed to maintain safe and comfortable water temperatures in resident hand sinks on the facility's C Hall (300 Hall). This failure affects 14 residents (R5, R10, R11, R13, R26, R31, R33, R38, R46, R52, R57, R58, R59, and R61) out of 18 reviewed for accident hazards on the sample list of 47. Findings Include: On 4/2/24 at 2:15 PM, the water temperature in the hand sink in room [ROOM NUMBER] had a stinging sensation to the hand. The water temperature in this same sink measured 119.4 degrees Fahrenheit (F) with an Illinois Department of Public Health Digital Automatic Calibration thermometer. room [ROOM NUMBER] had a hand sink water temperature of 115.3 F. room [ROOM NUMBER] had a hand sink water temperature measuring 122.3 F. room [ROOM NUMBER] hand sink water temperature measured 114.6 F. On 4/2/24 at 2:28 PM, V5 Maintenance Director, stated, We just got a new water heater and the mixing valve on it is so sensitive, I move it a millimeter and it sends the temperatures way off. V5 continued, Even the 114 (F) is too hot, our standard is to keep it below 110 (F). On 4/3/24 at 2:05 PM, the water temperature in the hand sink in room [ROOM NUMBER] measured 116.9 F. In room [ROOM NUMBER] the hand sink water temperature measured 117.3 F. The water temperature in the hand sink in room [ROOM NUMBER] measured 126.6 F. The water in this hand sink was hot enough to trigger a reflex withdrawal motion when a hand was placed under the water stream. In room [ROOM NUMBER] the water temperature of the hand sink measured 120.7 F, again hot enough to trigger a reflex withdrawal motion. The temperature of the water in the hand sink in room [ROOM NUMBER] measured 117.8 F. The hand sink water temperature in room [ROOM NUMBER] measured 115.7 F. On 4/3/24 at 3:07 PM, V5 Maintenance Director stated, Yesterday I adjusted the mixer valve to turn down the temperature, then I asked my Assistant to check the temperatures first thing this morning and they actually went the wrong way, they went up. We had a plumber out here and he said the mixing valve needs a whole new kit or replaced. On 4/3/24 at 3:10 PM, while observing the mixing valve, V5 stated, I have the valve turned all the way down so right now it should be passing basically 100 percent cold water but it isn't, so I know the temperatures are hot again today. The facility's Resident Roster dated 4/2/24 documents R5, R10, R11, R13, R26, R31, R33, R38, R46, R52, R57, R58, R59, and R61 reside on the facility's 300 Hall (C Hall). R5's Minimum Data Set (MDS) dated [DATE] documents R5 received a score of 2 out of a possible 15 during a Brief Interview for Mental Status (BIMS), rating R5 as severely cognitively impaired. R10's MDS dated [DATE] documents R10 did not have the cognitive capacity to complete a BIMS and received a staff assessment as moderately cognitively impaired with long term memory problems and could not recall the current season. R11's MDS dated [DATE] documents R11 received a score of 11 out of a possible 15 during a BIMS, rating R11 as moderately cognitively impaired. R13's MDS dated [DATE] documents R13 received a score of 14 out of a possible 15 during a BIMS, rating R13 as cognitively intact. R26's MDS dated [DATE] documents R26 received a score of 5 out of a possible 15 during a BIMS, rating R26 as severely cognitively impaired. R31's MDS dated [DATE] documents R31 received a score of 6 out of a possible 15 during a BIMS, rating R31 with severe cognitive impairment. R33's MDS dated [DATE] documents R33 received a score of 8 out of a possible 15 during a BIMS, rating R33 as moderately cognitively impaired. R38's MDS dated [DATE] documents R38 received a score of 2 out of a possible 15 during a BIMS, rating R38 as severely cognitively impaired. R46's MDS dated [DATE] documents R46 received a score of 10 out of a possible 15 during a BIMS, rating R46 as moderately cognitively impaired. R52's MDS dated [DATE] documents R52 received a score of 6 out of a possible 15 during a BIMS, rating R52 as severely cognitively impaired. R57's MDS dated [DATE] documents R57 received a score of 5 out of a possible 15 during a BIMS, rating R57 as severely cognitively impaired. R58's MDS dated [DATE] documents R58 received a score of 13 out of a possible 15 during a BIMS, rating R58 as cognitively intact. R59's MDS dated [DATE] documents R59 received a score of 6 out of a possible 15 during a BIMS, rating R59 as severely cognitively impaired. R61's MDS dated [DATE] documents R61 received a score of 11 out of a possible 15 during a BIMS, rating R61 as moderately cognitively impaired.

