Every finding on record at Elevate Care Palos Heights

Based on interview and record review, the facility failed to follow their post fall management policy by moving/picking up one resident ( R5 ) from the floor, who complained of head and neck pain following a fall before a nursing assessment and evaluation was performed for one of three residents reviewed for falls. Findings Include: R5 was admitted to the facility on [DATE] with a diagnosis of quadriplegia, amyotrophic lateral sclerosis (ALS) and dysphagia.R5's progress note dated 5/20/26 documents: At about 4:20 pm, this writer (V9) was informed by a CNA that R5 had a fall. Evening Supervisor immediately notified. This writer together with the Supervisor went to the room to check, upon entering the room, R5 was already back up on her wheelchair. V35 (R5's family) was at bedside and stated that R5 fell backwards on her high back wheelchair. R5 was being prepared to be put back in bed. V35 said, the back of the wheelchair was reclined, then the assigned CNA started removing the wheelchair's leg rests and moved R5's legs, that's when the wheelchair tilted all the way backwards causing the R5 to hit her head on the floor. There was a pillow behind the R5's head when the incident happened. R5 remained alert, oriented and verbally responsive, never lost consciousness, no respiratory distress, vital signs stable. Unable to complete Range of motion to extremities due to current diagnosis of quadriplegia and ALS. R5 complained of head and neck pain. MD notified of the incident, MD gave order to send R5 out to local emergency room for evaluation. V35, Supervisor and V2 (DON) made aware of the order. 911 called for possible head injury. Called and gave report to local emergency room nurse.Facility incident report dated 5/30/26 documents under statements: V24 stated that she was preparing resident (R5) for transfer while waiting for second Certified nursing assistant (CNA) due to resident being a mechanical lift. CNA stated that she took leg rests off the bed, and she was adjusting residents house shoes when the chair tilted backwards onto the floor. CNA stated the wheelchair was the reclined position, but she put the back of the wheelchair up. CNA stated that resident remained in the chair and resident pillow underneath her head CNA made nurse aware immediately. Facility CNA statement handwritten for V24 undated documents: wheelchair tilted backward towards the floor. So we got her up as much as possible, called the nurse. Facility incident report dated 5/30/26 documents under statements: V35 (R5's family) stated that the CNA pushed R5 into the room and was taking leg rests off the wheelchair. V35 stated V24 pulled R5 forward just a little bit and began adjusting residents footwear and wheelchair tilted backwards. V35 stated that she believed the wheelchair was still in reclined position. V35 stated that resident remained in the wheelchair and resident had a pillow underneath her head. On 7/21/26 at 1:20pm, V9 (nurse) said he did not witness R5's fall. V9 said, when he entered R5's room she was sitting up in her wheelchair. V9 said he did not witness R5 on the floor. V9 said, normally after a fall, the resident is assessed by the nurse prior to removing the resident. V9 said, he did not assess R5 prior to her being removed from the floor. On 7/21/26 at 3:16pm, V35 (R5's family) said V24 (certified nursing assistant) V35 took off R5's footrest on R5's high back wheelchair, V35 said, R5's high back wheelchair was leaning back. V35 said, V24 lifted R5's legs, started adjusting R5 's house shoes and R5 fell backwards in a sitting position in her wheelchair. V35 said R5 had a pillow under her head. R5 could not break her fall due to her diagnosis. On 7/21/26 at 3:27pm, V24 (certified nursing assistant) said, when a resident has a fall we usually call the nurse in to assess the resident prior to that resident being moved. V24 said, V35 (R5's family) and herself sat R5 back upright in her high back wheelchair. Facility policy dated 02/28/24 titled Post Fall Management Protocol documents under Post fall physical assessment: If fracture or head injury is suspected, Do not move resident and advise resident not to move affected area; complete head to toe assessment. Signs and symptoms of head injury of head injury that require immediate medical attention include: changes in alertness, confusion, seizures, muscle weakness on one or both sides, severe headache or stiff neck, repeated vomiting, unequal pupils, unusual eye movements and walking problems.

Based on interview and record review the facility failed to follow their abuse policy by not protecting one resident (R12) from theft of personal property. This failure resulted in R12 having her wallet stolen, unauthorize purchases on her credit cards by V29 (CNA/certified nursing assistant), and feeling unsafe at the facility for 1 of 3 residents (R12) reviewed for allegations of misappropriations of property. Findings include:R12 was admitted to the facility on [DATE] with the diagnosis of hypotension, type 2 diabetes, Parkinson's disease, hyperlipidemia, myocardial infarction . R12 Minimum Data Set, dated [DATE] document brief interview mental status score of 14 out of 15 which indicates cognitively intact. On 7/21/26 at 10:46 AM, called R12 but was unable to reach at the moment but was able to speak to V18 ( R12's family member). V18 said that R12 discovered her wallet was missing on April 6,2026. V18 said that the wallet contained R12'S drivers license, insurance card, credit cards, and cash. V18 said that the R12 is alert and oriented x4 and remembered having the wallet the morning of April 5, 2026. V18 said that R12 reported her wallet missing to the administrator on April 6,2026. V18 said that her brother received multiple notifications of fraudulent transactions that were made with the resident's missing credit cards. V18 said that the police were notified and a police report was made. V18 said that R12 was concerned for her safety after the incident.Resident inventory sheet dated 2/4/26 documents that R12 had a red/ black wallet and $30.00 cash.Investigation/police report dated 4/6/26 documents that on 4/5/26, R12's credit card was charged $225.50 from an internet online retail shoe store, $338.65 from an internet online marketplace, and $195.10 from an internet online women clothing store.Case supplemental report/police report dated 4/8/26 documents that three charges were attempted or made with R13's credit card on online retail stores and online marketplace that were access via the internet.Case supplemental report/police report dated 4/23/26 documents that V39(detective/police officer) received documentation from an online marketplace that the account is registered to V38(V29's listed personal/professional reference).V29's employment application dated 3/2/26 documents V38 listed as professional/personal reference and happens to live in the area listed on the case supplemental report.Elevate care assignment sheet dated 4/4/26 documents V29 working from 10:00 PM-6:00/6:30 AM in 700 unit.Elevate care assignment sheet dated 4/5/26 documents V29 working from 10:00 PM to 6:00/6:30 AM in 700 unit.Attendance application timecard documents on April 4,2026 V29 punched in at 9:55 PM and punched out on 6:17 AM and on April 5,2026, V29 punched in at 9:56 PM and punched out at 6:04 AM.R12's Elevate Care [NAME] Heights documentation survey report for the month of April 2026 documents that V29 was assigned to R12 on the dates of 4/4/26 and 4/5/26 during the shifts of 10:00 PM to 6:00 AM.A list provided by the facility of all employees that were terminated/resigned documents V29 was terminated on 4/20/26.On 7/22/26 at 1:43 PM, V1 (administrator) said that on 4/24/26 V1 received a call from V39 verifying if V38 was an employee at the facility.On 7/22/26 at 11:09 AM, an attempt to call V30 (police officer) listed on the police report but was unable to reach. Left voicemail message and provided a call back number, however V30 did not return the phone call.On 7/22/26 at 11:19 AM, attempted to call V29 (certified nursing assistant/CNA) but was unable to reach. Left voicemail message and provided call back number, however V29 did not return the phone call.Facility's abuse prevention and reporting policy revised on 1/22/2019 documents resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.Facility's abuse and retaliation policy prevention program dated 1/2026 documents the facility affirms the rights of our resident to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful temporary, or permanent use of resident's belongings or money without the resident's consent.

