Every finding on record at Birchwood Plaza

Based on observation, interview and record review, the facility failed to follow their policies by a) not ensuring all food items in the kitchen were labeled/dated, b) having expired food items in the kitchen, c) not recording temperatures for the refrigerators, freezers, dishwasher, and d) not following manufacturer instructions to use the three-compartment sink. This failure has the potential to effect 135 residents that eat food from the kitchen.Findings include:2/4/26 at 10:07 AM, toured facility kitchen with V18 (Food Service Supervisor) and observed:-a pan in the refrigerator labeled gelatine with prep date 1/27/26 and use by date 2/2/26-bucket of corn flake crumbs labeled with no prep date or opened date and use by date 12/30-bucket with rice inside labeled breadcrumbs with prep date 1/19/26 and use by date 1/23/26-a pan in the refrigerator covered with aluminum with meat balls/hamburgers 1/30/26 written on it. No indication if 1/30/26 is the date placed in the refrigerator or the date to discard.-a 55lb bag of Pizzeria Wheat Flour labeled 013125. V18 stated it was supposed to be picked up by distributer.-writer asked for the temperature logs for the refrigerators, freezers, dishwasher. Logs were not provided. V18 stated it was not started yet.2/5/26 at 10:48 AM, during puree preparation with V19 (Cook) and V18 (Food Service Supervisor) observed:-wash and sanitizer compartments not adequately filled with water-dishes not able to be completely immersed in wash and sanitizer compartments due to not being adequately filled with water-V18 continually instructing staff on using the 3-compartment sink-the blender bowl was not allowed to completely dry before blending the next dish-V19 wash the blender bowl and did not allow the bowl to stay immersed in the sanitizer for the appropriate time before setting it to dry2/6/26 at 3:04 PM, V18 (Food Service Supervisor) stated there should not be expired foods in the kitchen. They should be disposed of on the date it expires. It is a contamination hazard for residents and employees. Food items that are opened, should have the date it was opened and the manufacturer expiration date. If it's a dry food like a bean, I put the date opened and expired. Everything we use is within two weeks. A salad dressing, canned fruit, gelatine, we label with the date opened and we discard it within seven days. The labels should be accurate. The label should say/indicate what is in the bucket. Meat is thawed in the refrigerator for three days. If dated 1/30/26 it should not be in the refrigerator/kitchen. We are supposed to keep temperature logs of the refrigerators and freezers. To make sure everything is working and has the proper temperature and to keep a record. If refrigerators and freezers do not have the proper temperature food could spoil. Food has to be kept at the right temperature. We are supposed to keep a log of the dishwasher to make sure it is working properly, and it is dispensing the right amount of chlorine. The 3-compartment sink should be marked for what level to fill it. We eyeball it. During puree preparation, the sanitizer compartment was a little short on the water/sanitizer level. The blender was not completely immersed in the sanitizer sink. Items should remain in the sanitizer compartment at least one minute. They should dry for as long as it takes. We should not use the blender to prep the next puree dish if it is still wet. It is not correct to remove the dish from the sanitizer before one minute. I should not have been giving instruction while the staff was operating the sink. Next week I will inservice all the kitchen staff on using the 3-compartment sink. 2/6/26 at 3:55 PM, V3 (Director of Nursing) stated residents should not be receiving expired foods from the kitchen. It could cause illness. Dishes in the kitchen should be cleaned and sanitized to prevent infection, for infection control. Facility policy Discarding of Food, 6/2022, documents in part: Any packaged food items will be discarded by their use by date. All food items will be discarded within 7 days from day of preparation.Facility policy Storage of Dry Food, no date, documents in part: 4. Food stored outside its original package will be stored in a clean, covered container and labeled with the name of he food and labeled.Reviewed facility Sanitizing Record, Temperature Record, January 2026. February 2026 was not provided.Facility policy Refrigerature Temperature Policy and Procedures, 3/2020, documents in part: Refrigerator temperatures are to be recorded each morning.Facility policy Dish Machine Policy and Procedure, 3/2020, documents in part: Dish machines temperatures must be monitored and recorded before each time they are used (at least after each meal).Facility policy Sanitation - Pot and Pan Washing - 3 Part Sink, no date, documents in part: 6. Remove items from the rinse sink and submerge in sanitizing sink for one minute. 7. Air dry.The wall poster above the three-compartment sink, Procedures for 3 Compartment Sinks, no date, documents in part: Fill WASH and RINSE sinks with hot water. Immerse utensils in SANITIZER SINK for a full minute. Remove utensils from SANITIZER sink. Invert to drain. Let them air dry, do not wipe.

Based on observation, interview, and record review, the facility failed to acquire preadmission screening and resident review for 1 out of 7 residents (R12) in a total sample of 27 resident reviewed for resident assessment. These failures affect 1 resident (R12) in determining correct care settings for a resident with serious mental illness.Findings include:R12's MDS (minimum data set) dated on December 24, 2025, Brief Interview Score (BIMS) of 5, indicates that R12 is severely cognitively impaired.On 02/05/2026 at 11:24 AM, during record review for preadmission screening and resident review (PASRR) documents in part, short term approval without specialized services. Date of determination: April 5th, 2025. Date short term approval ends: August 3, 2025. On 02/06/2026 at 9:00 AM, V2 (Associate Administrator) stated the new PASRR Determination report was run today at 7:02 AM. V2 stated R12 does not require specialized services. V2 stated the results will be available to view on Monday 02/09/2026.On 02/06/2026 at 9:51 AM, V13 (Office Manager) stated it is important to follow up with the PASRR determination for the resident to receive the proper treatment. On 02/06/2026 at 2:53 PM, V3 (Director of Nursing) stated PASRR is important because if a resident is prescribed a new medication or has a new diagnosis, the information must be updated on the electronic medical record. V3 stated the information must be sent to maximus. V3 stated if maximus guidelines are not followed then the services that are supposed to be taking place will not be delivered. V3 stated the recommended date of August 3, 2025, for R12's PASRR determination was missed. Facility does not have a policy and procedure for PASRR, it follows the maximus guidelines.

Based on record review and interview, the facility failed to follow the Resident Assessment Instrument (RAI) manual to ensure timely submission of the Minimum Data Set (MDS) assessments for three (R5, R38, and R131) out of eight residents reviewed in a total sample of twenty-seven.Findings Include:Resident R5's annual MDS assessment dated [DATE] was submitted on 01/31/26.Resident R38's quarterly MDS assessment dated [DATE] was submitted on 01/31/26.Resident R131's quarterly MDS assessment dated [DATE] was submitted on 01/31/26, all exceeding the 14-day submission requirement.On 02/06/26 at 2:28 PM, V3 (Director of Nursing) stated that she is responsible for completing the Resident Minimum Data Set (MDS) assessments, ARD stands for the assessment reference date and that is when the assessment is due. She stated that fourteen days from the ARD, the completed assessment must be submitted to the federal agency. The accepted date posted on R5, R38, and R131 reflects the assessment was submitted to the federal agency late, and if the accepted date appears in red, it means it is late. Survey team with V3 reviewed R5, R38 and R131's recent MDS assessment and she stated that the assessments were submitted late, and that the importance of transmitting the MDS assessments in a timely manner is to be in compliance with the federal guidelines. R5, R38, and R131's MDS Transmission Screenshot. The facility policy titled, MDS, documents read in part: It is the policy of the facility that we follow the protocol in the RAI manual.Chapter 2: Assessments for the RAI Version 3.0 Manual dated October 2025, The MDS completion date must be no later than 14 days from the ARD.

Based on interviews and record reviews, the facility failed to ensure advance directive or code status is consistent with the comprehensive care plan of one (R17) out of six residents reviewed for advance directive in a sample of twenty-seven. Findings Include: R17's Minimum Data Set (MDS) dated [DATE] shows she is moderately cognitively impaired. R17's Electronic Medical Record (EMR) revealed she was initially admitted to the facility on [DATE] and she is [AGE] years old with diagnoses not limited to malignant neoplasm of unspecified site of unspecified female breast, iron deficiency anemia secondary to blood loss (chronic), other cerebral infarction, post-traumatic stress disorder, hypertensive heart disease without heart failure, and moderate persistent asthma with status asthmaticus. Physician Order Sheet active order as of [DATE] revealed; Do Not Resuscitate/DNR dated [DATE]. On [DATE] at 10:07 AM, R17 stated that her code status is DNR because she has lived for seventy-six years, and she would like for the facility to honor her wish. On [DATE] at 10:43 AM, V14 (Social Worker) stated she has been in the facility since [DATE], she oversees the advanced directives care plan, and R17 has an order for a DNR code status upon admission dated [DATE] on file. She also stated that the initial and comprehensive care plan should be consistent and reflect the actual DNR code status of R17 to prevent conflict of care. Surveyor with V14 reviewed R17 care plan which revealed that she is care planned on a full code status. On [DATE] at 2:57 PM, V3 (Director of Nursing/Minimum Data Set/Care Plan Coordinator) stated that it is her expectation that care plan would be completed accurately. R17 DNR code status should be care-planned as DNR and not as full code, because it is important to honor her wishes and to prevent inappropriate intervention in case of emergency. R17's DNR Form dated [DATE] documents in part; No CPR: Do not attempt resuscitation. R17's Advance Directives Care Plan initiated [DATE] with last revision dated [DATE], focus; resident is currently full code, intervention full code. Care Plan-Comprehensive Policy, documents read in part: Each resident's comprehensive care plan is designed to; reflect the resident's expressed wishes regarding care and treatment goals.