Based on interview and record review the facility failed to accurately record a resident's preference for life-sustaining treatment in the medical record for one (R24) of two residents reviewed for advance directives in the sample list of 24. Findings include: On [DATE] at 11:48 am, V2 Director of Nursing (DON) said, R24 recently updated R24's code status from a Full code to a Do Not Resuscitate (DNR). V2 said, the care plan coordinator should of received the updated form and updated R24's Care Plan to reflect the DNR status. V2 said, we must of missed it and its being updated now. R24's Physician Order Sheet (POS) dated [DATE] documents R24 as a Do Not Resuscitate (DNR). R24's POLST (Physician Order for Life Sustaining Treatment) dated [DATE] in R24's electronic medical record documents: Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation). (Selecting CPR means Full Treatment in Section B is selected). Section B: Full Treatment Primary goal of sustaining life by medically indicated means. In addition to treatment described in Selective Treatment and Comfort Focused Treatment, use intubation, mechanical ventilation and cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated. R24's POLST (Physician Order for Life Sustaining Treatment) dated [DATE] in R24's electronic medical record documents: No CPR: Do Not Attempt to Resuscitation (DNAR). R24's Care Plan dated [DATE] documents R24 formulated Advance Directives, R24's Advance Directives will be honored, Full Code and Guardian. The Advance Directive Policy revised ,d+[DATE] documents residents will be afforded the opportunity upon admission to the facility to submit any Advance Directive regarding their care in the facility, thereby informing the facility of each resident's desires regarding decision making and end of care. Each resident's medical record will reflect advanced directive in effect.

Based on observation, interview and record review the facility failed to implement wheel chair safety interventions for one resident (R1) of three residents reviewed for accidents in the sample of three. This failure resulted in R1 being improperly transferred and R1's leg becoming entrapped under the wheelchair resulting in a fracture at the distal metaphysis of the right femur. Findings include: The facility's Adverse Event Policy, dated 11/2017, documents an adverse event is an untoward undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof, which includes near misses. On 3/10/21 at 8:45am, R1 was in a reclining chair with her legs elevated, crying. R1 stated that she cannot talk until the pain medications take effect. R1 had immobilize brace in place on her right knee/leg. R1's Incident Report, dated 2/17/21, documents that R1 was being pushed to the bathroom and her foot dropped and R1 stated I heard something crack. R1's right knee x-ray, dated 2/17/21 documents an acute comminuted fracture at the distal metaphysis of the right femur. On 3/10/21 at 10:45am, V4, Unit Assistant, stated that she was pushing R1 back to her room, when R1 dropped her right foot and it went under the wheel chair. V4 stated that R1 said I heard something crack. V4 verified that R1 did not have her foot pedals on her wheel chair. On 3/10/21 at 11:00am, V5, Licensed Practical Nurse, stated that V4, Unit Assistant, was pushing R1 back to her room, and heard a scream. V5 stated that R1 dropped her right foot, it went under the wheel chair. V5 stated that R1 did not have the foot pedals on the wheel chair. V5 stated that when R1 is being transported in the facility, her foot pedals should have been on. On 3/11/21 at 9:00am, V3, Restorative/Registered Nurse, stated that R1 should have had the foot pedals on her wheel chair when being transported by staff.