Based on interview and Record review the facility failed to develop individualized ADLs (Activity of Daily Living) plan of care for Eight of Eight residents (R5, R6, R7, R8, R9, R10, R13, and R15) and failed to educate residents and family on anticoagulant medication for two residents (R8 and R9) in the sample reviewed for ADLs. This failure affected R5, R6, R7, R8, R9, R10, R13, and R15 who were dependent on staff for ADLs assistance and had the potential to affect all 98 residents residing in the facility.Findings include: R5's admission Record documents that R5 admission date as 05/26/2020 with listed diagnosis that includes but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety disorder, and muscle weakness (generalized) R5's MDS (Minimum Data Set) dated May 19, 2026, showed that R5 has a BIMS score of 13 indicating that R5 is cognitively intact. R6's admission Record documents R6's admission date as 05/06/2026 with listed diagnosis that includes but not limited to Hypokalemia, long term use of anticoagulants, and weakness. R6 MDS (Minimum Data Set) dated May 13, 2026, showed that R6 has a BIMS score of 14 indicating that R6 is cognitively intact. R7's admission Record documents that R7 admission date as 12/26/2024 with listed diagnosis that includes but not limited to anxiety disorder, pain left knee, long-term use of antithrombotic/antiplatelets, and type 2 diabetics mellitus without complications. R7 MDS (Minimum Data Set) dated May 20, 2026, showed that R7 has a BIMS score of 11 indicating that R11 is cognitively intact. R8 medical record admission record showed that R8 was admitted to the facility on [DATE] with diagnosis that includes but not limited to heart failure, anxiety disorder, Type 2 diabetes mellitus with diabetic chronic kidney disease and chronic kidney disease stage 3 unspecified. Long-term use of anticoagulants. R8 MDS (Minimum Data Set) showed that R8 has a BIMS score of 14 indicating that R8 is cognitively intact. R9 medical record admission record documents that R9 was admitted to the facility on [DATE] with diagnosis that includes but not limited to Chronic obstructive pulmonary disease unspecified, mental disorder not elsewhere specified, adult-onset fluency disorder, long-term use of anticoagulants, history of falling, restlessness and agitation. R9 MDS (Minimum Data Set) dated May 6, 2026, showed that R9 has a BIMS score of 14 indicating that R9 is cognitively intact. R10's admission Record documents that R10 admission date as 09/12/2023 with listed diagnosis that includes but not limited to Long-term use of anticoagulants, blindness one eye unspecified eye, gout, presence of pacemaker, dependence of cardiac pacemaker, and weakness. R10 MDS (Minimum Data Set) dated February 2, 2026, showed that R10 has a BIMS score of 06 indicating that R10 is cognitively impaired. During this investigation R9's medical record did not show any recorded education for R9 and family members. Reviews of R5, R6, R7, R8, R9, and R10 plan of care did not show any individualized interventions for ADLs (Activity of Daily Living) personal hygiene that includes shaving task. On 05/27/2026 at 9:30am, V2 DON (Director of Nurse's) stated that the care plan should be done following the Section GG of each resident according to their needs. V2 stated the way she knows it is to individualize the care plan for each resident. The cooperation program is what we follow, and they said since shaving is generalized care personal hygiene is what is rendered to all residents daily, so only mobility is focused. During this interview R5, R6, R7, R8, R9, and R10 were reviewed with V2 and was asked about ADLs care plan issue regarding care plan not individualized. V2 acknowledged that care plan should have interventions individualized, stating that it should be individual. On 5/27/2026 at 11:02 AM, V22 (MDS/Care Plan Coordinator / Licensed Practical Nurse) stated they changed her role to case manager and now she coordinates MDS and care plans. You have the care area assessments in MDS. V22 goes through the diagnoses first and looks at anticoagulants, psychotropics, things like that. The restorative nurse does the ADL care plans. She will formulate her assessment. V22 just coordinates. For the MDS sections, A is demographics. That is entered by the business office. Sections B, C, D, and E are done by social services. V22 does the care plans for the antidepressants and diagnoses, and she does the pain assessment in J, as well as surgery. Section F is completed by Activities. Sections GG and H are completed by Restorative. Section K is done by me. V22 looks at the dietary notes and the speech therapist notes. Section L is completed by me. Section M is done by wound care. V22 puts in what they entered in PCC. Medications are done by me. The top 1/2 of section O is done by me, the bottom 1/2 of section O is done by Restorative. Section P is restraints. We don't have any restraints in the facility. V22 does section Q. Social services do the discharge section. Activities of Daily Living (ADLs) are completed by restorative. For care plans, we meet. Restorative and therapy meet for ADLs. Restorative enters that care planning. V22 stated for R9 she thinks that the care plan for ADLs would be revised by Restorative. Restorative, Social Services and Nursing go to the care plan meeting. V22 does not attend it. They enter the care plan. V22 does not enter the care plan. On 5/27/2026 at 11:25 AM V23 (Restorative Director/Licensed Practical Nurse) stated, I complete the ADL fall and restorative care plans and update them as needed and quarterly. I assess residents for ADLs, I see how much assistance they need, if they need with bathing or if they need any specialty equipment. I am familiar with R9. V23 reviewed R9's care plan. I did not revise it on 5/26/2026. It was not me. If there is a care plan focus, there should be interventions to address the areas of focus and intended outcome. For R9, there are no interventions for the shaving area of focus. That is R9's preference. V23 stated every ADL care plan that she does, V23 addresses the specific needs for each resident. R9 prefers that his sister shave him. V23 stated she don't know who entered that. There are no interventions for that focus. There should be a way to see who went in and add that. V23 would have to ask corporate. R5, R6, R7, R8, R9, and R10 were shown to V23. V23 stated that the ADL care plan that the company uses is this care plan. Grooming is standard of care; they don't have just a care plan for grooming. If a resident has a deficit in one or multiple areas, it should be carefully planned and it should have interventions. This is the care plan that the company has taught us to use. The care plan should be personalized. We personalize mobility, but we don't personalize grooming. It is what the company uses. It should be adjusted for each resident. I mentioned something when they implemented the new care plans. They said that this is what they use companywide. It was brought up to corporate and we were told that this is what the company uses and what we were told to use. When a new employee starts, we have a restorative book. It is updated weekly – it talks about how they are transferred, personal hygiene. The restorative book should mirror the care plan – it is a quality-of-care issue. We also put information in the care profile for each resident. New employees need to look at both the Restorative book and the care plan to get an entire view of what the residents need as far as care. On 5/27/2026 at 11:53 AM V23 (Restorative Director/Licensed Practical Nurse) presented Patient Information Worksheet. V23 stated this is not part of the resident's record. We updated the Patient Information Worksheet This should be included in the care plan, but it isn't included. They updated the care plan process about a year ago. For at least a year, when they updated the care plan process, this information was missing from the care plan. I see the surveyor's concern. Usually when we update a care plan, the CMI meeting is restorative, Administrator therapy, social services, nursing. We discuss new residents, any changes, any reported concerns. The care plan is then updated as needed. In this facility, we must update both the care plan and then Patient Information Sheet, so the staff has correct information. R13 is [AGE] years old admitted to the facility on [DATE], face sheet listed the following past medical history: acute on chronic systolic (congestive) heart failure, pleural effusion not elsewhere classified, acute kidney failure, hypertensive heart and chronic kidney disease with heart failure, dependence on supplemental oxygen, peripheral vascular disease, hypothyroidism, long term (current) use of anticoagulant etc. On 5/26/2026 at 11:58AM, R13 was in his room, awake and alert, stated he is doing okay, has been at the facility for about 2 weeks. R13 was observed with lots of bruising and discoloration on both arms and legs, R13 said that he bruises easily and takes blood thinner. Care plan initiated 5/1/2026 documented that R13 is receiving anticoagulant therapy, Eliquis related to Atrial fibrillation. Interventions include but are not limited to administer medication as ordered, monitor for signs and symptoms of anticoagulant complications, avoid use of aspirin or Nonsteroidal anti-inflammatory drugs (NSAIDs). Active physician order for R13 shows the following: Aspirin oral tablet delayed release 81mg, give 1 tablet by mouth one time a day for heart health. Eliquis oral tablet 2.5mg (Apixaban) give 1 tablet by mouth every twelve hours for blood thinner. Medication administration record (MAR) for the month of May 2026 shows that R13 is taking both medications. On 5/27/2026 at 3:15PM, Surveyor presented this observation to V2 (DON) and V22 (LPN case manager) and they said that resident's care plan should be in accordance with physician order, they are not sure why the resident's care plan did not match with the physician order, for resident to have such care plan, the order must have come from the physician. They will investigate it and correct the problem. On 5/27/2026 at 3:02PM V24 (medical Director) was asked if R13 should be taking aspirin when his care clearly stated for resident to avoid aspirin and he said, it depends on the case, aspirin can be given for heart health, sometimes it is contraindicated, no one called him about resident's aspirin. Surveyor asked V24 if it's okay for R13 to be on Aspirin though his care plan stated to avoid it. V24 said, yes, R13 is on a low dose of Eliquis and low dose of aspirin, he is not sure why the care plan was initiated. On 5/27/2026 at 3:45PM, V22 said that she is the one in charge of the anticoagulant care plan, R13 was not on Aspirin when he originally came to the facility, he returned from the hospital with the medication, V22 said she should have revised the care plan to match resident's orders, she will take care of it now. R15 is 78 years admitted on [DATE], past medical history includes, but not limited to fracture of one rib, right side, subsequent encounter for fracture with routine healing, repeated falls, chronic respiratory failure with hypoxia, hyperlipidemia, anxiety disorder, long term (current) use of antithrombotic/antiplatelet, long term (current) use of aspirin, etc. Active physician order and MAR for R15 show that he is currently taking Aspirin 81 mg, one tablet a day for heart health, Plavix oral tablet, 75mg 1tablet one time a day for coronary artery disease (CAD). Review of baseline and comprehensive care plan for R15 does not show any care plan for resident's antithrombotic/antiplatelet medications. On 5/27/2026 at 3:15PM, V22 (LPN case manager) said that R15 is on antiplatelet so he should have a care plan for that, R15 was just admitted , V22 has not completed his care plan. V22 was asked if R15 has any antiplatelet care plan in his baseline care plan and she said no. Facility Comprehensive Care Plan presented with revision date 11/17/17 documented that the purpose of the policy is to develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Facility policy titled Morning Care (A.M. Care) documents that the purpose of the policy is to promote comfort, cleanliness and dignity. Facility policy titled shaving Male & female Residents documented that the purpose of the policy is to provide cleanliness, comfort, and improve morale. Listed procedure include but not limited to male residents will be assessed for daily shaving need and assisted as his functional needs indicate. The policy documents that this policy is a guideline only, each resident has his or her own set of circumstances which may require that this policy is not followed, the needs of each resident supersede this policy (confirming ADLs individualized care plan).