Based on observations, interviews, and record reviews the facility failed to follow their policy on resident's unable to use a call light by posting the lighthouse sign outside the room for one (R32) in a total sample of 27 residents reviewed.Findings include: R32's Minimum Data Set (MDS) dated on January 6, 2026, Brief Interview Score of 10, indicates that R32 is moderately cognitively impaired. Care plan with review date of 10/13/2025 documents in part, R32 is not able to use a call light. Purposeful rounding will be observed. Lighthouse posted outside room with bed number. On 02/04/2026 at 12:10 PM, Surveyor observed R32 sitting in her chair while finishing up her lunch. R32 is well groomed, appears to be calm and in a good mood. R32 appears to be comfortable and free of pain. R32 is alert and oriented to person with confusion of place and time. Surveyor did not observe the light house sign inside or outside R32's room. On 02/04/2026 at 12:12 PM, R32 stated she has concerns with staff not coming to help her when she needs them. Surveyor asked R32 if she utilizes the call light when she needs some assistance. R32 stated she will shout out for help because the staff takes a long time to help her. Surveyor asked R32 if she was able to locate the call light to avoid shouting for help. R32 pointed at the string that was attached to the overhead bed lamp. R32 pulled the string and turned on the overhead bed lamp. Surveyor redirected R32 to the red string that was on the floor. On 02/06/26 at 11:39 AM, Surveyor observed R32 in her room and appeared to be upset. R32 stated she is upset because she does not know what time her lunch is being served. Surveyor asked R32 if she had called for help while using the call light. R32 pointed at a string that was connected to the overhead bed lamp. Surveyor redirected R32 to the red string that was on top of her bed. R32 stated she was not aware that was a call light. Surveyor did not observe the light house sign inside or outside R32's room. On 02/06/2026 at 11:42 AM, V16 (License Practical Nurse) stated when a resident is confused the call light should be attached to their person. V16 stated the call light should always be visible, within reach, and properly working. V16 stated there is always staff available nearby to assist residents who are confused. V16 stated the resident should not have to shout out for help. On 02/06/2026 at 11:46 AM, V17 (Certified Nurse's Aide/ CNA) stated R32 was standing by the door earlier today. V17 stated R32 asked for assistance in setting up her electronics to call her sister. V17 stated she has not asked for anything else since then. V17 stated R32 should not have to shout out for help or stand by the door waiting for help. On 02/06/2026 at12:57 PM, V3 (Director of Nursing/ DON) stated residents' should always have a call light available in perfect condition ready to be used. V3 stated for the residents who are cognitively impaired due to their medical diagnosis, there is a sign that is called a the light house, which is a sign that is hung outside the resident room. V3 stated this sign allows staff to recognize that the resident may not be able to use the call light, therefor frequent rounds should be implemented. V3 stated R32 has it care planned and the staff is aware. V3 stated R32 should not be shouting out for help when she needs a staff member. Policy and procedure titled Policy for Residents unable to use the call lights with review date of January 2022 documents in part, Residents will be assessed upon admission, readmission, quarterly and for significant change for ability to use their call light pull cord. This facility will do these assessments to ensure staff provide additional monitoring for those residents who cannot reasonably be expected to use or understand the purpose of a call light. Lighthouse sign will be posted on the resident's door with their bed number. When the lighthouse is posted, this identifies this resident as not being able to use their call light and Purposeful Rounds will be implemented. These residents do not necessitate having a call cord in place as they have been assessed to be unaware of its purpose.

Based on observation, interview and record review, the facility failed to maintain dignity for one (R93) of three residents reviewed for dining services in a sample of 27.R93 is a [AGE] year-old individual whose current face sheet includes medical diagnosis but not limited to: unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other diseases of pharynx.MDS (Minimum Data Set) section c- cognitive status dated 12/16/2025 documents R93's brief interview for mental status (BIMS) as 4/15, indicating R93 has severe cognitive disabilities. section gg-self-care dated [DATE], documents R93 requires supervision touching assistance. On 02/04/2026 at 12:21PM, R93 was observed eating lunch dosing on and off. V8 (Certified Nursing Assistant -CNA) was observed going into R93's room, woke R93 and asked R93 if she wanted assistance with eating her food. R93 nodded her head yes. V8 stood over R93 and started feeding R93. V8 stated she is supposed to sit down while assisting residents with meals, but she (V8) cannot sit down because she has to check on other residents. V8 fed R93 three spoons of her lunch and left R93's room.On 02/06/2026 at 3:44PM, V3 (Director of Nursing) stated when staff is assisting a resident with feeding, the staff should sit facing the resident and should not be standing because standing can be intimidating to a resident and can appear as though staff is trying to force resident to eat. V3 further stated R93 needs encouragement to eat therefore, sitting while assisting R93 with meals creates a harmonious, comfortable and non-intimidating environment.R93's care plan dated 12/16/20 documents:-R93 may be at risk for weight loss r/t (related to) mild cognitive impairment resulting in mental status changes, confusion and disorientation.Policy titled Promoting/Maintaining Resident Dignity, dated 8/2013 documents:-It is the practice of this facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect.

Based on observations, interviews and record reviews, the facility failed to a.) ensure staff followed contact isolation precautions to prevent spread of infections for one (R81) of three residents reviewed b.) ensure that its staff follow the facility's policy and maintain clean technique/infection control practice while performing incontinence care to one (R8) resident out of eight residents reviewed in a total sample of 27. R81's current face sheet documents medical diagnosis to include but not limited to: sepsis, unspecified organism, cystitis, unspecified with hematuria, personal history of urinary (tract) infections, type 2 diabetes mellitus with unspecified complications, pneumonia, unspecified organism, other specified disorders of bladders of bladder. MDS (Minimum Data Set) section C-(Cognitive abilities) dated [DATE], documents R81's Brief Interview for Mental Status (BIMS) as 10/15, indicating R29 has cognitive moderate impairment. R81's Physician Order Sheet POS) dated 2/2/026 documents: Contact Isolation every shift for Proteus Bacteremia MDRO (multidrug-resistant organism) and ESBL (Extended-Spectrum Beta-Lactamase) on left foot wound. On 02/04/2026 at 11:55 AM, Observed enhanced barrier precaution signage on door. No contact isolation signage on the door. On 02/04/2026 at 12:01PM, V5(Certified Nursing Assistant -CNA) lifting, repositioning R81 in bed, and covering R81. V5 sat down near R81 and started assisting R81 with his lunch. V5 was observed without wearing gown or gloves. V5 states she was not aware R81 is on contact isolation. On 02/04/2026 at 12:09PM, V4(Registered Nurse-RN) stated the signage on R81's door is enhanced barrier precaution, but R81 should be on contact isolation for Extended Spectrum Beta-Lactamase (ESBL) on the left foot wound. The contact isolation signage should be on the door to alert staff and visitors of R81's contact isolation precautions. Staff are supposed to gown and glove before entering and leaving R81's room to prevent spreading germs, it's an infection control issue. V4 further said R81 can get sick from other people spreading germs to him. On 02/04/2026 at 12:49PM, V7 (Registered Nurse-RN/ Supervisor/ Infection Preventionist) stated there should be a contact isolation signage outside of R81's room to alert staff and visitors to the precautions to be observed in R81's room. R81 has ESBL of the wound on his left foot and that's why R81 is on contact isolation precaution. V7 stated staff must wear Personal Protective Equipment (PPE) and perform hand hygiene before going into R81's room to prevent the spread of germs. Spread of germs can be harmful to residents' health. V7 stated I don't know why the contact isolation signage was removed. It should be taped on R81's door to alert staff and visitors that R81 is on contact isolation precautions. It is physician order that should be followed. Facility Isolation Guidelines for Multiple Organisms: ESBL E.Coli, ESBL KP, ASBL Proteus mirabilis or any others with ESLB (ESBL=Extended -Spectrum Beta Lactamase) no date documents: -Any resident receiving any treatment or symptomatic will be put under Contact isolation. A sign will be placed outside the room to alert everyone about the precaution needed. On 02/04/26 at 12:33 PM, R8 stated I am likely to get urinary tract infections here, because when they clean me instead of wiping from front to back, they wipe from back to front. I can't think of any names. On 02/5/26 at 2:09 PM, V24 (Certified Nursing Assistant) stated that she has worked for the facility for six months and she rotates assignments and does not have a permanent set of residents that she cares for. V24 stated that it is her first job since obtaining her CNA training. She stated that she will be providing care to R8 shortly. On 02/05/2026 at 2:18 PM, V24 began to uncover the sheets from R8 and R8's flat sheet under her was soaked wet/soiled. V24 proceeded to detach R8's soiled brief from the front part of R8 as R8 is lying flat. V24 assisted R8 to turn to R8's right side and observed bowel movement. R8's bowel movement noted dark brown, soft, semi formed, residual left in the rectum, and V24 continued to clean, with different clean areas of the towel, she put soiled brief in the clear garbage bag. V24 placed dirty towel in another bag. V24 sprayed R8's rectum/buttocks with a perineal cleansing spray. She cleansed rectum with a dry towel. V24 then proceeded to tuck in R8's soiled flat sheet under R8. V24 applied the barrier cream to R8's buttocks and rectum area with the same gloves. V24 then proceeded to remove the gloves now and went in to wash her hands, washed her hands for 6 seconds. V24 applied new gloves and assisted R8 to turn to her left side, V24 touched the same soaked/soiled flat sheet when untucking it from R8 and is now applying the new green brief with the same gloves, proceeded to apply the barrier cream to the front of R8's perineal area. V24 closed the new brief and removed the gloves and applied new ones. V24 placed a new sheet, under the new brief, and placed pants on R8. V24 stated I am done providing perinea care and now I am going to assist R8 to the wheelchair via mechanical lift. V24 stated that she should have not touched the soiled sheet and then apply the barrier cream to R8's perineal area due to infection control. On 02/06/26 at 12:03 PM, V3 (Director of Nursing) stated that CNAs are not supposed to use same gloves that touched the soiled sheet to apply the barrier cream onto the resident. V3 stated that it is important to follow proper infection control when providing incontinence care. It R8's Face sheet documents that R8 is a [AGE] year-old individual who has diagnoses not limited to: urinary tract infection, multiple sclerosis, hypdronephrosis with renal and ureteral calculous obstruction, other reduced mobility. R8's Minimum Data Set (MDS), dated [DATE], documents R8 has a Brief Interview for Mental Status (BIMS) of 11 out of 15, indicating R8 is moderately cognitively intact. Facility document dated February 2023, titled Incontinence Care documents in part, to keep skin clean, dry, free of irritation and odor. Discard soiled linen/incontinence briefs properly. Wash your hands.

