Every finding on record at Elevate Care Chicago North

Based on observation, interview, and record review, the facility failed to supervise one resident (R16) who was at high risk for falls. This failure resulted in R16 falling to the floor and sustaining a subdural hemorrhage. This failure affected one resident (R16) reviewed for falls.Findings include:R16's medical diagnoses include but are not limited to cognitive social or emotional deficit, vascular dementia, hypertensive heart and kidney disease.R16's Minimum Data Set (MDS), dated [DATE], has a Brief Interview for Mental Status score of 6, indicating R16's cognition is severely impaired.R16's hospital records, dated 07/02/26, documents, Reason for admission unwitnessed fall, acute right hemispheric subdural hemorrhage.R16's fall scale evaluation, dated 06/13/26, has a score of 65, indicating R16 is a high risk for fall and documents, A. History of Falling: Has the Resident ever fallen before? Yes. C. Ambulatory Aid: What ambulatory aids if anse?y does the resident u 1. None/bedrest/wheelchair/nurse assist. E. Gait:. Weak - stooped but able to lift head without losing balance. Steps are short, resident may shuffle. 1. What type of gait does the resident exhibit? 2. Weak.R16's progress note, dated 07/02/26 at 12:33AM, documents, At around 11:50pm resident observed attempting to enter an incorrect resident room. Resident lost balance, fell backward and the back of his head made contact with the door. Writer immediately responded. Pillow placed under head for comfort and safety.On 07/28/26 at 3:22PM, V44 (Licensed Practical Nurse/LPN) stated R16 is considered a wanderer. V44 stated R16 can ambulate but R16 loses his balance when he ambulates. V44 stated R16 was ambulating throughout the hall barefoot headed towards R16's old bedroom at the time that R16 fell. V44 stated she did not redirect R16 when she saw R16 walking towards R16's old bedroom because she was giving another resident pain medication and cannot be expected to be everywhere at one time.R16's care plan, dated 05/26/26, documents, (R16) is at risk for falls r/t (related to) abnormal gait/mobility, unsteadiness of feet, h/o (history of) fall. (R16) will not sustain serious injuries from a fall through the review date. encourage (R16) to use non-skid socks during ambulation. offer bathroom assistance.On 07/29/26 at 11:08AM, surveyor walked from R16's current room to R16's old room, approximately 60 steps were taken to get from the current room to the old room.On 07/29/26 at 11:44AM, V45 (Certified Nursing Assistant/CNA) stated he checks R16 for incontinence episodes twice in his 8-hour shift. V45 stated R16 is a high fall risk and ambulates with an unsteady gait. V45 stated he had not checked R16's feet to check R16's footwear.On 07/29/26 at 11:30AM, R16 was observed with a urine-soaked adult brief on. V45 (CNA) left R16's bedroom without cleaning R16's soiled adult brief. R16 was observed from nurse's station from 11:30AM until 12:20PM; no staff was observed entering R16's bedroom to initiate cleaning of R16.On 07/29/26 at 12:20PM, R16 was attempting to get out of bed. R16 was observed with the same urine-soaked adult brief on. V38 (Licensed Practical Nurse/LPN) statedR16 was attempting to get out of bed and needed to be cleaned. V38 stated she will go to get the CNA to clean R16 and R16 should have been cleaned when it was noticed R16 was soiled.On 07/29/26 at 11:57AM, V38 (LPN) stated R16 should be cleaned when it is noted that he is visibly soiled. V38 stated R16 only tries to get out the bed when he is soiled or when trying to go to the bathroom. V38 stated R16 has been in his new room for a couple of months but still tries to go to use the bathroom in his old room. V38 stated R16's old room is more familiar to R16 and most evenings R16 attempts to go to R16's old room to use the bathroom. V38 stated R16 is not on a toileting program. V38 stated she believes if R16 was on a toileting program that would prevent R16 from getting up on his own trying to find the bathroom and falling.R16's care plan, dated 05/26/26, documents, (R16) has vascular dementia, hx (history) of brain aneurysm, schizophrenia. (R16) will remain free of complications r/t (related to) deficits. Assist with ADL's (Activities of Daily Living)) as needed.R16's care plan, dated 0526/26, document, Documented Safety Concerns. Resident will remain safe and free of falling. Perform safety risk evaluation on admission, as needed and upon changes in condition. Safety measures including strategies to reduce the risk of infection, falls, injury initiated as appropriate.Facility's policy titled Fall Prevention Program, revised 11/21/17, documents, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: the fall Prevention Program includes the following components: Methods to identify risk factors. Use and implementation of professional standards of practice.

Based on interview and record review, the facility failed to ensure staff increased their monitoring of resident body temperatures during an extreme weather-related event which affected 7 residents (R1, R2, R3, R5, R6, R7, R9) of 8 residents reviewed for quality of care during a heat related emergency in a total sample of 28 residents. Findings include:On 7/2/26 at 1:30pm, V1 (Administrator) submitted a facility roster which documented that the facility had a total census of 181 residents.The facility had building inspectors, HVAC (Heat Ventilation Air Conditioning) technicians and police officers onsite due to a heat related complaint. A document from the National Weather Service dated 6/29/26 indicated that an Extreme Heat Warning was in effect for the local area from 6/29/26 through 7/1/26. On 6/29/26, afternoon peak indices 100-110F (degrees Fahrenheit) were expected.The State agency also issued a Health Advisory to all the nursing facilities on 6/29/26. On 7/2/26 at 12:48pm, V4 (Building Inspector) indicated he took random ambient temperatures of resident rooms on all floors and of all hallways. V4 also indicated large fans were already in place on all resident units. V4 stated, If there is a complaint of heat, we come out. The average temperature of the first floor was 78 (F). The second floor was 81F. The third floor was 80F. The fourth floor was 80F. The 4th floor had one 83 degree reading because there was a resident that did not have the AC (air conditioner) unit on. V4 stated an HVAC company is on the way to place portable air conditioner units at the end of each hallway. V4 indicated this will pump cool air into the hallway and create less pulling of air from the rooms. V4 said, Three of four compressors are working. The one compressor will take one week or ten days to get. V4 stated the one compressor that is not functioning focuses on the hallways and that the other three functional compressors focus on the resident rooms. V1 (Administrator) submitted a work order dated 6/30/26 that reads that a call was made by the facility on 6/29/26 regarding a chiller that was not functional.On 7/2/26 at 1:07pm, V6 (Maintenance Director) confirmed the facility began taking increased measures on 6/30/26 by placing portable fans in the hallways and in resident rooms. On 7/8/26 at 2:30pm, V2 (DON-Director of Nursing) indicated the facility began to implement increased measures on 6/30/26 after the facility learned that one compressor was not functional. On 7/2/26 at 2:20pm, V2 indicated the following interventions that are currently in place for the residents are to do nursing rounding and assess/check vital signs every shift (every 8 hours) and offer hydration. On 7/7/26 at 2:25pm, V2 further indicated the staff need to look at residents' temperatures and assess them for overheating. V2 stated V6 was performing temperatures of the building internally and clinical staff were doing residents' vital signs. V2 stated, On the 2nd floor, we were doing residents temperatures every shift (every 8 hours) and as needed. We were not performing temperatures more often than that. V2 confirmed that the tracheostomy and ventilator dependent residents were on the 2nd floor and indicated that these residents would be highly vulnerable to extreme weather-related events. V2 stated, On a normal day, we check residents' vitals on the 2nd floor every shift. V2 was asked how the facility's emergency protocol is different from the normal protocol if the residents vital signs are still only performed every shift. V2 responded the facility did increased rounding on the floors, and the staff was more vigilant. V2 stated, If they do not exhibit symptoms then there's no reason to take the vital signs or temperature more frequently. On 7/8/26, V2 submitted vital signs records for R1, R2, R3, R5, R6, R7 and R9.The following is the frequency of temperatures that was documented on the Vitals Summary for R1, R2, R3, R5, R6, R7 and R9 during the heat related event for the time frame of 6/29/26 - 7/2/26:R1's body temperature was checked four times in four days. There is no documentation of a temperature on the date of her death, 7/2/26. R2's body temperature was checked two times in three days. There is no documentation of a temperature on the date of his death, 7/2/26. R3's body temperature was checked four times in three days. R5's body temperature was checked seven times in three days. There is no documentation of a temperature on 7/2/26. R6's body temperature was checked seven times in four days. R7's body temperature was checked three times in four days. There is no documentation of a temperature on 6/29/26.R9's body temperature was checked four times in four days. Based on the vitals summaries that were submitted for R1, R2, R3, R5, R6, R7 and R9, the facility was not compliant with their facility protocol of performing vital signs every shift. There also was no documentation for increased monitoring of body temperatures from 6/29/26-7/2/26. On 7/8/26 at 1:51pm, V2 confirmed during the heat related event in the facility, she did not direct staff to increase monitoring of residents' vital signs or temperatures. V2 agreed an increased assessment of vital signs could be an appropriate nursing intervention for extreme heat events. A facility policy dated 6/24/25 and titled, Code [NAME] - Extreme Weather & Temperatures documents, in part: Heat and Humidity: Definitions: Heat Exhaustion: Body temperature remains at normal level or slightly below or above. Heat Stroke: A profound disturbance of the body's heat-regulating mechanism, caused by prolonged exposure to excessive heat, particularly when there is little or no circulation of air. The first symptoms may be headache, dizziness and weakness. Later symptoms are an extremely high fever and absence of perspiration. Both definitions of Heat Exhaustion and Heat Stroke discuss body temperature affects yet the facility policy does not address monitoring body temperature as an intervention. An undated facility policy titled, Extreme Weather (Heat and Cold) Policy documents, in part: In an event of a disruption to our generator, heating, ventilation or air conditioning systems during extreme weather event, our facility will implement the following actions for extreme heat: 1. Activate extreme weather policy and procedure. The facility policy addresses monitoring resident temperatures for extreme cold but not for extreme heat.

Based on interview and record review, the facility failed to ensure residents were assessed and identified as highly vulnerable during an extreme weather-related event which affected 16 residents (R10, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, and R28) of 28 residents reviewed for an extreme weather-related event in a total sample of 28 residents. Findings include: On 7/2/26 at 1:30pm, V1 (Administrator) submitted a facility roster which documented the facility had a total census of 181 residents. On 7/2/26 at 2:20pm, V1 and V2 (DON-Director of Nursing) were asked if they conducted an assessment that identifies highly vulnerable residents during an extreme heat event for their facility. V1 indicated the facility assessment addresses that there are ventilator and respiratory dependent residents in the facility. V2 stated, No, we do not check anyone as being highly vulnerable for heat related issues. We just do our rounding and assess/check vital signs every shift and offer hydration more. V2 was asked if they identified any residents, based on their medical diagnoses, that would be directly affected by the extreme heat event that was occurring in their facility. On 7/2/26 at 4:30pm, V2 submitted three lists of residents: congestive heart failure (CHF) residents, COPD (chronic obstructive pulmonary disease) and hemodialysis (HD) residents. V2 identified these three populations as the ones that would be most affected by the extreme heat event. V2 was asked if the respiratory dependent residents, ventilator and tracheostomy, are assessed as highly vulnerable to extreme heat events. V2 confirmed these residents would definitely be considered highly vulnerable to heat. On 7/2/26 and 7/3/26, the lists for ventilator and tracheostomy residents were not submitted. On 7/7/26, V26 (Director of Respiratory Therapy) submitted two lists: Ventilator Patient List and Tracheostomy Patient List. The total number of listed Ventilator Patients is 26. R21, R22, R23, R24, R25, R26, R27 and R28 are listed on this document but were not identified as highly vulnerable on the three lists that the facility submitted for highly vulnerable residents. The total number of listed Tracheostomy Patients is 15. R10, R14, R15, R16, R17, R18, R19 and R20 are listed on this document but were not identified as highly vulnerable on the three lists that the facility submitted for highly vulnerable residents.On 7/6/26 at 12:36pm, V26 (Director of Respiratory Therapy) was asked if ventilator dependent and tracheostomy (trach) patients are highly vulnerable to extreme heat and weather conditions. V26 stated, If they have too much heat, and are sweating or diaphoretic, they can increase work of breathing. They would be vulnerable to the heat elements. V26 also stated the ventilator machines get hot. V26 said, If it gets too hot in the room, the ventilator machine can malfunction.On 7/8/26 at 11:40am, V25 (Pulmonologist) stated ventilator and tracheostomy patients would be highly vulnerable to the heat. A facility policy for Facility Assessment was requested and V1 provided the following document, dated 8/18/17 and titled, Facility Assessment Tool for (facility name) which reads, in part: Purpose: The purpose of the assessment is to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain the highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to follow physician orders by failing to perform blood glucose monitoring before meals for one resident (R1) in a sample of four reviewed.Findings include:R1 is a [AGE] year-old individual, whose current face sheet documents diagnoses including but not limited to: type 2 diabetes mellitus with unspecified complications, atherosclerotic heart disease of native coronary artery without angina pectoris, delusional disorders, major depressive disorder, recurrent, unspecified.R1's Minimum Data Set (MDS) section C-Cognitive abilities, dated 5/21/26, document R1's Brief Interview for Mental Status (BIMS) as 15/15, indicating R1 has intact cognitive abilities. Section GG - Functional Abilities documents R1 requires Supervision or touching assistance/ Partial/moderate assistance with Activities of daily living (ADL) care.R1's Physician Order Sheet (POS) dated 5/13/2026 documents:-Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 4 units subcutaneously before meals for DM (Diabetes)-and inject as per sliding scale: 151 - 200 = 2 unit; 201 - 250 = 4 unit; 251 - 300 = 6 unit; 301 - 350 = 8 unit; 351 - 400 = 10 unit inform MD if >400, subcutaneously before meals for DM.On 06/03/2026 at 12:20PM, V17 (Registered Nurse-RN) was observed on the unit in the hallway standing by her computer. V17 was asked what R1's blood glucose levels were before lunch. V17 stated she has not taken R1's blood glucose levels. V17 stated she was busy with another resident who was having issues. V17 further stated this is her second week working at the facility and does not know which residents need glucose monitoring.V16(Assistant Director of Nursing-ADON) joined in and stated she was checking on V17 to see how V17 was doing. V16 went to R1's room and found R1's lunch tray on the side table. R1 stated she was trying to eat but was in pain and needed assistance repositioning. V16 went to get R1 pain medication. At 12:36PM, R1 was observed eating her lunch and stated she was drinking her soup because she was hungry. V16 took R1's glucose levels which were 192mg/dL. V16 administered to R1 2 units of insulin Lispro per sliding scale and 4 units scheduled.V16 stated blood glucose monitoring is scheduled before meals. It gives accurate base line blood glucose levels. This documents whether the resident has low or high blood glucose levels and if resident need insulin to control blood sugar levels. Taking blood glucose levels after resident eats can give false reading which can lead to residents receiving incorrect insulin dosage.On 06/03/2026 at 1:22PM, V2(Director of Nursing) said blood glucose levels are supposed to be taken before meals because it lets the nurses know the resident's baseline before meals. Knowing the levels allows the nurses to follow physician orders and administer insulin as ordered. Risk of taking blood glucose levels after the resident has started eating is potential for blood glucose level to be elevated. This might not give a baseline for the resident and can lead to residents receiving insulin based on results taken after resident has started eating. This can affect a resident's treatment plan.V2 stated the facility does not have a policy on nurses following physician orders.

Based on interview and record review, the facility failed to follow its abuse policy related to prevention of potential abuse and reporting of abuse allegations for two (R2, R5) out of twelve residents reviewed for abuse. The findings include: 1.R2's face sheet / admission record shows initial admit date on 12/4/17, with diagnoses not limited to Type 2 diabetes mellitus with diabetic neuropathy, Hypertensive heart disease, Primary osteoarthritis, Hypothyroidism, Major depressive disorder, Unspecified dementia, Anxiety disorder, Insomnia, Gastro-esophageal reflux disease, Hyperlipidemia. MDS (Minimum Data Set), dated 3/13/26, shows R2's cognition is moderately impaired. On 4/21/26 At 11:12 AM, R2 was alert and verbally responsive, Spanish speaking, and able to speak and understand simple English. Requested V28 (Housekeeping) in R2's room as a Spanish speaking interpreter. R2 stated 2 ladies (Certified Nursing Assistants/CNAs) pulled / pushed her into the bathroom and she fell on the floor. R2 stated she was lying on the floor. She does not know the names of the staff, but she said they were African - American. R2 stated the incident happened on Sunday (4/12/26) morning. She stated she hit her head on the wall, and she hit her right arm on the floor and had bruises. R2 showed her right thigh to surveyor and observed with purplish / greenish discoloration on right thigh. She stated another staff member came in and helped her with the 2 CNAs to get up from the floor to her bed. She stated she was transferred to the hospital and was admitted for about 4-5 days. R2 stated she saw the 2 CNAs working in the facility after the incident. She stated she feels safe now. R2 stated she felt abused when the 2 CNAs pushed her and fell on the floor. R2 stated she can ambulate with cane by herself. R2's Nurses Notes, dated 4/12/26, shows: R2 fell at approximately 8:30AM. When R2 was asked what happened, R2 stated, I was pushed to the floor by CNA. Notified the administrator immediately. R2 was transferred to the hospital for medical evaluation. On 4/21/26 At 2:02PM, V17 (LPN / Licensed Practical Nurse) stated she had not seen abuse or staff pushing to cause harm to residents in the facility. V17 stated on 4/12/26, she heard a resident screaming / crying, and she went to R2's room right away. She stated she saw R2 in the bathroom in a sitting position on the floor. V17 stated R2 claimed she was pushed to the floor, referring to 2 CNAs (V19 and V39); both CNAs were not close to R2. V17 stated they assisted R2 back to bed with 2 CNAs. She said there was a bump on the right side of her head. R2 claimed she hit the wall. V17 stated she informed nurse assigned to R2 (V16) to follow up immediately. She said R2 was able to get up from sitting to standing position with assistance from V17 and 2 CNAs (V19 and V39). She stated R2 was able to ambulate from bathroom to her bed with supervision. V17 stated she was informed by V16 that she reported R2's claim of the pushing incident to (V1) administrator because it was physical abuse allegation. V17 stated the 2 CNAs were denying R2 was pushed. On 4/21/26 AT 2:26PM, V19 (CNA / Certified Nursing Assistant) stated on 4/12/26 around 8-9AM, she was passing breakfast trays to residents and saw R2 trying to feed her roommate. She stated V39 (assigned CNA) attempted to redirect R2 but R2 was not listening to V39. V19 stated she intervened and went inside the room and asked R2 if she wanted to go to bathroom to redirect her and R2 agreed. She stated R2 was ambulatory with no device, was wearing proper footwear. V19 stated she held the bathroom door open for her to go in. V19 stated R2 was saying racial slur Ni**er, Bi**h. V19 stated she stayed quiet, and she kept holding the bathroom door. V19 stated R2 then turned around and punched her on the face. V19 stated she tried to back up and R2 attempted to strike again. She stated she tried to remove herself from the situation but there was no space to back up. V19 stated she was trying to hold R2's hand to stop striking or hitting but could not hold R2. V19 stated R2 then lost her balance by snatching back from her and landed on the floor. V19 stated she did not push R2, and she did not have physical contact with R2. She stated they (V19 and V39) were not close to R2. V19 stated V17 (nurse) came to assess R2, who was aggressive. She stated R2 had a bump on the head and bruise on right elbow. V19 stated she did not see R2 hit her head on the door or any surface. She hit her elbow on the floor when she fell. V19 stated they assisted R2 from sitting to standing position, physically assisted R2 to walk to her bed. V19 stated when R2 was in bed, she was claiming she was pushed by 2 CNAs (V19 and V39). She stated R2 allowed her to assist her walking back to her bed. She stated R2 was not scared but she was upset because she fell and R2 was yelling. V19 said she was not suspended or was not sent home. V19 stated V38 (Manager on duty) was aware of the incident. She stated R2 was transferred to the hospital. V19 stated she was not suspended. She was not sent home, and she continued to work on the 4th floor caring for the residents. She said their Abuse Coordinator is the Administrator (V1) who was made aware of the incident and the claim of R2 that she was pushed. V19 stated pushing is an example of physical abuse. It was an abuse allegation because R2 claimed that she was pushed. V19 stated there was no pushing that happened between staff and R2. On 4/21/26 At 3PM, V39, (CNA / Certified Nursing Assistant), stated on 4/12/26 around 8:30AM, breakfast time, R2 was in the room and attempting to feed the roommate. She stated she was trying to redirect R2 and was not responding after redirection. She said V19 (CNA) walked into the room and redirected R2 to go to the bathroom. V19 opened the bathroom door, R2 refused to use assistive device – cane or walker. She stated R2 was calling out Ni**er, bi**h, turned around and punched V19 on the face. She said R2 snatched back, and she lost her balance and landed on the floor. V39 stated there was no pushing happened; they never had physical contact with R2. V39 stated she called the nurse right away. She stated R2's claim of pushing is an example physical abuse allegation. She stated it was reported to the Administrator who is the Abuse Coordinator. V39 stated she was not sent home or suspended; she was not removed from residents' care area. She continued to work with R2 and the rest of the residents assigned to her. On 4/21/26 At 3:25PM, V16 (LPN / Licensed Practical Nurse) stated she received an abuse allegation. R2 claimed CNAs (V19 and V39) pushed her to the floor. She stated there was a bump on the right side of the head. V16 stated she reported the incident right away to V1 (Administrator) who is the Abuse Coordinator and R2 was transferred to the hospital. V16 stated pushing is a suspected abuse. She said V39 (CNA) continued to work with R2. V16 stated R2 claimed V39 pushed R2. She stated V39 continued working with the residents on the 4th floor. On 4/21/26 at 3:45PM, V38 (Guest relation and Activity Director) stated she was the MOD (Manager on Duty) on 4/12/26, doing rounds to the 4th floor, and there were 4 staff in R2's room, 2 CNAs and 2 nurses. V38 stated she went inside the room, R2 is Spanish speaking so she requested housekeeper - Spanish interpreter. V38 stated R2 claimed that she was pushed and fell on the floor. V38 there was situation with R2 and the 2 CNAs. R2 was using inappropriate words Ni**er bi**h swinging at the CNA, lost her balance and fell on the floor. She stated V1, who is the Abuse Coordinator, was informed about the incident as it was an abuse allegation, staff were requested to write a statement. V38 stated V1 came to the facility to investigate the incident. She stated R2 was transferred to the hospital. V19 and V39 continued to work with residents on the 4th floor, they were not suspended, they were not removed from residents' care area. On 4/23/26 at 9:45AM, V1 (Administrator) stated he has been working in the facility for 2 years in the facility and he is the Abuse Coordinator. He stated if there is an abuse allegation involving staff, suspend staff pending investigation or removed from resident's care area immediately to keep resident safe. V1 stated the goal of the facility is for all residents to be free from abuse. He stated an example of physical abuse is hitting or intentional pushing. He stated R2 had a fall incident on 4/12/26; R2 was attempting to feed her roommate. V19 and V39 attempted to redirect R2, and she became aggressive. R2 attempted to strike V19, R2 pulled her arm away, and that's how R2 fell. V1 stated R2's son came to the facility and claimed that somebody hit his mom. V1 stated any abuse allegation should be reported to the State Agency within 2 hours and final report should be within 5 business days. V1 stated the purpose of reporting to the State Agency to make sure facility follows regulations. He stated he was not aware of R2's claim that she was pushed to the floor by V19 and V39 and the allegation was not reported to the State Agency. On 4/23/26 at 11:08AM, V2 (DON / Director of Nursing) stated their Abuse Coordinator is the Administrator and she is the designee when V1 is not around in the facility. She stated if there an abuse allegation involving the staff – suspend pending investigation or remove staff from residents' care area to keep resident safe or prevent possible abuse. She said an example of physical abuse is hitting or intentional pushing. V2 stated their goal is for all residents be free from abuse. She stated if there is an abuse allegation, it should be initially reported to the State Agency within 2 hours, and final report should be submitted in 5 days. V2 stated an abuse allegation is reported to the State Agency to make agency aware of the alleged abuse. Reviewed R2's EHR (Electronic Health Record) with V2 and read nurse's notes on 4/12/26: R2 stated, I was pushed to the floor by CNA. V2 stated R2 claiming she was pushed is an alleged physical abuse and should be reported to the State Agency. Facility's reportable for the month of April 2026, no abuse allegation reports for R2 submitted to IDPH (Illinois Department of Public Health). 2.R5's Minimum Data Set (MDS) assessment, dated 10/27/25, shows a BIMS (Brief Interview for Mental Status) of 15, which means R5 is cognitively intact. R5's comprehensive care plan does not include an individualized plan of care related to potential abuse. Initial abuse reportable sent to IDPH on 4/21/26 at 2:58 PM; date and time of incident 4/7/26 at 5:00 AM. On 4/21/26 at 11:34 AM, R5 stated there is a nurse [V45 (Licensed Practical Nurse/LPN] who works night shift on weekends. R5 stated after she had fallen onto the floor mattress beside the bed, she pressed the call light, V45 entered her room and kicked her in the lower back while telling her to get up. R5 stated the incident occurred around 1:00 AM. R5 stated no one witnessed the alleged incident because she was alone at the time with V45. R5 stated other staff later came into the room, including two male CNAs [Certified Nursing Assistants] and one female CNA. R5 stated she informed the male CNA that V45 had kicked her on her back. R5 does not remember the name of the CNA. R5 stated she also spoke with V1 [Administrator] that morning and informed him that V45 had kicked her. R5 stated V45 no longer comes to her room. R5 believed the incident occurred a couple of weeks earlier, possibly at the beginning of April. On 4/21/26 at 1:18 PM, V1 (Administrator) stated R5's allegation was not reported to IDPH [Illinois Department of Public Health] because he determined it was not abuse. V1 stated R5 reported she fell to the floor and staff came to assist her back into bed. V1 stated R5 mentioned kicking, but when V1 asked for clarification, R5 stated there was a pack of diapers on the floor because she was between the window area. V1 stated R5 then stated V45 kicked the diaper pack to the side. V1 stated nothing was mentioned about V45 kicking R5. V1 denied a police report was done. V1 stated per facility's abuse prevention policy, if a staff member had kicked a resident, V1 would report the allegation to IDPH, investigate it, and suspend the staff member pending the investigation to protect all residents. V1 stated V45 was not suspended because the allegation was not substantiated. V1 stated R5 had a care plan related to making false allegations and described her as drug seeking. V1 stated the facility's abuse policy is that abuse allegations must be reported immediately. V1 stated an initial report is completed within two hours, followed by a thorough investigation that includes interviews with staff and residents. V1 stated the final report is completed within five days. V1 stated he is the abuse coordinator and expects staff to report allegations to him immediately. V1 stated abuse in-service training is completed at least quarterly, as well as web-based and skills training. On 4/22/26 at 9:25 AM, a phone interview was conducted with V44 (Certified Nursing Assistant/CNA). V44 stated he was the CNA assigned for R5 at the time of the incident, but does not remember the exact date. V44 stated it was at the beginning of April. V44 stated between 1:00 AM to 2:00 AM, R5 was heard screaming for help and V44 observed R5 on the floor. V44 stated he notified V45 and two other CNAs. V44 stated they responded together and assisted R5. V44 stated he was present the entire time with V45 and stated V45 did not kick R5. V44 stated hours later, R5 claimed she had been kicked by V45, but V44 stated this did not occur. V44 stated the first time he became aware of R5's allegation was around 5:30 AM. V44 stated he went to R5's room to ensure she was okay and R5 stated she was calling the police and claimed V45 had kicked her. V44 stated he informed V45 of R5's allegation. V44 stated he later spoke with V1 after his shift, possibly around 8:00 AM. V44 stated V1 contacted him because police involvement had been mentioned by R5 and wanted to know what happened. V44 stated V1 said R5 reported that V45 had kicked her. V44 stated he explained the events as previously described to V1. V44 stated V1 called him again the previous day to ask whether anything in his statement had changed or whether he had additional information. On 4/22/26 at 9:56 AM, a phone interview was conducted with V45 (Licensed Practical Nurse). V45 stated she had never been suspended or sent home because of an abuse allegation. V45 stated she cared for R5 on the night the resident was found on the floor after stating she had fallen. V45 did not remember the exact date but believed it was at the beginning of April. V45 stated she was working with three other staff members that night [V44 and V46 (CNA)]. V45 stated she went home after the shift and did not receive any report about R5's abuse allegation. V45 stated the following day, V1 called and told her R5 reported that V45 had kicked her. V45 stated she was not told about the kicking allegation until the following day when V1 called V45. V45 denied ever kicking R5. V45 stated she was R5's nurse until 7:00 AM, when the next shift nurse arrived. V45 stated V1 did not suspend her pending investigation because V1 spoke with the staff and determined the allegation did not happen. V45 stated V1 documented the matter as a concern because the allegation of physical abuse was not substantiated. V45 stated she was told not to care for R5, but V45 continued to work on the same floor. The facility's residents' roster, dated 4/21/26, shows a total of 163 residents residing in the facility. Facility's Abuse and Retaliation Policy prevention program, dated 1/2026, shows: Employee of this facility who have been accused of abuse will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator, and it is determined that any allegation of abuse is unsubstantiated. Any incident or allegation involving abuse will result in investigation. When an allegation of abuse has been made, the administrator or designee, shall notify the Department of Public Health's regional office immediately by telephone or fax. Public Health shall be informed that an occurrence of potential abuse has been reported to the administrator and is being investigated. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.