Based on interview and record review the facility failed to ensure staff obtained the resident permission prior to checking for incontinence, and inappropriately touched a resident in her vaginal area. This affected one of three residents reviewed for abuse. This failure resulted under the reasonable person concept, in R1 expressing she felt angry, violated, she felt like V1 took something from her emotionally, she wanted to fight. R1 BIMs completed on 9/15/25 denotes in-part R1 was able to report correct year, R1 was able to report correct day of the week, R1 was able to repeat three words after first attempt. R1 face sheet shows diagnosis of fracture of shaft of left femur, chronic congestive heart failure, type two diabetes, atrial fibrillation, chronic kidney disease, COPD, history of DVT, anxiety disorder, major depression disorder, obesity, and GERD.R1's police report dated 9/19/25, denotes in-part report number 2xxx-xxxxx, offense criminal sexual abuse, R1 briefly spoke about this incident, in summary: R1 woke up to a male black fondling her vagina along the outside of her diaper. R1 told him to stop and get out, to which the CNA left. R1 wished to proceed with this incident criminally.On 9/22/25 at 11:28am R1, interviewed at hospital, R1 observed alert to person, place, and time. R1 described V1 as the alleged perpetrator. R1 said on 9/19/25 she was sleeping and something told her to wake up, R1 said she observed V1(CNA) hand between her legs under her brief touching her vagina. R1 described it like V1 was massaging her brief, and V1 hand touched her vagina. R1 describes that her brief was loose in the area where it gathers between the legs. R1 said she grabbed V1's hand and pushed it away. R1 said she asked V1 what he was doing and V1 said he was looking for some chicken. R1 said she told V1 to get the Fxxx out of her room. R1 said V1 left the room. R1 said she called her friend and daughter. R1 said her daughter called the police. R1 said she did not want to work with V1. R1 said she did not inform the Nurse, the Director of Nursing, the supervisor or the Administrator, that she did not want to work with V1. R1 said she would hold her urine when she worked with V1 because she did not want to work with V1. R1 said she did not want to work with V1 after she thought V1 got upset with her because he had to change her twice when she had diarrhea episode. R1 said she felt angry, violated, she fell like V1 took something from her emotionally, she wanted to fight.On 9/21/25 at 10:08am V1 (CNA) said he upon start of his shift he completed rounds informing all residents that he was their aide, including R1 and R1's daughter. V1 said throughout the shift he was checking on R1 to see if R1 needed anything. V1 said R1's daughter told him that R1 did not need anything every time. V1 said around 7:45pm he went to do rounds on R1. R1 was sleeping, he touched R1 lower leg to wake her. R1 woke up. V1 said he told R1 that I was there to make sure she is dry, R1 replied I think I'm dry, V1 said he told R1 I would like to check to make sure she was dry. V1 said he patted R1's brief, R1 was dry. V1 said he always let the residents know what he is about to do. V1 said he asked R1 if she needed anything and to have a good night. V1 said he did not round on R1 anymore after that. V1 said he did not provide incontinent care to R1 that shift, V1 said he figured that R1 family provided incontinent care to R1. V1 said he didn't think it was odd that R1 did not urinate that shift because he worked with R1 in the past and R1 did not urinate. V1 omitted getting permission to check R1's brief for incontinent episode. V1 said R1 is alert and orient, R1 is incontinent and in the past R1 would put the call light on if she needed to be changed of bowel movement. V1 said he worked with R1 a few times in the past.9/23/25 at 11:21am V9 (CNA) said when checking for incontinence and providing incontinence care, you should knock on the door, get permission to enter, announce yourself, inform the resident that you want to check and change their brief. V9 said if the resident is alert and orient, you should ensure to get permission before you touch them. If the resident refuses inform the nurse for guidance. V9 said if the resident is not alert and or has dementia, you should still announce yourself, inform the resident of the care you are planning to provide and keep them informed during the task. V9 said you check the brief by opening the Velcro, check the front, and also have the resident to turn to check the back because sometimes the resident brief looks dry in the front, and the brief is wet in the back. V9 said sometimes the brief is visibly soiled and you can see from the outside that it is wet. V9 said it is not the practice to pat/ massage or squeeze a brief.9/22/25 at 9:51am V5 (Director of Nursing) stated that the facility practice is to check the resident for incontinence, sometimes residents are not alert and orient, staff should announce themselves, inform the resident of what they are about to do. V5 said if a resident is alert and orient staff should get permission before touching a resident.9/22/25 at 3:35pm V11 (Social Service) stated she assessed R1's BIMS, V11 said R1 was alert and orient and forgetful of a few words during her assessment. 9/22/25 at 2:45pm V12 (Rehab Director) said R1 was dependent of staff for toileting, R1 needed one person assist with toileting, R1 could assist with turning.R1 care plan dated 9/16/25 denotes the resident denies having been exposed to trauma abuse/neglect prior to admission and denies having been the perpetrator of mistreatment, abuse, neglect, and/exploitation. The resident does not present with unusual risk in these areas at this time. The resident however does experience frailty/weakness. The resident will be treated with respect, dignity, and reside in the facility free of mistreatment (i.e., abuse/neglect) through the next review. Interventions are to conduct an Abuse/Trauma/Substance History assessment (as needed) to promote knowledge and understanding of residents past including social support system and coping mechanisms, and any history that may be useful towards the persons plan of care. Please encourage resident to maintain strong friendships and community involvement so that they are less likely to be isolated or lonely. Utilize person-centered care models that provide as much initiative, control, and self-determination as possible to address the persons physical, psychological, and social needs within a trusting, open, supportive and nonjudgmental professional relationship.R1 base line care plan dated 9/16/25 shows toileting not assessed.Facility policy titled Incontinence care with last revision date 4/20/2021, denotes in part to prevent excoriation and skin breakdown, discomfort and maintain dignity. Incontinent resident will be checked periodically in accordance with the assessed incontinent episode or appropriately every two hours and provided perineal and genital care after each episode. Explain the procedures to resident and bring equipment to bedside. Provide for privacy. perform hand hygiene and put on non sterile gloves. Facility policy abuse prevention and reporting effective date 11/28/2026 last revision date 10/24/22 denotes in-part; the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of the residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of abuse neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of the residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means abuse is the willful infliction of injury unreasonable confinement intimidation or punishment with resulting physical harm pain or mental anguish to a resident.