Based on observation, interview and record review the facility failed to ensure that one (R3) resident who depends on staff assistance for their ADL (Activities of Daily Living) care received shaving out of eight residents reviewed in a total sample of 27. This failure places residents at risk of being provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. On 02/04/2026 at 12:25 PM, R3 was noted with facial hair on her chin. R3 stated that she takes showers and staff assist her. R3 stated that staff have not removed R3's facial hair. R3 stated that she was not sure if they were rushing or not. R3 appears calm and cooperative, no behaviors noted. R3 noted with her head shaking a little. On 02/05/26 at 1:55 PM, R3 sitting on a chair, next to R3's bed, wearing own clothes, not shaved, still with facial hair on her chin. R3 preferred to speak in Spanish. R3 stated that no staff have come to ask R3 if she wanted to be shaved. R3 stated that she feels bad with her facial hair and that people are going to think I (R3) am a male.On 02/05/26 at 1:59 PM, V25 (Certified Nursing Assistant) stated that staff shave the facial hair of woman, only if the residents want to. V25 stated that the only resident who would refuse is no longer residing in the facility. V25 stated that it is important to assist the female residents to shave so they can look nice, and they really don't want any hair sticking out. V25 stated that staff can shave the residents anytime and it does not have to be on their shower days. V25 stated I was busy running around, I didn't get to shave R3 yet. R3 is a very nice lady, R3 does not fight or refuse.On 02/06/26 at 12:03 PM, V3 (Director of Nursing) stated that R3 needs help with shaving and R3 cannot shave herself. V3 stated that it is not ok for the resident to feel bad about her facial hair. V3 stated it can hurt her dignity. I am sorry about that, I will follow up about that one (R3) at once. R3's medical record (Face Sheet) documents R3 is a [AGE] year-old individual admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's Disease without dyskinesia, tremor, need for assistance with personal care. R3's self-care deficit care plan documents in part personal hygiene: requires total staff assist with personal hygiene and oral care. Facility document dated 08/2013, titled promoting/maintaining resident dignity documents in part it is the practice of this facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect. Groom and dress residents according to resident preference.

Based on observation, interview and record review, the facility failed to maintain medical records confidentiality for one (R29) of three residents reviewed in a sample of 27.R29 is an [AGE] year-old individual whose current face sheet documents medical diagnosis to include but not limited to type 2 diabetes mellitus with hypoglycemia without coma, chronic kidney disease, unspecified, unspecified osteoarthritis, unspecified site. MDS Section C - Cognitive Patterns documents R29's Brief Interview for Mental Status (BIMS) as 10/15 indicating R29 has moderate cognitive impairment.On 02/04/2026 at 12:25PM, V4's computer was observed on team one's medication cart in the middle of hallway with R29's personal health records (Medication administration Record) visible to anyone passing by the hallway. V4 (registered Nurse) was observed away from her computer standing near the dining room talking to a resident family member. V4 stated she was approximately 12 feet away from her computer and should have locked her computer screen before stepping away to protect R29's private information because of Health Insurance Portability and Accountability Act, (HIPPA). On 02/06/2026 at 3:30PM, V3(Director of Nursing) stated computer screens with resident's information should be faced away from other people's eyesight and locked when staff step away from the computer to protect resident's medical records from being viewed by unauthorized people. If left open to the public, a resident's privacy can be invaded and their private information used without a resident's consent, which is a HIPAA violation. Policy titled Summary of Notice of Privacy Practices, no date, documents:-We are required by law to maintain the privacy of your medical information.-We must follow the terms of this notice

Based on observation, interview and record review the facility failed to have a person-centered care plan that is consistent with the resident's current condition, goals, and services for one (R84) resident out of eight residents reviewed in a total sample of 27 residents. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. On 02/04/2026 at 12:50 PM, R84 was sitting on specialized chair, with a call light button, a red string attached to her right upper arm, on part of the gown. R84 noted to be very hard of hearing. Not able to hear. R84 asked this surveyor to grab R84's hair. This surveyor attempted to explain to R84 that she cannot assist her but will find someone to come and help her. R84 stated I didn't hear that, I try to read their lips. On 02/06/26 at 11:15 AM, V14 (Social Worker) stated that R84 is having a hard time of hearing, she can understand, when you talk to her, you have to talk to her closely to her ears. V14 stated that V7 is aware of R84's hearing impairment. V14 stated for residents that have hearing problems, there is always communication. Especially the caregiver is involved. I believe it should be care planned. There should be interventions. With V14, reviewed R84's care plan and V14 stated I don't see anything in the care plan regarding her hearing impairment. V14 stated that R84 should have a care plan goal and interventions in place addressing R84's hearing impairment. R84's current face sheet documents that R84 is a [AGE] year-old individual admitted to the facility on [DATE] with diagnoses not limited to: history of falling, anxiety disorder, unspecified dementia.R84's current care plan does not document R84 has intervention for hearing impairment.

Based on interviews, and record reviews, the facility failed to provide the required square footage of 80 square feet per resident for multiple resident bedrooms for 19 (111, 113, 114, 115, 116, 118, 121, 122, 210, 211, 212, 214, 215, 217, 311, 313, 315, 317, 325) rooms out of 86 rooms in the facility. This failure affected 26 (R13, R18, R28, R34, R36, R46, R49, R50, R57, R60, R67, R77, R84, R85, R90, R93, R94, R97, R99, R107, R109, R114, R125, R138, R139, R151) residents in the total sample of 137 residents.Findings include:On 02/04/2026 at 10:15 AM, V2 (Associate Administrator) stated the facility has a room waver for resident rooms that are less than 80 square feet for multiple residents and the 100 Square feet for single resident room. V2 provided a copy of a list of rooms that are included on the waiver.The (02/10/2026) email correspondence with V18 documented, in part The facility has an annual Waiver for Resident bedrooms that do not measure 80 square feet per resident in multiple residents bedrooms.The (02/10/2026) Waiver of 42 CFR 483.90. Physical Environment documented, in part The State Department of Public Health reviewed your facility's request for a waiver of the federal requirement for a resident's room must afford 80square feet per bed in multi-patient rooms. CMS is granting a waiver of the federal requirement at 42 CFR483.30. The waiver is granted for rooms: 111, 113, 114, 115, 116, 118, 121, 122, 210, 211, 212, 214, 215, 217, 311, 313, 315, 317, 325 and is subject to annual review.