Based on observation, record review and interview the facility staff failed to maintain control of a resident wheelchair to prevent injury for one resident (R1) of three reviewed for injury in the sample of 20. This failure resulted in R1 sustaining fractures of the Distal Tibia and Fibula. The finding's include: R1's Admission Face sheet documents [DIAGNOSES REDACTED]. The Face sheet listed R1's Emergency Contact and Power of Attorney for Healthcare (POA) as V17. R1's 2/26/19 Significant Change Minimum Data Sheet (MDS) documents R1 has moderate impairment for decision making and was unable to complete the Brief Interview for Mental Status (BIMS). This MDS documents that R1 requires extensive assistance of one staff for bed mobility and total dependence on two staff for transfers. R1 is non ambulatory, and requires extensive assistance of one staff for locomotion on the unit. R1's (MONTH) Physician order [REDACTED]. R1 also has an as needed (PRN) order for Tylenol 650 MG every 6 hours as needed for pain rated 1-4 (on a scale of 10). R1's Progress Notes dated 3/16/2019 at 5:57 pm (17:57) documents, While being transported back to room, resident's L (left) leg was bumped into the wall/door frame. Resident was very upset, no bruising noted, no swelling. PROM (Passive Range of Motion) performed w/o (without) pain. Will monitor. This was documented by Registered Nurse (RN) V4. On 3/17/2019 at 04:13 am R1's Medication Administration Note documents, [MEDICATION NAME] Tablet 650 MG , Give 1 tablet by mouth every 6 hours as needed for pain management requested for generalized pain rated at 6 out of 10. This was documented by RN V28. On 3/17/2019 at 9:27 pm (21:27) R1's Medication Administration Note states, [MEDICATION NAME] Tablet 650 MG Give 1 tablet by mouth every 6 hours as needed for pain management Resident requested for leg pain rated 5 out of 10. This was documented by V29 Licensed Practical Nurse (LPN). On 3/17/2019 at 10:52 pm (22:52) V28 documents in R1's Progress Note, Resident noted to have increased swelling to L (left) ankle and foot. Also complaining of increased pain to LLE (Lower Left Extremity). MD (Medical Doctor) notified. Awaiting response. Will continue to monitor. On 3/18/2019 at 7:25 am Licensed Practical Nurse (LPN) V15 documented in R1's Progress Note, Resident reporting extreme pain to left foot and ankle. Upon assessment, bruising at varying stages of healing and swelling noted. Per midnoc (midnight) RN, resident had been reporting this pain x 2 days. Resident states I don't remember what I bumped into but that foot hurts so bad. physician's orders [REDACTED]. On 3/18/2019 at 11:36 am R1's Health Status Note documents, Resident has refused to get out of bed and to eat this shift. Intermittent ice packs applied to L (left) foot and ankle today. Resident states she just wants to lay in bed and rest. Will continue to monitor LLE (Lower Left Extremity) and assist resident as necessary. Administrator notified of bruising to LLE and order for x-ray. On 3/18/2019 at 12:17 pm LPN V15 documented R1's Progress Note, L foot and L ankle x-ray results received and forwarded to MD, awaiting further direction. Called (V17 POA) to notify of L distal tibia/fibular fractures. (V17) requesting further information regarding incident, transferred to administrator. R1's Radiology Report dated 3/18/19 documented reason for X-ray was Pain, Bruising and Swelling, unsure of injury. The Findings of the Left Ankle, two view x-ray documented, Oblique/comminuted fractures are noted involving the distal tibia and fibula. Mild lateral displacement of the distal fracture fragments are noted. The Ankle Mortise is intact. Mild soft tissue swelling is present. Diffuse osteopenia is noted. The Impression documented Distal Tibia and Fibular Fracture. Certified Nurse Aide (CNA) V5 stated on 3/31/19 at 2:15 pm that V5 was pushing R1 back from dinner in the wheelchair. R1's feet were on the pedals and were extended slightly forward. As V5 was pushing R1 to R1's bedroom, V5 saw R2 standing up in the bedroom just before she got to R1's bedroom. V5 stated at that time that R2 is a fall risk so V5 let go of R1's wheelchair and went into R2's room to prevent R2 from falling. V5 stated when V5 came out of R2's room less than a minute later V5 saw R1 in R1's doorway holding R1's knee. R1 stated she had hit leg on the doorway. V5 stated she did not actually see R1 hit the doorway. V5 stated she was pushing R1 at a steady pace and did not stop R1's wheelchair before letting go of it to