Based on interview and record review, the facility failed to follow their policy to notify Department of Public Health regional office for an abuse allegation for two (R2 and R5) out of 12 residents reviewed for abuse. 1.R2's face sheet / admission record shows initial admit date on 12/4/17, with diagnoses not limited to Type 2 diabetes mellitus with diabetic neuropathy, Hypertensive heart disease, Primary osteoarthritis, Hypothyroidism, Major depressive disorder, Unspecified dementia, Anxiety disorder, Insomnia, Gastro-esophageal reflux disease, Hyperlipidemia. MDS (Minimum Data Set) dated 3/13/26 shows R2's cognition is moderately impaired. On 4/21/26 At 11:12 AM, R2 was alert and verbally responsive, Spanish speaking, and able to speak and understand simple English. Requested V28 (Housekeeping) in R2's room as a Spanish speaking interpreter. R2 stated 2 ladies (CNAs) pulled / pushed her into the bathroom and she fell on the floor. R2 stated she was lying on the floor. She does not know the names of the staff, but she said they were African - American. R2 stated the incident happened on Sunday (4/12/26) morning. She stated she hit her head on the wall, and she hit her right arm on the floor and had bruises. R2 showed her right thigh to surveyor and observed with purplish / greenish discoloration on right thigh. She stated another staff member came in and helped her with the 2 CNAs to get up from the floor to her bed. She stated she was transferred to the hospital and was admitted for about 4-5 days. R2 stated she saw the 2 CNAs working in the facility after the incident. She stated she feels safe now. R2 stated she felt abused when the 2 CNAs pushed her and fell on the floor. R2 stated she can ambulate with cane by herself. R2's Nurses Notes, dated 4/12/26, shows: R2 fell at approximately 8:30AM. When R2 was asked what happened, R2 stated I was pushed to the floor by CNA. Notified the administrator immediately. R2 was transferred to the hospital for medical evaluation. On 4/21/26 at 2:02PM, V17 (LPN / Licensed Practical Nurse) she stated she had not seen abuse or staff pushing to cause harm to residents in the facility. V17 stated on 4/12/26, she heard a resident screaming / crying, and she went to R2's room right away. She stated she saw R2 in the bathroom in a sitting position on the floor. V17 stated R2 claimed that she was pushed to the floor referring to 2 CNAs (V19 and V39), both CNAs were not close to R2. V17 stated they assisted R2 back to bed with 2 CNAs. She said there was a bump on the right side of her head; R2 claimed she hit the wall. V17 stated she informed the nurse assigned to R2 (V16) to follow up immediately. She said R2 was able to get up from sitting to standing position with assistance from V17 and 2 CNAs (V19 and V39). She stated R2 was able to ambulate from bathroom to her bed with supervision. V17 stated she was informed by V16 that she reported R2's claim of the pushing incident to (V1) Administrator because it was physical abuse allegation. V17 stated the 2 CNAs were denying R2 was pushed. On 4/21/26 at 2:26PM, V19 (CNA / Certified Nursing Assistant) stated on 4/12/26 around 8-9AM, she was passing breakfast trays to residents and saw R2 trying to feed her roommate. She stated V39 (assigned CNA) attempted to redirect R2 but R2 was not listening to V39. V19 stated she intervened and went inside the room and asked R2 if she wanted to go to the bathroom to redirect her and R2 agreed. She stated R2 is ambulatory with no device, was wearing proper footwear. V19 stated she held the bathroom door open for her to go in. V19 stated R2 was saying racial slur Ni**er, Bi**h. V19 stated she stayed quiet, and she kept holding the bathroom door. V19 stated R2 then turned around and punched her on the face. V19 stated she tried to back up and R2 attempted to strike again. She stated she tried to remove herself from the situation but there was no space to back up. V19 stated she was trying to hold R2's hand to stop striking or hitting but could not hold R2. V19 stated R2 then lost her balance by snatching back from her and landed on the floor. V19 stated she did not push R2, and she did not have physical contact with R2. She stated they (V19 and V39) were not close to R2. V19 stated V17 (nurse) came to assess R2 who was aggressive. She stated R2 had a bump on the head and bruise on right elbow. V19 stated she did not see R2 hit her head on the door or any surface. She hit her elbow on the floor when she fell. V19 stated they assisted R2 from sitting to standing position, physically assisted R2 to walk to her bed. V19 stated when R2 was in bed, she was claiming that she was pushed by 2 CNAs (V19 and V39). She stated R2 allowed her to assist her walking back to her bed. She stated R2 was not scared but she was upset because she fell and R2 was yelling. V19 said she was not suspended or was not sent home. V19 stated V38 (Manager on duty) was aware of the incident. She stated R2 was transferred to the hospital. V19 stated she was not suspended. She was not sent home, and she continued to work on the 4th floor caring for the residents. She said their abuse coordinator is the Administrator (V1) who was made aware of the incident and the claim of R2 that she was pushed. V19 stated pushing is an example of physical abuse. It was an abuse allegation because R2 claimed that she was pushed. V19 stated there was no pushing that happened between staff and R2. On 4/21/26 at 3PM, V39 (CNA / Certified Nursing Assistant) stated on 4/12/26 around 8:30AM, breakfast time, R2 was in the room and attempting to feed the roommate. She stated she was trying to redirect R2 and was not responding after redirection. She said V19 (CNA) walks into the room and redirected R2 to go bathroom. V19 opened the bathroom door, R2 refused to use assistive device – cane or walker. She stated R2 was calling out Ni**er, bi**h, turned around and punch V19 on the face. She said R2 snatched back, and she lost her balance and landed on the floor. V39 stated there was no pushing happened, they never had physical contact with R2. V39 stated she called the nurse right away. She stated R2's claim of pushing is an example physical abuse allegation. She stated it was reported to the administrator who is the abuse coordinator. V39 stated she was not sent home or suspended; she was not removed from residents' care area. She continued to work with R2 and the rest of the residents assigned to her. On 4/21/26 at 3:25PM, V16 (LPN / Licensed Practical Nurse) stated she received an abuse allegation. R2 claimed that CNAs (V19 and V39) pushed her to the floor. She stated there was a bump on the right side of the head. V16 stated she reported the incident right away to V1 (Administrator) who is the Abuse Coordinator and R2 was transferred to the hospital. V16 stated pushing is a suspected abuse. She said V39 (CNA) continued to work with R2. V16 stated R2 claimed that V39 pushed R2. She stated V39 continued working with the residents on the 4th floor. On 4/21/26 3:45PM, V38 (Guest relation and Activity Director) stated she was the MOD (Manager on Duty) on 4/12/26, doing rounds to the 4th floor and there were 4 staff in R2's room, 2 CNAs and 2 nurses. V38 stated she went inside the room, R2 is Spanish speaking, so she requested housekeeper - Spanish interpreter. V38 stated R2 claimed she was pushed and fell on the floor. V38 there was situation with R2 and the 2 CNAs. R2 was using inappropriate words Ni**er bi**h swinging at the CNA, lost her balance and fell on the floor. She stated V1, who is the Abuse Coordinator, was informed about the incident as it was an abuse allegation, staff were requested to write a statement. V38 stated V1 came to the facility to investigate the incident. She stated R2 was transferred to the hospital. V19 and V39 continued to work with residents on the 4th floor, they were not suspended, they were not removed from residents' care area. On 4/23/26 at 9:45AM, V1 (Administrator) stated he has been working in the facility for 2 years in the facility and he is the Abuse Coordinator. He stated if there is an abuse allegation involving staff, suspend staff pending investigation or removed from resident's care area immediately to keep resident safe. V1 stated the goal of the facility is for all residents to be free from abuse. He stated an example of physical abuse is hitting or intentional pushing. He stated R2 had a fall incident on 4/12/26, R2 was attempting to feed her roommate, V19 and V39 attempted to redirect R2, and she became aggressive. R2 attempted to strike V19, R2 pulled her arm away, and that's how R2 fell. V1 stated R2's son came to the facility and claimed that somebody hit his mom. V1 stated any abuse allegation should be reported to the State Agency within 2 hours and final report should be within 5 business days. V1 stated the purpose of reporting to the State Agency to make sure facility follows regulations. He stated he was not aware of R2's claim that she was pushed to the floor by V19 and V39 and the allegation was not reported to the State Agency. On 4/23/26 at 11:08AM, V2, (DON / Director of Nursing), stated their Abuse Coordinator is the Administrator and she is the designee when V1 is not around in the facility. She stated if there an abuse allegation involving the staff – suspend pending investigation or remove staff from residents' care area to keep resident safe or prevent possible abuse. She said an example of physical abuse is hitting or intentional pushing. V2 stated their goal is for all residents be free from abuse. She stated if there is an abuse allegation, it should be initially reported to the State Agency within 2 hours, and final report should be submitted in 5 days. V2 stated an abuse allegation is reported to the State Agency to make agency aware of the alleged abuse. Reviewed R2's EHR (Electronic Health Record) with V2 and read nurse's notes on 4/12/26: R2 stated, I was pushed to the floor by CNA. V2 stated R2 claimed she was pushed is an alleged physical abuse and should be reported to state agency. Facility's reportable for the month of April 2026 showed no abuse allegation reports for R2 submitted to IDPH (Illinois Department of Public Health). Facility's Abuse and Retaliation Policy prevention program, dated 1/2026, shows: Employee of this facility who have been accused of abuse will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator, and it is determined that any allegation of abuse is unsubstantiated. Any incident or allegation involving abuse will result in investigation. When an allegation of abuse has been made, the administrator or designee, shall notify the Department of Public Health's regional office immediately by telephone or fax. Public Health shall be informed that an occurrence of potential abuse has been reported to the administrator and is being investigated. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. 2.R5's Minimum Data Set (MDS) assessment, dated 10/27/25, shows a BIMS (Brief Interview for Mental Status) of 15, which means R5 is cognitively intact. R5's comprehensive care plan does not include an individualized plan of care related to potential abuse. Initial abuse reportable sent to IDPH on 4/21/26 at 2:58 PM; date and time of incident 4/7/26 at 5:00 AM. On 4/21/26 at 11:34 AM, R5 stated there is a nurse [V45 (Licensed Practical Nurse/LPN] who works night shift on weekends. R5 stated that after she had fallen onto the floor mattress beside the bed, she pressed the call light, V45 entered her room and kicked her in the lower back while telling her to get up. R5 stated the incident occurred around 1:00 AM. R5 stated no one witnessed the alleged incident because she was alone at the time with V45. R5 stated other staff later came into the room, including two male CNAs [Certified Nursing Assistants] and one female CNA. R5 stated she informed the male CNA that V45 had kicked her on her back. R5 does not remember the name of the CNA. R5 stated she also spoke with V1 [Administrator] that morning and informed him V45 had kicked her. R5 stated [V45] no longer comes to her room. R5 believed the incident occurred a couple of weeks earlier, possibly at the beginning of April. On 4/21/26 at 1:18 PM, V1 (Administrator) stated R5's allegation was not reported to IDPH [Illinois Department of Public Health] because he determined it was not abuse. V1 stated R5 reported she fell to the floor and staff came to assist her back into bed. V1 stated R5 mentioned kicking, but when V1 asked for clarification. R5 stated there was a pack of diapers on the floor because she was between the window area. V1 stated R5 then stated V45 kicked the diaper pack to the side. V1 stated nothing was mentioned about V45 kicking R5. V1 denied a police report was done. V1 stated per facility's abuse prevention policy, if a staff member had kicked a resident, V1 would report the allegation to IDPH, investigate it, and suspend the staff member pending the investigation to protect all residents. V1 stated V45 was not suspended because the allegation was not substantiated. V1 stated R5 had a care plan related to making false allegations and described her as drug seeking. V1 stated the facility's abuse policy is that abuse allegations must be reported immediately. V1 stated an initial report is completed within two hours, followed by a thorough investigation that includes interviews with staff and residents. V1 stated the final report is completed within five days. V1 stated he is the abuse coordinator and expects staff to report allegations to him immediately. V1 stated abuse in-service training is completed at least quarterly, as well as web-based and skills training. On 4/22/26 at 9:25 AM, a phone interview was conducted with V44 (Certified Nursing Assistant/CNA). V44 stated he was the CNA assigned for R5 at the time of the incident, but does not remember the exact date. V44 stated it was at the beginning of April. V44 stated between 1:00 AM to 2:00 AM, R5 was heard screaming for help and V44 observed R5 on the floor. V44 stated he notified V45 and two other CNAs. V44 stated they responded together and assisted R5. V44 stated he was present the entire time with V45 and stated V45 did not kick R5. V44 stated hours later, R5 claimed she had been kicked by V45, but V44 stated this did not occur. V44 stated the first time he became aware of R5's allegation was around 5:30 AM. V44 stated he went to R5's room to ensure she was okay and R5 stated she was calling the police and claimed V45 had kicked her. V44 stated he informed V45 of R5's allegation. V44 stated he later spoke with V1 after his shift, possibly around 8:00 AM. V44 stated V1 contacted him because police involvement had been mentioned by R5 and wanted to know what happened. V44 stated V1 said R5 reported that V45 had kicked her. V44 stated he explained the events as previously described to V1. V44 stated V1 called him again the previous day to ask whether anything in his statement had changed or whether he had additional information. On 4/22/26 at 9:56 AM, a phone interview was conducted with V45 (Licensed Practical Nurse). V45 stated she cared for R5 on the night the resident was found on the floor after stating she had fallen. V45 did not remember the exact date but believed it was at the beginning of April. V45 stated she was working with three other staff members that night [V44 and V46 (CNA)]. V45 stated she went home after the shift and did not receive any report about R5's abuse allegation. V45 stated the following day, [V1] called and told her that R5 reported [V45] had kicked her. V45 stated V1 reviewed the camera footage. V45 stated the incident happened around 1:00 AM and R5 was having behaviors. V45 stated a second incident occurred around 5:00 AM when staff again found R5 on the floor. V45 stated she was not told about the kicking allegation until the following day when V1 called V45. V45 denied ever kicking R5.

Based on observation, interview, and record review, the facility failed to ensure accurate medication administration by failing to verify the correct insulin dose prior to administration for one (R5) of three residents reviewed for medication administration.Findings Include:R5's clinical records show an admission date of 10/10/25. R5's order summary report, dated 4/21/26, reads: Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 12 unit subcutaneously one time only for DM [Diabetes Mellitus] for 1 Day. R5's progress notes dated 4/21/26 at 12:09 PM reads in part: [R5] blood sugar was checked-460, [V74] notified, ordered to give one time dose of 12 unit of insulin lispro. R5's care plan documents in part: (Date initiated 10/29/25) R5 has Diabetes Mellitus, on insulin. Diabetes medication as ordered by doctor.On 4/21/26 at 11:51 AM, a medication administration observation was conducted with V15 (Licensed Practical Nurse). V15 obtained R5's blood glucose reading of 460 and contacted V74 (Nurse Practitioner), who ordered Lispro insulin 12 units. At 12:05 PM, V15 prepared the insulin and presented it to V72 (Assistant Director of Nursing) for verification. V15 also showed the syringe to the surveyor. There were 13 units of insulin in the syringe. V15 then entered R5's room and was about to administer the insulin to R5. V15 and V72 were asked to recheck the dose in the syringe. V72 re-verified the syringe and removed 1 unit of insulin, correcting the dose to the ordered 12 units.On 4/21/26 at 2:05 PM, V2 (Director of Nursing) V2 stated insulin is a significant medication because it can cause adverse reactions. V2 stated if insulin is given improperly, the resident may become hypoglycemic or hyperglycemic. V2 stated hypoglycemia means a low blood sugar level from the resident's baseline. V2 emphasized the importance of following physician orders when administering medication to prevent adverse reactions. V2 stated after medication administration, the nurse documents in the MAR (Medication Administration Record) that the medication was given.The facility's INJECTABLE MEDICATION ADMINISTRATION policy reads: To administer medications via subcutaneous, intradermal and intramuscular routes in a safe, accurate, and effective manner.

Based on observation, interview, and record review, the facility failed to provide timely wound care for one (R1) out of three residents reviewed for wound treatment. Findings Include: R1's Electronic Health Record/EHR shows she was admitted to the facility on [DATE], she is [AGE] years old, her Brief Mental Status shows she is severely impaired. She has diagnoses not limited to chronic respiratory failure with hypoxia, encounter for attention to tracheostomy, dysphagia oropharyngeal phase, encephalopathy, dysphagia following cerebral infarction, aphonia, and dependence on supplemental oxygen.On 1/29/26 at 10:34 AM, R1 was supine in bed, non-verbal, and she was unable to respond to interview. On 1/29/26 at 3:06 PM, V7 (Wound Care Coordinator) stated he cannot recall if anyone told him about R1's left gluteal small skin alteration on 1/23/26 until 1/27/26 when he called the doctor for a treatment order. He also stated he realizes there was a delay of treatment, which could potentially worsen R1's wound. On 1/29/26 at 2:47 PM, via telephone, V11 (Licensed Practical Nurse/LPN) stated an unidentified Certified Nursing Assistant/CNA reported to her on 1/23/26 that R1 has small superficial skin alteration on her buttocks. She reported to the wound team, but she did not document the intervention anywhere in R1's medical record, V11 stated she knows if it is not documented that it means it was not done. On 1/29/26 at 2:50 PM, V2 (Director of Nursing/DON) stated she has been in the facility since June 2025, and it is her expectation that nurses would provide nursing interventions timely to prevent further tissue breakdown. She also stated R1's wound on her buttock is very small even though the treatment was not started until after three days. R1's Physician Order Sheet/POS active order as of 1/29/26 shows wound care, left gluteal cleanse with normal saline, apply zinc oxide paste, cover with silicone bordered foam every day and as needed (PRN) every shift dated 1/28/26. R1's Treatment Administration Record/TAR shows initial wound treatment, dated 1/27/26.R1's progress notes, dated 1/27/26, Wound Care: R1's Left Gluteal - Cleanse with normal saline, pat dry, apply Zinc Oxide paste, cover with Silicone Bordered Foam, every day and as needed/PRN.Change in condition policy, dated 7/8/24, documents: To ensure that medical care problems are communicated to the attending physician in a timely, efficient, and effective manner.Registered Nurse and Licensed Practical Nurse Job description: documents: Ensures timely notification of medical director.

Based on interview and record review, the facility failed to ensure staff documented administration of medications after the medications were administered. This failure affected 1 (R1) resident reviewed for pharmaceutical services in the total sample of 8 residents. Findings include:On 09/15/2025 at 11:49am, R1 stated V3-Licensed Practice Nurse would give his medications late. Occasionally, V3 works the evening shift.R1's admission Record documented R1's diagnoses include but not limited to dementia with mood disturbance, hypertensive heart disease, and adjustment disorder with depressed mood. R1's (06/19/2025) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15., indicating R1's mental status as cognitively intact. R1's 07/2025, 08/2025, and 09/2025 Medication Administration Record indicated V3 worked the evening shift on days 7/10, 7/14, 7/20, 7/21, 7/24, 7/31, 8/5, 8/11, 8/17, 9/14.R1's 07/24/2025 Medication Administration Audit Report Day Shift documented R1's Chlorhexidine Gluconate Solution 0.12 % 2x day, Metoprolol Tartrate Tablet 25 MG 2x a day, Gabapentin Capsule 300 MG 2x a day, Senna S Tablet 8.6-50 MG 2x a day were scheduled at 9am, the administration time was at 11:22am, documented time was at 11:22am and documented by V3 (Licensed Practice Nurse). R1's 08/05/2025 Medication Administration Audit Report Day Shift documented R1's Chlorhexidine Gluconate Solution 0.12 % 2x day, Metoprolol Tartrate Tablet 25 MG 2x a day, Gabapentin Capsule 300 MG 2x a day, Senna S Tablet 8.6-50 MG 2x a day were scheduled at 9am, the administration time was at 12:11pm, documented time was at 12:12pm and documented by V3 (Licensed Practice Nurse). R1's 08/11/2025 Medication Administration Audit Report Day Shift documented R1's Chlorhexidine Gluconate Solution 0.12 % 2x day, Metoprolol Tartrate Tablet 25 MG 2x a day, Gabapentin Capsule 300 MG 2x a day, Senna S Tablet 8.6-50 MG 2x a day were scheduled at 9am, the administration time was at 10:35am, documented time was at 10:36am and documented by V3 (Licensed Practice Nurse). R1's 7/10/2025 Medication Administration Audit report Evening shift documented R1's Chlorhexidine Gluconate 2x daily, Gabapentin 300mg 2x daily, Metoprolol Tartrate Tablet 25 MG 2x daily, Senna S Tablet 8.6-50 MG 2x daily, Protonix Tablet Delayed Release 40 MG every 12 hours, Anucort-HC Rectal Suppository 25 MG every 12 hours were scheduled at 6pm; and the administration time and documented time were at 9:51pm and documented by V3 (Licensed Practice Nurse). R1's 07/14/2025 Medication Administration Audit Evening shift documented tR1's Chlorhexidine Gluconate 2x daily, Gabapentin 300mg 2x daily, Metoprolol Tartrate Tablet 25 MG 2x daily, Senna S Tablet 8.6-50 MG 2x daily, Protonix Tablet Delayed Release 40 MG every 12 hours, Anucort-HC Rectal Suppository 25 MG every 12 hours were scheduled at 6pm;; the administration time was at 10:04pm, documented time was at 10:06pm and documented by V3 (Licensed Practice Nurse). R1's 07/20/2025 Medication Administration Audit report Evening shift documented R1's Chlorhexidine Gluconate 2x daily, Gabapentin 300mg 2x daily, Metoprolol Tartrate Tablet 25 MG 2x daily, Senna S Tablet 8.6-50 MG 2x daily, Protonix Tablet Delayed Release 40 MG every 12 hours were scheduled at 6pm; and the administration time was at 9:01pm, documented time was at 21:03pm and documented by V3 (Licensed Practice Nurse). R1's 08/11/2025 Medication Administration Audit report Evening shift documented that R1's Chlorhexidine Gluconate 2x daily, Gabapentin 300mg 2x daily, Metoprolol Tartrate Tablet 25 MG 2x daily, Senna S Tablet 8.6-50 MG 2x daily, Protonix Tablet Delayed Release 40 MG every 12 hours, Anucort-HC Rectal Suppository 25 MG every 12 hours were scheduled at 6pm; and the administration time was at 9:57pm, documented time was at 9:57pm and documented by V3 (Licensed Practice Nurse). On 09/17/2025 at 12:09pm, V3 (Licensed Practice Nurse) stated some residents have scheduled 6pm medications and 9pm medications during the evening shift. If the schedule is at 6pm, she administers the medication between 5pm and 7pm; and if the schedule is at 9pm, she administers the medication between 8pm and 10pm. V3 stated she is supposed to sign the eMAR (electronic Medication Administration Record) right after she gave the medications to acknowledge or document she gave the medications; she is not supposed to wait in documenting medication administration. V3 stated it is possible she opened the eMAR at 6pm, gave the medications to him (R1), and signed or acknowledged she gave the medications later during the 9pm medication pass. V3 stated she is expected to sign the eMAR right after the medications were administered. On 09/17/2025 at 12:21pm, V2 stated nurses are expected to sign or acknowledge the medications are administered right after the nurse gave the medications. Nurses are not expected to wait 3 hours or so to document they administered the medications. The purpose is to make sure the medications are administered timely. The 10/25/2024)Administration Procedures for All Medications documented, Policy. To administer medications in a safe and effective manner. Procedures: J. After administration, return to cart, and document administration in the MAR.

Based on interview and record review, the facility failed to provide supervision to residents who obtained and consumed alcohol in the facility for 5 of 10 residents ( R1,R2,R3,R4 and R5) of the sample. This failure resulted in an unsafe environment for the residents in the facility.Findings include:5 Residents (R1,R2,R3,R4, and R5) were involved in consumption of alcohol on facility premises.R1 is a [AGE] year-old female, with diagnoses including Cerebral Palsy, Morbid Obesity, Anxiety Disorder, and Depression. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview Of Mental Status) Score of 15/15, indicating intact cognition.R2 is a [AGE] year-old male, with diagnoses including heart disease with Heart Failure, Schizo-affective Disorder, and is an Identified offender. R2 was first admitted to the facility on [DATE]. R2 has a BIMS (Brief Interview Of Mental Status) score of 15/15.R3 is a [AGE] year-old male resident, with diagnoses including Hypertensive Heart Disease, and Peripheral Vascular Disease. R3 has a BIMS (Brief Interview of Mental Status) Score of 13/15.R4 is a [AGE] year-old female, with diagnoses including COPD (Chronic Obstructive Pulmonary Disease), Diabetes type 2, Hemiplegia and Hemiparesis following Cerebral Infarction, and Schizoaffective Disorder. R4 was first admitted to the facility on [DATE]. R4 has a BIMS (Brief Interview Of Mental Status) score of 15/15.R5 is a [AGE] year-old male with diagnoses including Hypertensive heart disease with heart failure, and COPD. R5 was first admitted to the facility on [DATE]. R5 has a BIMS (Brief Interview Of Mental Status) score of 15/15.On 8/19/25 at 9:50AM, V1 (Administrator) per phone, stated, On 7/30/25, (R1, R2, R3, R4, and R5) were found to be drinking alcohol on the 4th floor in the dining room. I don't know how they got the alcohol. All were put on a 30 day suspension from unsupervised community pass.On 8/14/25 at 11:42AM, V3 (Social Service stated, (R1) was caught drinking by a nurse that had approached her in the day room on 4th floor. There was a group of residents drinking at a table playing cards at around 7:30PM. The nurse reported incident to (R1s) doctor, and he ordered a urine test. I reviewed the camera and could see the group drinking alcohol from plastic drinking cups. The nurse also smelled liquor on the breath of (R1) and at the table of residents in the group. (R1, R2, R3, R4 and R5). As part of behavior agreement, (R1) was put on a 30 day restriction for unsupervised pass privileges. (R1) is receiving 1:1 psychosocial therapy. (R1) also participates in daily activities. I do not know where the group got the alcohol. None of the residents would provide any information. The other 4 residents were also put on a 30 day restriction. Today, (R1) wrote me a letter admitting to drinking alcohol that day. I have a copy in my files.On 8/14/25 at 1:33PM, V4 (Licensed Practical Nurse/ LPN ) stated, It was reported to me by a CNA (Certified Nursing Assistant), (V5), that (R1, R2, R3, R4, and R5) were seen in the dining room sitting at a table drinking alcohol. I tried to search belongings, but the residents wouldn't let me. I smelled alcohol at the table where the residents were sitting. I made them disperse. I contacted (R1's) physician and mother. The physician ordered a urine test to be done. That is all I can recall of the incident on 7/30/25.On 8/14/25 at 1:52PM, V5 (CNA) stated, There were residents in the dining room drinking. I reported this to the nurse. That is all I know.On 8/4/25 at 2:14PM, R6 stated, (interpreter for V6 was present),I was in the dining room. A group of residents including (R1, R2, R3, and R5) that I can remember had a small yellow/brown bottle and they were drinking from plastic cups. I went back to my room and told the CNA about it. The camera saw what happened. There are cameras in that room. That is all I know. I don't want to get in trouble. I was afraid to be in there when they were drinking.R1's progress noted, dated 7/30/25, states Note Text: Medication administration was held due to suspicion of recent alcohol consumption on facility property. Resident observed exhibiting signs consistent with possible intoxication, order of alcohol. Nursing and administrative staff notified. Per MD order, hold all meds till resident is drug screened. POA (Power of Attorney) has been notified. Awaiting further assessment and direction per facility policy.Review of R1's, R2's, R3's, R4's, and R5's physician orders do not show a physician order for the consumption of alcohol.Facility policy titled Alcohol Beverages includes:Purpose: To provide for the safe consumption of alcohol beverages.Guidelines: A physician order will be obtained for a resident to receive alcohol beverages in the facility.