Based on observation, interview, and record review, the facility failed to provide fall prevention interventions for residents who are at risk for falls and failed to ensure that residents at risk for falls do not have repeated falls. These failures affected 3 residents (R23, R43, and R58) who had repeated falls, and have the potential to affect one resident (R34), reviewed for falls and fall prevention interventions, in a total sample of 75 residents. Findings include: On 4/2/25 R23 was observed sitting at the edge of the bed with no staff nearby in the hallway. R23 had a wound dressing on the right foot and dark blue sock with smooth bottom on the left foot. The surveyor asked R23 if he(R23) needed some help. R23 stated that he's trying to exercise his legs. The surveyor called V23(RN/Registered Nurse) to assist R23. V23 stated I will get the CNA (Certified Nurse Assistant) to give him non-skid socks. Inquired from V23 if it was okay for R23 to not have proper footwear while awake and trying to exercise at the bedside, considering the fact that R23 has had several falls in the past. V23 stated that she would ensure that R23 wears a non-skid sock when not wearing his shoes to prevent R23 from falling. R23's care plan and progress notes show that R23 had repeated falls as dated below: 7/30/24; 9/4/24; 9/29/24; 10/18/24; 11/30/24; and 2/20/25. R23's records reviewed are as follows: Fall Risk Evaluation dated 3/26/25 shows that R23 is at risk for falls. Face sheet shows diagnoses which include but are not limited to History of Falls and Glaucoma. Care plan dated 10/14/22 states that R23 is at risk for falls related to poor safety awareness. Intervention states to provide proper well-maintained footwear. Basic Interview for Mental Status (BIMS) Score is 12 out of 15(Mild Cognitive Impairment). MDS (Minimum Data Status) dated 2/27/25 states that R23 uses wheelchair and walker. On 4/2/25 at 12:15pm, R43 was observed in the wheelchair in the hallway across from R43's room. R43's care plan shows that R43 had repeated falls as follows: R43's care plan and progress notes show that R43 had repeated falls as dated below: 9/23/23; 10/6/24; 10/12/24; 12/29/24; 2/13/25. R43's records reviewed are as follows: Fall Risk Evaluation dated 2/14/25 shows that R43 is at risk for falls. Face sheet shows diagnoses which include but are not limited to Difficulty Walking, Dementia, and Right Hip Pain. Care plan dated 10/14/22 states that R43 is at risk for falls related to poor safety awareness. Intervention states to provide proper well-maintained footwear. BIMS Score is 11 out of 15(Mild Cognitive Impairment). MDS section GG dated 3/25/25 states that R43 uses wheelchair and walker. On 4/1/25 at 10:40am, R58 was observed walking with a walker towards the dining room. R58's care plan and progress notes show that R58 had repeated falls as dated below: 11/7/24; 12/14/24; and 1/30/25. R58's records reviewed are as follows: Fall Risk Evaluation dated 3/10/25 shows that R58 is at risk for falls. Face sheet shows diagnoses which include but are not limited to Lack of Coordination, Weakness, Dementia, and Abnormal Posture. Care plan dated 1/30/24 states that R58 is at risk for falls related to poor safety awareness. Intervention states to provide proper well-maintained footwear. BIMS Score is 3 out of 15(Severe Cognitive Impairment). MDS section GG dated 3/15/25 states that R58 uses walker. On 4/2/25 at 2:10pm, V2(Director of Nursing) stated that the Restorative Nurse was not available. V2 stated all residents at risk for falls need to wear non-skid socks. V2 added that the facility has made efforts to reduce the fall incidents and still making progress and still doing in-services for staff about fall prevention interventions. Facility's Fall Precautions/Safety Interventions Policy states in part: Safety interventions tools may be implemented to provide safety to the residents and to prevent falls. Safety intervention tools include interventions such as low bed, bed/chair alarms, non-slip materials. Implementation/recommendations for special equipment such as low bed, mats or mattress on floor, nonskid socks, bed, and chair alarms. Facility's Patient Care Policy dated 2/2020 states in part: slippers or shoes and socks must be worn. If patient is ambulatory and wearing slippers, then the slippers must be of the nonskid type. 52232 Findings include: On 04/01/25 at 10:42AM, observed R34 in the second-floor activity room, sitting in the wheelchair during activity in progress. R34 was not wearing any shoes and was wearing gray sweat pants set and white socks with gray tips. No Non-skid bottom protection observed at this time. On 04/01/25 at 10:45AM V10 (Rehabilitation Aide), stated that R34 does not like to wear shoes and that he prefers socks. V10 also stated that during transfers and ambulation of residents, the expectation is for the residents to always wear shoes or at least non-skid socks to prevent them from falling. V10 affirmed that R34 was wearing white socks with gray tips and that those socks are not the nonskid socks. V10 also stated, that R34 is high risks for falls, and he must ambulate with help from the aides and should be wearing shoes or nonskid socks. On 04/01/25 at 3:15PM V7 (Nursing Supervisor), stated that the expectation is to make sure all high fall risk residents are wearing shoes or non-skid socks during ambulation, transfers and when in the wheelchair to prevent falls or injury. The Nursing Aides should be always using gait belts for transfers and ambulation of residents. Admission record review for R34 dated 11/21/2022, shows in part diagnosis including but not limited to: Weakness, Long term use of Anticoagulants, Abnormalities of Gait and Mobility, Chronic embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity (Bilateral), Hypertensive Heart Disease without Heart Failure, Chronic Kidney Disease, Anemia, Other Specified Spondylopathies of Lumbar Region, Alzheimer's Disease, Lack of Coordination, Major Depressive Disorder, , Dementia, Psychotic Disturbance, Mood Disturbance and Anxiety, Schizoaffective Disorder, Bipolar Type, Paranoid Personality Disorder. R34's Current Order summary report dated 11/21/2022 review shows in part orders for following: Activities without contraindications as tolerated, Anti-Coagulant Medication Use, Anti-depressant Medication use, Anti-psychotic Medication use, may use bed alarm for safety, Psychiatrist consult as needed, Psychologist consult as needed. Pharmacy portion of the same order summary report shows in part current medications included but not limited to: Metoprolol Tablets 12.5 milligrams (mg) by mouth twice a day for Hypertensive Heart Disease; Ferrous Sulfate 325mg three times a day for supplement; Mirtazapine Tablet 15mg at bedtime for Major Depressive Disorder; Olanzapine 2.5mg at bedtime for schizoaffective disorder (Bipolar Type); Valproate Sodium Oral Solution 250mg/5ml every 12 hours for bipolar disorder. Review of R34's Plan of care dated 11/21/2022 shows in part that R34 is at risk for falls due to cognitive and functional impairments. The Plan of care also shows in part, that staff should always ensure that resident wears non-skid footwear, with intervention initiation date of 10/11/2023. Review of R34's Minimal Data Sheet (MDS), section GG, dated 3/6/2025, shows in part that resident is dependent in toileting hygiene and shower/bath ability. MDS also shows in part that R34 needs substantial/maximal assistance in lower body dressing and putting on/taking off footwear, and personal hygiene. R34's MDS further states that R34 needs supervision or touching assistance with most of functional abilities included, but not limited to sit to stand and sit to lying positioning, rolling left and right, toilet transfer and walking. Review of facility's Fall Precautions/Safety Intervention policy dated 12/2023, shows in part, that fall risk assessment and functional Ability Assessment should be completed upon admission, readmission, quarterly and if significant change or decline in condition occurs. The policy also shows in part, that safety intervention Tools include, but are not limited to non-slip materials. Policy further shows the implementation/recommendations for special equipment fall prevention aids which include but are not limited to non-skid socks.

Based on observation, interview and record review, the facility failed to ensure that staff are feeding residents from a seated position during dining service which affected R7, R62, R73, and R77 in the total sample of 75 when reviewed for resident rights. Findings include: On 3/31/25 at 11:41 am, V13 (Certified Nursing Assistant, CNA) observed positioning R77 upright in R77's reclining wheelchair and provided R77 the lunch meal tray on top of the table over R77's lap. V13 opened up R77's plate cover to reveal a puree diet, set up food items close to R77 and utensils within reach. R77 began slowly touching a bowl on R77's tray. On 3/31/25 at 11:47 am, R77 is observed trying to eat the puree diet meal tray in front of R77 without R77 actively spooning food into R77's mouth. On 3/31/25 at 11:53 a.m., V13 (CNA) was observed standing next to R77, looking down at R77 in the reclining wheelchair. While in a standing position, V13 took R77's utensil and fed R77 three bites of food from R77's lunch meal tray. V13 then sat down on a stool chair next to R77. On 3/31/25 at 11:57 a.m., V13 was observed standing up from the stool chair and walking out of the dining room. On 3/31/25 at 11:58 am, V13 walks back into the dining room holding a plastic clear cup of water. V13 walks up to R77, and while in a standing position, feeds R77 one bite of food from the lunch meal tray. On 3/31/25 at 12:09 pm, V14 (CNA) observed in a standing position next to R7 who is seated in R7's wheelchair at the table. V14 observed feeding R7 food from the white bowl from R7's meal tray. On 3/31/25 at 12:14 pm, V12 (Licensed Practical Nurse, LPN) was observed in a standing position next to R73, who was sitting in a high-back wheelchair at the table. While standing, V12 was observed feeding R73 five bites of diced fruit from the white bowl and then sitting down in a chair next to R73. On 3/31/25 at 12:16 pm, V2 (Director of Nursing, DON) was observed in a standing position next to R62, who was sitting in a reclining wheelchair. While standing, V2 observed feeding R62 the lunch meal tray of liquids with a spoon. R62's diet card clearly posted on R62's lunch meal tray indicates clear liquid diet. R7's Admission Record documents, in part, diagnoses of vascular dementia, reduced mobility, chronic obstructive pulmonary disease, chronic ischemic heart disease, diastolic (congestive) heart failure, chronic kidney disease stage 3A, venous insuffiency (chronic, peripheral), iron deficiency anemia, schizoaffective disorder, generalized anxiety disorder, cataract, hearing loss, lack of coordination, difficulty in walking, and abnormal posture. R7's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 5 which indicates that R7 has severe cognitive impairment. R7's Functional Abilities for Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident is scored as Partial/moderate assistance-Helper does less than half the effort. R7's Care Plan, date initiated 12/23/23, documents, in part, a focus of (R7) may be at risk for weight loss related to mental status changes, confusion and disorientation. (R7) receives a Regular diet NAS (no added salt) regular Thin and requires partial moderate assistance with meals. R62's Admission Record documents, in part, diagnoses of dementia, dysphagia oropharyngeal phase, anorexia, abnormal weight loss, moderate protein-calorie malnutrition, absolute glaucoma, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, presence of cardiac implant and grafts, atrial fibrillation, pulmonary hypertension, iron deficiency anemia, hypertension, hyperlipidemia, major depressive disorder, cognitive communication deficit, osteoarthritis, adhesive capsulitis of right shoulder, abnormal posture, and lack of coordination. R62's MDS, dated [DATE], documents, in part, a BIMS score of 9 which indicates that R62 has moderate cognitive impairment. R62's Functional Abilities for Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident is scored as Substantial/maximal assistance-Helper does more than half the effort. R62's Care Plan, date initiated 11/1/24 and revised on 2/21/25, documents, in part, a focus of (R62) may be at risk for weight loss related to diagnoses of mild cognitive impairment resulting in mental status changes, confusion and disorientation, poor PO (oral) intake and diuretic use daily . and requires extensive assistance with meals. Appetite is poor to fair. R73's Admission Record documents, in part, diagnoses of multiple sclerosis, dysphagia oropharyngeal phase, severe protein-calorie malnutrition, arterial fibromuscular dysplasia, metabolic encephalopathy, chronic obstructive pulmonary disease, iron deficiency anemia, lack of coordination, aphasia, peripheral vascular disease, hyperlipidemia, major depressive disorder, and cramp and spasm. R73's MDS, dated [DATE], documents, in part, a BIMS score of 13 which indicates that R73 is cognitively intact. R73's Functional Abilities for Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident is scored as Dependent-Helper does all of the effort. Resident does none of the effort to complete the activity. R73's Care Plan, dated 11/5/24, documents, in part, a focus of Self-care deficit, require assist with ADLs with an intervention of Eating: (R73) is a feeder and requires partial staff assist to eat. Able to feed self when up in chair - staff assist to complete meals (revision on 1/3/25). R77's Admission Record documents, in part, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dementia, moderate protein-calorie nutrition, dysphagia oropharyngeal phase, polyosteoarthritis, kyphsois, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, pulmonary embolism, hypertension, cardiac murmur, anemia, irritable bowel syndrome, nuclear cataract bilateral, lack of coordination, difficulty in walking, and unsteadiness on feet. R77's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 5 which indicates that R77 has severe cognitive impairment. R77's Functional Abilities for Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident is scored as Dependent-Helper does all of the effort. Resident does none of the effort to complete the activity. R77's Care Plan, dated 6/6/24, documents, in part, a focus of Self-care deficit, require assist with ADLs with an intervention of Eating: (R77) is a feeder and requires substantial/max staff assist to eat (revision on 3/18/25). On 4/2/25 at 1:47 pm, when asked the process of nursing staff feeding a resident, V2 (DON) stated that for residents who need physical assistance, who have a short attention spans or who have a puree or mechanical soft diet, the nursing staff will feed the residents. V2 stated that all staff will prepare the meal trays by cutting large food items and preparing the resident's tray. When asked for specifics about the procedure for nursing staff feeding a resident, V2 stated that the nursing staff would place chest protector on the resident's chest to protect the clothes from spillage. V2 stated, The staff needs to be sitting down to feed a resident. When asked the purpose of a nursing staff member sitting down to feed a resident, V2 stated, If you are sitting, then it's not authoritative to the resident by standing over them. You need to be sitting to feed each resident. It's a dignity issue. This surveyor informed V2 of this surveyor's observations during the lunch meal on 3/31/25, which included V2 standing while feeding a resident. V2 acknowledges that V2 was standing while feeding R62 and that V2 should have retrieved the stool chair to sit while feeding R62. On 4/3/25 at 1:05 pm, V2 stated that R62 was ordered and was receiving a clear liquid diet on 3/31/25 due to preparation for a colonoscopy procedure on 4/2/25. Facility policy dated January 2023 and titled Feeding Policy documents, in part, Purpose: To provide adequate nourishment for the resident . Procedure: . 3. Sit beside the resident and him/her put the clothing protector in place. 4. Feed the resident slowly, offering a variety of food. Fill the fork or spoon no more than half full. Make sure that the resident chews and swallow the food before giving more. Facility policy dated November 2018 and titled Residents' Rights for People in Long-Term Care Facilities documents, in part, Your rights to dignity and respect: . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Facility Job description (undated) and titled Certified Nursing Assistant Job Description documents, in part, General Purpose: To perform non-professional direct patient care duties under the supervision of nursing personnel and to assist in maintaining a positive physical, social and psychological environment for the residents . Essential Job Functions (With or Without Reasonable Accommodation): . C. Food Service Functions: Duties: Prepare residents for meal and snacks; identify food arrangement and assist in feeding residents as needed . D. Resident's Rights Functions: Duties: Maintain resident confidentiality; treat residents with kindness, dignity and respect; know and comply with Resident's Rights rules.