Based on interview and record review the facility failed to follow their policy to report an allegation of abuse within two hours of receiving an allegation for one of three resident (R1) reviewed for abuse reporting. Findings include: 9/21/25 at 2:25pm V2 (LPN) stated that R1 and R1 family alleged abuse by staff on 9/19/25 around 10:30pm. V2 said the administrator was made aware that night.9/22/25 1:55pm V4 (VP of Operations) stated the administrator did not report the allegation of abuse to the state department with 2 hours of receiving the allegation. V4 said an allegation of abuse should be reported within two hours of receiving the allegation. 9/22/25 at V5 (Director of Nursing) stated she reported an allegation of sexual abuse on 9/20/25.Review of the reportable submitted to the state department, report date is 9/20/25 at 1:43pm for sexual abuse.Facility policy abuse prevention and reporting effective date 11/28/2026 last revision date 10/24/22 denotes in-part; 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. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the department of public health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. Internal reporting requirements and identification of allegation: any allegation of abuse or any incident that results in serious bodily injury will be reported to the department of public heath immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Based on observation, interview, and record review, the facility failed to maintain a working kitchen exhaust fan and failed to replace the broken tiles. This applies to all 92 residents consuming food from dietary services.On 7/10/25 at 11:25 AM, observed kitchen with broken floor tiles (ceramic) throughout the kitchen. Observed that the exhaust fan above the stove is not working and the temperature around the stove area was unusually hot. On 7/10/25 at 11:32 AM, V6 (Dietary Aide) stated, I have been working in this kitchen for one and a half years. The kitchen floor tiles have been broken since I started here. On 7/10/25 at 11:35 AM, V7 (Cook) stated, Our exhaust fan was not working yesterday either. Air is working with two window units. The kitchen floor tiles were broken when I started here five years ago. It's not comfortable and safe to have uneven kitchen floors with floor tiles missing throughout the kitchen floor.On 7/10/25 at 11:30 AM, V5 (Dietary Manager) stated, Our exhaust fan over the stove is not working today and is not taking the heat out. Our maintenance is checking on the exhaust fan. Our maintenance is in the process of replacing broken tiles. It shouldn't be like that.On 7/10/25 at noon, V8 (Maintenance Director) stated, The exhaust fan failed this morning. We are in the process of renovating the whole place. On 7/10/25 at 12:45 PM, V8 added, As a maintenance director, I focus mainly on the heating/air conditioning system. We are in the process of replacing the broken tiles all over the kitchen floor. The facility presented Environmental Services Policy (undated) document: It is the policy of the facility that it is constructed, equipped and maintained to carry out the functions of all services and to promote the health and safety of residents, personnel, public, and in compliance with all applicable Federal, State and Local regulations.On 7/11/25 at 11:01 AM, V2 (in an email communication) stated that 92 residents consume food from the dietary service.

Based on observation, interview, and record review, the facility failed to provide residents with a clean, comfortable, home-like interior. This applies to 5 of 8 residents (R4, R5, R6, R7, and R8) reviewed for the sanitary, comfortable, home-like environment.On 7/10/25 at 10:20 AM, observed 300 hallways with urine and feces smell, and a common shower room with a dirty/foul smell.On 7/10/25 at 10:22 AM, V12 (Housekeeping) stated that he doesn't know where the foul smell is coming from, and he is on his way to clean the common shower room. 1.R4 is a [AGE] year-old female having mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R4 is dependent on toileting hygiene.On 7/10/25 at 10:28 AM, observed R4 in her bed with an intense urine and feces smell. On 7/10/25 at 10:30 AM, V3 (Certified Nursing Assistant/CNA) checked on R4 for incontinence and was found with urine and feces-soaked brief with urine and feces leaked onto pads and then to linen with brownish discolored linen. 2.R5 is a [AGE] year-old female having severe cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R4 is dependent on toileting hygiene.On 7/10/25 at 10:28 AM, observed R5 in her bed with an intense urine and feces smell. On 7/10/25 at 11:00 AM, V3 checked on R5 for incontinence and was found with feces-soaked incontinent brief with feces leaked onto incontinent pad and linen with brownish discolored linen. 3.R6 is an [AGE] year-old female with moderate cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R4 is dependent on toileting hygiene.On 7/10/25 at 11:10 AM, observed the hallway close to R6's room with an intense urine and feces smell. On 7/10/25 at 11:10 AM, V3 checked on R6 in the presence of V2 (Director of Nursing), V4 (Nurse/LPN), and V13 (staffing coordinator). R6 was observed with smelly urine and feces-soaked dark brownish incontinent briefs that leaked on the incontinent padding and then onto linen. 4&5R7 is a [AGE] year-old female admitted on [DATE] with cognition intact as per the MDS dated [DATE].On 7/10/25 at 10:25 AM, R7 was in the hallway (just outside her room) and stated, Sometimes the hallways are smelly, my room is smelly because they just changed my roommate (R8)The facility presented an undated Housekeeping Services Policy document: it is the policy of the facility to maintain a clean, odor-free, comfortable, and orderly environment in all health care and public areas, which meets the sanitation needs of the facility and residents' right to a safe, clean, comfortable homelike environment.

Based on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 3 of 3 residents (R4, R5, and R6) reviewed for activities of daily living (ADL) care in a sample of 7. 1.R4 is a [AGE] year-old female having mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R4 is dependent on toileting hygiene. On 7/10/25 at 10:28 AM, observed R4 in her bed with an intense urine and feces smell. On 7/10/25 at 10:30 AM, V3 (Certified Nursing Assistant/CNA) checked on R4 for incontinence and was found with urine and feces-soaked brief with urine and feces leaked onto pads and then to linen with brownish discolored linen. A review of R4's bowel and bladder care plan document with interventions including cleaning the peri-area with each incontinent episode. Check upon rising, before, and after each meal, bedtime, and as needed (PRN). 2.R5 is a [AGE] year-old female having severe cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R5 is dependent on toileting hygiene. On 7/10/25 at 10:28 AM, observed R5 in her bed with an intense urine and feces smell. On 7/10/25 at 11:00 AM, V3 checked on R5 for incontinence and was found with feces-soaked incontinent brief with feces leaked onto incontinent pad and linen with brownish discolored linen. A review of R5's bowel and bladder care plan document, which includes interventions such as reminding, offering, and assisting with toileting needs as needed. 3.R6 is an [AGE] year-old female with moderate cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R6 is dependent on toileting hygiene. On 7/10/25 at 11:10 AM, observed the hallway close to R6's room with an intense urine and feces smell. On 7/10/25 at 11:10 AM, V3 checked on R6 in the presence of V2 (Director of Nursing), V4 (Nurse/LPN), and V13 (staffing coordinator). R6 was observed with smelly urine and feces-soaked dark brownish incontinent briefs that leaked on the incontinent padding and then onto linen. A review of R6's bowel incontinence care plan document to provide peri care after each incontinence episode. On 7/10/25 at 11:20 AM, V3 stated that she started her shift at 6:00 AM, and didn't get a chance to change some of her assigned residents including R4, R5, and R6. On 7/10/25 at 11:15 AM, V2 stated that the residents should get incontinent care at least every two hours and should have an odor-free environment. The facility presented an incontinence policy revised on 04/20/21document:Guidelines: Incontinent residents will be checked periodically per the assessed incontinent episodes or approximately every two hours and provided perineal and genial care after each episode.