Based on interview, and record review, the facility to ensure two [R1, R2] of five residents sampled was free of abuse from an employee. These failures resulted in R1 sustaining swollen discolored lips and pain, and R2 experiencing increase in pain and mental anguish. Findings Include, 1. R1's clinical record indicates R1 is a seventy-one-year-old, admitted with hemiplegia, hemiparesis following cerebral infarction affecting right dominant side, dysphagia, type II diabetes, vascular dementia, major depression, abnormal posture, lack of coordination, abnormal posture, gait and mobility, essential hypertension. R1's Minimum Date Set [MDS] section [C] indicates R1 is moderately cognitively intact. MDS section [GG] indicates R1 requires maximum assist with ADL care, transfers, and mobility in bed with repositioning. R1's Care plan documents: On 6/6/25, R1 reported physical abuse. R1 will benefit from restorative program due to generalized weakness, impaired mobility, and physical limitations. R1 is a fall risk: [2/28/25] applied bilateral floor mats when R1 is in bed. R1 is dependent with ADL care, turning and repositioning, sit to lying, and sit to stand. R1 requires use of full body lift for transfers. R1 will be treated with respect, dignity, ad resides in the facility free of mistreatment. R1's Progress notes documented: 6/6/2025 at 6:25 PM, Nurses Notes [V8, Registered Nurse] Note Text: R1's bottom lip was swollen. Notified the family and nurse practitioner [V10]. R1's IDPH [Illinois Department of Public Health] Reportable, dated 6/11/25, documents: Investigation completed. During nursing rounds [R1] alleged [V5, Certified Nurse Assistant] hit her while she was helping her with care. [V5] was immediately suspended. Interview with [R1] stated while she was receiving care from [V5], [R1] pulled the hair of [V5] and did not let go until [V5] pushed herself away. That is when [R1] was hit in the lip. No other staff or resident was in the room at the time. Based on the report by [R1], the facility will substantiate abuse. R1's 6/6/2025 6:22 PM V10, Nurse Practitioner, Progress Notes Late Entry: Swollen Right lip and jaw, follow up visit for acute and chronic medical conditions. HPI: [AGE] year-old female with a past medical history of ischemic stroke with no residual neurological deficit and hypertension. 6/6/25, [R1] was seen and examined due to being notified of right swollen lip and jaw due to possible fall. After interviewing the patient, [R1] claims that she was being changed by the CNA and she felt the CNA was being a little rough, so [R1] pulled the CNAs hair and yanked it down, then the patient explained that right after that the CNA punched her in the right side of her face. Right lip and jaw were swollen and bruised but [R1] could still talk and open/close her mouth, Eating meals. Will continue to monitor, notified Administrator [V1] and V2 [Director of Nursing]. R1's 6/10/2025 11:49 AM Nurses Notes: Note Text: [R1] complained of pain in the lips, assessed and discoloration noted, Tylenol given as ordered, ice pack placed on the lips checked within normal limit.` R1's 6/11/2025 1:00 PM, V10, Nurse Practitioner Progress Notes Follow up Swollen Right lip and jaw, follow up visit for acute and chronic medical conditions on 6/11, [R1] still complaining of right jaw pain, right lip swelling is improved, [R1] remains stable, Ordered Facial XR (x-ray) for facial bones. Results acute ischemic infarct resulting in LLE weakness and mild dysarthria history of multiple ischemic strokes in the past, and Vascular dementia. On 6/11/25 at 1:50 PM, surveyor R1's right side of lip with light colored red area noted. R1 stated, On Friday, [V5] was cleaning me up and changing my linen tossing me from side to side. I was hurting, and I told [V5] to stop pushing me hard on my side. I started yelling for [V5] to stop, but [V5] kept going. I reached up and was able to get hold of her hair then I pulled it, only to make her stop hurting me. Then [V5] took her fist and punched me in the mouth so hard it took my breath away. Once she punched me, she ran out of my room. Another nurse aide came into my room, and I told him what happened, then the nurses came in to check on me. My mouth and lips were hurting ever since Friday. My lips were swollen, black, blue, and bleeding. On 6/11/25 at 2:00 PM, R5 stated, On Friday when [R1] was beat up, I was not in the room, I was in the day room. I left out the room when [V5] came to clean [R1] up. Then once I returned, [R1's] mouth was swollen really bad and was black and blue. I was in shock, to see how bad [R1's] face looked. [R1] told me [V5] punched her in the mouth. On 6/12/25 at 11:00 AM, V6 [R1's Family Member] stated, Friday morning, I received a phone call from [V8, Registered Nurse]. V8 told me [R1] had a swollen bottom lip and administration will investigate the cause of the swelling. [R1] is alert and oriented x3; due to the stroke sometimes her speech is not clear on some days. Some people mistake her word delay for cognitive deficit, but that is not true. The next day I spoke with [R1] over the phone. [R1] said [V5] was cleaning her up and moving back and forth roughly, causing her pain to increase. [R1] said she was yelling out telling [V5] to stop, but she kept on being rough. So, [R1] grabbed [V5's] hair to make her stop, then [V5] with a closed fist punched [R1] on the side of her mouth and jaw. Saturday, I went to visit with [R1] and noted her lips swollen, black, and blue. There was not anyone for me to speak with on Saturday. On Monday I spoke with [V1, Administrator] and he told me basically the same story and he was investigating the allegation of abuse. I am a retired police officer. The facial trauma [R1] had definitely came from a facial punch, not from [R1] sliding out the bed onto the mats on the sides of her bed. Due to [R1] having a stroke, half of her body is paralyzed. [R1] is unable to stand up, she only can slide out the bed onto her floor mats. [R1] would not have got that type of injury from a slide and fall. I did not request [R1] to be sent to hospital. [V10, Nurse Practitioner] called me and gave me an update on his assessment. On 6/12/25 at 1:00 PM, V10 [Nurse Practitioner] stated, I am [R1's] nurse practitioner. I was in the facility the day of the incident. When I assessed [R1], her lip and jaw was swollen there was redness, blue purplish discoloration in the lip area noted. [R1] told me that [V5] was rough during care, and that she told [V5] to stop, but [V5] kept going, then [R1] grabbed [V5] hair and [V5] punched her [R1] in the right jaw, lip area. Once I assessed [R1], she could talk and eat, and did not have any acute findings. I ordered a facial X-ray no concerns of fracture. During my assessment, there was no active bleeding, however, I did see a tiny scab on the upper right lip was noted, but no active bleeding at that time. I did not send [R1] to the hospital because my assessment did not show any acute findings was going on, and there was no suspicion of a fracture. [R1's] still having residual pain and hurts mildly when she's chews. [R1] said it was mild pain and receives Tylenol for pain as needed. I saw [R1]; today the swelling has decreased, and she says she's feeling much better today. On 6/6/25, I notified administration about the allegation of abuse and my assessment on the injury. I did not get any notifications that [R1] had any fall on 6/6/25. On 6/12/25 at 2:18 PM, V8 [Registered Nurse] stated, I am new nurse, received my license a month ago. [R1] is alert and oriented x2-3, able to express herself to make her needs known. [R1] mostly stays in bed and needs maximal assistance with ADL care, repositioning, and transfers. I was [R1's] nurse on 6/6/25. I administered [R1's] morning medications, and there was no swelling nor bruising noted on [R1's] face. [V5] did not tell me that [R1] slid out her bed on to the floor mat. I would have assessed [R1], completed incident report, and make [V2, Director of Nursing] and [R1's] family member [V6] aware. Around 3:30 PM, a second shift certified nurse assistant told me to come look at [R1's] face. I observed [R1] with a significantly swollen lips that was black, blue, and purplish in color. [R1] was visibly upset and said [V5] was providing care and being rough, causing an increase in pain. [R1] said she yelled out to [V5] telling her to stop a few times, but [V5] kept pulling and pushing her from side to side, so [R1] said she reached up a grabbed [V5's] hair as [V5] was pushing her to [R1's] side. [R1] said [V5] got really upset, and then [V5] punched her [R1] in the mouth with her [V5] fist. I took [R1's] vital signs, and applied an ice pack on [R1's] mouth area. I notified [R1's] nurse practitioner [V10]; he was in the facility, phoned [R1's] family member [V6]. I also told the manager on duty [V9] and he called the Administrator for me. [V5] did not report to me that [R1] grabbed and pulled her hair. [V5] did not report any incident regarding [R1]. On 6/12/25 at 2:48 PM, V9 [Director of Restorative/Licensed Practical Nurse] stated, On 6/6/25, around 4:00 PM, [V8] notified me that [R1] said [V5] punched her in the face. I went to [R1's] room, and I saw [R1's] lips on the side was swollen and were discolored dark purple, blackish color. [R1] told me [V5] was hurting her during ADL care turning her back and forth hard, and asked [V5] to stop several times, but [R1] said [V5] kept going. [R1] said she then grabbed and pulled [V5's] hair to make her stop. [V5] punched her in the face with her [V5] fist. I then immediately called [V5] to the reception desk and asked her what happened. [V5] did not say nothing. [V5] punched out and left the facility. I notified [V1, Administrator]. I was instructed to call the police, and the police report was made. [R1] is alert and oriented x3, she has never made any allegation of abuse before. On 6/12/25 at 4:35 PM, V2 [Corporate Interim/Director of Nursing] stated, I been in this facility since April 2025. I was on vacation during the time of ]R1's] incident on Friday, 6/6/25. I returned on Tuesday and learned about the allegation of abuse. I went to see [R1 ]and observed her lower lip swollen purplish in color. I asked [R1] was she okay, she responded yes. I did not ask [R1] what happened, I did not want to trigger her trauma. I had nothing to do with the investigation. On 6/12/25 at 4:50 PM, V3 [Assistant Director of Nursing] stated, I was made aware 6/6/25 by [V9], that [R1] alleged [V5] punched her [R1] in the mouth. [V5] was suspended and sent home. I made [V2, Director of Nursing] aware and [V1, Administrator]. I saw [R1] on Monday, 6/9/25, and noted [R1] with swollen lips, dark in color. I sent a message to [V2, Director of Nursing] in regard to the allegations. On 6/13/25 at 10:22 AM, V5 [Certified Nurse Assistant] stated, I was working a double shift on 6/6/25. First shift I worked on the first floor with [R1]. On 6/6/25, around 9AM, [R1] slipped out of bed like she normally does. [R1] was observed lying on the floor mat next to her bed face up. I assisted her back to bed; nothing was wrong with [R1's] face. I told [V8, Registered Nurse] but [V8] said she was too busy, and for me to put [R1] back into bed. After lunch around 1PM, I went to provide ADL care to [R1], and she needed a linen change. There was nothing wrong with [R1's] lips or mouth area. During ADL care, out of nowhere, [R1] grabbed my hair and pulled down. When [R1] finally let go of my hair, I left out of [R1's] room and reported the situation to [V8]. After the incident, I never went back into [R1's] room. Later, I was working second shift on the third floor, when I was paged to come down into to the lobby. [V9, Restorative Nurse] the manager on duty, asked me what happened between me and [R1]. I told him the same story. [V9] told me that I was suspended pending abuse investigation. I punched out and left the facility. I did not hit [R1] on her face, lips, mouth or anywhere. I am familiar with [R2]. I did not have any conflicts with [R2]. I have never been rough while providing care to [R1] nor [R2]. I did not receive abuse training. I do not know who the Abuse Coordinator is for the facility. I started working at the facility April 2025. On 6/13/25 at 1:20 PM, V11 [Certified Nurse Assistant] stated, I worked on Friday, June 6th, and I did not hear any yelling from [R1's] room. I did not see any swelling or bruising on [R1's] mouth on 6/6/25, but I was not [R1's] CNA on that day. I am familiar with [R1]; she is alert, oriented x3. [R1] requires extensive assist with ADL care, repositioning and transfers, due to her being paralyzed on one side. [R1] is not able to stand up or walk. There are times [R1] slides out of bed. We all make sure the floor mats stay in place to prevent any injuries. I received abuse in-service a couple of weeks ago. The abuse coordinator is the administrator. 2. R2's clinical record documents R2 is a seventy-year-old, admitted with hemiplegia, hemiparesis following cerebral infarction affecting left side, dysphagia, chronic obstructive pulmonary disease, abnormal gait and mobility, lack of coordination, abnormal posture, essential hypertension, reduced mobility, and muscle wasting. R2's Care plan documents: R2 has deficit in bed mobility due to generalized weakness, impaired gait, balance, pain secondary to CVA and left sided hemiparesis. R2 will be treated with respect, dignity, ad resides in the facility free of mistreatment. R2's IDPH Initial Reportable, dated 6/12/25, documents: [R2] is alert and orientated x3. During rounds with IDPH surveyor, [R2] reported that [V5, Certified Nurse Assistant] ate his food a few times, was rough when giving care, and verbally rude many times when interacting with [R2]. [V5] was suspended previously due to investigation. [R2] was told [V5] no longer works at the facility. [R2] has no distress and feels safe in the facility. Family and physician made aware. Police department made aware. Full report to follow. On 6/12/25, at 4:30 PM, during rounds with V1 [Administrator] R2 stated, I remember [V5]. Her and my niece have the same name. I would place on my call light, and she would barge into my room and say 'what do you want', being so rude and disrespectful all the time. I told [V5] that I was going to tell my family that she was so rude and hurts me when providing care. [V5] said that was fine, and have my family come wipe my a**. When [V5] provided ADL [activities of daily living] care, she would push me on my side rough and hard, which would increase my pain. One day I received my food tray around 12 noon. [V5] came into my room before I could eat, she removed my food tray. On those days, I just didn't eat. [V5] was very cruel, mean, disrespectful, and [V5] was being rough, caused me to have pain. [V5] was physically and verbally abusive to me more than once. It made me feel bad about myself, sad, less than a man. I am here because I need the help, not to feel terrible about myself. I don't want [V5] to care for me anymore. I told you [ V1/ Administrator] a few days ago, how [V5] provided care to me, I told you everything. V1 stated, I do not recall you [R2] telling me this information, I will investigate, complete and send in the IDPH reportable today. On 6/12/25 at 4:45 PM, V1 [Administrator] stated, The incident occurred on 6/6/25, on first shift, approximately 2PM. [V8, Registered Nurse] was [R1's] nurse and was supervising [V5, Certified Nurse Assistant]. A 3PM-11PM Certified Nurse Assistant told [V8] that [R1's] mouth was swollen and bruised, and [R1] said [V5] punched her in the mouth. [V8] assessed [R1] with the manger on duty, [V9, Director of Restorative Services], and [V9] notified me of the allegation of abuse. [V5] was immediately suspended and left the facility. [R1] told me during ADL care with [V5], she [R1] pulled [V5's] hair due to [V5] being rough, then [V5] hit [R1] on the lip. I completed the IDPH reportable. [V5] was interviewed, and said [R1] did pull her hair, but said she did not hit or punch [R1], and does not know how [R1's] lip was injured. Inservice of abuse prevention and reporting were given to staff. [R2's] allegation of abuse from [V5]; a reportable to was sent into IDPH today, and I started an investigation. Based on the report from [R1] and the injury, the facility will substantiate that the alleged abuse happened, and [V5] was terminated today [6/12/25]. All staff received abuse training on 6/9/25. Policy documented: Abuse Prevention and Reporting Policy dated 10/24/22. This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods, physical, sexual, mental, verbal, unreasonable confinement, and involuntary seclusion. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual including a caretaker of goods or services that are necessary to attain and or maintain physical, mental or psychosocial well -being.

Based on interview, and record review, the facility failed to implement and maintain an effective abuse training program for one [V5] of three employees reviewed. Findings include, On 6/11/25 at 1:50 PM, surveyor observed R1 right side of lip with light colored red area noted. R1 stated, On Friday, [V5] was cleaning me up and changing my linen, tossing me from side to side. I was hurting, and I told [V5] to stop pushing me hard on my side, I started yelling for [V5] to stop, but [V5] kept going. I reached up and was able to get hold of her hair then I pulled it, only to make her stop hurting me. Then [V5] took her fist and punched me in the mouth so hard it took my breath away. Once she punched me, she ran out of my room. Another nurse aide came into my room, and I told him what happened, then the nurses came in to check on me. My mouth and lips were hurting ever since Friday. My lips were swollen, black, blue, and bleeding. On 6/12/25, at 4:30 PM, during rounds with V1 [Administrator] R2 stated, I remember [V5]; her and my niece have the same name. I would place on my call light, and she would barge into my room and say 'what do you want', being so rude and disrespectful all the time. I told [V5] that I was going to tell my family that she was so rude and hurts me when providing care. [V5] said that was fine and have my family come wipe my a**. When [V5] provided ADL care, she would push me on my side rough and hard, which would increase my pain. One day I received my food tray around 12 noon. [V5] came into my room before I could eat, she removed my food tray. On those days I just didn't eat. [V5] was very cruel, mean, disrespectful, and [V5] was being rough, caused me to have pain. [V5] was physically and verbally abusive to me more than once. It made me feel bad about myself, sad, less than a man. I am here because I need the help, not to feel terrible about myself. I don't want [V5] to care for me anymore. I told you [ V1/ Administrator] a few days ago, how [V5] provided care to me, I told you everything. V1 stated, I do not recall you [R2] telling me this information, I will investigate, complete and send in the IDPH [Illinois Department of Public Health] reportable today. On 6/13/25 at 10:22 AM, V5 [Certified Nurse Assistant] stated, I was working a double shift on 6/6/25. First shift I worked on the first floor with [R1]. After lunch around 1PM, I went to provide ADL care to [R1], and she needed a linen change, there was nothing wrong with [R1's] lips or mouth area. During ADL care, out of nowhere, [R1] grabbed my hair and pulled down. When [R1] finally let go of my hair, I left out of [R1's] room and reported the situation to [V8, Registered Nurse]. After the incident, I never went back into [R1's] room. Later, I was working second shift on the third floor when I was paged to come down into to the lobby. [V9, Restorative Nurse], the manager on duty, asked me what happened between me and [R1]. I told him the same story. [V9] told me that I suspended pending abuse investigation. I punched out and left the facility. I did not hit [R1] on her face, lips, mouth or anywhere. I am familiar with [R2]. I did not have any conflicts with [R2]. I have never been rough while providing care to [R1] nor [R2]. I do not receive abuse training. I do not know who the Abuse Coordinator is for the facility. I started working at the facility April 2025. On 6/11/25 at 11:20 AM, V4 [Human Resource/Corporate Interim] stated, I been in human resources for five years. I been in this facility since 5/28/25. [V5] was hired on 4/22/25, After careful review of [V5's] employee file, [V5 ]did not receive Abuse training upon hire, during orientation, nor the course of her [V5] employment. All staff is to receive abuse training and prevention upon hire before working with residents. The abuse training should be maintained in the employee's file. On 6/12/25 at 4:45 PM, V1 [Administrator] stated, I am the Abuse Coordinator of the facility. All employes are required to received abuse training, reporting and prevention upon hire prior to the employee working with the residents. The Abuse training is to prevent abuse from occurring and teaching the employee how to respond appropriately to aggressive residents. If an employee does not receive abuse training, it could potentially increase the risk for abuse. The abuse training should remain in the employee file. Policy documented: Abuse Prevention and Reporting Policy dated 10/24/22. Orientation and Training of Employees: During orientation of new employees, the facility will cover at least the following topics: What constitutes abuse. How to assess, prevent and manage aggressive, violet reactions of residents in a way that protects both the resident and staff. This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods, physical, sexual, mental, verbal, unreasonable confinement, and involuntary seclusion. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual including a caretaker of goods or services that are necessary to attain and or maintain physical, mental or psychosocial well -being.

Based on observation, interview, and record review, the facility failed to follow a resident's care plan and physician's order to keep head of bed up to 45 degrees for a ventilator dependent resident (R73); failed to closely monitor a resident receiving continuous oxygen and failed to follow physician's order to ensure a resident was receiving the correct oxygen flow rate for one resident (R118); and failed to date/label and maintain proper storage of oxygen nasal cannula tubing in a plastic bag when not in use for two (R91, R419) out of four residents reviewed for respiratory care in a final sample of 32. Findings Include: 1. R118's electronic health records documented R118 was admitted in the facility on 3/7/23, with diagnoses not limited to Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, Dementia, and Depression. R118's Minimum Data Set, dated dated [DATE], shows R118 is moderately impaired with cognition, and is dependent on staff's assistance on dressing, grooming, and personal hygiene. R118's order summary report shows an order for: Oxygen at 2 LPM per Nasal Cannula continuously - Monitor oxygen saturation every shift for Hypoxia (ordered 9/23/24). On 5/13/25 at 11:53 AM, R118 was observed sleeping in bed. R118's oxygen (O2) concentrator was running continuously with the O2 flow rate set to 3 liters per minute (LPM). R118's oxygen nasal cannula tubing was noted on the floor and not inside R118's nose. On 5/13/25 at 11:59 AM, V15 (Agency Licensed Practical Nurse/LPN) verified R118's oxygen order in the electronic health record; R118 should be getting 2 LPM of continuous oxygen via nasal cannula. On 5/15/25 at 9:14 AM, V2 (Interim Director of Nursing) and stated nurses should be monitoring that the resident's oxygen is on the right setting. V2 stated O2 setting is based on the physician's order, and should be followed for effective use. The facility's OXYGEN DELIVERY SYSTEM policy (no date) documents: It is the policy of this facility that oxygen will be delivered to the residents based upon physician's orders utilizing the following systems: A. Oxygen concentrators providing more than 93% oxygen concentration at flow rates ranging from 1 LPM to 10 LPM. 2. R73's clinical records included diagnoses of chronic respiratory failure with hypoxia, encounter for attention to tracheostomy, dependence on respirator [ventilator] status, and encounter for attention to gastrostomy. R73's Minimum Data Set, dated dated [DATE], showed R73 is total dependent on staff assistance for his ADLs (Activities of Daily Living) and is severely impaired with cognition. R73's order summary report showed an order for head of the bed > 45 degrees all the time (ordered 3/10/25). R73's care plan showed R73 has oxygen therapy related to respiratory illness (date initiated 4/25/24) with one intervention that reads, Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45 degrees). R73's care plan also shows R73 is ventilator dependent related to respiratory failure (date initiated 5/5/21) with on intervention that reads, Keed head of bed elevated above 30 degrees unless providing care or resident request. On 5/13/25 at 12:29 PM, R73's lying in bed awake, non-verbal, tube feeding was running, and his head of bed slightly up to approximately 10 to 20 degrees. R73's face was flushed and noted gasping for air. Surveyor immediately called V17 (Regional Respiratory Therapist/RT). On 5/13/25 12:31 PM, V17 and another RT repositioned R73, suctioned, and raised his head of bed. On 5/13/25 at 12:35 PM, V16 (Agency Licensed Practical Nurse) and V18 (Respiratory Therapy Director) entered R73's room and assessed R73. Vital signs read: 98% oxygen saturation; blood pressure was 130/85; and 102 heart rate. On 5/13/25 at 12:39 PM, V18 (RT Director) stated R73's head of bed should be up at least 30 degrees to avoid aspiration. V18 stated if the head of bed is too low, R73 could aspirate and experience respiratory distress. R73's progress notes, dated 5/13/25 at 1:52 PM documented by V16, reads in part: [V16] was alerted by respiratory that R73 was in distress. R73 was assessed. Vitals were taken and were 130/85, pulse 102, oxygen 98. V42 (Nurse Practitioner) was notified and will come in the facility to assess R73. The facility's VENTILATOR SET UP (no date) documents: It is the policy of this facility that the respiratory therapist will ensure ventilator equipment is in place and that the patient is received and stabilized in an orderly manner. 49486 3. R91's Minimum Data Set (MDS), dated [DATE], Brief Interview Score (15) indicates R91 is cognitively intact. R91's Physician Order Sheet (POS), dated 5/13/25, shows an active diagnosis of chronic respiratory failure with Hypoxia, chronic obstructive pulmonary disease, chronic systolic congestive heart failure, and chronic ischemic heart disease. R91 has an active order for oxygen at 3-4 Liters per minute, per nasal cannula continuously for Shortness of Breath (SOB) and wheezing. On 5/13/25 at 12:35 PM, V3 (Licensed Practical Nurse/LPN) entered R91's room. R91 was up in bed, oxygen nasal cannula tubing hanging on his wheelchair touching the floor, not dated, and not in a plastic bag. V3 stated the oxygen tubing should be dated and in plastic bag when not in use to prevent contamination, and she will discard the tubing right now. 4. R419's Minimum Data Set (MDS), dated [DATE], Brief Interview Score (15) indicates R419 is cognitively intact. R419's Physician Order Sheet (POS), dated 5/13/25, shows active diagnoses of acute respiratory failure with hypercapnia, dependence on respirator ventilator status, and chronic obstructive pulmonary disease. R419 has an active order for oxygen at 2 liters per minute, per nasal cannula every day and evening shift. On 5/13/25 at 12:54 PM, V5 (Respiratory Therapist) entered R419's room. R419's oxygen nasal cannula tubing hanging on the oxygen concentrator tank, not dated, and not in a plastic bag. V5 stated having the oxygen nasal cannula hanging out on the oxygen tank makes R419 at risk for breathing in germs like bacteria, and the oxygen nasal cannula should have been contained in a plastic bag when not in use. V5 also stated the tubing should be dated weekly so that staff will know when the tubing was changed. On 5/15/25 at 8:56 AM, V2 (Interim Director of Nursing/DON) stated it is his expectation nurses will change, and date oxygen nasal cannula tubing every Thursday night, and as needed. He also stated that oxygen nasal cannula tubing should be stored in a plastic bag when not in use to maintain good hygiene and prevent infection as much as possible.