Based on observations, interviews and records review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program and failed to refer level II residents and residents with possible serious mental disorder and/or intellectual/developmental disability, for level II resident review upon a significant change in a mental status assessment. These failures affected three residents (R22, R34, R76) and have the potential to affect additional 34 residents with diagnosis of mental disorder and/or intellectual/developmental disability in the whole facility in a sample of 75. Findings include: On 3/31/2025 at 2PM, Review of facility's Admission Record, shows R22 admitted to facility on 3/27/2012, with diagnosis included but not limited to: Unspecified Dementia (Unspecified Severity), Major Depressive Disorder (Recurrent), bipolar disorder (Unspecified), Hemiplegia and Hemiparesis following nontraumatic intracerebral Hemorrhage. On 04/01/25 at 12:55 PM, facility presented a copy of most recent Preadmission and Resident Review (PASARR) form for R22., dated 3/24/2024. Review of the document shows in part, mental health diagnosis of Major Depressive Disorder and Dementia. No other mental health diagnosis is observed on the form. No bipolar disorder diagnosis is listed on the PASARR form. R22's PASARR also shows in part, that no Level II is required after review of the assessment. Detailed Record review of Illinois Preadmission Screening and Resident Review (PASARR) Level I Form for R22 dated 3/25/2024, shows that Level I screen does not show presence of serious mental illness or an intellectual/developmental disability (IDD). Page two of the PASARR form also shows that no more screening is needed unless presence of serious mental illness or IDD or a significant change in treatment needs arises. Last page of the form shows in part name and date of completion by V28, on 3/25/2024. On 4/2/2025 at 2:30 PM, Admission record review for R34, dated 11/21/2022, shows in part diagnosis including but not limited to: Alzheimer's Disease; Lack of Coordination; Major Depressive Disorder; Dementia, Psychotic Disturbance, Mood Disturbance and Anxiety, Schizoaffective Disorder (Bipolar Type) and Paranoid Personality Disorder. On 4/2/25 at 2:30 PM, R34's Current Order Summary Report Review dated 4/2/2025, shows in part, active orders for following: Anti-depressant Medication use and Anti-psychotic Medication use; Psychiatrist consult as needed, and Psychologist consult as needed. Pharmacy portion of the same order summary report shows in part current medications included but not limited to: Mirtazapine Tablet 15mg at bedtime for Major Depressive Disorder; Olanzapine 2.5mg at bedtime for schizoaffective disorder (Bipolar Type); Valproate Sodium Oral Solution 250mg/5ml every 12 hours for bipolar disorder. On 4/3/2025 at 1:15 PM, Received a copy of PASARR Level I screen documentation for residents R34, and R22 from V18 and. Also received a List of all residents with mental health diagnosis or intellectual/developmental disability in the facility, that totaled 37 residents. R22, R34 and R76 were included on the list. On 4/3/2025 at 1:15 PM, during phone interview, V28 stated that the reason for updated request for PASARR Level 1 screening dated 4/2/2025 for R22 and R34, was due to the initial PASARR Level 1 screenings (dated 3/25/2024 for R 22 and 3/27/24 for R34) were missing initial mental health diagnoses of Bipolar and Schizophrenia Disorder. 52136 Findings include: On 3/31/25 at 1:00 PM, R76's records were reviewed for PASARR 2 screening related to her MDS indicator of No PASARR with diagnosis. The PASARR 1 dated 8/8/2023 documented that resident did not require a PASARR 2 screen. On 8/14/2023 new diagnosis of schizoaffective disorder was listed on R76's Diagnosis information list sheet, no PASARR 2 screening was found in R76's chart. R76's face sheet dated April 2, 2025, shows R76 was admitted to the facility on [DATE] with multiple diagnosis: Schizoaffective disorder, multiple sclerosis, peripheral vascular disease, severe protein calorie malnutrition, dementia, quadriplegia, adult failure to thrive, acute embolism. R76's MDS (Minimum Data Set) dated February 3, 2025, shows R76 has a score of 3 which means R76 has severe cognitive impairment. On 04/01/25 at 03:11 PM, V28 (Receptionist) stated she is the person in the facility responsible for completing PASARR screening for residents and that R76 should have had a PASARR 2 completed after the new diagnosis was listed. V28 stated that the nurses should have informed her that there was a new diagnosis added on 8/14/23, and she was not sure why it wasn't completed since then .V28 stated she would complete the PASARR 2 screening request when she comes on duty the following morning. On 4/2/2025 at 9:00am, V28 presented a form with Maximus PASARR Pro-1 screen on it she stated the request for PASARR 2 has been submitted and will be done as soon as possible.

Based on interview and record review, the facility failed to ensure a resident's psych diagnoses were included in the pre-admission screening. This failure affected 1 (R109) resident reviewed for accuracy of pre-admission screening in the total sample of 75 residents. Findings include: R109's (printed 03/31/2025) Diagnosis Report documented that R109's diagnoses: (include but not limited to) schizoaffective disorder and schizophrenia with onset date of 05/24/2022. R109's (5/24/2022) Psychotropic consent documented, in part Risperdal 0.5mg twice daily. Supporting Diagnosis: Schizophrenia. R109's (Active Order as Of: 04/03/2025) Order Summary Report documented, in part Anti-psychotic episodic medication Use: monitor and observe. Active: 02/25/2023. Behavior monitoring related to psychotic disorder with delusions due to known physiological condition, schizophrenia, schizoaffective disorder. RISPERIDONE 0.5 MG TABLET Give 1 tablet orally two times a day related to SCHIZOPHRENIA. Active. 02/25/2023. R109's (Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Indicating R109's mental status as moderately impaired. Section I - Active Diagnoses. Psychiatric/Mood Disorder. I6000. Schizophrenia. R109 's (03/28/2024) Notice of PASARR (Pre-Admission Screening And Resident Review) Level I Screen Outcome documented, in part PASARR level I Determination: No level II required - NO SMI/ID/RC (serious mental illness/intellectual disability/reasonable condition). Diagnoses. Major depression. Level I Attestation and Signature. Name: (V28 -Receptionist/Office Manager). Of note, schizophrenia and schizoaffective disorder were not included as one of R109's diagnoses. On 04/02/2025 at 1:59pm, V28 (Receptionist/Office Manager) stated we sat through the webinar before the Maximus started. When I do the PASARR, I know I have to put in the psyche diagnoses of the resident like schizophrenia and schizoaffective disorder. I have no answer to why I did not include the psych diagnoses of (R109). If the schizoaffective disorder and schizophrenia diagnoses were not included in the pre-admission screening, the determination of need will be affected. It would come out as not needing a PASARR level II screening. On 04/02/2025 at 1:33pm, V18 (Associate Administrator) stated (V28) is in charge of doing the PASARR. She is sending it to Maximus via the Assessment Pro. She is non-clinical. She does not know the behavior of our residents and their medications. It should be the nurse and the social service department guiding her on what medications, diagnoses, and behavior of the residents to put in the PASARR. The PASARR screening of (R109) was not accurately completed because the diagnoses of schizophrenia and schizoaffective disorder were not included. R109's (04/01/2025) Notice of PASARR level I Screen Outcome documented, in part Determination: Refer for Level II Onsite. Suspected or confirmed PASARR condition(s): Mental Health Disability. Your health care professional and Maximus completed PASARR level I screen for you. This screen shows that you need a face to face level II evaluation. The purpose of this evaluation is to decide whether a nursing facility is able to meet your needs. Diagnoses: Schizophrenia and Schizoaffective disorder and Major depression. The (undated) Preadmission and resident review documented, in part The purpose of a PASARR level II assessment is to determine if the person has a condition which qualifies under the PASARR program and if so, make sure that a nursing facility is necessary of if help can be received in the community.