Based on the interview and record review, the facility failed to establish and maintain a system for recording and releasing resident funds based on generally accepted accounting principles. This applies to 1 of 3 residents (R1) reviewed for the resident fund in a sample of 8.R1 was an [AGE] year-old male admitted on [DATE] with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE].On 7/10/25 at 9:10 AM, V10 (R1's granddaughter) stated, After my grandpa (R1) passed away on 6/7/25, my mom received a phone call from the nurse that R1 had $200 cash and a cashier's check of $400 to be picked up. When my mom and my grandma (who passed away one week after my grandpa) stopped by to collect money, V1 (administrator) told them that the money had already been released. But we never received that money. They are saying my grandma (who passed away) picked it up in April (4/7/25). But my grandma doesn't even drive. Somebody must have driven her to the facility, and we would know if that happened.On 7/10/25 at 12:15 PM, V2 (Director of Nursing/DON) stated, A Couple of months ago, the administrator gave money to the wife and daughter. He might have forgotten to record it. On 7/10/25 at 1:12 PM, V1 (Administrator) stated, R1's wife showed up at the nurses' station on 4/17/25 (before R1's death) to collect the money which was in an envelope in V2's office. I texted V2 asking for money. The money was in V2's safe, and since V2 wasn't available that day, I instructed V13 (Staffing Coordinator) to retrieve it from V2's office. The money was in an envelope, which V13 was to hand over to R1's wife. Our normal process of releasing resident funds is to have the responsible party sign the receipt for the money. Somehow, I don't have any proof available that the fund was released to the family.A review of the grievance form documented that the facility filed a grievance form on 6/10/25 in regards to R1's granddaughter's inquiry about R1's fund ($240 in cash and check). A review of the clinical records and documentations for April 2025 indicates that no documentation stating that the fund was released to R1's family.

Based on observation, interview, and record review the facility failed to ensure appropriate infection control practices in proper handling of respiratory equipment. This deficiency affects two (R6, R23) of four residents in the sample of 20 reviewed for Infection control. Findings include: On 1/21/25 at 11:05 AM, R23 observed in wheelchair alert and responsive. R23 nebulizer mask observed on top of dresser uncovered and tubing with no date or label. On 1/21/25 at 11:10 AM, V5(Licensed Practical Nurse) made aware of above findings and said that nebulizer mask should be covered in a plastic bag with date on tubing, V5 said nebulizer mask should not be left on top of dresser uncovered. On 1/22/25 at 2:00 PM, V2 (Director of Nursing) said that her nebulizer masks should be placed inside a plastic bag with tubing labeled and dated for infection control purposes. Facility's Policy on Nebulizer- Medication Administration revision: 10-9-18 Guidelines 23. When equipment is completely dry, store in a plastic bag with the resident's name and date on it. 24. Change equipment and tubing weekly. 49871 On 1/21/2025 at 11:35 AM R6's CPAP machine on the nightstand with mask/cannula not stored in a plastic/zip lock bag. V5 (Licensed Practical Nurse) said CPAP mask/cannula should be in the bag when not in use. On 1/23/2025 at 10:45 AM V2 (Director of Nursing) said CPAP mask/cannula should be stored in a plastic/zip lock bag when not in use. Admission Record: Diagnosis Information: Sleep Apnea, Unspecified; Obstructive Sleep Apnea (Adult) (Pediatric) Order Summary Report: CPAP to be worn at bedtime Care Plan: Interventions: CPAP to be worn at bedtime Policy and Procedure: Oxygen & Respiratory Equipment - Changing/Cleaning Review/Revisions: 1-7-19 Guidelines: Purpose: 1. To provide guidelines to employees for changing all disposable respiratory supplies. 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission. Procedure: 2. Nasal Cannula c. A clean plastic bag with a zip lock or draw string, etc. will be provided to store the cannula when it is not in use.

Based on observation, interview, and record review the facility failed to ensure call light is within reach affecting 2 of 2 (R2, R34) residents reviewed for Accommodation of Needs in a sample of 20 Findings Include: On 1/21/2025 at 11:20 AM, R2 in bed, call light not within reached. V6 (Certified Nursing Assistant/CNA) said R2 uses a custom call light that V6 was not able to find within R2's reach. On 1/23/2025 at 10:45 AM, V2 (Director of Nursing/DON) said call light should be within reach of resident. Admission Record: Diagnosis Information Cerebral Palsy, Unspecified Contracture, Unspecified Joint Care Plan: Encourage R2 to use custom call light r/t contractures of all extremities for staff assistance. Policy and Procedure: Call Light, Revisions: 2-2-18 Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in timely manner. 1. 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 accessible location. 40001 On 1/21/2025 at 11:30am R 34 was observed in bed asking for her call light, R34 call light was observed on the floor under her bed out of reach. On 1/21/2025 at 11:35am V11(Nurse) said her call light should be in reach and attached the call light to the bed in reach. On 1/23/2025 at 12:40pm V2(Director of Nursing-DON) said R34 has multiple sclerosis and she expect her call light to be always in reach. An admission record dated 1/23/2025 indicated that R34 has a diagnosis of multiple sclerosis. A care plan dated 1/13/2023 indicates that R34 has a focus of at risk for falls related to deconditioning an intervention to keep call light and desired personal items within reach.

Based on interview and record review the facility failed to ensure a proper blood draw from a resident with limb precautions. This failure affected 1 resident (R1) of 3 reviewed for laboratory services. Findings include: On 10-22-24 at 9:55 AM, V8 (Concerned Party) said 3rd Party Company came to facility and drew blood from R1's wrong arm despite the right arm precaution bracelet and sign at head of the bed. V8 said POA was present and POA told V2 (Director of Nursing) and primary nurse. V8 said V2 and primary nurse said they were not aware of lab coming to draw labs on 10-10-24. V8 said R1's arm was swollen as a result of the incorrect blood draw. On 10-24-24 at 9:29 AM, V1 (Administrator) said V2 reported the incorrect blood draw to him. V1 said V1 and V2 went to R1's room and visualized limb R1's alert signage above the bed and R1's limb alert bracelet. On 10-23-24 at 10:23 AM, V2 (Director of Nursing) said R1 had a bracelet and sign above the bed indicating right arm precautions (no blood draws and blood pressures). V2 said all staff was aware because of bracelet, sign, physician orders, and possible CNA tasks (computer charting). V2 said lab tech came to draw labs from R1's right arm despite right arm precautions. V2 said R1's family said R1's arm was already swollen. V2 said she did not notice any additional swelling to R1's arm after the blood draw. V2 said it would be best practice for lab tech to get minimal report (precautions) from the nurse. V2 said she encourage staff to engage lab tech if they have any questions. Family made concern of improper lab draw. DON notified MD and received order for Doppler study to right arm. V2 called 3rd party lab and the 3rd party lab liaison came to facility to meet R1 and family. V2 said liaison verified R1's bracelet and limb alert sign above bed. On 10-22-24 at 10:20 AM, V3 (Licensed Practical Nurse) said she was aware of no blood draws or blood pressures to R1's right arm. V3 said this was charted in resident record, stated in communication report, wrist band stating right arm restriction, and sign found in the resident room. V3 said family was present and would be able to remind staff. V3 said she recalls R1's right arm swollen after the blood draw. V3 said she does not recall R1 complaining of pain. V3 said she is not aware of any further issue. On 10-22-24 at 10:57 AM, V4 (Licensed Practical Nurse) said she was aware of R1's right arm restriction because she admitted R1 with orders for right arm precautions, V4 saw R1's bracelet, and facility made sign indicating right limb precaution. V4 said she did not work when R1 blood was drawn. V4 said she is not aware of any adverse reaction after blood draw and did not notice any changes. V4 said R1 should have no blood draws from right arm because it is ordered and stated by bracelet and sign in R1's room. V4 said the phlebotomist or lab technicians should check with primary nurse if they have any questions. On 10-23-24 at 1:52 PM, V8 (Director of Phlebotomy Services) said on 10-11-24 she was made aware of a blood draw on R1's wrong side. V8 said the usual phlebotomist was not on duty and a covering phlebotomist drew blood from R1's wrong (right) side. V9 said phlebotomist told V8 that he did not see R1's bracelet or any sign above R1's bed. V8 said lab account manager came to facility and verified R1 had a right arm precaution sign above R1's bed. V8 said phlebotomist was re-educated on policy of communication with staff. On 10-23-24 at 2:12 PM, V9 (Registered Nurse) said residents will come with bracelet (limb precaution) from the hospital and the facility would not remove the bracelet. V9 said she was the admitting nurse and became aware of limb precautions from the family who instructed no blood draw or blood pressures to R1's right arm. V9 said she did not know phlebotomist was at the facility to draw blood. V9 said R1's family made concern of improper blood draw. V9 said V1 and V2 spoke with R1's family. V9 said she assessed R1 with no new findings. V9 said MD gave orders for Doppler study and there was no findings and no change in R1's arm swelling. Physician Order Summary documents Right Limb precaution: NO B/P, blood draw in right arm. Laboratory Services form dated 10-12-24 documents: This is a record that serves as written proof of completion of training. Tech has been retrained on verifying draw site before completing the draw. As well as communicating with staff members when he has questions. R1's Alteration in Hematological Status Care Plan documents: Interventions: Monitor and document vital signs B/P only to legs. Blood draws to left arm only. Phlebotomy General Guidelines Policies and Procedures (dated 9-15-22) documents: Introduction: Phlebotomists play a critical role in the collection of blood samples. This requires using skillful techniques in communication and correct site selection for collecting the samples.