assist R2. V4 RN stated on 3/31/19 at 2:40 pm that on Saturday Evening (3/16/19) at 6:00 pm CNA V5 reported V5 had bumped R1's wheelchair into the wall. R1's leg hit the door frame of the bedroom. When V4 went to assess R1, R1 told V4 She pushed me into the wall. V4 stated she assessed R1 and preformed PROM (Passive Range of Motion) on R1's legs and R1 had no complaint of pain. V4 saw no indication of injury at that time. V15 LPN stated on 4/1/19 at 9:55 am V15 had not worked the weekend V15 came to work on 3/18/19 at 6:00 am V15 got report from the night shift that R1 has swelling, bruising and pain V15 informed MD V9 who ordered an X-ray, and ice. On 3/31/19 at 4:53 pm DON V2 stated she was on vacation when the incident with R1 occurred. V2 called Dr (V9) on Tuesday 3/19/19. V9 told V2 that the fracture was not spontaneous. Dr V9 said the injury was caused by an impact to break the two bones. On 4/1/19 at 2:19 pm Physician V9 stated that R1 had received a distal tibia and fibular fracture. V9 stated the break was not spontaneous, something happened to R1's leg and it broke. V9 stated the staff speculated that the injury might have occurred when R1's leg was banged into a door. V9 stated that R1 is not weight bearing and does not walk. On 3/31/19 at 4:30 pm Director of Nurses (DON) V2 stated they reenacted the incident with V5 pushing V2 in the wheelchair. In the reenactment V2's left leg did hit the door frame. V2 stated if R1's wheel chair went into the room, R1's foot on the pedal could have been jarred and there was a night stand inside the doorway. V2 stated (R1) sits with her legs out and has no below the knee function of legs from polio. R1 keeps legs covered with a blanket you can't see R1's feet. R1 also has foot drop. V2 stated she told V5 to be a little more cautious when transporting residents. R1 was observed on 3/31/19 at 3:00 pm seated in a reclined geriatric chair with R1 legs elevated on a padded footrest. R1 stated her leg felt fine. When asked how R1 had injured the leg. R1 responded she did not know she thought maybe she fell .

Based on interview and record review the facility staff failed to report an incident of possible injury to R3 during a transfer for one of four residents in the sample. This failure resulted in a delay of eight days for medical assessment, treatment and identification of a fracture. This failure resulted in R3 also being treated for [REDACTED]. The findings include: R3's October 2012 Physician order [REDACTED]. R3's Minimum Data Set ((MDS) dated [DATE] identified R3 with moderate cognitive impairment. R3 was independent in bed mobility and required limited assist of one staff for transfers. R3 required extensive assist of one staff for ambulation. The 9/04/12 significant change MDS identified R3 needed extensive assistance of two staff for transfers and documented no ambulation had occurred during the assessment period. Nurse's Notes dated 8/08/12 11:30 am documented a new order for an X-ray of the right ankle. There were no previous notes for August 2012 or July 2012 that indicated the circumstances that resulted in a need for an X-ray of R3's ankle. The 8/08/12 notes document a portable X-ray was done on R3's ankle. The X-ray results dated 08/08/12 identified a "spiral [MEDICAL CONDITION] fibula". Nurse's notes dated 8/08/12 documented Physician Z3 was notified and responded with a new order for non-weight bearing to right ankle, and apply ice as needed. A walking boot was also ordered to protect R3's ankle. An 8/13/12 order for Tylenol 650 mg (milligrams) twice a day for Pain Management was received on 8/13/12. According to the R3's Nurse's Notes and September 2012 Physician Orders, R3 remained non weight bearing, utilizing a hoyer lift for transfers until 9/25/12 when R3 became weight bearing as tolerated and received therapy eval and treatment orders. On 10/22/12 at 9:50 am Administrator E1 was asked about the investigation of R3's ankle fracture. E1 stated he had to work backwards to determine how the fracture occurred. E1 found out during interviews that R3 had hit her ankle on the bed during a transfer with CNA E13 and E14. E1 stated on 10/22/12 at 10:10 am that R3 had complained of pain to therapy staff during ambulation and they reported it to the nurses and no one else. Restorative Nursing records for August 2012 documented R3 was ambulated to meals 8/01-8/08/12 am. Physical Therapy Aide E11 confirmed on 10/22/12 at 10:30 am R3 continued to ambulate though she was complaining of pain. E11 reported R3's