Based on observation, interview and record review, the facility failed to provide timely oral care for a dependent resident (R44) and failed to provide personal hygiene shaving care for a female, dependent resident (R56) which affected 2 residents (R44, R56) in the total sample of 75 residents when reviewed for activities of daily living (ADL) care. Findings include: On 3/31/25 at 11:14 am, R56 is observed laying in bed and noted with mustache hair that is dark gray hair on upper sides of lips. R56 is observed with gray and white hair chin hair, about 1/2-3/4 inch in length, on underside of R56's chin. When asked if R56 is comfortable with the lengthy facial hair, R56 stated, I (R56) would prefer not to have it. When asked if R56 has been offered during ADL care by the CNA to shave the facial hair, R56 stated no. R56 stated, I would take care of it at home, but I am not at home and need help. R56's Admission Record documents, in part, diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, type 2 diabetes mellitus, shortness of breath, hypertension, obesity, hyperlipidemia, encephalopathy, major depressive disorder, anxiety disorder, and hidradenitis suppurativa. R56's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 11 which indicates that R56 has moderate cognitive impairment. R56's Functional Abilities for Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands is scored as Substantial/maximal assistance-Helper does more than half the effort. R56's Care Plan, initiated on 9/20/22 and revised on 12/20/22, documents, in part, a focus of Self-care deficit, require assist with ADLs r/t (related to) weakness with an intervention of Personal Hygiene: (R56) requires extensive staff assist with personal hygiene and oral care. R56's ADL charting from 3/4/25 to 4/2/25 for Personal Hygiene documents, in part, that R56 had no resident refusals documented for personal hygiene care. On 4/2/25 at 1:47 pm, V2 (Director of Nursing, DON) stated that ADL (activities of daily living) care is provided by CNAs so residents look and feel good. V2 stated that ADL care provided by CNAs is done daily for all residents and includes washing their faces, combing hair, and shaving facial hair. V2 stated, Shaving is included and offered with the grooming from CNAs. When asked does shaving facial hair apply to female residents as well, V2 stated, Yes. The same for females. They don't want no facial hairs for a mustache or a beard and that female elderly residents can have lengthy facial hair that grows on sides of mustache and under the chin (as surveyor observed V2 demonstrating by pointing to the areas on V2's face). V2 stated that if a resident refuses to be shaved, the CNA will try at a later time. V2 stated that if the resident refuses again, it will be documented as a refusal, and the nurse will notify the resident's family member and the resident's physician. Facility policy dated 2014 and titled Shaving the Resident documents, in part, Purpose: 1. To keep the resident well groomed. 2. To refresh the resident. Equipment: 1. Electric shaver (if owned by resident). 2. If no electric shaver, then the following: A. Basin of warm water. B. Foam lather (shaving cream). C. Disposable razor. D. Face towel. E. Mirror. F. Tissues. G. After-Shave lotion. Procedure: 1. Explain nature of treatment to resident at the level of understanding. 2. Raise head of bed, If not contraindicated. 3. Place towel under chin. 4. Wet face and lather generously. 5. Hold skin taut and shave in the direction of hairs. Start under the sideburns and work downwards over the cheeks toward the chin. Work upward from the neck under the chin. 6. Use short film strokes and rinse razor frequently. 7. Use caution when shaving around lips and nose as these are very sensitive areas. 8. After beard is removed, wash face well with soap and water, dry well, apply after-shave lotion if desired. 9. Use new disposable razor for each resident. 10. Throw disposable razor in the sharps container. Facility policy dated November 2018 and titled Residents' Rights for People in Long-Term Care Facilities documents, in part, Your rights to dignity and respect: . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Facility Job description (undated) and titled Certified Nursing Assistant Job Description documents, in part, General Purpose: To perform non-professional direct patient care duties under the supervision of nursing personnel and to assist in maintaining a positive physical, social and psychological environment for the residents . Essential Job Functions (With or Without Reasonable Accommodation): A. Personal Care Functions: Duties: Assist residents with daily bath, dressing, grooming . D. Resident's Rights Functions: Duties: Maintain resident confidentiality; treat residents with kindness, dignity and respect; know and comply with Resident's Rights rules. 32338 On 3/31/25 at 11:10am and again at 11:45am, during observation of residents on the first floor, R44 was observed awake in bed with visible accumulated creamy brown substance on the teeth. The surveyor asked R44 about the last time staff assisted her(R44) with mouth care, and R44 stated that it's been a long time. V32(CNA/Certified Nurse Assistant) stated that she has not done mouth care for R44, but she would come back to do it. R44's care plan dated 9/15/23 states that R44 has a self-care deficit and requires assistance with ADLs (Activities of Daily Living). BIMS (Basic Interview for Mental Status) score dated 2/26/25 shows a score of 11(Mild Cognitive Impairment). Face sheet shows diagnoses which include but are not limited to Right Hand Contracture, Right Knee Contracture and Osteoporosis. Facility's Policy titled Patients Care All Shifts states in part: Teeth and/dentures must be kept clean with daily oral hygiene.

Based on observation, interview and record review, the facility failed to ensure that staff perform hand hygiene during resident dining service prior to feeding a resident, in between feeding separate residents, and after staff touching their personal body then feeding a resident to prevent and/or contain the possible spread of infectious microorganisms. These failures affected R28, R43 and R77 in the total sample of 75 when reviewed for infection control. Findings include: On 3/31/25 at 12:00 pm, V13 (Certified Nursing Assistant, CNA) observed sitting on the stool chair feeding R77 in the dining room. V13 is observed sitting positioned next to R77 (who is sitting on V13's right side) and also next to R43 (who is sitting on V13's left side). R43 is observed feeding R43's self while sitting in R43's reclining wheelchair. V13 observed stopping from feeding R77, and V13 reaches over to R43's tray then touches and moves R43's blue coffee cup which was in contact with the remainder of R43's brown bread crusts that were on the lunch meal tray. V13 stated to R43, It's (brown bread crusts) mushy. V13 does not perform hand hygiene, turns back to R77 and continues to feed R77. On 3/31/25 at 12:02 pm, V11 (CNA) is observed in front of R43's reclining wheelchair in the dining room and is in a seated position feeding R28. V11 stands and does not perform hand hygiene. V11 is observed walking up to R43 who has R43's lunch meal tray on a table over R43's lap, and V11 observed lifting up R43's white meal plate from the tray and then sits the food plate back down on R43's tray. On 3/31/25 at 12:04 pm, V11 observed touching R43's spoon which is in the bowl of mushroom soup on R43's lunch tray. V11 does not perform hand hygiene and walks back to R28, sits down and feeds R28 again. R43 observed touching the same spoon in the mushroom soup bowl and stirring R43's soup. R43's Admission Record documents, in part, diagnoses of severe protein-calorie malnutrition, dementia, dysphagia oropharyngeal phase, osteoarthritis, shortness of breath, chronic obstructive pulmonary disease, asthma, iron deficiency anemia, type 2 diabetes mellitus, chronic kidney disease stage 3A, diaphragmatic hernia, hypertension, bipolar disorder, malignant neoplasm of colon, difficulty in walking, unsteadiness on feet, and irritable bowel syndrome. R43's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 10 which indicates that R43 has moderate cognitive impairment. R43's Functional Abilities for Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident is scored as Partial/moderate assistance-Helper does less than half the effort. R43's Care Plan, date initiated 11/11/22, documents, in part, a focus of (R43) the potential for weight changes with an intervention of Assist with meals (Feed/Set-Up) as needed (initiated 11/11/22). R43's Care Plan, dated 9/12/22, documents, in part, a focus of (R43) is at risk for COVID-19 Infection. Nursing Home Residency with an intervention of Staff to perform hand hygiene before and after each encounter with resident and others (initiated 9/12/22). R77's Admission Record documents, in part, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dementia, moderate protein-calorie nutrition, dysphagia oropharyngeal phase, polyosteoarthritis, kyphsois, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, pulmonary embolism, hypertension, cardiac murmur, anemia, irritable bowel syndrome, nuclear cataract bilateral, lack of coordination, difficulty in walking, and unsteadiness on feet. R77's MDS, dated [DATE], documents, in part, a BIMS score of 5 which indicates that R77 has severe cognitive impairment. R77's Functional Abilities for Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident is scored as Dependent-Helper does all of the effort. Resident does none of the effort to complete the activity. R77's Care Plan, dated 6/6/24, documents, in part, a focus of Self-care deficit, require assist with ADLs with an intervention of Eating: (R77) is a feeder and requires substantial/max staff assist to eat (revision on 3/18/25). R77's Care Plan, dated 6/5/24, documents, in part, a focus of (R77) is at risk for COVID-19 Infection. Nursing Home Residency with an intervention of Staff to perform hand hygiene before and after each encounter with resident and others (initiated 6/5/24). On 4/2/25 at 1:47 pm, when asked within the process of CNAs feeding residents, when is hand hygiene to be performed, and V2 (Director of Nursing, DON) stated, Before they (CNAs) touch anything. They start giving food to one resident and do it before giving food to another resident. When asked the purpose of hand hygiene by staff while passing meal trays and feeding residents, V2 stated, Infection control. When asked why a staff member who is feeding one resident must perform hand hygiene before touching another resident's meal tray or feeding another resident, V2 stated, You don't know what a resident has (infection). V2 stated that if a CNA touches another resident's tray or food items then goes to feed another resident without performing hand hygiene, the CNA's hands could be contaminated. And they are handling food items on trays. V2 said that this CNA could transmit unknown bacteria to other residents. Facility policy (undated) titled Subject: Infection Control Standard Precautions documents, in part, Standard Precautions will be used in the care of all residents regardless of their diagnosis or presumed infection status. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, nonintact skin, and mucous membranes. Procedure Implementation: 1. Handwashing: a. Wash hands after touching . contaminated items, whether or not gloves are worn. b. Wash hands immediately after gloves are removed, between resident contacts and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. c. Use a plan (nonantimicrobial) soap for handwashing. Facility policy dated 2014 and titled Hand Hygiene documents, in part, The purpose is to provide guidelines for the proper hand washing to prevent the spread of infection to other personnel, residents and visitors. Compliance Guidelines: All facility personnel must wash their hands for at least 20 seconds under the following conditions: . 2. Between resident contacts . Additional Considerations: . Antiseptic solution may be applied to hands after proper hand washing. If sinks are not readily available, a waterless antiseptic may be used between tasks normally requiring hand washing unless hands are visibly soiled. Hands should be washed with soap and water as soon as possible. Facility Job description (undated) and titled Certified Nursing Assistant Job Description documents, in part, General Purpose: To perform non-professional direct patient care duties under the supervision of nursing personnel and to assist in maintaining a positive physical, social and psychological environment for the residents . Essential Job Functions (With or Without Reasonable Accommodation): . C. Food Service Functions: Duties: Prepare residents for meal and snacks. 52136 Findings include: On 3/31/25 at 11:47 AM, R28 was observed in dining room sitting in recliner high back chair resting, R28 a bedside table was next to R28 in preparation for lunchtime set up by staff. On 3/31/25 at 11:47am, V11(Certified Nursing Assistant) was observed in dining room sitting next to R28, V11 did not sanitize her hands prior to cutting food and feeding R28, V11 then opened the milk carton and placed her finger inside the carton to pull open the box to pour the milk into the cup then began to feed R28 her soup. At 11:56am, V11 stood up to go get a straw, she touched the chair handles after placing the straw in the drink and she gave the drink to R28 without any hand sanitizer utilized. At 12:06pm, V11 was observed touching her face, touching her ear on left side, and touching the chair handles without utilizing hand sanitizer. At 12:08pm, V11 stood up again to check another resident then began to rub her legs while still feeding R28 no hand sanitizer utilized. At 12:12pm, V11 was observed rubbing her left eye while she was still feeding R28, and no hand sanitizer was utilized. R28's face sheet dated April 2, 2025, shows R28 was admitted to the facility on [DATE] with multiple diagnoses including Dementia, spinal stenosis, adult failure to thrive, diabetes mellitus, major depressive disorder, hypertension, anxiety. R28's MDS (Minimum Data Set) dated January 3, 2025, shows R28 has a score of 3 which means R28 is severe cognitive impairment and Selfcare performance is scored at a 2 for eating which means R28 requires Substantial/maximal assistance with eating [staff does more than half the effort for feeding R28]. 04/02/25 at 02:08 PM, V2 (Director of Nursing) stated my expectations for the nurses prior to feeding a resident is to perform hand hygiene either wash their hands with soap and water or use hand sanitizer , to decrease risk for contaminating food.V2 stated that she expects staff to perform hand hygiene if they get up from feeding a resident to assist another resident and if they touch their face or any body parts, or clothing to prevent infection to decrease risk for transmitting infection from their clothing or body parts to resident.