Based on interview and record review, the facility failed to prevent one resident (R1) from mental abuse caused by a staff member and failed to ensure the staff member had limited access to R1. This failure applied to one (R1) of three residents reviewed for abuse and resulted in R1 feeling on guard, untrusting and unsafe while living in the facility. Findings include: R1 is a [AGE] year old female who admitted to the facility 2/16/24. R1 has diagnoses that include Conversion disorder (functional neurological system disorder) and Generalized Anxiety Disorder for which she is receiving treatment in the facility. R1 is cognitively intact and uses a wheelchair for mobility according to the minimum data assessment dated [DATE]. On 8/21/24 at 8:34PM, R1 was observed resting in bed, alert and coherent. R1 was interviewed and expressed an incident with a staff member (V3) that occurred a few weeks ago. R1 said that one evening, she went to the kitchen because she was hungry and asked V3 Dietary Aid for some food. V3 refused to give any food or snacks and called R1 a beggar. R1 said that she believed V3 was upset with her because she offered V3 soda pops from her personal refrigerator, but later stopped. R1 said, when she was refused food and V3 called her a name, she reported it to V1 administrator and V4 Dietary Manager via a letter. After the letter was received, the administrator had a meeting with R1, R1's family member and V4 Dietary Manager to discuss the incident. The end result led to V3's termination. R1 continued and said that about three weeks later, V1 came to R1's room insisting that R1 give V3 another chance because V3 was remorseful, and she should forgive V3 as [R1 is] a good Christian woman. R1 began crying as she continued. R1 said V1 then brought V3 into her room to make V3 apologize to R1, however he just said a general apology, not anything that he did wrong. V1 rehired V3 to be a CNA (Certified Nursing Assistant). R1 said, I was okay thinking that I wouldn't see V3 much because V3 was working in the kitchen, but now as a CNA, I see V3 all over and V3 even comes in my room to drop off the meals and take the tray. R1 said I feel so guarded around V3 because I don't trust V3. There have even been times that V3 has backed me up into a wall away from the cameras where no one could see and say ugly things to me. R1 continued to cry and said I thought I did all the things right by reporting and I don't feel safe and secure when V3 is around. I am also concerned if what he is doing to me, he can be doing to others that can't defend themselves. On 9/21/24 at 1:10pm V4 Dietary Manager said they received a letter from R1 that said that while working as a dietary aid, V3 was coming to her room drinking her personal drinks and watching television. V4 said 'there is no reason for any dietary aid to be going into a resident's room. When R1 told V3 she didn't want him to come into her room anymore V3 refused R1 snacks such as cereal and sandwiches. These things are allowed to be given when the kitchen is open by any kitchen staff.' After V4 received the letter, Guest Services Manager, the Administrator and V4 had a meeting with R1 and R1's family member. After the meeting, V4 said that V1 Administrator initiated an investigation into the issue and V3 was let go by Human Resources a day or two after. V4 found out V3 was terminated when V4 was told to remove V3 from the schedule. On 9/21/24 at 1:23pm V5 Human Resources Director said that V5 was aware of an incident with R1 who stated that V3 called her a beggar. I spoke with V1, who followed up with V3 and I was told to terminate V3 for discourteous behavior which is based off the handbook and facility policies. Employee Disciplinary Report reviewed for V3 dates the incident 9/2/24 with facts: Employee displayed improper conduct and discourteous behavior with patient which has resulted in termination. The report was dated 9/5/24 by V5. V3 was interviewed via phone on 9/19/24 and 9/21/24. During both interviews, V3 was evasive, omissive and unprofessional. During the interview on 9/19/24 at 10:16pm V3 said that V3 was irritated about being questioned by this Surveyor. When V3 was asked about any incident that occurred involving R1 and V3, V3 said he was told about it by an unknown staff member, and that there was no allegation brought against him. V3 also said that he had never been suspended or terminated. On 9/21/24 at 4:05pm, V3 said that there was a day that R1 came to the kitchen to ask for food, but the staff were about to leave and V3 told R1 the kitchen was closed. V3 said R1 always come to the kitchen asking for food, and V3 didn't give her any when she asked. V3 said V1 investigated an allegation against him but V3 didn't take the accusation seriously. Then V3 said I got fired for some b*****t. V3 said V1 Administrator asked V3 to come back as a CNA and was asked to apologize to R1. V3 said, he went to R1's room with V1 but said, I didn't apologize, I just said I'm sorry. On 9/21/24 at 2:45pm V1 Administrator said V1 was unaware that R1 was emotionally upset that V3 became a CNA and is giving direct care in the facility because V1 believed that after V3 issued an apology, R1 had forgiven V3. V1 said V3 should not be going into R1's room or giving care to R1, however it's possible that R1 would see V3 working elsewhere in the facility. Concern form dated 9/2/24 taken by V1 Administrator stated, Resident stated a dietary aide went into her room and took a beverage. Corrective actions taken: Writer interview the dietary aide (V3) Dietary aide stated he removed the dietary tray after mealtime. Offer to replace beverage declined. Abuse Prevention and Reporting policy revised 4/22 states in part; The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The abuse policy was acknowledged and electronically signed by V3 on 8/27/24 at 4:10PM.

Based on interview and record review, the facility failed to provide evidence that an allegation of misappropriation of property was thoroughly investigated for a resident. This failure applied to one (R1) of three residents reviewed for misappropriation of property. Findings include: On 9/21/24 at 2:45pm V1 Administrator said, R1 informed (V1) of a concern that V3 Dietary Aid was taking and drinking R1's personal drinks. V1 said (V1) did not ask any other residents or staff about this allegation and V1 was unable to provide any written documents related to a related investigation. Concern form dated 9/2/24 taken by V1 Administrator stated, Resident stated a dietary aide went into her room and took a beverage. Corrective actions taken: Writer interview the dietary aide (V3) Dietary aide stated he removed the dietary tray after mealtime. Offer to replace beverage declined. Abuse Policy revised 4/22 states in part; Investigation Procedures: Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual. Confidentiality: .Even if the facility investigation is not complete, the administrator will cooperate with any Department of Public Health investigation in the matter.