Based on observation, interview, and record review, the facility failed to ensure food items were properly labeled and dated. These failures have the potential to affect all 130 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:15 AM, V20 (Food Service Director) stated all items in the refrigerator should be labeled and dated with a delivery date, an open date, and use by date. V20 stated highly perishable items are discarded after seven days. V20 stated it is everyone's responsibility to label and date items. V20 stated labeling and dating items in the refrigerators are important so the staff does not serve outdated or expired food to the residents which could potentially make them sick. On [DATE] at 9:18 AM, the following items were found in the walk-in refrigerator: 1.) Sliced ham hand wrapped in plastic wrap, dated [DATE]. V20 stated the date [DATE] was the day the ham was sliced by the staff in the kitchen. The package was not labeled with a use by date. 2.) Large plastic container of grape jelly covered in plastic wrap. There was no label or opened or use by date. 3.) Opened 5-pound bag of shredded mozzarella cheese, dated with delivery date [DATE]. The item was not labeled with an open or use by date. On [DATE] at 9:35 AM, inside the reach in cooler observed the following item: 1.) Opened 5-pound container of sour cream labeled with a delivery date [DATE]. There was no use by or opened date on the container. V20 stated since it is not labeled with an opened date, there is no way of knowing how long it has been opened, and it should be used within one week from the opened date. On [DATE] at 1:32 PM, V25 (Registered Dietitian) stated, Labeling and dating is important to ensure the food is not bad or spoiled, and then potentially be served to a resident. For this reason, it is important for items to be labeled with an opened date and a use by date, so the staff knows when the food items should be tossed out. The potential problem with foods not being labeled or dated is the possibility that someone could get sick from bad food if served beyond the expiration date. On [DATE], facility provided list of diet orders for all residents in the facility. The diet order list indicates there is 26 residents receiving nothing by mouth (NPO). Facility provided policy titled, Food Storage (Dry, Refrigerated and Frozen), dated 2020, documents all food items will be labeled, and the label must include the name of the food and the date by which it should be sold, consumed, or discarded. Facility provided policy titled, Cold Storage Areas, undated, documented to date, label, and properly secure all products removed from original containers with all items labeled stating the contents inside, the date opened and the appropriate use-by-date.

Based on observation, interview, and record review, the facility failed to ensure a visitor entering a contact isolation room was wearing proper personal protective equipment (PPE) for one resident (R67), and failed to ensure staff wore the proper PPE when providing care for 3 (R41, R72, R219) residents on Enhanced Barrier Precautions. These failures has the potential to affect 60 residents residing on the third floor, and 60 residents residing on the fourth floor. Findings Include: 1. R219 was admitted to the facility on [DATE], with diagnoses not limited to Type 2 Diabetes Mellitus with Hyperglycemia, Acute Kidney Failure, Dependence on Renal Dialysis, Gastrostomy, Hypertensive Heart Disease, Shaken Infant Syndrome, Cerebral Palsy, Epilepsy, Abnormalities of Gait and Mobility, Polycystic Ovarian Syndrome, and Blindness, Both Eyes. R219's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicates resident is rarely/never understood. R219's Order Summary Report documents: Enhanced Barrier Precautions: Dialysis catheter. Every shift. Order date 04/30/25. On 05/13/25 at 12:08 PM, R219 was observed in bed. V8 (Restorative) was observed in R219's room adjusting R219's brief. Enhanced Barrier Precaution signage was observed at R219 room entry. V8 did not have on a gown while providing care. V8 stated, I was adjusting (R219's) diaper. (R219) has a g (gastric) tube. I should have on PPE (Personal Protective Equipment), a gown and gloves. I did not have on a gown. On 05/15/25/ at 09:16 AM, V2 (Interim Director of Nursing) stated, When providing care for a resident on Enhanced Barrier Precautions, the PPE (Personal Protective Equipment) that should be worn is a gown and gloves, as stated on the signage. If the gown and gloves are not worn, there is a potential for the spread of infection. Enhanced Barrier Precautions Signage documents: Stop, Providers and staff must also: Wear gloves and a gown for the following High Contact Resident Care Activities. Providing Hygiene, changing briefs or assisting with toileting. Device care or use: central lie, urinary catheter, feeding tube, tracheostomy. Policy: Titled Enhanced Barrier Precautions (EBP), revised 04/01/24, documents: Purpose: To minimize the risk of acquiring, transmitting, or complications resulting from multi-drug-resistant organism (MDRO) colonization among residents in this setting. (Contact precautions would be warranted over EBP when there is a risk of transmission of an actively infectious agent). Populations Affected: Residents with existing or colonized MDRO's where other transmission-based precautions are not warranted. Residents at increased risk of MDRO acquisition (Residents with wound or indwelling medical devices). Equipment Needed: Gowns, Gloves, Room Notification signage. Guidelines: Residents will require the use of personal protective equipment (PPE) for high-risk activities such as: bathing, dressing, toileting, transferring residents, linen changes, wound care, handling indwelling medical devices. PPE required: Gowns, Gloves. Persons expected to encounter these circumstances are to don PPE (gown and gloves) in accordance with the activity that will be encountered when caring for the Resident. 44103 2. R67's Order Summary Report, printed on 5/14/25, reads: Contact Isolation Precautions: Clostridium Difficile CDIFF every shift for 10 days (ordered 5/6/25). R67's care plan shows R67 is on contact isolation precautions due to positive test for clostridium difficile, CDIFF with one intervention reads in part: Educate resident/family/staff regarding safety guidelines and infection control procedures. On 5/13/25 at 12:49 PM, R67's room was observed with an isolation cart setup outside her room. A contact precautions signage was noted posted on R67's door that indicates: Everyone must clean their hands, including before entering and when leaving the room. Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. V37 (R67's Family Member) was inside R67's room, not wearing isolation gown or gloves. Surveyor attempted to interview R67 and V37, but both stated they do not understand English. On 5/13/25 at 12:55 PM, V12 (Licensed Practical Nurse) stated R67 is on contact isolation for Clostridium difficile (C. diff). V12 stated R67 is still on current antibiotic treatments. V12 stated she calls R67's family member to communicate with R67. On 5/13/25 at 12:57 PM, V11 (Infection Preventionist/Registered Nurse) stated the nurse and the isolation signage should inform staff and visitors what proper PPE to wear when entering a resident's room on transmission-based precaution. V11 stated the family is educated, and the facility's receptionists should notify visitors if a resident is on isolation precaution. V11 stated V37 should have been notified R67 is on contact isolation, and V37 should be wear proper PPE (gown and gloves) inside R67's room. V11 stated it is important for staff and visitors to wear proper PPE inside a resident's room on transmission-based precaution to eliminate transmission of C. diff or any bacteria the resident has. The facility's Infection Precaution Guidelines, dated 5/15/23, documents: It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of Isolation Precautions. In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care items. 49486 3. R41's Minimum Data Set (MDS), dated [DATE], Brief Interview Score (12) indicates R41 is moderately cognitively intact. R41's Physician Order Sheet (POS), dated 5/14/25, shows an active diagnosis of chronic respiratory failure with Hypoxia, hypertensive heart and chronic kidney disease with stage five end stage renal disease, dependence on renal dialysis, and scabies. R41 has an active order for enhanced barrier precautions. 4. R72's Minimum Data Set (MDS), dated [DATE], Brief Interview Score (10) indicates R72 is moderately cognitively intact. R72 Physician Order Sheet (POS) dated 5/14/25 shows an active diagnosis of encounter for attention to gastrostomy. R72 has an active order for enteral feed every 4 hours gastrostomy tube water flush 150 milliliter (ml). On 5/14/25 at 9:25 AM, observed V22 (Registered Nurse/RN-Agency) entering R72's room flushing her gastrostomy tube (GT) without wearing a gown as Personal Protective Equipment (PPE). At 9:28 AM, V22 also entered R41's room to take her blood pressure reading without wearing a gown. Surveyor asked V22 why she entered R41 and R72's rooms without wearing PPE despite an Enhanced Barrier Precautions (EBP) signage posted by the door? She stated, You cannot interview me because I am from the agency, and she stated she should have worn gown before entering both rooms, but nobody gave her report as to what she needs to do when providing contact care to residents with EBP signage. Surveyor asked V22 what could be the potential effect of what she has done? She did not respond, and moved away from surveyor. On 5/14/25 at 11:43 AM, V34 (Registered Nurse/RN) stated all staff and visitors should read and follow instruction on the EBP signage by the door to ensure correct PPE is/are worn before providing direct care like GT, dialysis arteriovenous (AV) fistula monitoring, wound care, tracheostomy care, taking of blood pressure reading, and Foley catheter care. A gown and a pair of gloves should be worn to prevent cross contamination, and cross transmission of infection. On 5/15/25 at 8:56 AM, V2 (Interim Director of Nursing/DON) stated the agency staff should be following the policy and procedure of the facility regarding patient's care, and there should be a physician order for EBP. It is V2's expectation that nurses, either agency or regular staff, will read, follow signage, wear a gown and gloves when providing contact care like; GT, wound, urinary catheter, dialysis (AV) fistula, and taking of blood pressure reading especially for a resident with diagnosis of scabies with a (AV) fistula. V2 also stated V22 should wear a gown when providing any contact care to R41, R72, and any residents with EBP signage by the door to prevent spread of infection. The facility EBP signage posted by the doors of R41 and R72's rooms documents: Wear gloves and a gown for high contact resident care activities.

Based on observation, interview, and record review, the facility failed to ensure staff provided privacy during care for 1 (R219) resident observed for resident rights in a sample of 32. Findings Include: R219 was admitted to the facility on [DATE], with diagnoses not limited to Type 2 Diabetes Mellitus with Hyperglycemia, Acute Kidney Failure, Dependence on Renal Dialysis, Gastrostomy, Hypertensive Heart Disease, Shaken Infant Syndrome, Cerebral Palsy, Epilepsy, Abnormalities of Gait and Mobility, Polycystic Ovarian Syndrome and Blindness, Both Eyes. R219's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicates resident is rarely/never understood. On 05/13/25 at 12:08 PM, R216 was observed from the doorway in bed. V8 (Restorative) was observed in R216's room adjusting R216's brief, with the door open, the privacy curtain open, and R216's roommate, R28, privacy curtain open. Enhanced Barrier Precaution signage was observed at R216 room entry. V8 did not have a gown on while providing care. V8 stated, (R219) has a g-(gastric) tube. I was adjusting (R216's) diaper, I should have given (R216) her privacy, and had on PPE (Personal Protective Equipment), a gown and gloves. On 05/15/25/ at 09:16 AM, V2 (Interim Director of Nursing) stated, My expectation when staff is providing care for a resident is privacy. The staff should have had the door closed or used the privacy curtain. Policy: Titled Resident Rights, reviewed 01/04/19, documents: Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to: Privacy and confidentiality. Titled Incontinence Care, revised 01/26/18, documents: Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Procedure: 1. Explain procedure to resident and bring equipment to bedside. Provide privacy. Rationale/Amplification: Avoid unnecessary exposure.

Based on observation, interview, and record review, the facility failed to provide an specialized call light within reach for a resident with limited movement. This affected one (R56) out of six residents reviewed for call lights in a total sample of 32. Findings include: R56 has diagnoses which includes but not limited to Quadriplegia, Neuromuscular Dysfunction Of Bladder, Unspecified, Pressure Ulcer Of Sacral Region, Stage 4, Anxiety Disorder, Chronic Embolism And Thrombosis Of Other Specified Veins, Post-Traumatic Stress Disorder, Chronic, Hydronephrosis With Renal And Ureteral Calculous Obstruction, Hypokalemia, Unspecified Protein-Calorie Malnutrition, Iron Deficiency Anemia, Constipation, and Encounter For Attention To Ileostomy. R56's MDS (Minimum Data Set), dated 01/23/25, documents intact cognitive function. MDS, dated [DATE], documents R56's primary medical condition is Traumatic Spinal Cord Dysfunction and impairment in range of motion on both sides of upper/lower extremities and dependency on staff to perform all ADLs (Activities of Daily Living) and transfer. R56's comprehensive care documents R56 has a ADL self-care performance deficit due to generalized weakness, musculoskeletal impairment secondary to quadriplegia and includes intervention to encourage R56 to use bell to call for assistance. R56's comprehensive care plan also contains focus for fall risk and includes intervention be sure call light is within reach and encourage resident to use it for assistance as needed. On 05/15/25 at 7:58 AM, R56 was lying in bed. Call light was on the floor under R56's bed. R56 stated he cannot reach the call light, and he cannot use that type of call light with his hands because he cannot press the button on it with his fingers. R56 stated he is paralyzed. R56 stated he used to use a blow call light (air activated call device) when he was living in a different unit/room, but when he was readmitted from the hospital, he was readmitted to this room, and since then he has not had any call light he can use. R56 stated when he needs help from the staff, he will yell for the Certified Nursing Assistant (CNA) and if they do not come, he will try to use his cell phone to call for help, but the staff does not always answer the phone. When this happens, he just has to wait until someone checks on him, which sometimes takes a long time, especially at night. R56 stated he used to use the air activated call light and wants it back, because that is the only type of call light he can consistently use and get a response from staff. On 05/15/25 at 8:01 AM, V19 (Registered Nurse/Nursing Supervisor) observed R56's call light on the floor, picked it up off the floor, and put the call light within R56's reach. V19 stated R56 has a call light, but it was on the floor, and he could not reach it. V19 stated the call light should be within R56's reach. R56 told V19 that he cannot use that type of call light because he cannot press the button on it. V19 stated R56 should have a call light that he can use which accommodates his disability. V19 stated it is important for R56 to have access to a call light, so that he can call for help and receive the care he needs when he needs it. V19 stated even though R56's room is next to the nursing station and R56 has access to a phone, R56 having access to a call light which R56 can use is a priority, and should be provided to him. On 05/15/25 at 8:16 PM, V2 (Interim Director of Nursing) stated, The purpose of the call lights is so the residents can call for assistance when needed. Call lights should be located within reach of the resident. The facility needs to accommodate the resident needs, so if they are unable to use the traditional call light, then the facility would provide that resident(s) with a padded or air activated call device. The residents are rounded on every two hours, and the potential problem with the resident not having access to the call light, is the then the staff would not know if the resident needs assistance in between this two-hour period. Even though (R56) has access to his phone, and his room is near the nursing station. He should still have access to a call light he can use, so that he can request assistance as needed. The call light triggers automatically at the nursing station with an alarm sound so everyone can hear it. If (R56) is using his phone to call the nursing unit, he is dependent on a staff picking up the phone at the nursing station to answer the call, so if no one picks up the phone, he potentially will not get the help he needs. Facility provided policy titled, Call Light, dated 02/02/18, which documents the purpose is to respond to residents' requests and needs in a timely and courteous manner and guidelines include but not limited to, all residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable location and hand bells will be provided for alert dependent residents when positioned out of reach of permanent call light when needed. Facility provided document titled, Residents' Rights for People in Long-Term Care Facilities - Illinois Long-Term Care Ombudsman Program dated 11/18 which documents in part, your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life and your facility must provide equal access to quality of care regardless of diagnosis, condition and your rights to safety include facility must be safe, clean, comfortable and homelike.

Based on interview and record review, the facility failed to refer residents to the appropriate state designated authority for re-screening and Level II referral. This failure affects three residents (R17, R84, R93) out of five residents reviewed for Preadmission Screening and Annual Resident Review (PASARR) in a total sample of thirty-two. Findings Include: 1. R84's Minimum Data Set (MDS), dated [DATE], shows R84 is moderately cognitively intact. R84's face sheet shows she is [AGE] years old, initially admitted to the facility on [DATE] with diagnoses of bipolar disorder current episode depressed, severe with psychotic features. There is no documentation to show R84 was referred to the appropriate state-designated authority for Level 2 PASARR evaluation and determination. On 5/14/25 at 1:52 PM, surveyor asked V24 (Social Services Consultant) for a Level 2 PASARR screening for R84; she provided the surveyor with an omnibus budget reconciliation act (OBRA) initial screening dated 12/15/20. V24 stated R84 was not revaluated since (assessment company) took over two years ago. V24 has no Level 2 PASARR for R84. V24 was unable to provide a level 2 PASARR, and the facility does not have PASSAR policy. On 5/15/25 at 11:00 AM, V24 provided R84's level 1 PASSAR, dated 5/14/25. 46342 2. R93 admitted to the facility 11/17/21. R93's diagnoses includes Schizoaffective Disorder, Bipolar Type, Obsessive Compulsive Disorder, Post-Traumatic Stress Disorder, and Anxiety Disorder. R93's Order Summary Report, dated 05/14/25, documents Duloxetine for Bipolar, Hydroxyzine for Anxiety Disorder, Seroquel for Schizoaffective Disorder. R93's MDS (Minimum Data Set), dated 03/16/25, indicates R93 has intact cognition. R93's OBRA (Omnibus Budget Reconciliation Act) Initial Screen, dated 11/12/21, documents no the individual has (not) been formally diagnosed with a mental illness verified by a DSM-IV classification which substantially impairs the person's cognitive, emotional and/or behavioral functioning and no, there are (no) other indicators of mental illness. On 05/14/25 at 1:09 PM, V24 (Social Service Consultant) stated R93 had an OBRA completed when he was initially admitted , but he was not re-evaluated after (assessment company) took over the program in March 2022. V24 stated R93 should have been re-submitted to (assessment company) in March 2022 for re-evaluation, but it was not done. V24 stated she just submitted for R93 to be evaluated for PASRR I (Pre-Admission Screening & Resident Review) today. V24 provided document titled Notice of PASRR Level I Screening Outcome, dated 05/14/25, documents suspected or confirmed PASRR condition (MH) mental health disability and refer to Level II onsite. V24's PASRR Outcome Explanation documents the PASRR Level I screen shows that you need a face-to-face Level II evaluation and PASRR Level I screen and Level II evaluations are required by Federal law, 42 U.S.C. 139(e)(7). You need this evaluation because you may have serious mental illness and the purpose of this evaluation is to decide whether a nursing facility is able to meet your needs. 39779 3. R17 was admitted to the facility on [DATE], with diagnoses not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Generalized Anxiety Disorder, Contracture of Muscle, Left Hand, Major Depressive Disorder, Recurrent, Moderate, Epilepsy, Migraine, Muscle Spasm, Hypertensive Heart Disease, Hyperlipidemia, Anemia, Delusional Disorders, Monocular Exotropia, Right Eye, Cognitive Communication Deficit, Long Term (Current) use of Anticoagulants, Chronic Embolism, and Thrombosis of Unspecified Vein. R17's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 14, indicating intact cognitive response. R17's Interagency Certification of Screening Results, dated 04/23/19, document: Screening indicated nursing facility services are appropriate. R17's OBRA (Omnibus Budget Reconciliation Act) 1 Initial screen dated 04/23/19. R17's Notice of PASRR Level I Screen Outcome, dated 05/15/25, documents: Suspected or confirmed PASRR Condition(s): (MH) Mental health Disability. This screen shows that you need a face-to-face Level II evaluation. You need the evaluation because you may have serious mental illness or an intellectual/developmental disability. Reason for Screening: This nursing facility resident has never had a PASRR Level I screen. Ascend Outcome: Rationale: A PASRR Level II evaluation must be conducted. On 05/14/25 at 01:50 PM, V24 (Social Service Consultant) stated (assessment company) was not a thing until 2022. I can create a request for (R17). (R17) had an OBRA and was admitted in 2019. On 05/14/25 at 03:26 PM, V24 (Social Service Consultant) presented the surveyor with a form titled PASRR (Preadmission Screening and Resident Review) Pro-I. PASRR Level 1 Screen, dated 05/14/25. V24 stated I have worked here as the consultant since June or July of 2022. I was made aware of the PASRR, but I cannot recall the exact date. It should be done if there is a change in condition, a new diagnosis, for everyone with a suspicion of a mental illness and prior to admission.

Based on observation, interview, and record review, the facility failed to provide one to one feeding assistance and properly position a resident in bed consistent with the plan of care during meals. This deficient practice was observed for 1 (R28) resident observed during the dining task in a sample of 32. Findings include: R28 was admitted to the facility on [DATE], with diagnoses not limited to Dementia, Flaccid Hemiplegia Affecting Left Nondominant Side, Dysphagia, Oropharyngeal Phase, Type 2 Diabetes Mellitus with Hyperglycemia, Epilepsy, Diastolic (Congestive) Heart Failure, Chronic Kidney Disease, Stage 3, Depression, Anxiety Disorder, Hypertensive Heart Disease with Heart Failure, Unspecified Intellectual Disabilities, and Gastro-Esophageal Reflux Disease. R28's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 03, indicating severe cognitive impairment. R28's Care Plan documents: Focus: R28 requires a Mechanically Altered Diet r/t (related to) dysphagia. Per nurse, resident C/O (complain of) difficulty swallowing & coughing / choking w/ (with) medication. Diet: general, pureed. Interventions: Position head of bed up for meals. Date Initiated: 12/30/19. 1:1 feeding assistance Date Initiated: 04/19/24. Monitor Intake Date Initiated: 12/02/21. Monitor during mealtime. Date Initiated: 12/02/21. Monitor for signs and symptoms of aspiration or choking. Continue supervision to maximize PO (by mouth) intake. Focus: R28 presents with impaired ability to feed self-due to impaired cognition. Desired Outcome: R28 will receive hands on staff assist during meals to stimulate adequate meal completion. Interventions: Ensure appropriate positioning to facilitate safe swallowing. Give verbal cues and hands on assist as needed to resident while eating. R28's Order Summary Report documents: Consistent Carbohydrate, No added salt diet Pureed texture. Nectar Consistency. Pleasure feed diet. R28's MDS Section G -Functional Ability A. 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. (02) Substantial/maximal assistance - Helper does more than half the effort. Helper lifts and holds trunk or limbs and provides more than half the effort. On 05/13/25 at 12:21 PM, R28 was observed in bed at a 45-degree angle, attempting to eat a pureed diet, unassisted by staff. R28's left hand was observed to be flaccid and laying on the bed. On 05/13/25 at 12:28 PM, V9 (Agency Licensed Practical Nurse) stated, It looks like (R28) is feeding herself at a 45-degree angle. It looks like she (R28) should come up. V9 went to the side of R28's bed, picked up the bed control, and elevated the head of R28's bed. V9 then said (R28) is now at a 90-degree angle. V9 was asked what could potentially happen when R28's head of the bed was at a 45-degree angle while eating. V9 responded, (R28) could aspirate on her food and choke. On 05/15/25 at 09:16 AM, V2 (Interim Director of Nursing) stated, (R28) should be in an upright position while eating. If (R28) was at a 45-degree angle while eating, she could aspirate. On 05/15/25 at 09:40 AM, V13 (Restorative Director) stated, When we do the quarterly assessment, we add new interventions as appropriate. (R28) is a 1:1 feeder, but it depends on the day because sometimes (R28) is able to feed herself. Most of the time the staff have been feeding (R28). Since (R28's) care plan intervention has 1:1 feeder, (R28) should be a 1:1 feeder. When a resident is eating while in the bed, they should be in an upright position when being fed and eating to prevent aspiration. Policy: Titled Feeding and Assisting Residents to Eat, undated, documents: Purpose: To assist the resident to obtain nutrients and hydration. Procedure: 3. Assist resident to comfortable position, 60 degrees - 90 degrees. Titled Restorative Nursing Program, revised 01/04/19, documents: Purpose: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Includes, eating and swallowing. Each resident involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care. Develop and individualized program based on the resident's restorative needs and include the restorative program on the care plan. A functional maintenance program may include range of motion provided during routine daily care such as dressing, grooming/hygiene, eating, transfers bathing etc.

Based on observation, interview, and record review, the facility failed to ensure communication assistive materials were readily accessible for a resident (R67) who speaks a foreign language, and failed to provide communication tools or communicate with one resident (R161) who has communication deficit out of three residents reviewed in a final sample of 32. Findings Include: 1. R67's clinical records show an admitted [DATE]. R67s Minimum Data Set, dated dated [DATE], shows R67's preferred language is Urdu. R67's communication care plan shows R67 presents with an alteration in ability to communicate related to speaking a foreign language. On 5/13/25 at 12:49 PM, R67 was observed in bed alert and verbally responsive. V37's (R67's Family Member) was at bedside, visiting. Surveyor attempted to interview R67 and V37. R67 stated, Urdu. No English. Surveyor asked and gestured if R67 has communication board to use to communicate in English, but R67 was unable to understand. Surveyor could not find any type of communication board or binder in R67's room to communicate with R67. On 5/13/25 at 12:55 PM, V12 (Licensed Practical Nurse) stated she calls R67's family member to communicate with R67. V12 stated she is not sure if there is any staff in the facility that speaks R67's language. V12 did not answer when asked what they do if no family member is available to translate for R67. 45111 2. R161's current face sheet documents his medical diagnoses includes but not limited to: dysphagia, oropharyngeal phase, type 2 diabetes mellitus with diabetic chronic kidney disease, anoxic brain damage, not elsewhere classified, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, and end stage renal disease. Minimum Data Set (MDS) Section C - Cognitive Patterns, dated 4/8/25, does not document R161's Brief Interview for Mental Status (BIMS) score. MDS Section GG - Functional Abilities documents R161 is dependent on staff for all ADL (Activities of Daily Living) care. On 05/13/2026 at 12:20PM, R161 was observed laying in bed awake, bed in low position, floor mats in place. V4 was observed in R161's room hanging his nutritional supplement, and R161 was observed trying to communicate with V4, but his words were not coming and were not coming out loud. He was speaking very slowly. R161 was observed making facial grimaces and crying. V4 finished hanging the nutritional supplement, and asked R161 what he was trying to say. V4 stated she could not understand R161, and left the room saying, Let me ask (V10, Certified Nursing Assistant) what you are saying because I cannot understand you. V4 left the room and did not return. R161 was asked what was wrong and if he needed help. R161 very softly and slowly explained he was experiencing back pain. On 05/13/2026 at 12:38 PM, V4 was in the hallway standing by her medication cart. V4 was asked if she found out what R161 was trying to communicate to her. V4 stated she could not find V10, therefore, she did not go back to R161's room because she cannot understand him. 05/13/2026 at 12:40 PM, V2(Interim Director of Nursing), and V4 went to R611's room and found R161 crying, and when asked by V2 what was wrong, R161 very slowly and softly stated he was having back pain. V2 stated V4 should have used a communication board to communicate with R161, or taken the time to understand what R161 was trying to communicate, so that his needs are met. V4 stated there is no communication board, and she had not seen one by the nursing station. On 05/15/2025 at 11:13AM, V6(Social Services Director) stated residents are screened for communication needs during the initial assessment upon admission to the facility. V6 stated there is a communication line(phone) at the nursing station that nurse call for interpreter services. V6 further stated there is communication /letter board in the Social Services office to be used with residents who have difficulties. If determined a resident needs a communication board, to communicate their needs, the communication board is kept in the resident's room. V6 stated she has not interacted with R161 a lot, but she knows he goes to speech therapy. V6 stated it is important for residents with communication deficits to be provided a way of communicating with staff so they can communicate their needs. On 05/15/2025 at 11:24AM, V29 (Speech Pathologist) stated R161 can communicate using a few words, can answer questions, and is able to communicate when he is hungry, in pain, or has other needs. V29 stated R161 is very clear and understandable communicating his need, although he has a very quiet voice, but anybody can understand him if they pay close attention to what he is saying. V29 stated R161 is in speech therapy to help his voice get stronger, but his speech is very clear. V29 stated if asked a question, R161 understands and answers questions, but in a very soft voice. V29 stated when talking to R161, staff need to be patient so that they can hear what R161 is saying. V29 stated R161 is not able to use the communication board effectively because he closes his eyes and does not keep them open for a long time. Even when he is awake, he will respond even when his eyes are closed, and his speech is very understandable if someone takes to time to listen to him. V29 stated staff need to pay close attention to residents who have speech deficits so that their needs are not overlooked. Policy titled Language Assistance Services, no date: -It is the policy of this facility to offer language assistance services to all residents who are determined to have a language or communication barrier

Based on observation, interview, and record review, the facility failed to provide routine medications to one resident (R2) as ordered by the prescriber to meet R2's needs. This failure resulted in R2 having pain, vomiting, and diarrhea. Findings include: R2's medical diagnoses include but are not limited to type 2 diabetes with hyperglycemia, chronic kidney disease stage 2, essential hypertension, major depressive disorder, long term use of insulin, and hyperlipidemia. R2 Brief Interview for Mental Status (BIMS) score, dated 04/02/25 is 15, which indicated R2's cognition is intact. R2's physician order, dated 03/27/25, documents, Tramadol tablet 50mg (milligrams). Give 1 tablet by mouth every 12 hours for moderate to severe pain. R2's physician order, dated 03/27/25, documents, Creon oral capsule delayed release particles 36000-114000 unit .Give 1 capsule by mouth three times a day for indigestion. R2's medication administration record for Tramadol document code NA on 03/28/25, 03/29/25 and 03/31/25, which indicated that medication is not available. R2's medication administration record for Creon (pancreatic enzyme) document code for NA on 03/28/25 and 03/31/25, which indicated not available. R2's care plan, dated 04/04/25, documents, Has potential for pain or experiences pain related to gastric disorder limited mobility, osteomyelitis, MDD (major depressive disorder), chronic ulcer left heel .Will have acceptable level of pain based on the 0 to 10 scale .Medications as ordered, if ineffective, notify physician. Facility's document titled Packing Slip Proof of Delivery shows R2's medications were delivered on 03/28/25 at 3:29am. Proof of Delivery slip shows that Creon quantity of 100 capsules were delivered. On 04/21/25 at 12:13pm, R2 stated R2 did not receive his pancreatic enzyme or pain medication. R2 stated because he did not receive the medication for his pancreas, he had vomiting and diarrhea, and could not get out of bed for days. R2 stated the pancreatic enzyme lessens his stomach pain and decreases the diarrhea. R2 stated he has been keeping his medication in his drawer, and takes it when he needs it, because the nursing staff does not give him the medication when he needs it, or when he is supposed to have it. On 04/21/25 at 2:29pm, V18 (Nurse Practitioner/NP) stated he was not aware R2 had not received his medications. V18 stated Creon is a pancreatic enzyme. V18 stateD if R2 doesn't receive the pancreatic enzyme, then R2's vomiting and diarrhea could worsen. On 04/22/25 at 1:35pm, V2 (Director of Nursing/DON) stated NA means not available, which means the medication was not given. V2 stated records for new admissionS are reviewed before the resident comes to the facility to assure the facility can meet the needs of the resident. V2 stated R2 not receiving his Creon medication as ordered could have caused his nausea, vomiting and diarrhea, and unnecessary pain. On 04/23/25 at 11:59am, V4 (Registered Nurse/RN) stated she did not give R2 his Creon medication because she couldn't find it. V4 stated she called pharmacy and was told that the medication was delivered to the facility, but she couldn't find it, so she documented the medication was unavailable. V4 stated days later, she found the medication in the top drawer of the medication cart. V4 stated the nurse that placed the order for R2's tramadol did not get a prescription signed by the nurse practitioner, so the pharmacy did not fill the prescription. V4 stated when the tramadol was scheduled, she was unable to give it because it was not available. V4 stated she had the NP sign a prescription for R2's tramadol, so that it could get filled. Facility's policy titled Administration Procedures For All Medications, dated 10/25/2014, documents, Policy: To administer medications in a safe and effective manner. Facility's undated job description titled Registered Nurse (RN) documents, Summary: The RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times .Essential Duties and Responsibilities: .Prepare and administer medications as ordered by the physician.