Based on observation, interview, and record review, the facility failed to ensure that a resident ordered for Enteral g-tube (gastrostomy tube) feeding received the correct amount of Enteral feeding. This failure affected one resident (R76) out of one resident reviewed for Enteral/G-tube feeding in a sample of 75 residents. Findings include: On 3/31/25 at 10:35 AM, R76 was observed laying in her bed resting. R76 is alert and talkative, denies pain or discomfort when asked on interview. R76's Enteral g-tube feeding bottle was observed with a date of 3/31/25 but the Enteral g-tube feeding machine was off and not connected to the resident at that time. R76's Enteral g-tube bottle was observed by this surveyor with 1/3 of the Enteral g-tube feeding amount gone from the bottle. On 3/31/25 at 10:40 AM, V12(Licensed Practical Nurse, LPN) stated she did not turn the g-tube feeding off and doesn't know who turned it off or how long it was off. On 04/01/25 at 11:00 AM, V12(LPN) stated she is the nurse in charge of R76 and that she started her shift this am at 7:00am. V12 stated she has not turned g-tube feeding off since the start of her shift, and that the night nurse hung the Enteral g-tube feeding at 6am before she came on shift. This surveyor observed Jevity 1.2 Enteral g-tube feeding bottle dated and labeled with 4/1 at 6am and R76's name. V12 came into the room and observed the Enteral g-tube feeding and stated 100ml (milliliters) has infused at this time. She stated 4 hours have passed and R76 should have received at least 280 milliliters of feeding by now. V12 stated if R76 doesn't receive her appropriate amount of feeding, R76 can lose weight or get a disease if she doesn't receive her total volume. R76's face sheet dated April 2, 2025, shows R76 was admitted to the facility on [DATE] with multiple diagnosis: Schizoaffective disorder, multiple sclerosis, peripheral vascular disease, severe protein calorie malnutrition, dementia, quadriplegia, adult failure to thrive, acute embolism. R76's MDS (Minimum Data Set) dated February 3, 2025, shows R76 has a score of 3 which means R76 is severe cognitive impairment and that R76 receives her nutrition from feeding tube. R76's Physician Order Summary Report dated 8/9/23 documents that R76 is NPO which means (Nothing by mouth), and Enteral Feed Order dated 11/18/24 documents Jevity 1.5 via g-tube at 70 ml/hr for 20 hours (on at 4pm off at 12pm). R76's Care plan dated 3/23/25 states Jevity 1.5 at 70 ml/hr over 20 hours, [ staff to provide total assistance with tube feeding and water flushes]. On 04/02/25 at 02:12 PM, V2 (Director of Nursing) stated her expectations of the nurse who is administering Enteral g-tube feeding to a resident is that they make sure feeding is running according to physicians' orders start and stop time, that the resident is laying in upright position to decrease risk for aspiration. When asked if a resident is scheduled to receive 70ml Enteral g-tube feeding hourly and four hours have past how much Enteral g-tube feeding do you expect the resident to have received, V2 stated she would expect the g-tube feeding to have infused 280ml of g-tube feeding and if the resident receives 100 ml within 4 hours the resident has not received their adequate amount of caloric intake; they should have received according to how the dietician calculates the calorie intake for each patient. Facility policy dated January 2023 and titled Tube Feeding documents, in part, To maintain proper nutrition and hydration. To prevent complications from tube feeding. Procedure: Fill in information on label (i.e. residents name, start time, and rate) .When a Physician orders a tube feeding to run either continuous or over 24 hours, the Consulting Dietician will assess the resident's nutritional needs. Once the calorie and protein needs are calculated, the total amount of formula required will be divided between each shift allowing time for the feeding to be off for care. Facility job description dated 9/2001, titled Job duties RN/LPN, Nursing care functions and Drug and Treatment functions: Prepare and administer medication and treatments as ordered by the physician.

Based on interviews, and record reviews, the facility failed to provide the required square footage of 80 square feet per resident for multiple resident bedrooms for 19 (111, 113, 114, 115, 116, 118, 121, 122, 210, 211, 212, 214, 215, 217, 311, 313, 315, 317, 325) rooms out of 86 rooms in the facility. This failure affected 29 (R5, R14, R18, R27, R44, R46, R49, R53, R54, R58, R59, R60, R64, R72, R78, R80, R82, R83, R89, R103, R106, R110, R116, R123, R125, R126, R130, R133, R134) residents in the total sample of 75 residents. Findings include: On 03/31/2024 at 9:51am, during the entrance conference with V3 (Administrative Consultant). V3 stated we have a waiver for our room sizes. We do this waiver every year. On 04/01/2025 at 10:55am, V18 (Associate Administrator) we have rooms that have less than the required square footage for each resident. Each room has 2 certified beds. We ensure all the required furnishing and equipment for these residents are met, and these are included in our plan of correction. We did not make any repairs or construction since the last annual survey. The (04/02/2025) email correspondence with V18 documented, in part The facility has an annual Waiver for Resident bedrooms that do not measure 80 square feet per resident in multiple residents bedrooms. The (04/16/2024) Waiver of 42 CFR 483.90. Physical Environment documented, in part The State Department of Public Health reviewed your facility's request for a waiver of the federal requirement for a resident's room must afford 80square feet per bed in multi-patient rooms. CMS is granting a waiver of the federal requirement at 42 CFR483.30. The waiver is granted for rooms: 111, 113, 114, 115, 116, 118, 121, 122, 210, 211, 212, 214, 215, 217, 311, 313, 315, 317, 325 and is subject to annual review. The (undated) Policy Resident Room Waivers documented, in part The facility complies with the IDPH and CMS federal requirements for the waiver of the resident room sizes. The facility has an annual waiver for resident bedrooms that do not measure 80square feet per bed in multi-patient rooms. The rooms identified is (sic) listed below: 111, 113, 114, 115, 116, 118, 121, 122, 210, 211, 212, 214, 215, 217, 311, 313, 315, 317, 325, and 210.

Based on observation, interview, and record review the facility failed to ensure that medication cart, treatment cart with residents' medication was not left un-attended and unlocked when not in the visual proximity of the nurse and not in use to prevent tampering and accidental hazard. This failure has the potential to affect all the 40 residents residing on the 1st floor of the facility. Findings include: On 12/24/24, at 10:30 AM, on the 1st floor, the medication cart was noted in the hallway without a nurse present and not within the nurse vicinity. V6 LPN (Licensed Practical Nurse) who oversaw the medication cart stated that I just went to pick up something. When asked about facility policy on medication storage /medication cart storage. V6 stated that the medication cart must be locked when not in use or where the nurse can see it. At 10:40 AM, the treatment cart was noted unattended to and unlocked with resident treatment medication noted in the cart in the hallway. When V2 DON (Director of Nurse's) who was coming out of the elevator was shown the cart and was asked about the facility policy/protocol on medication storage and cart storage. V2 stated those are treatment meds (Medications) it should be locked when not in use. Medication carts should be locked when not within the visual distance to the nurse. The facility policy titled Administration Procedures for All Medication presented with revised date November 2011, documents under security that all medication storage area that include carts are always locked unless in use and under the direct observation of the medication nurse.