Based on interview and record review, the facility failed to report an allegation of misappropriation of property for a resident and failed to timely report an allegation of physical abuse for one resident to the Illinois Department of Public Health (IDPH). These failures applied to two (R1, R3) of three residents reviewed for abuse. Findings include: R1 is a [AGE] year old female who admitted to the facility 2/16/24. R1 has diagnoses that include Conversion disorder (functional neurological system disorder) and Generalized Anxiety Disorder for which she is receiving treatment in the facility. R1 is cognitively intact and uses a wheelchair for mobility according to the minimum data assessment dated [DATE]. Concern form dated 9/2/24 taken by V1 Administrator stated, Resident stated a dietary aide went into her room and took a beverage. Corrective actions taken: Writer interview the dietary aide (V3) Dietary aide stated he removed the dietary tray after mealtime. Offer to replace beverage declined. On 9/19/24 at 10:49pm, V1 Administrator said (V1) did not report the incident with R1 to Illinois Department of Public Health because (V1) didn't recognize the allegation as misappropriation of resident property. An initial investigation was reported to IDPH the following day on 9/20/24. R3 is a [AGE] year old female who admitted to the facility 6/18/24 with diagnoses that include multiple fractures and autism. On 9/20/24 at 3:56pm V3 was observed in bed alert and coherent. V3 called their representative and POA (Power of Attorney) on speaker phone during this interview. V8 (R3's Family member) said sent an email regarding concerns that R3 shared about V6 CNA (Certified Nursing Assistant) roughly providing care. V8 also notified nursing staff but was unable to recall who (V8) spoke to. V1 Administrator provided the email confirming that V8 communicated the allegation on 9/14/24. On 9/19/24 at 10:49pm, V1 Administrator said (V1) did not report the incident to IDPH until 9/16/24, because (V1) didn't check the email over the weekend. According to V8's time sheets, V6 was on duty and provided care 9/14/24 and 9/15/24 after V8 reported the allegation to V1. Abuse Prevention and Reporting policy revised 4/22 states in part; The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. All resident, visitors, volunteers, family members or other are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to the administrator or an immediate supervisor who must then immediately report it to the administrator or the person acting as administrator in the administrator's absence. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Reports should be documented, and a record kept of the documentation. 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 until the results of the investigation have been reviewed by the administrator.

Based on interview and record review, the facility failed to protect a resident from misappropriation of resident property. This failure applied to one (R1) of three residents reviewed for misappropriation of property. Findings include: R1 is a [AGE] year old female who admitted to the facility 2/16/24. R1 has diagnoses that include Conversion disorder (functional neurological system disorder) and Generalized Anxiety Disorder for which she is receiving treatment in the facility. R1 is cognitively intact and uses a wheelchair for mobility according to the minimum data assessment dated [DATE]. On 8/21/24 at 8:34PM, R1 was observed resting in bed, alert and coherent. R1 was interviewed and expressed an incident with a staff member (V3) that occurred a few weeks ago. R1 said at one time, she was friendly with V3 Dietary Aid and offered some of her own personal soda from her refrigerator. R1 said she began to get uncomfortable when V3 would come into her room while she was napping and asked V3 to stop coming to the room. At the time, R1 didn't have a roommate, and then she got a roommate, R1 told V3 he couldn't come into the room anymore out of respect for the roommate. On 9/21/24 at 2:45pm V1 Administrator said, R1 informed them of a concern that V3 was taking and drinking her drinks. Concern form dated 9/2/24 taken by V1 Administrator stated, Resident stated a dietary aide went into her room and took a beverage. Corrective actions taken: Writer interview the dietary aide (V3) Dietary aide stated he removed the dietary tray after mealtime. Offer to replace beverage declined. According to V3's personnel file, V3 was terminated 9/5/24, related to this incident. Employee Disciplinary Report reviewed for V3 dates the incident 9/2/24 with facts: Employee displayed improper conduct and discourteous behavior with patient which has resulted in termination. The report was dated 9/5/24 by V5. Abuse Prevention and Reporting policy revised 4/22 states in part; The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The abuse policy was acknowledged and electronically signed by V3 on 8/27/24 at 4:10PM

Based on interview and record review, the facility failed to maintain a record of controlled substances proof of use accounting for each dose of narcotic medications given and disposed. This failure affected 15 of 15 residents (R6-R21) who were reviewed for disposition of controlled drugs. Findings include: This survey was conducted on-site in the facility from [DATE] to [DATE]. On [DATE] at 2:43pm V2 Director of Nursing and V3 Nursing Supervisor were interviewed regarding reconciliation and destruction of controlled medications. V3 and V4 said that they, along with V4 Assistant Director of Nursing were responsible for disposing controlled medications that were discontinued or not sent home with the residents. V3 said that they were unable to provide documentation in any of the resident's health record that accounted for each dose of controlled medication used and/or disposed. V3 said that once the medications were disposed under witness, the individual Resident Controlled Drug Receipt/Record/Disposition Form was disposed in the shredder and not uploaded into the electronic record. V3 was unable to provide explanation for this practice or how discrepancies were able to be reviewed without the sheet accounting for each dose. On [DATE] at 9:37AM V1 Administrator said that the facility did not have a policy stating that the forms needed to be preserved in the resident records. During this investigation, the facility provided two versions of forms used by nursing staff to record use of controlled substance medications: Controlled Substances Proof of Use and Controlled Drug Receipt/Record/Disposition Form. Both forms state which both state in part: Every dose must be accounted for. Facility policy titled Medication/Narcotic Destruction revised ,d+[DATE] states in part: 8. The drug disposition record must contain, as a minimum, the following: a. Resident's name, b. Date drug destroyed, c. Name of drug, d. Strength of drug, e. Prescription number, f. Quantity destroyed, g. Method of destruction, h. Signatures of witnesses. On [DATE] at approximately 3:00pm V2 Director of Nursing provided Drug Disposition Records from [DATE], [DATE] and [DATE]. These forms provided by V2 did not include the method of destruction as stated in the policy. V2 said that the forms were kept for their own records in the office and said the form was personally taken from the Internet. V2 said they were unaware that the disposal of medications should be reflected on the resident's individual record which is accompanied with the medication supplied by the pharmacy. The following are the residents reviewed for not having a complete accounting for each dose of controlled medications: R6 admitted to the facility on [DATE] and discharged [DATE]. Active medications at the time of discharge included hydrocodone/acetaminophen ,d+[DATE]mg (milligrams), Pregabalin 75mg and alprazolam 1mg. V3 documented disposal on [DATE] of seven tablets (tabs) of pregabalin, 11 tabs of hydrocodone/acetaminophen ,d+[DATE]mg, and 14 tabs of alprazolam. R7 admitted to the facility [DATE] and discharged [DATE]. Active medications at the time of discharge included oxycodone/acetaminophen ,d+[DATE]mg. V3 recorded four tablets were disposed on [DATE]. R8 was admitted [DATE] and discharged [DATE]. Active medications at the time of discharge included acetaminophen/Codeine ,d+[DATE]mg, clonazepam 0.5mg and hydrocodone/acetaminophen ,d+[DATE]mg. V3 documented disposal on [DATE] of 30 tabs of hydrocodone/acetaminophen, 19 tabs of acetaminophen/codeine and 10 tabs of clonazepam. R9 was admitted [DATE] and discharged [DATE]. Active medications at the time of discharge included hydrocodone/acetaminophen ,d+[DATE]mg. V3 documented disposal on [DATE] of 26 tablets. R10 was admitted [DATE] and still resides in the facility at this time. Physician order sheet includes clonazepam 0.5mg ordered [DATE] and discontinued [DATE]. V3 documented disposal of 30 tabs on a Drug disposition record dated [DATE]. R11 was admitted [DATE] and still resides in the facility. Physician Order Sheet includes an active order for tramadol 50mg. According to R11's orders, tramadol was discontinued [DATE] due to R11 being hospitalized and the order was reinstated upon return to the facility on [DATE]. V3 documented 29 tabs of tramadol 50mg disposed on [DATE]. R12 was admitted [DATE] and expired in the facility with hospice services on [DATE]. Active orders at the time of expiration included lorazepam 2mg/ml (milliliter) dispensed as 30ml bottle. This medication was ordered [DATE] and discontinued [DATE]. Alprazolam 0.25mg tablets ordered [DATE] and discontinued [DATE]. Other orders active at the time of discharge included morphine sulfate oral solution 20mg/5ml dispensed as 30ml bottle and hydrocodone/acetaminophen ,d+[DATE]mg tables. V3 documented on [DATE] disposition record: morphine 100mg/5ml 29ml (disposed), morphine 100mg/5ml 22ml (disposed) as well as alprazolam 0.25mg three tablets, hydrocodone/acetaminophen ,d+[DATE]mg 29 tabs, lorazepam 2mg/ml- 22ml (disposed). R13 was admitted [DATE] and still resides in the facility. Physician's order sheet includes an original order for hydrocodone/acetaminophen ,d+[DATE]mg as needed for pain on [DATE]. R13 was admitted to the hospital on [DATE] and returned to the facility [DATE] with an order to reinstate the medication. V3 documented disposal of 3 tabs of hydrocodone/acetaminophen ,d+[DATE]mg on [DATE]. R14 admitted to the facility [DATE], discharged to the hospital [DATE] and did not return. Physician's order sheet included tramadol 50mg ordered [DATE] and discontinued [DATE]. V3 documented 28 tabs disposed on [DATE]. R15 admitted to the facility [DATE] and discharged [DATE]. Physician order sheet included zolpidem ER (extended release) 12.5mg tablet. V3 documented disposal of six tablets of zolpidem 12.5mg on [DATE]. V3 also documented zolpidem 10mg five tabs disposed for R15, however this order history could not be identified on the Physician's Order Sheet. R16 was [DATE] and still resides in the facility. Physicians order sheet indicates that hydrocodone Acetaminophen ,d+[DATE]mg was ordered [DATE] and discontinued when R16 was hospitalized on [DATE]. The medication was reinstated on return to the facility [DATE]. V3 documented disposal of 11 tablets [DATE]. R17 admitted to the facility [DATE] and discharged [DATE]. Physician Orders at the time of discharge included hydrocodone acetaminophen ,d+[DATE]mg tablets and morphine sulfate 30mg tablet. No Proof of use forms were identified in the electronic health record. V3 documented disposal of morphine 30mg six tablets on [DATE]. No documentation was provided for acetaminophen ,d+[DATE]mg tablets. R18 was admitted to the facility [DATE] and discharged to sister facility [DATE]. Physician's Order Sheet at the time of discharge included tramadol hydrochloride 50mg tablet ordered [DATE]. This medication was discontinued [DATE], three weeks after R18 was discharged from the facility. V3 documented disposal of 19 tramadol 50mg tabs on [DATE]. R19 admitted to the facility [DATE] and discharged [DATE] to a long-term care facility. Physician's Order Sheet at the time of discharge included order for Hydrocodone-Acetaminophen ,d+[DATE]mg. V3 documented disposal of 22 tablets on [DATE]. R20 admitted to the facility and still resides in the facility. On [DATE], V3 documented disposing six tablets of alprazolam 0.5mg tablets. Physician's Order Sheet reviewed indicated that alprazolam 0.5mg was an active order at the time of disposition, and the control proof of use is not available to review for reconciliation. R21 admitted to the facility [DATE] and still resides in the facility. Physician's order sheet reviewed ,d+[DATE] indicates that tramadol 50mg was originally ordered [DATE] and continues to be an active medication. On [DATE], V3 documented disposition of two tramadol 50mg medicine cards- 30 tablets on one and 10 tablets on another. On [DATE] at 10:05AM V5 Pharmacist said the nurses are expected to document the count of each medication using the count sheet that is accompanied with the medication dispensed. The expectation of the facility is that they are responsible for maintaining and carrying out their own policy for destruction of controlled substances. [DATE] at 10:22AM V6 Medical Director said the nurses should be accounting for each pill on the count form and the Medication Administration Record. This form should be a part of the Resident's medical record so that it could be referenced in the future for review such as now.