Based on interview and record review, the facility failing to affirm the right of the resident (R2) to be free from physical abuse and to have a safe environment, resulting in R1 punching R2 in the face. This failure resulted in R2 crying, and R2 being afraid R1 would attack R2 again. Findings Include: R1's face sheet shows R1 has diagnoses including Schizophrenia and Unspecified Intellectual Disabilities. R1's Minimum Data Set (MDS), dated [DATE] and 12/22/24, shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) score of 15, and has the ability to walk. R1's behavior care plan documented: (dated initiated 3/21/2019) R1 displays behavioral symptoms related to severe mental illness. These are manifested by rummaging, or taking food off of food carts, or unattended food. R1 may become agitated when redirected and display aggressive behavior. R1 demonstrates behavioral distress as manifested by yelling to towards staff, residents physically abusive behavior when agitated; attempting to push, shove, scratch, or otherwise harm another person. This behavior occurs 1-3 times per week and is related to being challenged by mental illness, ineffective coping mechanisms. R2's face sheet shows R2 has diagnoses including Hemiplegia Affecting Right Dominant Side, Vascular Dementia, Schizoaffective Disorder, Anxiety Disorder, Right Hand Contracture, and Epilepsy. R2's MDS, dated [DATE], shows R2 has moderately impaired cognition with BIMS of 12 and requires substantial maximal assistance from staff with activities of daily living. R2's progress notes, dated 12/8/24 at 1:28 PM, documented by V11 (Agency Nurse) reads: (R2) was involved with another patient's behavior issue. (R1) was eating lunch wanted more food so (R1) walked to the cart in the hall. (R1) did not see a tray that he could take off the cart so (R1) started pulling used trays off the cart in anger. (R1) walked to the nurses' station and started throwing things. (R2) was sitting at the nurses' station eating and being observed due to fall risk when it was reported that (R1) struck (R2). Both patients were immediately separated and (R1) was placed on one-one observation. NP (Nurse Practitioner) and Family were made aware and (R2) was given a shot of Ativan to calm (R2) down and reported seizures noted following incident. (V10, Assistant Director of Nursing) and all other necessary parties made aware. The facility's final abuse reportable sent to the State Agency (SA) documented: Incident date was 12/8/24 at 1:05 PM. Based on a complete and thorough investigation, (R1) had just finished with his lunch and brought his lunch tray back to the food cart for collection, as per his routine and baseline. (R1) was still hungry and instead of asking the staff for more food from the kitchen, he stated he thought he would look for an extra tray on the cart that he could take food from. (V8, Former Certified Nursing Assistant/CNA) saw (R1) attempting to take someone else's tray of food and asked (R1) if he was still hungry, he could get him another tray or plate of food. Politely, (V8) also asked (R1) to please not take any food off the trays on the cart as they belong to other residents. Suddenly, (R1) became upset and walked away. (R2) was near the area of the event and as (R1) walked away, (R1) abruptly made unwanted contact with (R2) using an open hand. (V8) witnessed the incident and immediately separated (R1) from (R2). (R1) apologized at that moment and was assisted back to his room, kept under direct supervision, and was also provided with a new tray of food as per (R1's) request. V8's witness statement from the facility's investigation, dated 12/8/24, documented, (R1) was going through the lunch trays. I told (R1) to stop. (R1) got upset and began throwing trays off the cart and throwing a box at me. (R1) went to (R2) who was sitting eating (R2's) lunch and hit (R2). (V17, Certified Nursing Assistant) tried to stop (R1) and once we attmepted to redirect and get the nurse (R1) apologized. On 1/26/25 at 9:54 AM, R2 stated R2 does not remember another resident punching R2 on the face. R2 stated, I don't remember that incident. I usually remember something like that, but I don't remember. R2 stated R2 knows R2 is forgetful. R2 stated R2 had stroke and has had many seizure episodes. R2 stated R2 does not walk anymore and R2's right side is paralyzed. On 1/26/25 at 10:01 AM, R1 stated, I'm upset. I always get upset. When I'm angry, I hit people. When surveyor asked R1 to clarify what R1 had just said, R1 repeated the same answer, I'm upset. I always get upset. When I'm angry, I hit people. R1 stated R1 is not angry or upset now, but R1 refused to answer further interview questions. On 1/26/25 at 11:09 AM, a phone interview was conducted with V8 (Former CNA). V8 stated, It happened around lunch time the incident was about the lunch tray. (R1) wanted to dig in and I told him to stop twice; the third time (R1) got upset. (R1) ran over to me. (R1) threw everything at me whatever he could grab from the nurses' station. I did not give (R1) any reaction. I just stood there and looked at (R1). I was just looking at (R1). (R1) didn't stop and when (R1) saw that I was not reacting to his behavior, (R1) went straight to (R2) and punched (R2) in the face. (R2) cried. (R2's) face was really red from the punch. (R2) was sitting on a geri (geriatric) chair by the nurses' station because we would always put (R2) there to closely monitor him because (R2) has history of seizures. (R2) was crying and (R2) said that he was scared that (R1) would come back and attack (R2) again. (R2's) face was red. When this happened, I immediately go get the nurse. They were agency nurses; they told me to call the ADON (V10, Assistant Director of Nursing). I went back to the nurses' station and saw (R1) was trying to throw food at (V17, CNA). I called the ADON and was told to call the police. I called the police and then the ADON came up and talked to (R1). Right after this incident, a few minutes later after (R2) got punched, (R2) had seizures. I don't know who checked on (R2). On 1/26/25 at 3:21 PM, V8 verified R1 came up to R2 and intentionally punched R2 in the face because R1 had seen V8 did not react to R1's aggressive behavior. V8 stated after R1 punched R2, R1 apologized. V8 stated R1 punching R2 is a type of physical abuse because R1 hit R2 knowing R2 could not move and could not defend himself. On 1/26/25 at 11:23 AM, V17 (Certified Nursing Assistant) V17 stated V17 did not witness the initial incident. V17 stated, I was passing by and I heard (V8) telling (R1) to stop. I saw (R1) angry and (R1) was trying to throw food at me. I backed away. I went to go ask for help. I called (V8) back and told (V8). On 1/26/25 at 12:27 PM, V10 (Assistant Director of Nursing) stated V10 was doing rounds in the building, and was stopping on the fourth floor, and the staff was saying to V10 that R1 had just hit R2 in the face. V10 stated V10 instructed the staff to immediately separate R1 and R2. R1 was placed on one-on-one supervision and R2 was assessed. V10 stated V10 assessed R2 with the nurse, but does not remember which nurse. V10 stated R2's face was slightly red, but no open wounds. V10 stated originally, R2 said he was okay, but then R2 said R2 was anxious and nervous about R1 hitting R2. V10 stated R2 did not say R2 was scared. V10 stated approximately 6 minutes after the incident, R2 had two seizures that lasted for 4 to 5 minutes. On 1/26/25 at 10:08 AM, V7 (Certified Nursing Assistant) stated R1 has impulsive behavior. V7 stated R1 would throw stuff when R1's mad. V7 stated R1 is not always mad, but when R1 gets upset, R1 would try to hit people, like staff or other residents. R1 needs to be re-directed when he's upset because when R1's upset he would be throwing things and try to hit other people. V7 stated it's R1's behavior ever since and R1 has a history of getting physically aggressive with staff and residents when R1's upset. On 1/26/25 at 11:01 AM, V16 (Social Service Director). stated R1 is alert and oriented times 3-4 (person, place, time, event) and is pretty aware. V16 stated R1 has little bit of anger/temperament issues at times when R1 is confused and overstimulated. V16 stated R1 gets agitated at times and requires re-direction if R1's unfamiliar with staff; sometimes R1 has been known to grab trays. V16 stated R1 had history of being agitated and if that happens, staff needs to provide brief one on one with R1. V16 stated when R1 is agitated, Staff needs to remove (R1) from the situation and provide one to one counselling to calm (R1) down. Talk to (R1). (R1) is usually able to tell you. (R1) will most likely apologize. (R1) has impulsive behaviors and has problem solving impairment. If (R1's) upset or agitated, right away, staff needs to calm (R1) down and talk to (R1) and re-direct (R1). For example, tell (R1) to come walk with me or talk to me. If you don't address the behavior or try to talk back with (R1), it will become worse. It will continue to escalate (R1's) anger. On 1/26/25 at 11:53 AM, V2 (Director of Nursing) stated abuse is anything that puts the resident in an intentional harm. The types of abuse are physical, verbal, sexual, financial, emotional. V2 stated an example of physical abuse is hitting a resident. On 1/26/25 at 2:29 PM, V1 (Administrator) stated the residents have all the right to be safe in the facility, to be able to be free from abuse and feel at home, and state anything without any repercussion, and be part of their care. V1 stated if there is a resident-to-resident altercation, the residents should be separated immediately. V1 stated the incident that happened between R1 and R2 on 12/8/24 was not a form of physical abuse, because R1 acted unintentionally. V1 stated the reason why R1 and R2 were not sent out to the hospital for further evaluation was because V1 feels like it was not a form of abuse based on V1's investigation. On 1/27/25 at 11:35 AM, V11 (Agency Nurse) stated, I just remember that I was called by the CNA I don't remember who was the CNA. I was told that (R1) struck (R2) on the face. I did not witness it. The facility's Abuse Prevention and Reporting policy, dated 10/24/22, documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation or property, and mistreatment of residents. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The facility's RESIDENTS' RIGHTS policy (undated) documents: The residents have the right to safety, must not be abused and residents' facility must be safe, clean, comfortable and homelike.

Based upon record review and interview, failed to revise fall prevention interventions; failed to implement appropriate fall prevention interventions; and failed to provide supervision to one of four residents (R2) reviewed for falls. These failures resulted in R2 sustaining a fall, laceration (above the right eye), and stitches. Findings include: R2's diagnoses include but not limited to osteomyelitis, low back pain, unsteadiness on feet, abnormalities of gait/mobility, lack of coordination and weakness. The facility incident reports affirm R2 fell on [DATE], 10/12/23 and 11/27/23. R2's (1/10/24) BIMS (Brief Interview Mental Status) determined a score of 9 (moderate impairment). R2's (1/10/24) functional assessment affirms R2 requires substantial/maximal assistance with chair/bed to chair transfer. R2's care plan includes (6/14/23) Resident is at risk for falls related to deconditioning and gait/balance problems. Interventions: (10/3/23) Resident is encouraged to ask for (as needed) pain medications for increased pain and before transferring to wheelchair. (11/28/23) Staff will ensure bilateral floor mats are in place while resident is in bed. Resident will be evaluated and treated as ordered by PT (physical therapy) and OT (occupational therapy). R2's (11/27/23) progress notes state resident found on floor next to bed lying on his back. Resident reported he was trying to reach his phone charger and slid out of the bed. Resident noted to have small 1 cm (centimeter) laceration above his right eye. Resident transported to ER (emergency room ) for further evaluation. Resident was brought back to the facility, the laceration at the upper side of the right eye was stitched. R2's (11/27/23) incident report affirms resident was found next to bed on the floor lying on his back. No witnesses found. On 5/8/24 at 1:58pm, surveyor inquired about R2's fall risk assessment prior to falling in the facility. V2 (Director of Nursing) reviewed R2's electronic medical record and stated, I see that there's an assessment 9/11 (2023) the score was 26 (moderate fall risk). Surveyor inquired what fall prevention intervention was implemented post R2's (10/2/23) fall. V2 responded, Is encouraged to ask for PRN (as needed) medication for increase pain before transferring to wheelchair on 10/3/23. Surveyor inquired what fall prevention intervention was implemented post R2's (10/12/23) fall. V2 replied, I haven't seen really an entry for 10/12 and affirmed R2's care plan was not revised on or about 10/12/23. Surveyor inquired about staff requirements if a resident falls. V2 stated, They (staff) need to update the care plan. Surveyor inquired about R2's (11/27/23) fall/injury. V2 (Director of Nursing) responded, According to the note here resident found next to bed on floor lying on his back has small 1 centimeter laceration above eye. Resident was reaching for phone charger and slipped out of bed. Surveyor inquired what fall prevention interventions were implemented post (11/27/24) fall. V2 replied, 11/28 it's says (R2) will be treated with PT (Physical Therapy) and OT (Occupational Therapy) as ordered. Will ensure bilateral floor mats are in place while (R2) is in bed. Surveyor inquired if staff supervision was included on R2's fall prevention interventions . V2 stated, I didn't see that. On 5/14/24 at 2:13pm, surveyor inquired about fall prevention. V20 (Medical Director) stated, If I label them (residents) as a fall risk, I try to put measures in place to prevent the fall. For every single fall they (staff) call, and we implement something. Surveyor inquired about potential harm to a resident that sustains an unwitnessed fall. V20 responded, You can have a subdural hematoma, head trauma, visceral injuries, or fractures. Falls can cause many potential injuries. The fall prevention program (revised 11/29/22) states the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The fall prevention program includes the following components: Care Plan addresses each fall, interventions are changed with each fall, as appropriate. Safety interventions will be implemented for each resident identified at risk. The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care.

Based upon interview and record review, the facility failed to ensure that 1:1 feeding assistance was provided to three of three residents (R2, R3, R4) reviewed for nutrition. These failures resulted in R2 sustaining significant weight loss. Findings include: 1. R2's (11/22/23) physician orders state weigh upon admission and weekly x4 for 5 weeks (end date: 12/28/24). R2 was discharged from the facility 1/10/24. R2's (1/10/24) BIMS (Brief Interview Mental Status) determined a score of 9 (moderate impairment). R2's (1/10/24) functional assessment affirms resident requires supervision or touching assistance with eating. R2's (5/2/23) admission weight was 202.1# (pounds). R2's (12/18/23) progress note states writer received a call from resident's parents requesting resident be put on feeder list for assistance due to unsteadiness of hand while eating. IDT (Interdepartmental Team) made aware. R2's (1/9/24) dietary assessment states weight 144# (pounds). IBW (Ideal Body Weight) 190#. Weight over 1, 3, and 6 months is as follows: 12/1/23- 160.6#; 10/3/23 - 176# ; 7/23/23 - 187#. Significant weight loss at 1, 3, and 6 months is unplanned and likely related to poor oral intake at mealtimes. Continue 1:1 feeding assistance to maximize oral intake. R2's weights are as follows: 5/2/23 (Admission): 202.1# 7/23/23: 187#; 15.1# weight loss; -7.5% 10/3/23: 176#; 26.1# weight loss; -12.9% 12/1/23: 160.6#; 41.5# weight loss; -20.5% 1/9/24: 144# 58.1# weight loss; -28.7% R2's (January 2024) documentation survey report affirms eating assistance for 20 out of 29 meals was not documented. On 1/1/24 (breakfast & lunch) and 1/5/24 (dinner) setup or clean us\p assistance was documented. On 5/8/24 at 11:20am, surveyor inquired if R2 was able to feed himself. V16 (Social Service) stated, I know he would drink on his own, but I don't recall. Surveyor inquired if R2's family requested R2 receive feeding assistance. V16 responded, December 18th is when I received a call from the mother; she wanted the resident to be put on the feeding list due to unsteadiness of his hand while eating. Surveyor inquired if feeding assistance was provided to R2. V16 replied, I don't know. On 5/8/24 at 3:13pm, surveyor inquired what blank spaces on the documentation survey report indicate. V18 (Restorative Aide) responded, They haven't been done that day. On 5/14/24 at 2:23pm, surveyor inquired about potential harm to a resident that sustains significant weight loss. V20 (Medical Director) stated, in part, Malnutrition. The dietary policy (revised 10/17/19) states residents identified at nutritional risk may be weighed weekly or bi-weekly as per physician order or IDT recommendation. Weekly weights may be discontinued if the resident's weight has remained stable for four consecutive weeks or as determined by the IDT, Dietician, or the Physician. 2.R3's diagnoses include quadriplegia. R3's (4/19/24) dietary assessment includes 1:1 feeding assistance. R3's (April 2024) Documentation Survey Report states resident will eat all meals with one-person total assist as tolerated, however, 49 of 90 meals were not documented. 3. R4's diagnoses include quadriplegia. R4's (4/19/24) dietary assessment includes 1:1 feeding assistance. R4's (April 2024) Documentation Survey Report affirms eating assistance for 51 of 90 meals were not documented. The restorative nursing program (revised 1/4/19) includes but is not limited to eating and swallowing. Develop an individualized restorative program as appropriate based on the assessment information.