pain several times to nursing, then she reported the pain to her supervisor who ordered the X-ray. On 10/22/12 at 9:00 am R3 was asked how she fractured her ankle. R3 stated "They" (did not know the staff names) were assisting her and told R3 to put her arms around the staff's neck, then staff twirled R3 around and R3 "hit her ankle on a pipe" on the bed. R3 stated they did not use a gait belt. R3 said " It hurt terrible, I screamed." R3 stated she walked on it a few days and later she got an X-ray and found out "it was cracked". On 10/22/12 at 10:05 am CNA E14 stated during telephone interview, On (7/31/12) E14 was orienting with CNA E13. E14 was observing the transfer of R3. E14 stated E13 picked R3 up from the bed and "smashed" R3's ankle on the side rail. E14 stated the half rail was in the raised position and R3 was seated high in the bed. A gait belt was not used. E13 picked R3 up using a "bear hug" transfer. E14 stated R3 was in a lot of pain. E14 stated he did not report the incident. When E13 asked about reporting it to the nurse, E13 had told him that she was not going to report it, stating R3 would be "OK". DON E2 confirmed on 10/22/12 at 10:10 am they did not realize R3 had a fracture until 8/08/12. E2 did not know why E14 and E13 did not report the incident to the nurse when it happened. E2 stated they had to work backwards during the investigation to find out when R3 was initially injured because the staff did not report the incident. E2 stated she did not find out about R3's injury until she came back from vacation on 8/13/12. E2 was gone from 8/03 until 8/12/12 and had to finish the final investigation upon her return. E2 provided the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R3 received PRN (as needed) [MEDICATION NAME] 5-500 (mg) twice on 8/01/12 (nothing documented in Nurses notes for 8/01/12). R3 received PRN [MEDICATION NAME] on 8/08, 8/09, and 8/12 for pain. Scheduled Tylenol twice a day was started on 8/13/12. E2 confirmed on 10/22/12 at 3:30 pm that staff's lack of reporting resulted in a delay in medical assessment, treatment and identification of R3's fracture.

Based on observation, record review and interview the facility failed to follow the plan of care for safe manual and mechanical transfers for two resident (R1,R3) sampled for falls in a total sample of four. This failure resulted in R1 receiving a shoulder dislocation and leg fracture and R3 receiving an ankle fracture. The findings include: 1. R1's October 2012 Physician order [REDACTED]. R1's MDS (Minimum Data Set) dated 10/02/12 identified R1 as cognitively intact, required extensive assistance of two staff for bed and transfers and was non ambulatory during the assessment period. R1 weighed 180 pounds and had unsteady balance. R1's Fall Risk Care Plan dated 7/03/12 had an approach dated 7/06/12 "Fall intervention for fall on 7/06/12: Sit to Stand with Carrier Sling". Nurses Notes dated 7/06/12 documented "(R1) was being transferred with a Sit to Stand lift when (R1) lifted her arms straight up into the air, causing (R1) to begin sliding down. The CNA lowered (R1) to the floor". Notes document no injury occurred. The Transfer Assessment Tool dated 7/06/12 assessed (R1) as needing a stand lift transfer with the carrier sling. The Care Plan had another intervention added on 9/19/12, "Fall intervention for fall on 9/19/12: "PT/OT (Physical Therapy and Occupational Therapy) to eval (evaluate) and treat. Transfer via Hoyer." R1's Nurses' Notes dated 9/19/12 5:00 am documents a Certified Nurse Aide (CNA), E9 was getting R1 up from bed to wheelchair using the sit to stand lift when the resident became agitated and removed her hand and swung her left arm out around the (sling) strap. E9 then placed her knee behind the resident and lowered the resident down onto R1's knees with the sit to stand to the floor mat. The notes document "resident c/o (complained of ) left shoulder pain. No swelling or bruising. Resident asked what she did stated "I moved my arm out of that thing and it hurts!" Resident unable to rate pain continues to yell about pain.. Upon body assessment no injuries noted but holding her knees and complaining of pain..resident continues of c/o Left shoulder pain and states "I hurt all over". PRN (as needed) Norco 5-325 given at 5:12 (am)..for pain." The notes document the Power of Attorney and Physician were notified the resident was lowered to floor with the sit to stand at 6:00 am. The Nurses Notes document R1 continued to complain of pain in shoulder and