Based on interview and record review the facility failed to properly transfer a resident (R2) who is totally dependent on staff for transfers; and failed to ensure that R2 was free from injuries of unknown origin for one of four residents (R2) reviewed for Injury of Unknown Origin on the sample list of four. These failures resulted in R2 sustaining a left tibia comminuted fracture involving the tibia with multiple fracture clefts, pain and swelling to the left leg. Finding include: R2's face sheet shows that R2 has a diagnosis which includes but not limited to: Nondisplaced comminuted fracture of shaft of the left tibia subsequent encounter for closed fracture with routine healing. R2's Minimum Data Set, dated dated dated [DATE] shows that R2 requires Total dependence two-person assistance for transfers. R2's Brief Interview for Mental Status (BIMS) shows that R2 has memory problems. On 09/25/23 at 12:23 PM, R2 was observed in bed awake and alert not able to communicate needs. V4 (Certified Nursing Assistant) was observed feeding/assisting R2 with R2's lunch meal. R2's feet was observed in a heel protector with swelling observed to R2's left foot, and no discoloration noted. V4 stated, R2 was not getting out of bed on 09/25/23 due to the unit with COVID 19 positive residents. When V4 was asked regarding R2's transfer status from the bed to the wheelchair V4 stated, V4 transfers R2 and does not need help with transferring R2 and R2 was not getting out of bed on 09/25/23. On 09/25/23 at 12:30 PM, V9 (Licensed Practical Nurse, LPN) R2's nurse was asked regarding R2's transfer status. V9 stated, I'm (V9) not sure about that. It (referring to the residents on the second-floor unit transfer status) on the daily assignment sheet but they (referring to the CNA's) know their job. On 09/26/23 at 10:31 AM, V8 (Certified Nursing Assistant, CNA) stated, V8 works with R2 as the facility frequently and was R2's CNA on 09/06/23 and 09/07/23. V8 stated, on 09/07/23 V8 was about to clean R2's lower perineal area and lower extremities when V8 observed R2 with swelling to the left leg from the knee to the ankle are while V8 was providing care to R2 in bed after breakfast. V8 stated, V8 got R2's upper body area dressed in a blouse but did not get R2's lower area dressed. V8 stated, when V8 touched R2's left leg, R2 screamed. V8 stated, V8 then went to get V11 (Licensed Practical Nurse, LPN) and V11 assessed R2's left leg and dialed 911 to send R2 to the local hospital. V8 stated, R2 did not return to the facility when V8 left on 09/07/23. V8 was asked regarding how does V8 transfer R2's from the bed to the wheelchair. V8 stated, on 09/26/23 V8 transferred R2 from the bed to the wheelchair by picking R2 up from R2's bed and carrying R2 to R2's wheelchair. V8 stated, I (V8) carry her (R2) because she is not big. I (V8) sit R2 on the side of the bed and place R2's wheelchair next to R2's bed and carry R2 to from R2's bed to R2's wheelchair. V8 stated that R2 does not assist with R2's transfer and that V8 carry's R2 when transferring R2 from bed to wheelchair and from the wheelchair to the bed. V8 also stated, on 09/06/23 V8 carried R2 from R2's wheelchair back to R2's bed after breakfast to provide incontinence care to R2 and carried R2 from R2's bed back to R2's wheelchair so R2 could go back to the dining room for activities after V8 provided incontinence care to R2 after lunch. V8 stated, R2 remained in the dining room after V8 shift was over on 09/06/23 for the 3:00 pm - 11:00 pm to place R2 back to bed. V8 also explained, if a resident is new to V8, V8 will ask the charge nurse or another CNA how to transfer the resident. On 09/26/23 at 11:20 AM, V10 (Restorative Nurse, Registered Nurse, RN,) stated that all residents are assessed by therapy department upon admission and that therapy department at the facility recommends the residents transfer status. V10 stated, residents transfer status is verbally told to the nurses and the nurses share the information regarding the residents transfer status with the CNA's verbally. V10 stated, the residents transfer status is also placed in the residents electronic medical record in the special instructions task bar section on the residents profile. V10 stated, R2 required moderate assistance of one person for transfer prior to R2's injury in 09/07/23. V10 explained, staff should never carry a resident to transfer a resident from bed to the wheelchair or from the wheelchair to the bed. V10 also explained, carrying a resident when transferring a resident is not safe for the patient or staff and can cause injury to the staff and the resident. On 09/26/23 at 2:20 PM, V11 (Licensed Practical Nurse, LPN) stated, V11 was R2's nurse on 09/07/23 . V11 stated, on 09/07/23 in the morning after breakfast, V11 was passing medication to the residents and V8 (CNA) notified V11 that R2's left leg was different from R2's right leg. V11 explained, R2 was still in bed when V11 assessed R2's left leg swollen from the knee to the toe area with a purplish discoloration. V11 stated, R2 complained of pain to R2's left leg and V11 called V2 (Director of Nursing DON). V11 stated, V2 stated that R2's left leg appeared fractured and V2 dialed 911 to send R2 to the local hospital. V11 stated, R2 did not return to the facility on [DATE] during V11's shift. V11 stated, V11 was not R2's nurse on 09/06/23 and V11 did not receive in report any changes with R2's condition or that R2 had an injury to R2's leg on 09/07/23. On 09/26/23 at 2:56 PM, V12 (R2's Nurse Practitioner) stated, V12 is R2's nurse practitioner. V12 stated, V12 recall the facility calling V12 regarding R2's left leg having discoloration and swelling. V12 stated, V12 gave orders to send R2 to the local hospital emergency room (ER) for an evaluation. V12 stated, R2 sustained a comminuted fracture to R2's left leg. V12 also explained, R2 had an orthopedic evaluation and was not a candidate for surgery for R2's leg due to R2's co-morbidities. When V12 was asked regarding how R2's injury occurred, V12 stated, the facility denied that R2 sustained a fall and that it was difficult for V12 to state how R2's left leg fracture occurred. V12 stated, R2 is a resident with dead weight, fragile bones and R2's injury was probably from an improper transfer from staff. V12 was asked regarding staff transferring a resident by carrying a resident from the bed to the wheelchair. V12 stated, staff should have a mechanical lift device especially for the elderly like R2 otherwise the staff is subjecting the resident to trauma or a fall and placing everyone at a risk for an injury if the staff is carrying a resident during transfer. On 09/27/23 at 11:10 AM, V2 (Director of Nursing, DON) stated, on 09/07/23 V2 was called to R2's room to assess R2's left leg and observed R2's left leg with swelling from the knee to the toes with discoloration to R2's left foot toes. V2 stated, V2 called V12 (R2's Nurse Practitioner) and was given orders to send R2 to the local hospital for an evaluation. V2 stated, R2 was diagnosis with a left leg fracture and sent back to the facility in a post mold cast to R2's left foot area. V2 stated, R2 was given orders for R2 to follow up with orthopedic surgeon and that R2 was seen by the orthopedic physician who said R2 was not a candidate for surgery and removed R2's post mold cast due to concerns for R2 acquiring skin breakdown to R2's foot/leg area from the post mold cast. V2 was asked regarding how R2 obtained the injury to R2's left leg. V2 stated, V2 did not know. V2 explained, V2 interviewed all the staff and staff denied R2 falling. V2 was asked regarding resident transfers at the facility. V2 stated, the therapist and the restorative nurse work together to determine a residents transfer status. V2 stated that the CNA's are made aware of a residents transfer status in the residents electronic medical record Plan of Care (POC) section under the task label. V2 stated that the facility uses two types of transfers for residents. V2 stated, the CNA's transfer the residents with a gait belt assist transfer. V2 explained, the resident must be able to stand and ambulate when the CNA's are doing a gait belt transfer. V2 then stated, with a gait belt with assistance transfer when the staff places the gait belt around the resident in case the resident loses balance the staff can ease the resident to the chair or floor. V2 then explained, staff also use a mechanical lift device transfer with two staff members to transfer the resident. V2 stated, staff should not carry a resident from the bed to wheelchair for a transfer because the staff can hurt themselves and staff can cause injury to the resident. The facility's daily staffing from August 06, 2023, and August 07, 2023, shows that V8 was working in facility. The facility's document dated 09/10/23 and titled Incident Investigation Interview Statement Employer Profile authored by V8 (CNA) documents, in part: I (V8) usually pick her (R2) up to get her (R2) out of bed because she (R2) is so light. The facility's undated policy titled General patient transfer techniques documents, in part: General Rules of Patient Transfer: 2. Get equipment you need . 5. Get the people help you need. R2's Transfer Self Performance reviewed with concerns for facility following R2's as a total dependence transfer status. R2's medical record profile shows that R2 transfer status is two person (Mechanical Lift) 2 person assist. R2's Fall Risk Evaluation dated 07/31/23 and 09/08/23 reviewed. R2's Care Plan dated 02/13/23 shows that R2's Focus: Self-Care deficit require assist with ADL (Activities of Daily Living) . Intervention: Transfer: R2 requires extensive to total 2 staff assist to move between surfaces. R2's Minimum Data Set, dated dated dated [DATE] shows that R2 requires Total dependence two-person assistance for transfers. R2's Brief Interview for Mental Status shows that R2 has memory problems. R2's progress note dated 09/07/23 authored by V11 (LPN) shows that CNA notified V11 that R2's left knee all the way to the left foot was swollen and also noted R2's left eye was swollen. 911 was called and R2 was sent to the local hospital for evaluation. R2's incident report dated 09/07/23 authored by V2 (DON) shows that V2 noted R2 with swelling from the left knee down to the foot and R2's foot purplish in color upon touching the left knee the resident is grimacing. The facility's Initial Reportable incident to the local state agency dated 09/07/23 at 9:21 pm, shows that R2 sustained a left Tibia comminuted fracture involving tibia with multiple fracture clefts. The facility's Final Reportable incident to the local state agency dated 09/11/23 at 4:11 pm, shows that R2 sustained a left tibia comminuted fracture involving tibia with multiple fracture clefts and returned to the facility on [DATE] with a post mold cast of left leg and is to follow up with orthopedic physician. R2's local hospital record dated 09/07/23 shows diagnosis of closed fracture of proximal end of left tibia, unspecified fracture morphology initial encounter. R2's Radiology report dated 9/7/23 documents: Findings:: Left tibia and fibula: Comminuted fracture involving the tibia is identified with multiple fracture clefts. There is predominantly transverse fracture cleft involving the proximal tibial metaphysis however there is another vertically oriented fracture cleft along the lateral tibial diaphyseal cortex.