Based on observation, interview, and record review, the facility failed to adequately supervise 1 (R1) of 3 residents reviewed for elopement. This failure resulted in R1 leaving the facility unsupervised, sustaining a fall when he eloped from the facility, and R1 being taken to the hospital. R1 was diagnosed with a left foot fracture. This situation was identified as an Immediate Jeopardy. The Administrator was notified of the Immediate Jeopardy on 01/30/2024. The Immediate Jeopardy began on 1/5/2024, and was removed on 2/1/24. The facility presented an acceptable removal plan on 2/1/24. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan. The findings include: R1's health record documented admitted [DATE], with diagnoses not limited to: Chronic respiratory failure with hypoxia, Chronic systolic (congestive) heart failure, Dysphagia, Encounter for attention to gastrostomy, Chronic obstructive pulmonary disease, Unspecified fracture of left calcaneus, subsequent encounter for fracture with routine healing, Ischemic cardiomyopathy, Unspecified abnormalities of gait and mobility, Other lack of coordination, Unspecified lack of coordination, Weakness, Acute kidney failure, Hypertensive heart disease with heart failure, Hypothyroidism, Gastro-esophageal reflux disease without esophagitis, Vitamin d deficiency, Encephalopathy, Anemia in other chronic diseases classified elsewhere, and Abnormal posture. MDS (Minimum Data Set), dated 11/16/23, indicated R1's cognition was intact. R1 needed substantial/maximal assistance with eating, oral hygiene, upper body dressing; Total assistance/dependent with toileting hygiene, shower/bathe self, lower body dressing; Partial/moderate assistance with personal hygiene. MDS showed R1 was always incontinent of bladder and frequently incontinent of bowel. Community survival skills, dated 11/16/23, documented: R1 does not appear to be capable of unsupervised outside pass privileges at this time. No care plan found for R1 supervised outside pass privileges. R1's physician order sheet (POS) with no order for pass privileges. Progress notes, dated 1/5/24, documented: R1 was out of the facility during med pass. Progress notes, dated 1/6/24, documented: - R1 has been admitted to hospital for observation. - R1 readmitted from hospital via stretcher by two paramedics staff. R1 is Ax4 (alert x 4), he has non-displaced left foot fracture. V21 (Nurse Practitioner/NP) progress notes, dated 1/9/24, documented: - R1 seen today for a follow up visit for acute and chronic medical conditions/ER (emergency room ) visit on 1/6/24. R1 states LLE (left lower extremity) pain d/t (due to) recent fracture, wants pain medicine. - A&P (Assessment and Plan): Non-displaced LLE fx (fracture). Went out on pass but did not return. Found at hospital with this dx (diagnosis). PM&R (Physical Medicine and Rehabilitation) progress notes, dated 1/10/24, documented: - CC: S/P (status post) left calcaneal non-displaced fracture - 1/6/24: R1 was out on pass, believes he lost his balance when trying to stand up, ultimately leading to ER evaluation due to left lower extremity pain. R1 was diagnosed with LLE non-displaced fracture of calcaneus. - R1 reporting mild to moderate pain in left foot heel. Pain is described as achy, intermittent. R1's MAR (Medication Administration Record) showed: - Haloperidol scheduled at 12:00pm on 1/5/24 was not signed or initialed. - Haloperidol scheduled at 6:00pm on 1/5/24, 12:00am and 6:00am on 1/6/24 were not given due to R1 not in the facility. - Atorvastatin, Lisinopril, Quetiapine Fumarate, Metoprolol Tartrate scheduled at 9:00pm on 1/5/24 were not given due to R1 not in the facility. - Protonix scheduled at 6:00am on 1/6/24 were not given due to R1 not in the facility. - Enteral feed order every 4 hours 150ml of water to be administered via hydration set with pump scheduled at 2:00pm on 1/5/24 was not signed or initialed, scheduled at 6:00pm, 10:00pm on 1/5/24, 2:00am and 6:00am on 1/6/24 were not given due to R1 not in the facility. - Enteral feeding: G-tube (Gastrostomy) - Jevity 1.5 at 75ml/hr (milliliter per hour) on at 6pm or until a total volume of 900ml infused scheduled at evening and night: on 1/5/24 was not administered due to R1 not in the facility and scheduled day on 1/6/24 was not signed or initialed. Survey team interviewed V2 (Director of Nursing) on 1/28/24 and stated that nurses should document in the Medication Administration Record (MAR) to reflect that the medications were administered. V2 stated that if it's not signed or not documented in the MAR, that means the medications were not given and nurses should document the reason why they were not given and inform the physician. Hospital records documented in part: - admitted : 1/5/24. Admission type: Emergency. discharge date : 1/6/24 - Encounter information: 1/5/24 at 9:17pm. - Chief complaint: Foot pain - Reason for admission: Closed displaced fracture of body left calcaneus, initial encounter (Primary). Closed non-displaced fracture of left calcaneus, unspecified portion of calcaneus, initial encounter. - ED (Emergency Department) notes dated 1/6/24 at 12:38am: R1 presents for evaluation of left foot injury. States he was just walking on the street tripped and fell and now with pain to the left heel. Painful bearing weight. - X-ray of left foot dated 1/5/24: Acute nondisplaced calcaneal fracture. On 1/29/24, no care plan found for R1 supervised outside pass privileges and elopement. On 1/26/24 at 12:10pm, R1 was sitting in a wheelchair alert, and oriented to person, time, place, and situation, verbally responsive. R1 stated about 2 weeks ago, he tripped, fell , and had a broken left foot. On 1/26/24 at 12:58pm R1 observed sitting in a wheelchair. R1 stated he tripped and fell in the driveway/parking lot by the store, picked up by emergency services/ambulance, and they brought to the hospital. R1 stated he had a broken left foot. R1 stated no surgery was done in the hospital. He cannot put weight on his left foot. R1 stated he left the facility around 2 or 3pm in his wheelchair by himself, without informing the staff. R1 stated around 4pm - 5pm, he went to the store by himself and fell . On 1/26/24 at 1:41pm, V5 (Registered Nurse / RN) stated, On 1/5/24, (R1) did not go out on pass. (R1) went to smoke and left the building without informing the staff. Around 1:30 pm, (R1) was at the front desk and was not seen after that time. V5 stated he was working double that day, but for the 3-11 shift, he was assigned to 4th floor. V5 stated V8 (Licensed Practical Nurse/LPN) was assigned on 2nd floor and called him asking where R1was at because they could not find him. V5 stated, Staff looked outside and could not find (R1). DON (Director of Nursing) was informed. One of the CNAs (Certified Nursing Assitants) coming to work for 3-11 shift, saw the wheelchair with facility's name by the bus stop. On 1/26/24 at 1:56pm, V7 (Certified Nursing Assistant/CNA) stated, (R1) goes outside patio to smoke regularly, but would come back after smoking. V7 stated she was working double shift at the time R1 left the facility without informing staff. V7 stated she heard an overhead page saying code green, meaning elopement or resident was missing. V7 stated, All staff was looking for (R1) but couldn't find him. (V23, CNA) saw R1 by the bus stop while she was driving to facility to work for 3-11 shift. Some staff went back to bus stop to look for (R1), but he was not seen. V7 stated staff saw R1's wheelchair with facility's name. Staff informed managers. On 1/26/24 at 2:10pm, V8 (Licensed Practical Nurse/LPN) said he has been working in the facility for almost 3 years, and regularly works on the 2nd floor for 3-11 shift. V8 stated on the day that R1 was missing, he did his rounds before shift started, and R1 was not in his room, but he knows usually would stay on the 1st floor talking to fell ow residents or smoking, and would come back to the unit before dinnertime. V8 stated he heard an overhead page Code Green, meaning elopement or resident was missing. V8 stated staff was looking for R1 but could not find him. V8 stated, The whole 3-11 shift (R1) was missing. The facility called the closest hospitals in the area and staff was looking for him in the neighborhood, because it was a cold night, but (R1) was not found. V8 stated V9 (Social Service) informed R1's family and R1's doctor. V8 stated he did not call R1's doctor. V8 stated he did not know the whereabouts of R1 for the whole 3-11 shift, and scheduled medications were not given. On 1/26/24 at 2:22pm, V4 (Social Service Director/SSD) said she was not able to recall the exact date, but maybe about 2 weeks ago, Social Service received a call from the receptionist saying R1 wanted to go to the store. V4 stated the receptionist was informed R1 could not go by himself to the store, and R1 needed supervision to go to the community. V4 stated R1 was missing in the facility or could not be seen in the building. Reviewed R1's EHR (electronic health record) with V4, and V4 stated the assessment for community pass indicated R1 needed to be supervised. Care plan reviewed, none found. On 1/26/24 at 2:39pm, V9 (Social Service/SS staff) stated, The purpose of the community pass assessment is to make sure that a resident is aware of his surrounding and safe/appropriate to go out in the community. (R1) needed supervision with community pass. V9 stated she was unable to recall an exact date, but about 2 weeks ago, they received a call from the receptionist asking if R1 could go out to the community independently, and receptionist was informed R1 could not go out of the facility by himself. V9 stated around 3pm-4pm, code green was activated. All staff were looking for (R1) and administration called the hospital, but could not find (R1). V9 stated she informed R1's family. V9 stated around 6pm, she left the facility; R1 was still not found. On 1/26/24 at 3:17pm, V2 (Director of Nursing/DON) said, (R1) needs supervision to go out on pass. If a resident needed supervision for community pass, a care plan should be in place. For any individualized assessment with identified concerns, the resident should have a care plan to address and to guide staff on how to care for the resident. V2 stated she was off on 1/5/24, but she was notified R1 left the building without permission. V2 checked R1's EHR (electronic health record) remotely, and it indicated R1 was cognitively intact, and not a risk for elopement. V2 stated she was worried because it was very cold that day. V2 stated, The same day, maybe close to 11pm, I called hospital and was informed by hospital staff that (R1) was being evaluated in the emergency room . On 1/6/24, (R1) came back to the facility with diagnoses of left foot fracture. I sent the initial and final report of the injury - left foot fracture-- to State Agency/IDPH (Illinois Department of Public Health). V2 stated she could not remember if she informed the nurse on duty at that time, but she informed the Administrator (V1) and corporate. V2 stated V1 (Administrator) spoke with the hospital nurse as well. On 1/26/24 at 4:00pm, V11 (Receptionist) said she usually comes to work at 2:45pm, and R1 was not in the facility at that time. V11 stated she would know, because R1 would always stay on the first floor. V11 stated one resident told her that he did not see R1, his smoking buddy. V11 called the 2nd floor nurse (V8), and V8 stated V8 did not see R1. V11 stated she called the 7-3 shift nurse (V5), who was working double on that day, but was assigned to 4th floor for 3-11 shift, and said he last saw R1 after lunch time. V11 stated she then activated the code green, meaning elopement/missing resident. V11 stated, All staff was looking for (R1). (V23, Certified Nursing Assistant/CNA) was asking for whom the code green was for, and was informed that (R1) was missing. V11 stated V23 said on her drive to work, she saw R1 in his wheelchair by the bus stop, about a block away from the facility. V23 went to check the bus stop, saw the facility wheelchair, but did not see R1. V11 stated there were 3 other CNAs (V3, V13, and V19) that went to the bus stop, saw the wheelchair which was brought back to the facility, but R1 was not found. On 1/28/24 at 9:30 am, V3 (Certified Nursing Assistant/CNA) said about 2 weeks ago, unable to remember the exact date, she heard an announcement/overhead page for code green, meaning elopement or missing resident around 4pm before dinner time. V3 stated V5 (Registered Nurse/RN) said R1 was seen by V23 (CNA) on her drive to work for 3-11 shift at the bus stop about a block away from the facility. V3 stated she (V13, CNA) and V19 (CNA) went to the bus stop, saw R1's wheelchair, and took it back to the facility. V3 stated they were looking for R1 in the neighborhood area, including the store, but R1 was not found. V3 stated they were told R1 went out to get a cigarette. V3 stated she never heard the whereabouts of R1 for the whole 3-11 shift. On 1/28/24 at 10:59am, R1 was lying in bed, alert and oriented to person, time, place, and situation. R1 stated about 2 weeks ago, he left the facility in his wheelchair by himself, and went to the store without telling anybody. R1 stated he left his wheelchair by the bus stop about a block away from the facility and walked to the store by himself. He tripped and fell by the store's driveway/parking lot. R1 stated somebody saw him and called emergency services/ambulance and he was brought to the hospital. R1 stated he broke his left foot. On 1/28/24 at 11:07am, V13 (CNA) said on 1/5/24, she was working double on the 4th floor, and heard one of the residents was missing. V13 stated the receptionist told her R1 was missing between 3pm - 4pm. V13 stated V23 (CNA) saw R1 by the bus stop about a block away from the facility. V3 stated she and V19 (CNA) went out to the bus stop, and R1's wheelchair was found, but R1 was not there. V13 stated they went to the neighborhood to look for R1, but to no avail. V13 stated after almost an hour of looking for R1, they went back to the facility and brought R1's wheelchair with them. V13 stated they informed V9 (Social Service) that R1 was not found. On 1/28/24 at 3:09pm V19 (CNA) said, About 2 weeks ago, around 3-4pm, I heard an overhead announcement code green (Elopement / missing resident). One resident was missing and (V23, CNA) had commented that (R1) was seen at the bus stop. V19 stated she and 2 other CNAs (V3 and V13) went to the bus stop, before 5pm, and saw the wheelchair, but R1 was not there. V19 stated they looked in the neighborhood for almost an hour, but R1 was not found. V19 stated R1's wheelchair was brought back to the facility, and they informed the nurse R1 was not found. On 1/28/24 at 3:59pm, V22 (R1's attending physician) was interviewed via phone, and stated V22 was not aware R1 was missing on 1/5/24. V22 stated, If the nurse documented that (V21, Nurse Practitioner/NP) was made aware, then it could be. Documentation is proof that (V21) or (V22) was informed about the incident, and if there was no documentation then it was not done. The facility can determine if the resident is safe to go out on pass by himself; if the assessment of (R1) indicated that (R1) needed supervision, then (R1) should have supervision to go out of the facility. The facility should have closely monitored and supervised (R1) so he can't leave the facility by himself, as it is not safe according to the assessment done by the facility. V22 stated R1 should have not gone out of the facility unsupervised. V22 stated if there was a left foot fracture, as confirmed by the hospital, it could be a result that R1 went out of the facility unsupervised. On 1/29/24 at 10:08am, V21 (R1's Nurse Practitioner) was interviewed via phone, and V21 stated she was not informed R1 was missing on 1/5/24. V21 stated she saw R1 in the facility after hospitalization , and knew R1 went out on pass, fell , and had a left foot fracture. V21 stated if the assessment showed R1 needed supervision, then R1 should have somebody with him when out of the facility for safety. V21 stated if R1 left his wheelchair and walked to the store by himself, then it was not safe for him. V21 stated the left foot fracture from a fall in the community could have been prevented if R1 went out with supervision. On 1/29/24 at 10:19am, V20 (Director of Human Resource/HR) stated V24 (former receptionist) was let go about a month ago due to attendance issues and overall performance. V20 verified V24's last day of work was on 1/12/24. On 1/29/24 at 11:31am, V24 (Former Receptionist) was interviewed via phone, and V24 stated she was let go the second week of this month. V24 stated V1 told her that she was not able to provide information that they needed, and family were complaining that information regarding residents were not provided correctly. V24 stated a week prior to her termination, she saw one resident leaving the facility, but came back after. V24 stated the following day, she was called by V1, and V1 told her one resident left the faciity on her shift and was missing. On 1/29/24At 11:43am, V23 (CNA) said she passed the bus stop about 1-2 blocks away from the facility, saw a person with a hoodie in a wheelchair, but was unable to identify who he was. V23 stated she arrived in the facility around 3:07pm to work for 3-11 shift. V23 stated after her rounds on the 2nd floor, she heard a code green, meaning elopement or missing resident. V23 stated she went to the receptionist, and was informed R1 was missing. V23 stated she informed the receptionist she saw a man in his wheelchair by the bus stop, and she thought it was R1. V23 stated around 3:30pm, she drove to the bus stop and saw facility's wheelchair, but R1 was not found. V23 stated she also looked in the neighborhood, but not able to find R1. V23 stated she arrived the facility, met the Administrator, and informed V1 she was not able to find R1. On 1/29/24 at 12:11pm, V4 (Social Service Director/SSD) said, Elopement protocol such as code green was activated, locked down the unit and did a head count, searched residents in the building, premisea, neighborhood, and called hospitals when (R1) was missing on 1/5/24, except police were not informed. Documentation was not done because we were advised by corporate not to do so. V4 stated she left the facility around 6:45pm, with no information about R1's whereabouts. V4 stated she heard the following morning R1 was found in the hospital with a left foot fracture. V4 stated she verified again Monday (1/9/24) what to do, and was advised by corporate not to document. On 1/29/24 at 12:55pm, V1 (Administrator) stated from his recollection R1 was alert and oriented x 3, went outside to the front of the facility, and V1 was informed later in the evening, about 3-4pm R1 was missing and did not receive the medications. V1 stated staff was looking in the building, but R1 was not seen. V1 stated they searched the premises but did not find R1. V1 stated the facility called the family, and was informed they did not take R1 out on pass. V1 stated one of the staff informed them R1 was seen by the bus stop at the corner of the facility. V1 stated staff went back to the bus stop, but did not find R1, and brought back the wheelchair to the facility. V1 stated he called the hospitals, but did not find R1. V1 stated =later that night, he called another hospital and was informed R1 was there. V1 stated =he informed V2 (Director of Nursing/DON) =R1 was found in the hospital ,and maybe 11-7 shift nurse was informed that R1 was in the hospital. V1 stated documentation was not completed correctly. V1 stated that police were not informed, if it was considered an elopement. On 1/29/24 at 1:24pm V2 (Director of Nursing/DON) stated staff is expected to follow policy for elopement. V2 stated R1's doctor was informed on the 6th, but was not informed on the 5th when R1 was out of the facility without permission. V2 stated if it was considered an elopement, then it should have been reported to the State Agency or IDPH (Illinois department of public health). V2 stated she reported the injury of the left foot fracture to IDPH. V2 stated that possibly, the incident /accident and left foot fracture could have been prevented if R1 went to the community supervised. Facility's missing resident/elopement policy, dated 11/15/18, documented: - Alert staff by announcing Code Green over the paging system. - The Administrator and Director of Nursing (DON) will evaluate the situation and develop a plan of action based on the individual resident. - The following steps should occur: > A nurse should notify the attending physician. > Notify the sheriff and / or police department and file a missing person report. > Complete incident report and notify the state agency according to reporting guidelines. > Document appropriate notations in the medical record. Facility's Community pass guidelines, dated 11/25/19, documented: - Purpose: to define the facility and the resident's responsibility when a resident leaves the facility whin the consent/order obtained by the facility's PCP. Many individuals admitted to the facility have a history of psychosocial problems, mental illness, physical ailments, substance abuse and poor impulse control. As a result, certain residents may not be fully capable of negotiating safely in the community independently. The Immediate Jeopardy began on 1/5/24 and was removed on 2/1/24 when the facility took the following actions to remove the immediacy: Corrective actions for affected residents: o R1 reassessed for elopement risk and proper supervision and monitoring implemented. o R1 was reassessed and was determined he was not safe for out on pass privileges. o The facility has conducted a comprehensive review to identify any other residents at risk for elopement. o All residents identified to be at risk for elopement are being rounded on and visually observed hourly by line staff on the units. o The receptionists are to monitor the front door from the hours of 7am to 11pm. When receptionist goes on break, another staff member covers the front desk to monitor the front door until the receptionist returns. o The facility front door is kept locked and can only be open by the receptionist or via a code input on the keypad located both inside and outside of the front door. Between the hours of 11pm to 7am, the front door is locked, and alarm is set to go off and notify all first floor staff of any attempts to open the door both from the inside and the outside. o Emergency QA meeting conducted on 01/30/2024 at 3pm. o V1 (Administrator) has educated the Social Services Department on assessing all independent residents to determine any at risk for elopement. o A list of residents at risk for elopement has been updated and placed in a binder at each nurses station and at the front desk. V4 (Social Services Director) has educated all staff on 1/5/24 on where to locate the list of residents at risk for elopement. o SS (Social Service) will audit elopement risk assessments to ensure they are completed on admission and every quarter, daily for the first 4 weeks and then weekly for 3 months. o V4 (Social Services Director) has educated all staff on 1/5/24 on the elopement policy and procedures. This includes immediately overhead paging of Code Green and doing a whole facility head count to identify any potential missing residents, immediate lockdown of all floors is implemented, meaning no resident is allowed to leave the floor/unit until a full headcount is completed and the All Clear is initiated. Return all residents to respective floors/units. Administrator, DON/ADON, emergency contact/POA, and physician to be notified immediately. Area police department to be notified as directed by the Administrator. o A Code Green drill has been conducted by V26 (Maintenance Director) on 1/30/24 for the 3pm-11pm and 11pm-7am shifts and on 1/31/24 for the 7am-3pm shift to ensure facility staff responds appropriately. A Code Green drill will be conducted by V26 weekly on random shifts for the first month, and monthly thereafter to ensure staff responds efficiently. o V4 (Social Services Director) has educated all staff on the independent out on pass policy. Only residents with current physician orders are eligible for independent out on pass privileges. A list of residents with orders for out on pass has been created and placed in a binder at each nurses station and at the front desk area. If a resident is not on the independent out on pass list, they do not have these privileges. The Social Services Department should be contacted to confirm any details and terms for residents with out on pass privileges. o V4 (Social Services Director) has educated staff on the updated smoking policy. Residents who smoke have been identified and the list updated. List has been placed in a binder at each nurses' station and at the front desk. The facility has implemented scheduled smoke times throughout the day with supervision. o Staff, vendors, and agency not present in the facility, will be educated prior to starting their next shift. This training will be ongoing for new hires in the orientation process. o V1 (Administrator) and V2 (DON) have been educated on 1/30/24 by V34 (Regional Director of Operations), on identifying reportable events which include elopement as per facility guidelines including timely reporting to IDPH, notifying, and obtaining a police report, and ensuring emergency contact/POA and physician have been made aware. o V4 (Social Services Director), will interview random staff in random shifts to ensure they have an understanding on the elopement procedures, the independent out on pass policy, and the smoking policy, daily for the first week, and weekly thereafter. o Findings of the quality review audits will be brought to the facility QA meeting until such time as the committee has determined substantial compliance has been achieved and recommends ongoing monitoring. The facility presented a plan to remove the immediacy on 1/30/24. The abatement plan was returned to the facility for revisions. The facility presented a revised plan on 1/31/24. State Agency accepted the plan on 2/1/24. On 2/1/24 via observation, interview, and record review, confirmed and verified the implementation of facility's removal plan. Observed resource binder regarding community pass, smoking guidelines and elopement process. List of residents who smoke, residents who have independent community access and residents who are at risk for elopement were also included in the resource binder placed in every nurse's station and reception desk. V5 (RN), V8 (LPN), V15(LPN), V19 (CNA), V23 (CNA), V27 (Physical Therapist/PT), V28 (RN), V29 (RN), V30 (CNA), V31 (CNA), V33 (CNA) interviewed and stated that in services for elopement, community pass and smoking were provided. All stated elopement drill was conducted. On 2/1/24 at 2:21pm, V26 (Maintenance Director) stated Elopement drill was done on 1/30/24 for 3-11 shift around 9pm and 11-7 shift around midnight and on 1/31/24 for 7-3 shift around 9:30am. V26 stated all employees who participated on elopement drill followed the elopement procedure properly. On 2/1/24 at 2:34pm, V27 (Social Service/SS consultant) stated SS is reviewing elopement assessments for all residents to ensure it is in place. V27 stated SS revised R1 elopement assessment and was added to the elopement risk kept by the reception desk and nurse's station. V27 stated SS reviewed community survival skills assessment making sure up to date and list of independent residents who can go to community are kept by the reception desk and nurse's station and the rest of the residents needed supervision with community pass. V27stated care plan for residents that needed supervision for community pass will be added. On 2/1/24 at 3:46pm, V2 (DON) stated in-service provided regarding reporting significant incident to IDPH. Stated nurses were also re-educated regarding importance of documentation and notifying MD once resident is missing. V2 stated facility will make sure to call doctor, family, police, and will report incident IDPH and document all the steps were done. On 2/1/24 at 3:57pm, V1 (Administrator) stated he received an in-service from V34 (Regional Director of Operations) regarding the process of reporting to IDPH and police department for any elopement incident.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development of a pressure ulcer or injury for a resident identified at risk; failed to document on the electronic treatment administration record (TAR) after each treatment for 1 (R2) resident with multiple acquired pressure ulcers; failed to revise the care plan to reflect alteration of skin integrity, approaches, and goals for care for 2 (R2 and R4) residents with multiple acquired pressure ulcers; and failed to provide specialty mattress for 1 (R4) resident with multiple acquired pressure ulcers. These failures affected 2 (R2 and R4) out of 3 residents reviewed for pressure ulcers. As a result of these failures, R2 developed a facility acquired stage III pressure ulcer to left ear, and a facility acquired stage IV pressure ulcer to coccyx / sacrum. Additionally, R4 developed a facility acquired unstageable pressure injury to sacrum, facility acquired deep tissues pressure to right heel, and facility acquired unstageable pressure injury to left heel. The findings include: 1. R2's electronic heath record (EHR) documented an admitted [DATE], with diagnoses not limited to Respiratory failure, Encounter for attention to tracheostomy, Dysphagia, Encounter for attention to gastrostomy, Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage, Other encephalopathy, Kidney disease stage 4 (severe), Chronic diastolic (congestive) heart failure, Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, Epilepsy, unspecified, not intractable, without status epilepticus, Unspecified abnormalities of gait and mobility, Unsteadiness on feet, Contracture of muscle multiple sites, Abnormal posture, Need for assistance with personal care, Anemia in chronic kidney disease, Gastro-esophageal reflux disease without esophagitis, Covid-19, and Pressure ulcer of sacral region, stage 4. Facility's concern form, dated [DATE], showed there was a concern regarding R2's wound being facility acquired. MDS (Minimum Data Set), dated [DATE], showed R2's cognition was severely impaired. R2 needed total assistance / dependent with oral, toileting and personal hygiene, shower / bathe self, upper and lower body dressing, roll left and right. MDS showed that R2 was always incontinent of bowel and bladder. MDS showed R2 had Stage IV pressure that was not present on admission or re-entry. R2's care plan, dated [DATE], documented: Actual Alteration in skin integrity r/t (related to) new/worsening blister. No care plan found in R2's EHR for facility acquired Stage III pressure ulcer to Left ear and facility acquired Stage IV pressure ulcer to Sacrum/coccyx. R2's wound assessment details report, dated [DATE], documented: Wound: Coccyx Date Identified: [DATE] Source: Facility-acquired Clinical Stage: Stage IV Measurement Size (cm - centimeter): 4.00 x 3.00 x 0.50 (L x W x D - Length / Width / Depth) R2's wound assessment details report, dated [DATE], documented: Wound: left ear Date Identified: [DATE] Source: Facility-acquired Clinical Stage: Stage I Measurement Size (cm): 1.2 x 0.20 x 0.00. Assessment for level of risk for acquiring pressure wounds, dated [DATE], [DATE], ,d+[DATE], [DATE], [DATE] and [DATE], showed R2 was high risk. R2's TAR (treatment administration record) was not signed/initialed that treatment was done or provided to sacrum on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. R2's TAR was not signed that treatment was provided to left ear on [DATE], [DATE], [DATE] and [DATE]. R2's order summary report, dated [DATE], with order: Site: Sacrum Cleanse with wound cleanser, pat dry with gauze, apply collagen and ALG to site and cover with dry dressing every day shift. Site: Left Ear Cleanse site with NSS, Pat dry, apply xeroform and cover with dry dressing every day shift AND as needed for if dressing becomes compromised apply PRN (as needed). Wound Nurse Practitioner notes, dated [DATE], documented: 1. Stage III pressure injury to left ear. Measures 0.4 x 0.2 x 0.1 cm. Wound is 100% granular tissue. Scant serous exudate. 2. Stage IV injury to sacrum. Measures 3.7 x 2.2 x 1 cm. Wound is 100% granular tissue. Moderate serous exudate. On [DATE] at 10:34am, wound care observation conducted with V12 (Wound Care Coordinator), V15 (Wound Care Nurse) and V35 (Wound Nurse Practitioner). R2 was lying in bed, G-tube feeding on hold, with tracheostomy tube attached to cool aerosol. Air mattress in place; bilateral heel lift boots. R2's sacral wound was 100% granulating (beefy red), no maceration on surrounding area. V12 was doing wound treatment, assisted by V15. V35 measured sacral wound, and stated R2 has active Stage IV pressure ulcer with no bone exposure, measuring 3.7x2.2x1cm. R2 hadopen skin on left ear, and V35 stated that wound is still active and classified as Stage III pressure ulcer. V35 measured left ear wound, and stated it was 0.4x0.2x0.1cm, 100% granulation. On [DATE] at 3:16pm, R2's EHR (Electronic Health Record) reviewed with V12, and V12 stated R2's has no wounds upon admission on [DATE]. V12 stated R2 has facility acquired pressure ulcer to coccyx, and it was identified on [DATE]. R2 has another facility acquired pressure ulcer on left ear. On [DATE] at 10:06am, V35 (Wound Nurse Practitioner / NP) said she is following R2 due to multiple pressure ulcers. V35 stated R2 has facility acquired unstageable wound to sacrum, identified on [DATE]. V35 stated, (R2) went to the hospital, and debridement was done to the sacral wound. Upon (R2's) readmission, the wound to sacrum was classified as stage 4 pressure ulcer. Wound treatment should be done as ordered. If wound treatment is missed or not done, it could lead to worsening of wound, or the wound could deteriorate. The plan of care is important and should reflect the status of the wound for appropriate wound care or treatment. In theory, if care plan is not updated, the team is not aware of the status of the wound. (R2) has also acquired Stage III pressure ulcer to left ear. At 11:15am, V12 (Wound Care Coordinator/ Licensed Practical Nurse/LPN) stated wound care/treatment is done as ordered, and electronic treatment administration record (ETAR) is signed or initialed for accountability. V12 stated, Signing ETAR is important; it is a documentation to prove that treatment was provided to the resident. If ETAR was not signed or initialed, it means that treatment was not provided to the resident. If wound treatment was missed or was not provided to the resident, wound could worsen, deteriorate, or could lead to infection. Care plan should reflect the status of the wound that would include goals and appropriate interventions. V12 stated the wound location sacrum/coccyx is the same. V12 stated wound documentation to left ear Stage I was a typo error, and it should be Stage III, not Stage I. Facility's Pressure injury and skin condition assessment policy, dated [DATE], documented: - The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care. - Physician ordered treatments shall be initialed by the staff on the electronic treatment administration record after each administration. 46342 2. R4 is a [AGE] year-old female, admitted to the facility [DATE], with diagnoses not limited to Alcoholic Cirrhosis of Liver ithout Ascites, Dysphagia, Unspecified Severe Protein-Calorie Malnutrition, Metabolic Encephalopathy, Unsteadiness on Feet, Unspecified Abnormalities of Gait and Mobility, Weakness, Need for Assistance with Personal Care, Opioid Dependence with Withdrawal, Alcohol Dependence with Withdrawal Delirium, Anxiety Disorder, and Hypokalemia. Upon admission, R4 was ambulating with use of a walker. R4 sustained a fall on [DATE] requiring hospitalization from ,d+[DATE] to [DATE], with left hip pinning for left displaced femoral neck fracture. R4 was non-ambulatory upon readmission post fall. R4's Braden Score for predicting pressure sore risk on [DATE] was assessed as being at moderate risk based on score of 13. R4 had surgical incision to left trochanter which healed [DATE] and surgical incision to left lateral upper thigh which healed [DATE]. R4's skin care plan, initiated on [DATE], documented: R4's potential for pressure ulcer development (related to) history of ulcers and included three interventions including 1.) administer treatments as ordered and monitor effectiveness, 2.) educate resident family/caregivers as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent position, 3.) inform resident/family/caregivers of any new area of skin breakdown dated [DATE]. There were no changes to R4's skin care plan focus or interventions since last revision date on [DATE]. R4's MDS (Minimum Data Set), dated [DATE], documents R4's BIMS (Brief Interview of Mental Status) score of ,d+[DATE], indicating moderately impaired cognition, and R4's functional abilities documents R4 requires supervision or touching assistance for eating, toileting, dressing, ambulating, transfers. R4's MDS, dated [DATE], documented functional abilities that R4 requires dependent care (helper does all of the effort) for toileting, dressing and dependent care to substantial/maximal assistance with mobility and transfers. R4's MDS (Minimum Data Set), dated [DATE], document R4's BIMS (Brief Interview of Mental Status) score of ,d+[DATE], indicating severely impaired cognition and R4's functional abilities documents that R4 requires substantial/maximal assistance with toileting, dressing, and rolling left to right. Other functional abilities (sit to lying, lying to sitting on side of the bed, sit to stand, chair to bed to chair transfer, toilet transfer) were not attempted due to medical condition or safety concerns. R4 developed three facility acquired pressure injuries. Per V35's (Wound Nurse Practitioner) wound assessment signed [DATE], identified unstageable pressure injury to sacrum measuring (6.0x6.0x0.0) with 50% necrotic tissue with minimal serous exudate. V35's wound assessment, signed [DATE], documents facility acquired deep tissues pressure to right heel measuring (2.5x4.0x0.0) with 100% necrotic tissue, minimal serous exudate with deterioration in surface area and facility acquired unstageable pressure injury to left heel measuring (3.0x3.0x0.0). R4 was transferred to hospital on [DATE] for change in condition, including fever and shortness of breath. R4 expired on [DATE], per R4's electronic health record. On [DATE] on 3:17 pm, V12 (Wound Care Coordinator/LPN) stated prevention measures are individualized per residents and general interventions include use of a low air loss mattress, frequent turning depending on resident comfort level, but typically every 2 hours, consult with the Registered Dietitian to see if appropriate to add in protein and vitamins. V12 stated R4's pressure wounds were facility acquired. V12 stated R4 used to be mobile with the use of a walker when R4 was initially admitted . V12 stated after R4's fall, R4 was in bed post-op, and totally dependent on staff for activities of daily living. V12 stated causes of R4 developing pressure wounds could be attributed to R4 not being ambulatory, spending longer periods of time in bed, no longer communicating needs and increased moisture related to incontinence. V12 stated R4 was being rounded on every 2 hours, turned every 2 hours, provided incontinent care as needed, and given nutritional supplements to aid wound healing. V12 stated R4 was at an increased fall risk, so therefore, a low air loss mattress was not indicated. V12 stated V12 had a meeting with V22 (Restorative Director) when R4 returned from the hospital in [DATE], and they decided it was not safe for R4 to use a low air loss mattress. V12 stated V12 did not think it would be appropriate to use a low air loss mattress, and therefore, did not recommend it to the Wound Care Nurse Practitioner. V12 stated V12 was not the Wound Care Nurse who was at the initial meeting when R4's pressure wound to sacrum was identified. V22 stated normally V22 would talk to the Wound Care Nurse Practitioner about changes in environment, such as ordering a low air loss mattress for a resident. V12 stated V12 does not know if use of a low air loss mattress was discussed with the Wound Care Nurse Practitioner. V12 stated the Wound Care Nurse Practitioner was aware R4 had fallen and sustained injury, so V12 assumed the Wound Care Nurse Practitioner would also agree not to use a low air loss mattress due to R4's history of falling. V22 stated usually for someone who developed an acquired pressure wound, they would use a low air loss mattress. V22 stated, It is rare to say no to a low air loss mattress, but (R4) was a special case. On [DATE] at 9:08 AM, V24 (Certified Nursing Assistant) stated R4 was on a regular mattress the entire time R4 was at the facility. V24 stated a low air loss mattress and/or wedges were not used. V24 stated at some point, R4 did have orders for heel protectors, but R4 would kick them off. V24 stated R4 required extensive assistance with positioning, and stated R4 would only rotate positioning from side to side with staff assistance, R4 could not do it on her own. Facility policy titled, Pressure Ulcer Prevention, dated [DATE], documents: purpose is to prevent and treat pressure sores/injuries and specialty mattresses such as low air loss, alternating pressure may be used as determined clinically appropriate and specialty mattresses are typically used for residents who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds.