received PRN pain medicine on 9/19/12 at 3:00 pm refusing to hold on to the lift, at 5:30 pm refusing to feed self because sore, and 7:50 pm R1 was in bed yelling out about her arm, and received pain medication. R1's physician Z4 was notified about R1's continued complaints of pain on 9/19/12 at 8:00 pm and an order for [REDACTED]. A Portable X-ray was taken on 9/19/12 at 8:20 pm. The X-ray result showed R1 had a left shoulder dislocation. The notes document Z4 was notified and gave an order to send R1 to the emergency room . R1 was sent to the emergency roiagnom on [DATE] at 11:00 pm. Nurse's Notes document R1 returned from the hospital on [DATE] at 4:09 am with [DIAGNOSES REDACTED]. Nurse's Notes dated 9/21/12 noted R1 returned from an appointment with an orthopedic surgeon with new orders for X-rays of Right hip and bilateral knees. R1 received portable X-rays on 9/22/12. The Radiology Report dated 9/22/12 identified R1 had an "Acute mildly displaced supracondylar fracture" of the left knee. The facility Occurrence Report dated 9/19/12 documented CNA E9's witness statement that (R1) moved her left arm up and over the (sling) strap and when resident started to slide out of of sit to stand, E9 placed her knee behind the resident and lowered the resident to the floor mat then came and got the nurse. Nurse E7 stated during interview on 10/18/12 approximately 12:30 pm that she was working on 9/19/12 approximately 5:00 am when she was notified that R1 was on the floor on the mat in her room. E7 was told by the CNA E9 that during the sit to stand transfer R1 had thrown up her arms and started to slide. E9 got behind R1 and lowered her to the mat. E7 stated she assessed R1 for Range of Motion and Pain. R1 could move the left arm but was it was sore. R1 complained of pain to the knees. E7 stated R1 has arthritic knees and often complains of knee pain. E7 notified the Physician who told E7 to give R1 pain medication and monitor R1 for pain. E7 stated she went off shift at 6:00 am and returned to work on 9/19/12 at 6 pm. R1 continued to complain of pain on the evening shift and was X-rayed and a fracture was identified. Restorative Nurse E3 stated on 10/18/12 at 1:15 pm that she did the investigation of R1's incident . E3 stated R1 was to utilize a carrier sling for the sit to stand lift. E3 explained a carrier lift has additional leg straps that help support the resident. Restorative Nurse in training, E10 stated at that time, R1 started using a carrier sling in July 2012. A demonstration of the use of a regular sit to stand sling and the carrier sling was done with Restorative Nurse E10 on 10/18/12 at 1:45 pm. The regular sling fastened around the lower back and abdomen could slide up when lifted with the lift to the arm pits, the carried sling had two leg straps that crossed between the legs and attached to the sling. When E10 was in the carrier sling she could take her arms out of the sling and lift her legs off the foot platform and the leg straps would support the weight. E3 and E10 stated the carrier sling was used when R1 was injured because the CNA floor sheet for September 2012, "Transfer Via Sit to Stand with Carrier Sling" section was signed off on 9/19/12 by E9. Nurse E7 stated on 10/18/12 at 1:30 pm that R1 had been using the regular sit to stand sling, not the carrier sling during the incident on 9/19/12. E9's personnel file contained a written warning dated 9/19/12 "Use of carrier sling did not use sling on resident -Return demonstration." the warning was signed by DON (Director of Nursing), E2. On 10/18/12 at 2:00 pm E3 was informed that E9 had received a write up for not using the carrier sling. E3 responded that she was not aware of that. On 9/19/12 at 3:00 pm DON E2 confirmed that she had spoken to E9 who had confirmed E9 had not used the carrier sling. E2 stated " All (E9) thought about was to get (R1's) arm down out of the sling". E2 told E9 regardless of the type of sling used, you never want to take a resident down onto her knees. E2 stated E9 made a bad decision considering R1's brittle bones and weight which resulted in the fracture. 