Based on observation, interview, and record review, the facility failed to provide individualized fall risk measures in place prior to a resident sustaining a fall for a resident assessed as being at high fall risk upon admission; and failed to put new individualized fall risk interventions in place for each subsequent fall for one (R4) out of three residents reviewed for falls. This failure resulted in R4 sustaining a fall on 08/24/23, resulting in a left hip pinning for left displaced femoral neck fracture, and R4 also sustaining two additional falls on 09/21/23 and 11/13/23. Findings include: R4 is a [AGE] year-old female, admitted to the facility 07/07/23, with diagnoses not limited to Alcoholic Cirrhosis of Liver Without Ascites, Dysphagia, Unspecified Severe Protein-Calorie Malnutrition, Metabolic Encephalopathy, Unsteadiness on Feet, Unspecified Abnormalities of Gait And Mobility, Weakness, Need For Assistance With Personal Care, Opioid Dependence With Withdrawal, Alcohol Dependence With Withdrawal Delirium, Anxiety Disorder, and Hypokalemia. R4's MDS (Minimum Data Set), dated 07/13/23, documents R4's BIMS (Brief Interview of Mental Status) score of 10/15, indicating moderately impaired cognition. R4's Activities of Daily Living (ADLs) Assistance documents R4 requires supervision or touching assistance for eating, toileting, dressing, ambulating, transfers. R4's MORSE Fall Scale Evaluation, dated 07/07/23, documents score of 55, indicating high risk for fall, based on criteria including, but not limited to R4's history of falling, use of walker, and secondary diagnosis. R4's care plan, dated 07/07/23, documents R4 is at risk for fall (related to) deconditioning, gait/balance problems and encephalopathy. Interventions included educate R4/family/caregivers about safety reminders and what to do if a fall occurs (07/07/23), review information on past falls and attempt to determine cause of falls. Record possible root cause. Alter remove any potential causes as possible (07/07/23), needs activities that minimize the potential for falls while providing diversion and distraction (07/07/23), and physical therapy to evaluate and treat as ordered (07/07/23). On 08/23/23 at 5:00 am, V55's (Licensed Practical Nurse, Agency) progress note documented V55 heard a thud and (R4) cried out for the nurse, when (V55) entered (R4's) room (R4) was sitting upright on the floor. (R4) states that (R4) walked toward (R4's) nightstand to get her pants and stumbled backwards hitting her head on the wall. (R4) was transported to hospital for evaluation. Per hospital records, R4 was hospitalized ,d+[DATE]-[DATE] with a hip fracture requiring left hip pinning for left displaced femoral neck fracture. R4 was non-ambulatory upon readmission. Upon readmission, R4's fall risk care plan interventions were adjusted on 08/29/23 as follows: keep furniture in locked position, keep needed items, water and personal items in reach, maintain a clear pathway free of obstacles, staff will assist R4 with hygiene care and dressing as needed, receive physical therapy((PT)/occupational therapy (OT) as ordered, be sure call light is within reach and encouraging R4 to use it for assistance as needed, ensure R4 is wearing appropriate footwear when transferring or mobilizing in wheelchair. On 01/03/24 at 9:08 am, V24 (Certified Nursing Assistant) stated after R4's fall in August 2023, R4 was bed bound, and was no longer using a walker, and did not get out of bed anymore, and R4's cognition was declining. V24 stated R4 was in a room which was at the end of the hallway near the dining room, not near the nursing unit. On 01/04/24 at 12:45 pm, V54 (Certified Nursing Assistant) stated V54 is a CNA, who used to take care of R4. V54 stated before R4's fall, R4 was out and about participating in activity functions, walking around the unit using a walker, and could do things for herself. V54 stated R4 declined big time after the fall, and spent all of her time in bed, requiring total care. V54 stated R4 was continually trying to get up out of bed, and R4's room was at the end of the hall, not near the nursing unit. On 01/03/24 at 11:59 pm, V22 (LPN Restorative/Fall Coordinator) stated upon initial admission, R4 had unsteady gait, but was able to ambulate with a walker. V22 stated R4 was determined to be at a high risk for falls based on unsteady gait, use of a walker, history of falling, and medical diagnoses. V22 stated R4 fell early in the morning on 08/24/23, while trying to get herself dressed. V22 stated staff was aware of R4's preference to get up very early in the morning and get herself dressed. V22 stated having R4's bed in the lowest position and use of two floor mats were interventions V22 thinks the facility was using for R4. Upon reviewing R4's care plan, V22 stated V22 does not see low bed position or use of floor mats as part of R4's care plan, but stated it should have been part of R4's care plan, so that the staff would know what to do. V22 stated the facility uses agency nursing and CNAs, so it is important for resident care plans to be up to date. V22 reviewed the new intentions added (08/27/23) to R4's fall care plan, and stated it is possible having some of these interventions previously implemented before R4's fall in August could have potentially prevented R4 from falling. On 09/21/23 R4 sustained a second fall. Per nursing progress note, dated 09/21/23, R4 was found sitting on floor with no injuries. R4's care plan, dated 09/22/23, had an intervention added of R4 will receive assistance with getting up out of bed to transfer into wheelchair from nursing staff as tolerated. On 11/13/23, R4 sustained a third fall. Per nursing progress note, dated 11/13/23, R4 was found lying on floor to the right of her bed. R4 reports R4 was trying to get out of bed, and states R4 hit her head and had pain,; full body assessment completed, and R4 was sent to the hospital for evaluation. Per hospital records, R4 was admitted due to fall with no findings/injuries. R4's fall risk care plan was updated 11/13/23, documenting R4 was sent out for medical evaluation due to fall. There were no new interventions added to R4's fall care plan after the 11/13/23 fall. On 01/03/23 at 2:00 pm, V21 (Director of Rehab) stated, (R4) was discharged from physical therapy on 08/04/23, and doing well at discharge, requiring supervision with transfers, ambulating 100 feet with roller walker with supervision, eating independently. (R4) was re-evaluated by physical therapy 08/29/23, following a fall with left femur fracture and was being seen by physical therapy from 08/29/23-09/25/23 and 09/27/23-10/27/23. At this time, physically (R4's) level changed from supervision to maximum dependence on bed mobility and transfers, upper extremity dressing moderate assistance, lower body dressing was dependent, grooming was moderate assistance, eating was supervision with minimal assistance. At the end of the two months, (R4) improved to a lying to sitting on the side of bed from max to moderate assist, but was still a maximum assist with transfers from bed to chair, requiring a (mechanical lift) lift for safety purposes. Due to (R4's) minimal progress, (R4) was discontinued from therapy. V21 stated R4's barriers included R4's cognitive deficits, and poor safety awareness, which increased her risk for falls and progress in therapy. V21 stated safety measures should have included R4's bed in the lowest position and floor mats on floor next to R4's bed, and these should have been care planned. V21 stated, (R4) was picked up again by therapy 11/15/23 for physical therapy following another fall. (R4) had changed to moderate to maximum assist for lying to sitting, and transfer was not attempted due to safety on the day of eval (evaluation). (R4) was discharged from therapy on 12/12/23, and was still max (maxium) for bed mobility, unable to transfer requiring 2+ assist with (mechanical lift), and at this point (R4) was a feeder. (R4's) fall was a big set back that had a significant change in (R4's) functional status. V21 stated if R4's fall/injury was not to that level of severity, then the setback would not have been that significant. V21 stated the fall contributed to R4's lack of mobility because R4 was not able to ambulate as she could upon initial admission to the facility. V21 stated R4 had poor self-awareness of R4's deficits, which placed R4 at higher risk for continued falls. On 01/04/23 at 10:22 am, V20 (R4's Medical Doctor) stated R4 was identified as being at high risk for falls upon admission. V20 stated fall risk precautions were in place for R4, and R4 was receiving physical therapy. V20 stated V20 did not know what they do specifically for their fall precautions, because they are specific to each resident, but there are standard things they do for fall precautions. For example, put a resident closer to the nursing station, watch them more carefully, low bed potentially, no clutter in the room, well lit room, no rugs. V20 stated R4 was also under weight and malnourished, which leads to deconditioning, and places a resident at increased risk for falls and fractures. Facility policy titled Fall Prevention Program, dated 11/21/17, documents: 1.) the purpose it to assure the safety of all residents at the facility, the program will include measures which determine the individual needs of each resident and implementation of appropriate interventions. 2.) Care plan incorporates preventative measures and interventions are changed with each fall. Facility policy titled Comprehensive Care Plan, dated 11/17/17, documents: the purpose to develop a comprehensive care plan that directs the care team and incorporates the residents' goals, preferences and services that are able to maintain the resident's highest practicable physical, mental and psychosocial well-being and the care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving.

Based on observation, interview, and record review, the facility failed to follow their weight policy, and failed to care plan a resident that sustained significant weight loss for 1 out of 3 residents (R5) reviewed for nutrition. These failures resulted to R5 experiencing significant weight loss that was not reported, addressed, or care planned. Findings include: R5 is [AGE] years old, initially admitted on [DATE], with principal diagnosis of end stage renal disease, dependence on renal dialysis, and hypertensive heart. R5's BIMS (Brief Interview of Mental Status), dated 11/2/2023, scored 15; meaning R5 has an intact cognition. Documentation of R5's weight history reads that resident was declining as to his weights: Initial weight of R5 dated 5/4/2023 was 201.9 LBS (pounds) 6/2/2023 weight was 187 LBS post dialysis. 7/3/2023 weight was 187 LBS post dialysis. 8/1/2023 weight was 180 LBS post dialysis. 9/13/2023 weight was 178 LBS post dialysis. 9/19/2023 weight was 167.2 LBS post dialysis. 10/03/2023 weight was 176 LBS post dialysis. 11/1/2023 weight was 160.6 LBS post dialysis. 12/1/2023 weight was 160.6 LBS post dialysis. 12/13/2023 weight was 155.1 LBS post dialysis. 12/22/2023 weight was 144.1 LBS post dialysis. 1/2/2023 weight 59.4 KG (kilograms) or 130.95 LBS post dialysis. V48 (Registered Dietitian) progress notes: Date 6/18/2023, documents R5 had significant weight loss at 1 month, which is unplanned or unavoidable related to osteomyelitis, fluid loss, and hemodialysis visits. Date 8/15/2023, documents R5 had significant weight loss at 3 months, which was planned and likely related to fluid loss. Dated 10/5/2023 and 10/9/2023, documents R5 had significant weight loss at 1 month, which was planned and likely related to fluid loss. Dated 11/6/2023 and 11/24/2023, documents R5 had significant weight loss at 1, 3, and 6 month,s which was planned and likely related to fluid loss. Dated 12/15/2023, documents R5 had significant weight loss at 3 and 6 months, which was planned and likely related to fluid loss. On 1/2/2024 at 1:57 pm, R5 was not in his room. Nursing staff stated every Tuesday, Thursday, and Saturday R5 goes down to the basement to do dialysis. In the basement, R5 was seen in dialysis clinic. V50 (Dialysis Registered Nurse) said that it will take few minutes for R5 to finish dialysis. On 1/3/2024 at 12:10 pm, R5 was on his bed, and appeared to be weak and unable to respond to questions when asked. R5 was visually thin, with his body showing his bones prominence to his face, body, upper and lower extremities. R5's lunch tray was on a moving table at the foot area of the bed. V24 (Certified Nursing Assistant) came inside the room and stated, He (R5) has been like this for a week. He does not eat at all. V24 gave R5 half spoon full of puree food and green beans. R5 did not eat any of the food. V24 gave R5 juice and said, This is the only thing he takes. R5 took a few sips and stopped responding to V24. At 2:10 pm, V25 (Registered Nurse), stated, (R5) was declining, he was not like this before. V25 stated staff used to just set up the table, and R5 would eat. R5 did not need to be fed before. V25 said R5 has protein supplement that was given to him today; it is inside her cart, and was given today. Upon checking her cart, protein supplement cannot be found. V25 said if not in her cart, she [NAME] from the other cart, and showed the protein bottle in another cart. V25 was asked, how much food R5 ate during lunch? V25 pointed to V26 (Certified Nursing Assistant) and said, Did you feed (R5)? V26 said, Yes, (R5) did not each much. V25 was informed it was V24 who fed R5, and not V26. V25 said, I did not know that it was (V24) who fed (R5). V25 was asked if any of the staff encouraged or offered alternative food or supplement to R5? V25 said, I was not aware (R5) did not eat. On 1/4/2023 at 11:30 pm, R5 was brought by V24 (Certified Nursing Assistant) down to dialysis center. V50 (Dialysis Registered Nurse) observed taking the weight of R5, and said R5's current weight pre dialysis is 63 KG (kilograms) or 139 LBS (pounds). On 1/4/2024 at 10:58 am, V48 (Registered Dietitian) stated, (R5) had significant weight loss, and it was due to many factors, not only fluid loss. Interventions need to be in the care plan. Staff should encourage (R5) when not eating. (R5's) weight on 12/13/2023 was 155.1 LBS, that decreased to 144.1 LBS, or 11 LBS decrease on 12/22/2023 was a significant weight loss. V48 stated it was not communicated to him to address the problem. V48 said, Yes, there was lapse of communication. A review of R5's full care plan does not address significant weight loss. On 1/3/2024 at 3:54 pm, V16 (Dietary Technician) stated she does the assessment and care plan of R5. V16 took the copy of R5's full care plan, after review. V16 stated, There is no plan of care for significant weight loss that addresses the problem. The care plan needs to be updated based on recommendation of the Dietitian. Whatever the dietitian recommends needs to be put on the care plan. On 1/4/2024 at 12:32 pm, V2 (Director of Nursing) reviewed R5's care plan and stated, This is not correct, I mean the care plan of (R5) does not address significant weight loss, and its goal cannot be achieved. Yes, (R5) is losing weight, and there are many factors, including antibiotic use. Weight Policy, dated 11/14/12 with a revision date of 11/17/19, was reviewed and reflects: Residents identified at nutritional risk may be weighed weekly or by weekly as per the physician order or Interdisciplinary Team. Re-weight should be obtained if there is a difference of 5# or greater (loss or gain) since previous recorded weight. Re-weight should be taken as soon as possible after an unanticipated weight change is noted and prior to calling a physician (Usually within 72 hours). Undesired or unanticipated weight gains/loss of 5 % in 30 days, 7.5% in three months, or 10% in six months shall be reported to the physicians, Dietician, and/or Dietary Manager as appropriate.

Based on interview and record, the facility failed to ensure that residents are free from staff to resident verbal and mental abuse for two of two residents (R1,R2) reviewed for abuse. This deficient practice resulted in R1 verbalizing feelings of anger and R2 demonstrating sadness. Findings include: R2's medical record (Face Sheet, MDS-Minimum Data Set) documents R2 is a severely cognitively impaired [AGE] year-old admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Atherosclerotic Heart Disease, and Asphasia. R1's medical record (Face Sheet, MDS-Minimum Data Set is a cognitively intact [AGE] year-old admitted to the facility with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea, Chronic Kidney Disease, Stage 4; Major Depressive Disorder, Legal Blindness, and Anxiety Disorder. Facility's final incident report date 10/24/2023, documents, On 10/17/2023 at approximately 3:30 PM, it was reported to the administrator that a CNA was rude to these residents (R1, R2) during care. (V4-Former Certified Nursing Assistant) alleged perpetrator declined comment. (R2) said (V4) told me to shut up. (R1) said when (V4) was providing care to me, she was not nice. Social Service Designee (V12-Director of Social Service) said (R2) and (R1) reported to me that the CNA was being discourteous and rude to them when she was providing them care. I reported it to the administrator. I did not witness the event. Based on the investigation, the CNA was suspended from the facility and then terminated from employment for discourteous behavior to residents. V4's (Former CNA-Certified Nursing Assistant) Employee Disciplinary Action Report, dated 10/18/2023 documents: 10/17/2023 Policy Violation, Quality of Work, and Resident Health/Safety Concern. Employee was suspended pending investigation for improper customer service and rude behavior towards two residents on 10/17/2023. Employee was informed via telephone on 10/18/2023 that the allegation was substantiated and she was being terminated for failure to provide customer service to residents and policy violation for dignity and respect. On 11/7/2023 at 11:11 AM, 12:03 PM, and 2:16 PM, V3 (LPN-Licensed Practical Nurse) said, I was doing the morning medication pass, it was on a weekend, I don't remember the exact date. I heard (V4, CNA-Certified Nursing Assistant) scream at (R2). She screamed at (R2) to shut up, you're too loud. V3 said R2 is non-verbal but makes grunting sounds. V3 said after V4 screamed at R2, R2 appeared upset; R2 put his head down and wheeled himself to his room. V3 said R1 told V3 that V4 was rude to R1 when R1 asked V4 to change R1 sometime in the afternoon on the same day. V3 said she did not report the incident right away; she said waited until Monday when she reported it to the V10 (ADON-Assistant Director of Nursing). V3 said that V4, as far as she knows, continued to work her shift. V3 did not send V4 home. V3 said she did not say anything to V4 when V4 screamed at R2. V3 described V4 as aggressive/abrasive. I didn't want to confront her; I knew I was supposed to. I kept checking on (R2) to make sure he was okay. On 11/7/2023 at 11:20 AM, R1 was observed sitting up in bed. R1 said she asked V4 to change her; (V4) responded she wasn't going to change me. I told her I was going to report her. She said, 'go ahead, they won't do anything.' It made me really angry. On 11/7/2023 at 11:57 AM, V5 (CNA-Certified Nursing Assistant) said he would immediately report to the Administrator any abuse. On 11/7/2023 at 12:08 PM, V6 (CNA-Certified Nursing Assistant) said residents did complain to her that V4 (Former Certified Nursing Assistant) was mean to them. I didn't report it to anyone. I should report any abuse to the Administrator right away. On 11/7/2023 at 2:50 PM, V9 (Director of Human Resources) said V4 (Former CNA-Certified Nursing Assistant) was terminated by V1 (Administrator) on 10.18.2023 for improper customer service and dignity and respect. On 11/7/2023 at 3:07 PM, V1 (Administrator) said, (V3,LPN) reported the allegation to Social Service Designee (V12, Director of Social Service), during stand-up meeting at approximately 9:45 on 10/17/2023. Social Service Designee then reported to me on the phone on 10/17/2023. I wasn't in the facility at the time. I pulled over, did the reportable on my phone. On 11/7/2023 at 3:35 PM, V10 (Assistant Director of Nursing/ADON), stated, I was made aware of it I believe it was on Monday morning; I was informed during stand-up. (V3, LPN) said (V4, Former CNA) yelled at (R2) to shut up. I don't when this happened off the top of my head, I feel like it was three weeks ago. (V9, Director of Human Resources) would have that information because we suspended her (V4) pending investigation. V10 confirmed both V3 and V4 were working at the same time. It happened a couple days prior to me hearing about it; that (V4) yelled at (R2) and was rude to (R1). On 11/7/2023 at 2:41 PM, V12 (Director of Social Service) said. I found out during morning rounds on the 4th floor, I don't recall the date or time. (V3, LPN) stated this during morning rounds. (V3) said she witnessed (V4, Former CNA) yelling at (R2); (V4) told him to shut up and go to his room. The resident (R2) was down, not himself, he was quiet, isolating himself in his room after the incident. He's (R2) on the unit on the daily. I followed up with (R1). She said that (V4) came into the room, (R1) asked for another CNA, (V4) brushed her off, was extremely rude, using profanity, and told (R1) she was stuck with her (V4). V12 said, It's not appropriate behavior; its verbal abuse and should be reported immediately. On 11/8/2023 at 9:38 AM, V2 (Former Director of Nursing) said via telephone, she was aware of the incident involving R2 and V4 (Former CNA). V2 said she became aware of the allegation during a stand-up meeting (didn't remember date), when V3 (LPN-Licensed Practical Nurse) reported V4 yelled at R2. Allegations of abuse should be reported immediately. The resident and aggressor should be separated; the aggressor should be removed from the facility to protect the resident. On 11/8/2023 at 10:36 AM, V1 said, Abuse should be reported immediately, when it happens. If allegation of abuse is staff to resident, then we would suspend employee immediately. At that moment the priority is the safety of the resident, keep the resident(s) safe. They (the allegations) were reported to me on 10/17/23, and that's when I started my investigation. (V4, Former CNA) was not in the building at the time, so I called (V9, Director of Human Resources) and told (V9) to tell (V4), as soon as she walked in the building, that she was suspended pending the outcome of investigation. I just moved forward with the termination (V4's). Both incidents occurred in the same day; that is a termination. Profanity not allowed; it is abuse. Surveyor asked V1 if telling a resident to shut up, you're too loud is abuse, V1 refused to answer, then said, We'll go with what you're saying. I need to go back and review this (incident) with my regional. Facility's Abuse Prevention and Reporting-Illinois policy (Reviewed/Approved by IDT 12.17.2021) documents: - Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. -Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communications, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. - Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. - Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property is unsubstantiated. Employee Handbook documents: Each resident also has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. You are required to immediately report all alleged violations involving mistreatment, neglect or abuse, including misappropriation of resident property and injuries of unknown source, to the Administrator or other Facility representative, in accordance with federal and state laws.

Based on observation, interview and record review, the facility failed to prevent 1 resident (R3) from removing dialysis access port dressing. This failure resulted in R3 being hospitalized and treated for infection. Findings include: Face Sheet Dated 5/24/23 documents, R3 has diagnoses that include but are not limited to Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 chronic kidney disease, or End Stage Renal Disease; Dependence on Renal Dialysis; Unspecified Severe Protein-Calorie Malnutrition; Vascular Dementia; Unspecified Atrial Fibrillation; Atherosclerotic Heart Disease of Native Coronary Artery; Metabolic Encephalopathy. R3's Hospital medical record dated 5/9/23, documents in part: Medical Problems, Vascular catheter dysfunction, Infection of exit site of hemodialysis catheter; Continue Taking the Following Medication, Vancomycin/0.9% Sod Chloride 1 gram/250 ML intravenous piggyback, every 24 hours for S/P(after) Port placement. R3's Dialysis Communication Report dated 5/8/2023, documents in part: Attention Primary Floor Nurse: Continue to monitor patients' blood pressure and access dressing after treatment. For Catheters (CVC), the dressing must always remain intact and clean and dry. If removed by the patient or soiled, make sure the limb clamps are closed and catheter caps are in place. Cleanse exit site with alcohol prep pad, ChloraPrep, or Betadine wipe/swab, and apply a sterile dressing after cleansing agent has dried. Promptly notify dialysis staff if this occurs. R3's Dialysis care plan date initiated: 9/28/2021 documents in part: R3 has dialysis related to renal failure, , with desired outcome of will have no signs or symptoms of complications from dialysis, with interventions including check and reinforce dressing daily at access site, requires sterile dressing change per POS (physician order sheet). On 5/23/23 at 3:30 PM, V3(Licensed Practical Nurse) stated, V3 checks for drainage, redness and swelling at the port site. If there is drainage, V3 takes R3 downstairs to dialysis. V3 stated, dialysis oversees the port including the dressing. stated, V3 checks for drainage, redness and swelling at the port site. If there is drainage, V3 takes R3 downstairs to dialysis. V3 stated, dialysis oversees the port including the dressing. On 5/23/23 at 3:30 PM, V3 (Licensed Practical Nurse) stated V3 checks for drainage, redness and swelling at the port site. If there is drainage, V3 takes R3 downstairs to dialysis. V3 stated dialysis oversees the port including the dressing. On 5/23/23 at 3:25 PM, Surveyor and V3 visited R3 at bedside and observed no dressing covering R3's port area. On 5/24/23 at 11:18 AM, V6 (Regional Manager for facility's in-house dialysis unit) stated, Our expectation is they(nursing staff) notify us if the dressing is off. If the dressing is off, it can lead to infection because the site is open. On 5/24/23 at 12:06 PM, V16 (Dialysis Technician/Patient Care Technician) stated all the time, before, during and after treatments, R3 is scratching at the site. R3 removes the dressing. Sometimes R3 scratches and removes the dressing before going back upstairs so have to re-clean and re-dress. On 5/24/23 at 12:15 PM, V17 (Registered Nurse) stated, Most of the time when here R3 takes off the dressing. Sometimes R3 scratches at the skin. On that Monday there was no dressing, and I noticed R3's skin was open, red with no odor, not deep. The wound was next to the port not directly on it. I was able to dialyze with no problem. I called the Nephrologist who said to send R3 out to hospital. On 5/24/23 at 12:45 PM, Surveyor and V6 visited R3 at bedside and observed R3 had no dressing covering port area. On 5/24/23 at 2:05 PM, V8 (Director of Nursing) stated, nurses monitor the port site every shift, making sure the dressing is intact, and for signs and symptoms of infection. If there is an issue with the site, they notify the dialysis nurse. The floor nurse is supposed to notify the dialysis nurse if the dressing is not in place and if they see anything unusual. There is potential for bacteria to enter in and possibly infection. R3 does pull the dressing off. We have an order to apply mittens to put on R3 for periods of agitation. On 5/24/23 at 2:40 PM, V9 (Infection Preventionist) stated, R3 was sent out to the hospital to get dialysis line unclogged. On 4/4/23, R3 was on antibiotic for infection of the dialysis line. The hemodialysis port, permacath, is very large. The bacteria, MRSA, since 3/27/23, that R3 had in the port can lead to sepsis faster because it leads to the heart. Any line, tube or drain puts the patient at a high risk for infection. R3 was getting the antibiotic through a midline. R3 pulled it out and we got a new midline placed. R3 missed one antibiotic treatment. R3 did have an infection 5/8. R3 was placed on antibiotic at the hospital but did not continue here. On 5/25/23 at 12:37 PM, V12 (Nurse Practitioner) said, R3 constantly digs at it(port site). R3 does not listen to staff instructions to stop digging at it (port site). That is 100% causing the infection. The mittens are not going to stop R3. Short of chemically or physically restraining, R3 is not going to stop. R3's care plan documents in part: R3 tends to scratch or pick at dialysis catheter site, causing scarring at times, or pull-out tubing, date initiated: 5/23/2023, with desired outcome of will comply with staff redirection and behave in a safe manner, with interventions including intervene when any inappropriate behavior is observed. R3's care plan dated 5/23/23 documents in part: Use mittens to bilateral hands for prevention of injury to self and characterized by high risk for self-injury, impaired mobility, physical aggression related to anxiety, injury, motor agitation, date initiated 5/23/2023(initiated after R3 acquired infection), with desired outcome of will not injure self and will not remove life sustaining devices, with intervention including apply bilateral mittens to hands remove every 2 hours and as needed.