2. R3's October 2012 Physician order [REDACTED]. R3's Minimum Data Set ((MDS) dated [DATE] identified R3 with moderate cognitive impairment. R3 was independent in bed mobility and required limited assist of one staff for transfers. R3 required extensive assist of one staff for ambulation. The 9/04/12 significant change MDS identified R3 needed extensive assistance of two staff for transfers and documented no ambulation had occurred during the assessment period. Nurse's Notes dated 8/08/12 11:30 am documented a new order for an X-ray of the right ankle. There were no previous notes for August 2012 or July 2012 that indicated the circumstances that resulted in a need for an X-ray. The 8/08/12 notes document a portable X-ray was done on R3's ankle. The X-ray results dated 08/08/12 identified a "spiral fracture of the distal fibula". Nurse's notes dated 8/08/12 documented Physician Z3 was notified and responded with a new order for non- weight bearing to right ankle, and apply ice as needed. On 8/09/12 Z3 ordered a walking boot for R3. R3 remained non weight bearing until 9/25/12 when she became weight bearing as tolerated and received therapy eval and treatment orders. The August 2012 POS documented an order on 8/13/12 for Tylenol 650 mg twice per day for pain management. The August 2012 Medication Record showed R3 received PRN (As Needed) Vicodin 5-500 milligrams (mg) twice on 8/01/12. R3 received PRN Vicodin on 8/8,8/9, and 8/12. R3 started receiving scheduled Tylenol on 8/13/12. On 10/22/12 at 9:00 am R3 was asked how she fractured her ankle. R3 stated "They" (did not know the staff names) were assisting her and told R3 to put her arms around the staff's neck, then staff twirled R3 around and R3 "hit her ankle on a pipe" on the bed. R3 stated they did not use a gait belt. R3 said " It hurt terrible, I screamed." R3 stated a few days later she got an X-ray and found out "it was cracked" and they put a big boot on her foot. Director of Nurse's E2 was asked on 10/22/12 at 9:30 am for an incident report investigation for R3's ankle fracture. E2 stated she did not have an incident report in the computerized Risk Watch system as R3's fracture did not occur as a result of a fall. E2 stated Administrator E1 would have the investigation of fracture. Administrator E1 provided a copy of an initial "Report to Illinois Department of Public Health" dated 8/09/12 and a final report dated 8/13/12 regarding R3's fracture . The final report summary stated "(R3) was being transferred with one assist to bed on 7/31/12 and hit her leg on the bed. No complaints, redness or bruising noted. On 8/08/12, resident unable to stand or transfer. X-ray obtained with [DIAGNOSES REDACTED]." E1's investigation notes documented on 7/31/12 R3's leg/knee banged while being put to bed. Staff involved were Certified Nurse Aide E13 and Orientee CNA E14. E1 stated on 10/22/12 at 9:50 am that he interviewed E13 and E14. E1 did not take any signed statements from the aides. The surveyor informed E1 R3 had stated that she had been transferred without a gait belt with her hands around the neck of the aid when she got hurt. E1 stated "That sounds right". E1's notes documented R3 had reported pain to therapy staff, and therapy staff reported the pain to the nurse but no one else. Restorative CNA E11 stated on 10/22/12 at 10:30 am R3 was on a restorative walking program. The restorative documentation showed R3 was ambulated to the dining room on days and evenings from August 1-8 2012. E11 stated R3 complained of pain in her ankle while ambulating and E11 had verbally reported this to Nursing Staff on several occasions (did not know specific dates). E11 then reported R3's ankle pain on 8/08/12 to her Restorative Supervisor E3, who got orders for the X ray and they discovered the fracture. On 10/22/12 at 10:05 am CNA E14 stated during telephone interview, On (7/31/12) E14 was orienting with CNA E13. E14 was observing the transfer of R3. E14 stated E13 picked R3 up from the bed and "smashed" R3's ankle on the side rail. E14 stated the half rail was in the raised position and R3 was seated high in the bed. E14 stated E13 did not use a gait belt. E13 picked R3 up using a "bear hug" transfer. E14 stated R3 was in a lot of pain. E14 stated he did not report the incident. He asked E13 about reporting it to the nurse and E13 had told him that she was not going to report it, stating R3 would be "OK". DON E2 stated on 10/22/12 at 10:10 am that she interviewed E13 who told her E13 went up underneath R3 with a "Bear Hug" transfer in the bed when R3 hit her ankle. E2 did not know why E14 did not report the incident to the nurse when it happened. The facility "Gait Belt Policy & Procedure" dated 6/15/09 states "Gait belts will be used on all residents requiring non mechanical assistance with transfers and or ambulation." E14's personnel file contained a verbal counseling dated 8/14/12 for non use of gait belt with improper transfer.