Based on interview and record review, the facility failed to correctly assess pain for a resident and failed to administer pain medication before pressure ulcer wound dressing changes, for a resident (R1) who has pressure ulcers in ten locations on the body that are at multiple stage 3 and stage 4 pressure ulcers This failure affected one resident (R1) of two residents reviewed for pain management and due to multiple stage 3 and stage 4 pressure ulcers could go up to the tissues and muscles and bones and be very painful for R1. Findings include: On 11/7/22 at 11:39am, R1 was observed in bed with multiple pressure ulcer wound dressings. R1 did not respond to greetings and could not obey instructions. R1 was non-verbal. R1's MDS (Minimum Data Status) dated 11/1/22, section B shows that R1 is in a persistent vegetative state. R1's MDS section C dated 11/1/22, does not show any score for BIMS (Basic Interview for Mental Status). On 11/7/22 at 1:55pm, V6 (RN/Registered Nurse) stated that R1's family complained about R1 not getting pain medication for pressure ulcers. V6 added that he (V6) usually asks the wound nurse for the time frame for wound dressing change for R1 so R1 can be given pain medication before the wound care. On 11/16/22 at 12:06pm, V14 (R1's family) stated On October 15th, I went to see him (R1) at the nursing home and a female nurse was changing the dressing on him (R1). I asked when was the last time he (R1) got pain medicine, and the nurse looked in the computer and said it was on the 13th of October. That was how I knew that my brother was left in pain when they changed the dressings. On 11/17/22 at 11:47am, V13 (R1's Physician) was interviewed regarding R1's pain during dressing changes with ten different pressure ulcers on the body. V13 stated, R1 has over the counter pain medication (Tylenol) for mild to moderate pain and [MEDICATION(S)] for severe pain, and that they should be careful not to give too much narcotic pain medication, but we want to make sure he's comfortable. V13 explained that it's not easy to assess pain with [CONDITION(S)] [CONDITION(S)], but there could be pain during dressing changes and turning and repositioning the patient, and the pain medication should be given about half hour before the dressing changes. The surveyor informed V13 that the records show that R1 did not get any type of pain medication for a several days. V13 responded I did not know that they didn't give it (pain medication) for days, that's not good. I will follow up on this. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Face Sheet shows a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 9/21/22 states that R1 has acute/chronic pain related to wounds; Intervention states Administer Analgesia as per orders. Give half hour before treatments or care as needed. R1's care plan dated 9/21/22 with revision date 10/31/22 states that R1 has multiple pressure injuries as listed: Anterior neck, Left Achilles, left lateral Malleolus, Left Ear, Left Heel, Left Ischium, Left Lateral Foot, Left Trochanter, Right Ischium, and Sacrum. Intervention states in part Administer medications as ordered. R1's POS dated 10/27/2022 shows an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's POS dated 9/20/22 has orders for Acetaminophen 500 mg, give 1 tablet via G-Tube every 4 hours as needed for pain, do not exceed 4000mg per day. R1's MAR for 10/1/22 through 10/31/22 has no entries for the Pain Level and no Acetaminophen was given. R1's MAR for 10/1/22-10/31/22 and 11/1/22 to 11/30/22 show that R1 was scheduled to have pain level assessed/rated every 4 hours and receive [MEDICATION(S)] 5mg via G-Tube according to the pain level. However, R1 did not receive the scheduled pain-rating on 10/10/22, 10/12/22, 10/14/22 through 10/18/22; 11/5/22 and 11/6/22, and no pain medication was given on those dates. On 11/7/22 at 2:00pm, V5 (Wound Care Nurse) was interviewed regarding pain medication for R1 for the multiple pressure ulcers. V5 stated, I try to notify the nurse to give pain medication 30 minutes prior to changing the dressings. On 11/9/22 at 11:18am, V2 (Director of Nursing) was interviewed. V2 stated, Because the patient is non-verbal, we must anticipate the pain; he has so many stage 3 and stage 4 pressure wounds. The pain medication should be scheduled round the clock for comfort. We will let the doctor know. V2 was asked to describe the kind of pain someone with multiple stage 3 and stage 4 pressure ulcers could possibly experience during a dressing change. V2 stated Stage 4 pressure ulcer could go up to the tissues and muscles and bones and could be very painful. On 11/9/22 at 11:53am, V12 (Wound Care Coordinator-RN/Registered Nurse) was interviewed regarding R1's pain medication before wound treatment. V12 stated, We try to medicate him (R1) 30 minutes before wound dressing change. (R1) was admitted with all the wounds; none of them was acquired at the facility. On 11/9/22, V11(Nurse Manager) presented R1's Admission Pain assessment dated [DATE] to the surveyor. This Pain Evaluation shows in #1 Met that R1 Obeys commands, denies weakness, tremors, numbness or tingling. This inaccurate assessment was brought to the attention of V11. V11 stated, Oh no, the patient does not obey command and is not verbal, that is wrong. It was an agency nurse that did the pain assessment. Also, #2, #3 and #4 of the assessment were left blank and not assessed. The surveyor asked V11 how a nurse would be able to manage pain for a resident with ten pressure ulcers, who is non-verbal, and the agency nurse that did the pain assessment wrongly assessed the pain. V11 nodded and did not respond to this question. On 11/9/22 at 11:36am, V2 (Director of Nursing) presented the facility's policy on pain management. The policy dated 11/28/12 with revision date 7/6/2018 states: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness Pain Management Program includes Assessment of non-verbal residents for signs and symptoms of pain. #12 states: Pain Control will be assessed during routine medication passes. The facility did not follow these guidelines.

Based on observations, interviews and record review, the facility failed to provide a custom foam pillow as ordered for one (R4) of four residents reviewed for specialized rehabilitation services. This failure resulted in the interruption of the healing process of R4's left hip after surgery. Finding include: R4 is a [AGE] year old, male, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/2/18, V26 (Physician - Surgeon) documented orders for R4, Diagnosis: [REDACTED]. Please position left hip at 90 degrees of hip flexion and neutral hip abduction at all times. Do not let hip/leg flop outwards on bed. Needs to be supported with multiple pillows/foam egg crate, etc. On 9/21/18, V26 (Physician - Surgeon) documented orders for R4, Please continue to prop up left hip to neutral adduction, 90 degrees of hip flexion - PATIENT NEEDS CUSTOM FOAM PILLOW MADE. R4's Physician order [REDACTED]. On 11/26/18 at 12:50 pm, R4 was observed lying supine in bed on a low air loss mattress. V24 (Certified Nursing Assistant, CNA) stated that R4 had recently returned from a doctor's appointment and that V24 had finished incontinence care for R4. No foam pillow was observed propping up or supporting R4's left hip in a neutral adduction. R4's hips were observed grossly abducted (outward) positioned on back. On 11/27/18 at 10:25 am, R4 was observed lying supine (on back) in bed on a low air loss mattress. No foam pillow was observed propping up or supporting R4's left hip in a neutral abduction. On 11/27/18 at 12:00 pm, V24 (CNA) and V27 (CNA) were preparing to perform R4's incontinence care. A vinyl, dark blue wedge was observed under R4's left hip and left lateral leg. V24 stated that the wedge is used to keep R4's left leg in a more upright position. V24 and V27 log rolled R4 from left side to right side for cleansing and changing R4's diaper and then returned the wedge back under R4's left hip and left lateral leg. On 11/27/18 at 3:04 pm, V23 (Restorative Aide) was observed performing PROM exercises with R4 in his bed. A vinyl, dark blue wedge remained under R4's left hip and left lateral leg. When asked if the vinyl, dark blue wedge, currently in use, was R4's custom pillow that was ordered after R4's recent left hip surgery, V23 said, No. R4 stated, It's in the closet. V23 opened R4's closet door and removed a dark gray, foam pillow. V23 placed the dark gray, foam pillow on R4's bed and pointed to the carved out area on the foam pillow where R4's left knee bend would rest. V23 then placed the dark gray, foam pillow back in the closet without use to R4. On 11/28/18, V22 (Restorative Nurse, Licensed Practical Nurse) was interviewed and stated when V22 received V26's (Physician - Surgeon) order for R4's custom foam pillow, V22 conferred with V20 (Physical Therapy Director) about which specialty pillow was to be ordered for R4. V22 stated that V22 phoned V26's office and asked V37 (Physician's staff) for clarification on the custom pillow order for R4 and that no name or description of the special pillow was provided. R4's Restorative Notes, dated on 10/15/18 at 3:33 pm, V22 (Restorative Nurse, LPN) documented, (V22) made a call to (V26's) office and spoke to (V37) for clarification of the order special pillow . (V22) spoke to rehab director and found an alternative pillow to order. Called (V37) again and checked if the alternative pillow would be okay. Per (V37) it would be okay as long as it can support the leg. Will continue to monitor (R4). R4's Restorative Notes, dated 10/22/18 at 10:43 am, V22 (Restorative Nurse, LPN) documents, Follow up note on the special pillow. (V22) was able to find an alternative pillow called ' Knee Positioning Pillow.' Was ordered and delivered in the facility. (V22) and nurse on duty of resident placed the pillow on the left knee of resident. Resident did not verbalize any pain or discomfort. Will continue to monitor resident. On 11/28/18, V10 (Registered Nurse, RN) was interviewed and stated that V10 received V26's order for R4's custom foam pillow. V10 stated that V10 carried out R4's order for the special pillow by transferring the order to the medical record and informing both therapy and restorative departments. Facility undated policy, titled Physicians Orders, documents, in part: A. Physician Orders. 2. The order is to be entered into the resident's medical record and noted by the staff nurse, either RN or LPN. On 8/16/18, V26 (Physician - Surgeon) documented orders for R4, Please continue to prop up left hip to neutral position, 90 degrees of hip flexion. On 10/15/18, V26 (Physician - Surgeon) documented orders for R4, Continue to attempt to keep left hip propped up to neutral abduction. 90 degrees of hip flexion, and neutral rotation. R4's POS documents this order as active on 10/15/18. R4's Physical Therapy - Therapist Progress & Discharge Summary on 9/25/18, V32 (Physical Therapy Assistant) documents, in part: Short Term Goals History. Positioning: (R4) can tolerated neutral position of hips to facilitate proper and correct orientation of the joint. End of Goal Status as of 9/25/2018: GOAL NOT MET - on 9/25/2018, (R4) exhibits bilateral hips in flexed/abducted/external rotation. Long Term Goals: Positioning - General. GOAL NOT MET - on 9/25/2018, Nursing staff (Nurse/CNA) and Restorative Nurses/Aides will be able to facilitate maintaining the hips in neutral position at all times for proper and correct orientation of the joint. No documentation of a custom foam pillow order or implementation is noted in R4's Physical Therapy - Therapist Progress & Discharge Summary on 9/25/18. Facility Invoice titled, Packing List, dated 10/11/18, documents Knee Positioning Splint Left. 1 shipped. R4's Care Plan with last review completed on 11/5/18 documents, Focus: (R4) readmitted on [DATE] after Left girdlestone procedure due to contracture and promote reduction in pain. Desired Outcome: Wound will heal and progress without complication through the review date. Interventions: Prop hip on pillows so Left hip is in neutral abduction position (with knee and hip bent and knee pointed straight). V26 (Physician - Surgeon) was interviewed and stated that V26 had taken R4 to surgery for [REDACTED]. V26 stated that R4 has followed up with him recently in the office on 9/21/18, 10/15/18 and 11/26/18. V26 stated that V26 has never seen R4 with the custom made pillow that V26 ordered. When asked if the facility had notified V26 of any delay in ordering the custom made pillow, V26 stated that the facility response was that they never got the custom made pillow. V26 said that V14 (Family member) would come to R4's appointments with R4. V26 stated that when V26 asked V14, to V14's knowledge, if the facility was using a special pillow for R4's left hip positioning, V14 stated that there was no special pillow being used with R4. V26 stated that in reviewing his notes during the interview, V26 ordered on [DATE] for R4's hip to be positioned in neutral adduction. V26 said that after R4's left hip girdlestone surgery, the purpose of the pillow is to allow the hip to heal in its neutral position. V26 stated that the facility caused harm to R4 by not ordering promptly and using the custom foam pillow to position R4's left hip in its neutral position because it's no better than it was before the surgery. V26 concluded by saying that now R4's left hip is fixed, externally rotated.

Based on observation, interview and record review, the facility failed to follow its policy on prevention and management of pressure ulcer related to repositioning for one (R2) of three residents reviewed for pressure ulcers. These deficient practices resulted in worsening and non-healing of R2's Stage 4 pressure ulcer on the sacrum. Findings include: R2 is a [AGE] year - old, male, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per facility's census report, R2 was transferred to the local hospital on [DATE] and last readmission to the facility was on 09/12/18. R2's MDS (Minimum Data Set) dated 10/24/18 documented: Section (Sec.) C - has short and long-term memory problem; severely impaired cognition for daily decision making Sec. G - total dependence from two persons physical assist during transfer; total dependence from one person physical assist during dressing, eating, toileting, hygiene and bathing. Sec. G0400 - has impairment on both upper and lower extremities Sec. H -has indwelling urinary catheter and frequently incontinent of bowel Sec. M - has one Stage 4 pressure ulcer Sec. M1200: Skin and Ulcer/Injury Treatments - pressure reducing device for chair; pressure reducing device for bed; nutrition or hydration intervention; pressure ulcer/injury care. R2's Wound Expert Notes documented the following measurements: Pressure Ulcer Stage 4 Sacral 09/13/18 - 2.5cm (centimeters) x 2.5cm x 1.2cm 09/20/18 - 2.7cm x 3cm x 0.5cm 09/27/18 - 3.0cm x 2.5cm x 0.5cm 10/02/18 - 2.0cm x 2.0cm x 0.5cm 10/09/18 - 3.0cm x 2.8cm x 0.4cm 10/16/18 - 3.0cm x 3.5cm x 0.4cm 10/23/18 - 2.0cm x 3.0cm x 0.5cm 10/30/18 - 2.0cm x 3.0cm x 0.5cm 11/06/18 - 2.5cm x 4.0cm x 1.0cm 11/13/18 - 3.0cm x 4.5cm x 1.0cm 11/21/18 - 3.0cm x 4.5cm x 1.0cm R2's POS (Physician order [REDACTED].>09/15/18: Sacrum - cleanse with NSS (normal saline solution), pat dry, skin prep periwound, apply [MEDICATION NAME], apply calcium alginate, and then cover with dry dressing daily and PRN (when necessary). 10/04/18: change position form side to side only avoiding supine position, wedge use may be helpful; daily skin inspection. R2's current Care Plan on skin breakdown documented: Interventions: Avoid positioning on pressure areas whenever possible; Turn/reposition every 2 hours and PRN per facility protocol. On 11/26/18 at 12:00 PM, R2 was observed in bed, asleep, has [MEDICAL CONDITION] connected to oxygen at 10 LPM (liters per minute), has gastrostomy tube, has indwelling urinary catheter connected to urine bag. R2 was positioned lying on his back on bed, with a wedge pillow placed under right arm. R2's lower back was resting on a low air loss mattress. The following positions were observed on R2 while on bed: 12:00 PM - lying on his back; wedge pillow placed under right arm; lower back resting on the mattress 12:15 PM - lying on his back; wedge pillow placed under right arm; lower back resting on the mattress 12:30 PM - lying on his back; wedge pillow placed under right arm; lower back resting on the mattress 12:45 PM - lying on his back; wedge pillow placed under right arm; lower back resting on the mattress 1:00 PM - lying on his back; wedge pillow placed under right arm; lower back resting on the mattress 1:15 PM - lying on his back; wedge pillow placed under right arm; lower back resting on the mattress 1:30 PM - lying on his back; wedge pillow placed under right arm; lower back resting on the mattress 1:45 PM - lying on his back; wedge pillow placed under right arm; lower back resting on the mattress 2:00 PM - lying on his back; wedge pillow placed under right arm; lower back resting on the mattress On 11/27/18 at 10:35 AM, V3 (Wound Care Nurse), assisted by V30 (Certified Nurse Aide, CNA) were about to perform wound care treatment on R2. It was observed that R2 was lying on his back. V3 was asked regarding positioning on R2. V3 stated, When repositioning R2, the lower back should not be resting on the mattress, it should be offloaded. V30 was asked on how to prevent and manage pressure ulcers. V30 stated, we must turned and repositioned R2 every two hours; there should be no wrinkles on the bed, change the incontinent brief every two hours as needed and when we do repositioning on him, a wedge pillow should be placed on the upper back when we turned R2 to the side and make sure the wound is offloaded. Wound care treatment was observed with no issues noted. On 11/28/18 at 1:42 PM, V2 (Assistant Director of Nurses) was interviewed regarding prevention and management of pressure ulcers. V2 stated, Staff needs to do proper incontinence care and correct way of positioning of residents with pressure ulcers. Residents with pressure ulcers should be repositioned every two hours. A wedge pillow can aid during repositioning. The use of air loss mattress also prevents pressure ulcers. On 11/28/18 at 11:30 AM, V8 (Wound Care Physician) was asked regarding pressure ulcer prevention and management. V8 stated, It is easy to do prevention of pressure ulcers from healing. Staff needs to do repositioning every two hours. And when staff do the repositioning, it has to be from side to side, off-loading the affected area, avoiding supine position. A wedge pillow is used and has to be placed above the pressure ulcer when on the side position. For R2, at one point the pressure ulcer on the sacral area is healing, so if staff are implementing the same prevention rule, it will be resolved and healed. Facility's policy titled, Wound Prevention on Positioning dated 10/17 documented in part, General: The facility will position residents in a comfortable and appropriate way. The residents will be repositioned at least every two hours, if they are unable to reposition themselves. Guideline: 2. When residents are in bed, they will be repositioned from side to side and on their back if unable to do so themselves. op

Based on interview and record review the facility failed to utilize a proper transfer technique for 1 of 3 residents (R2) reviewed for Accidents and Incidents in a total sample of 5. This failure resulted in R2 being transferred to the local hospital with a fracture to the left wrist. Findings Include: The Incident Report dated 11/2/16 documents that R2 was being transferred from the wheelchair to the bed by E8 (CNA) and E9 (CNA). After the transfer, R2 had complaints of pain and was noted with redness and swelling to the left wrist and informed staff that E8 had pulled the left hand while assisting the resident. The MD was notified, an x-ray was done and indicated that R2 had sustained a non-displaced fracture to the left wrist. A complete investigation was done and concluded that E8 assisted R2 by holding both wrists during the transfer from the wheelchair to the bed. The resident was sent to the local hospital for further evaluation and treatment. On 12/30/16 at 1:30pm E3 (DON) stated The CNA's are educated on proper transfer techniques upon hire, annually and during monthly educational sessions. When I spoke with the resident, R2 did a demonstration on how the transfer occurred and stated that E8 grabbed both wrists. The resident did not notice pain right away but there was swelling not long after the transfer. During the investigation I spoke with the CNA's involved and E8 demonstrated that R2's wrists were held. E8 stated that R2 reached out so the staff member just grabbed the resident's arms. I did education regarding proper transfer techniques and using a gait belt. On 12/30/16 at 1:15pm Z1 stated R2 did have some underlying issues that would put the resident at a higher risk for fractures. R2 had Osteopenia, which is a demineralization of the bones. R2 was very frail and had a low albumin level. This fracture could have occurred from a transfer but of course I wasn't there to witness what happened. The Facility's Policy on a 2 Person Transfer documents that staff should place a gait belt snugly around the resident's waist. The resident should be instructed to place one or both hands on the arm rests of the chair or the sitting surface to assist in pushing. The resident should lean forward while pushing, and a gait belt is used to provide assistance.

Based on interview and record review, the facility failed to follow the care plan for one resident (R9) out of four residents in a sample of 30 reviewed for falls by not properly transferring R9 with a mechanical lift. This failure resulted in R9 falling and obtaining a laceration with sutures on her forehead. In addition, facility failed to ensure R9's lateral trunk and side supports were on R9's motorized wheel chair. This failure resulted in R9 falling to the floor with no injury. Findings include: R9 ' s physician order [REDACTED]. R9 ' s MDS (Minimum Data Set) dated 3/17/15 denotes a score of 3/3 under Transfer section which signifies that R9 is an extensive assist with two person physical assist. R9 ' s incident reports were reviewed. R9 had falls on 6/5/14, 7/21/14, 1/17/15, and 3/13/15. Incident report denotes the following: On 6/5/14 at 6:45am, R9 had a fall with a cut in her forehead. Incident report denotes that R9 had a witnessed fall. R9 was being transferred by two cna ' s (E13 and E14) from bed to wheel chair. One of the cna ' s foot accidentally got caught in the wheel of the wheel chair, causing staff to fall with R9. R9 sustained a cut on the forehead from her roommate ' s bed. R9 started to bleed. R9 ' s cut was cleaned with normal saline. Dressing and sterile strips were applied. Pain medication was given. Nurse practitioner was made aware. Patient was transferred to local community hospital. Nursing notes dated 6/5/14 at 3pm indicate that the nurse followed up with the hospital. Nursing note denotes: " R9 was admitted with a [DIAGNOSES REDACTED]. R9 had seven stitches done on the forehead. CT (Computerized Tomography) scan of the head, xray of the spine and left ankle was done with negative results. R9 was admitted for overnight observation. " Facility reported the initial and final reports to IDPH (Illinois Department of Public Health) in a timely manner. Care plan was updated. On 4/6/15 at 3:15pm, R9 stated, " I had a fall last June. I was so angry with the staff. They did not use a mechanical lift. I know that one of the cna ' s was E14. I forgot the other cna ' s name. The two cna ' s pulled me up from the bed with their arms (one on each side) and brought me to my wheel chair. One of the cna ' s foot got stuck in the wheel chair and I fell with the cna. I hit my head on my roommate ' s old bed which was made of steel. I started bleeding a lot. They should have used the mechanical lift. My mom couldn ' t take care of me at home. I ' m heavy and that ' s why they have to use a mechanical lift. " R9 ' s 6/5/14 incident report does not contain any statements from the two cna ' s. The incident report does not contain any information that a mechanical lift was used. E2 (Assistant Director of Nursing) provided the staffing sheet for 6/4/15 (night shift). Staffing sheet denotes that E20 (Registered nurse) and the two cna ' s (E13 and E14) were on duty that night. E2 stated that E20 no longer worked at the facility. On 4/8/15 at 7:45am, telephone interview was conducted with E14. E14 stated the following: " The other cna ' s foot got caught up in R9 ' s wheel-chair. We did not use the mechanical lift because no one told us about using a mechanical lift. The nurse never told me this information. This was my first time getting her up. We picked R9 up from the bed and transferred to her wheel chair. She slid and fell . R9 hit her head on the wheel of the roommate ' s bed. R9 was bleeding. I guess I could have found out without the nursing telling me. You know it was last minute, they told us to get her ready because she had a doctor ' s appointment. And we had to hurry. That ' s why we did not use the mechanical lift. " At 12:50pm, during facility presentation, E2 stated " Nurses are to communicate to (cna ' s) certified nursing assistants which residents require mechanical lifts and it ' s also posted on signs in the residents ' rooms. The cna ' s should have looked at the signs about how R9 should have been transferred. " At 1:45pm, telephone interview was conducted with E13. E13 stated the following: " R9 was in a regular wheel chair and she was a 2 person assist. My leg got caught in the wheel chair. R9 was about to fall, but we eased her to the floor. R9 hit her head on the roommate ' s bed. R9 started screaming and she started bleeding. Initially, R9 stated that she did not want us to use the mechanical lift. Okay, I ' ll be honest. I never worked with R9 before. I never asked her if we should use the mechanical lift. We should have used the mechanical lift, so she would have not fallen. " R9 ' s primary physician could not be reached. Z3 (nurse practitioner for R9 ' s physician) stated through telephone interview the following: " They should have a used a mechanical lift to transfer R9 from the bed to the wheel chair. The fall could have been prevented. It ' s difficult to say. But yes, I agree with you, using a mechanical lift will reduce the risk of her falling. " Facility's policy titled Fall Prevention and Management Program: The Purpose of the Fall Prvention and Management Program denotes in part the use of lift aid for transfers as a fall prevention strategy/intervention. Facility failed to use this intervention on 6/5/14. R9 has several care plans which denote that R9 had a history cerebral vascular accidnet with right side weakness, spinal fluid leak, and VP shunt placement. R9 is to be transferred using a hoyer lift and requires the use of a chair belt due to the presence of certain medical symptoms and conditions such as poor trunk control, impaired balance and history of falls. R9 has morbid obesity and is totally dependent with transfers. R9 will transfer self from bed to wheelchair with total assist to maintain level of performance daily 6-7 days a week. R9 is a two person assist with Hoyer Transfers. Encourage R9 to keep Hoyer pad under her chair after transfer as she prefers to take it out after transfers. Facility's care plan policy denotes in part that "plans of care are developed by the interdisciplinary team, to coordinate and guide care interventions and goals for the residents." Occupational therapy screen denotes that R9 is total assist with Hoyer (from bed to wheel chair) and is to have a seatbelt while in chiair and supervision at all times. R9 exhibits right side trunk weakness and difficulty with proprioception for upright sitting in wheel chair. Incident report dated 3/13/15 denotes that R9 was observed on the floor of the speech therapy gym as a result of a witnessed fall. R9 fell on the right side from her motorized wheel chair when she lost her balance and tried to reach something on the floor. R9 hit her head on the floor, but did not sustain any injuries. R9 was assessed, vitals were done, neurological checks were done, Z3 and family were notified, and incident report was completed. R9 was transferred to the nearest hospital. X-rays of hip reveal that there is no fracture, dislocation or focal bone destruction. CT (Computerized Tomography) reveals there is no fracture or intracranial hemorrhage. On 4/6/15 at 2pm, interview with E15 (Physical Therapy Assistant/ Therapy Manager) was conducted. E15 stated the following: "I was not present where R9 actually had her fall. R9 is not in therapy now. The speech therapy student was doing services for R9 for free as part of a learning experience. The speech therapy student was being supervised by E10 (Speech language pathologist). They were all in the gym downstairs. R9 leaned over to the right and started sliding. The speech therapy student, E10, and the physical therapists came and lowered her down to the floor. R9 claims she hit her head, but I think the hospital reports said there were no injuries. I noticed some parts of the motorized wheel chair were missing. The two trunk lateral supports for the right and left sides were missing and the right side leg support were missing. They are used to keep R9 alligned and to prevent R9 from falling. If she had those supports, the fall could have been prevented. The next day, I saw R9's mother. I asked her if she knew what happened to the supports. R9's mother went and got the supports from R9's closet. R9 and her mother did not know who took the supports off. I called maintenance and had them put the supports back on R9's wheel chair. R9 came to us from another facility with that motorized wheel chair. The wheel chair has no warranty. And it has not been 5 years yet. Otherwise, she's eligible to get a new one. I would just call the company. I know she complained that the supports were too snug. She was getting heavier and the supports were too tight. That's why they were probably taken off. I don't know who did it. R9 had no strength in her legs. She had poor trunk control as well. She also had a seat belt restraint as well. R9 was not in therapy anymore. Her last days of therapy were as follows: 4/3/14 (Physical Therapy), 6/30/14 (Speech Therapy), and 10/13/14 (Occupational therapy). While she was in therapy, we the therapists would inspect the wheel chair to make sure it was intact and functioning well. Since R9 was not in therapy anymore, the nurses and cna's are responsible for the upkeep and maintenance of the wheel chair. If the cna's and nurses noticed the supports were missing, they should alerted someone. Also, if R9 reported the supports were too tight, the staff member should have came to me and told me. I would have called maintenance to have them readjusted. We don't have a specific policy for the upkeep and maintenance of wheel chairs." At 2:30pm, E10 stated the following: "R9 had weakness more in her legs than her hands. She was a paraplegic. After her back surgery, she had a stroke on the right side. Yes, R9's last fall was last month. My back was facing R9. I know R9 was being supervised by the speech therapy student. I know she didn't have her lateral trunk supports. I remember she said the trunk supports were annoying. She slid even though she had the seatbelt on. There were two physical therapists that came and assisted R9 back to the wheel chair. She went to the hospital and the x-rays were negative." At 2:54pm, E11 (physical therapist) stated, "R9 came to the gym. I just finished lunch and I was doing paperwork. My back was facing R9. When I heard she was falling, I stood up to help her. She felt to her right side. I know that she didn't have her lateral supports. When she was in therapy earlier last year, she had mentioned that her supports were too tight. They were not adjusted or removed then. I'm not sure who removed them. If a resident complains of the lateral supports being too tight, we should have told the nurse or maintenance to fix the chair." At 3:02pm, E12 (Physical Therapist) stated, "My back was facing R9. I heard the panic and I saw R9 stooping to the right side. R9's seat belt was on on, but she did not have the supports. We unbuckled her seat belt and lowered her down. Then we called the nurse and she went to the hospital." On 4/6/15 at 3:15pm, R9 stated, "I don't remember who took my supports off from my wheel chair. I kept telling everyone that the supports were uncomfortable, but no one would do anything about it. It was too tight. My dad does maintenance on my wheel chair. Maybe, he took them off. I'll ask him today. I slid from my wheel chair (3/13/15) and smacked my face. I did not have supports on that day." At 3:25pm, E15 showed surveyor that R9's wheel chair had her supports reinstalled on her wheel chair after she talked to maintenance. On 4/6/15 at 5:45pm, telephone interview was conducted with Z15 (R9's mother). Z15 stated, "Myself and R9's father did not take the supports off R9's wheel chair. I don't know who did. Can you call me back later. I'm at the pharmacy." Facility's form titled Motorized Wheelchair Evaluation Form dated 10/17/14 and 3/9/15 denote in part that R9 has the physical capabilities for the safe performance of a motorized wheelchair. It also denotes that R9 is supervised at all times and is to lower her speed. However, there is no documentation in the Motorized Wheelchair Evaluation Forms or R9's medical record which state that R9's wheel chair was routinely checked for the maintenace. Neither was there any documentation regarding the lateral supports.