Based on interview and record review, the facility failed to safely transfer a resident with a mechanic lift. This failure resulted in staff transferring R2 to bed from wheelchair via mechanical lift, during the transfer R2's left foot bumped the footboard which resulted in fracture to the left distal tibia. This failure affected 1 resident (R2) in a sample of 5 reviewed for accidents. Findings include, Facility's reportable to state agency (4/29/24) documents in part: R2 was observed by floor nurse exhibiting s/s (signs and symptoms) of pain. PRN (as needed) pain medication given and effective. MD (doctor) made aware and gave an order for x-ray. The X-ray showed a fracture to the left distal tibia. Family and MD made aware, orders received to transfer resident to the ED (emergency department) for further evaluation and treatment. Family made aware of transfer. Upon investigation it was found that on 4/26/24 V14 (CNA) stated that as she and V13 (CNA) were transferring R2 to bed from wheelchair via mechanical lift. During the transfer, R2's weight shifted causing her left foot to bump the footboard. R2 was safely positioned in bed, and V12 (LPN) was summoned to assess R2. V12-V14 all stated that R2 did not complain of pain or discomfort at this time. V12 stated that she assessed R2 and noted no visible signs of injury no bruising, redness or swelling and no skin alterations to that area. V13 and V14 went on to assist R2 with ADL (incontinence care) care in bed and R2 still did not display any signs of discomfort. R2 rested comfortably in bed for the rest of their shift. R2 was assessed for pain every shift, daily, with out change until 4/29/24. On 4/29/24 Staff nurse noticed the area to be tender to touch. PRN pain medications given with effectiveness. Ice pack applied and leg elevated. MD made aware with order for x-ray. Family notified. X-ray results showed fracture of distal tibia. MD made aware with order to send R2 out to hospital for evaluation and treatment. Family made aware. R2 remains in the hospital at this time and plan of care will be updated upon her return. R2 was alert and oriented with a BIMS (Brief Interview for Mental Status) of 9 (meaning moderately impaired). R2's diagnosis included but are not limited to: Altered Mental Status, History of Falling, Difficulty in Walking, Muscle Weakness. On 6/8/24 at 9:25 am, V12 (Licensed Practical Nurse ) said she recalls the incident. V12 said, on 4/26/24 she (V12) and V14 (Certified Nursing Assistant) were assigned to R2. V12 said, V14 came and got her and said that upon transferring R2, her foot hit the foot board, she assessed the resident and there was no pain, no bruising was noted and that was it. V12 said, she does not recall writing a progress note about this incident. V12 said, with mechanical lifts there needs to be 2 people. When asked V12 should this incident be reported to V2 (Director of Nursing), V12 said no, because R2 didn't complain of pain, she was normal upon inspection, there was nothing alarming for V12 to go further. V12 said, she has been working in the facility for little over 3 years. Review of R2's progress notes affirms V12 did not document R2 hitting her leg on the foorboard on 4/26/24. On 6/8/24 at 10:20 am V2 (Director of Nursing) said on 4/29 V17 (LPN) asked for V2 to go and see R2's left ankle as the resident was complaining of pain. V2 said, facility sent R2 to the hospital, at that point V2 started to ask questions to what happened and she got many witness statements. V2 said, her investigation revealed that V14 (Certified Nursing Assistant) and V13 (Certified Nursing Assistant) were transferring R2 via mechanical lift and the pad shifted, as they were lowering her down R2 hit her foot on the foot board, it has a wood foot board. R2's assigned CNA was V14 and V13 was orienting. V2 said, V13 was a cna who just started working at the facility and just needed a 3 day orientation. V2 said, both V13 and V14 could not explain how the mechanical lift pad shifted. V2 said, per their statements, V13 was guiding the lift while V14 was operating the mechanical lift. V2 said both staff said they hooked the pad on the lift, when they were lowering R2 down, the pad shifted and when she hit her foot, they got the nurse immediately. V2 said, staff could not explain how the pad shifted causing the injury, that it jsut happened. V2 said, regarding procedure for a resident incident it, there should be an incident report opened from that, and V2 should have been made aware of the incident. V2 said regarding operationg a mechanical lift, it should be 2 people, staff need to make sure the pad is placed correctly under the resident, and all rings are secured on the mechanical lift, than once all is secure that the resident can be transfered. V2 said, the purpose of 2 person assist with mechanical lifts is to prevent injury. V2 again said, V13 and V14 both said the mechanical lift pad shifted and they could not explain how that happened. V2 said, after this incident, all cna's got mechanical lift hand on training and V13 and V14 also got a written test on mechanical lifts. V2 said, she has been working in the facility since March 2024 and she does not know what kind of mechanical lift training staff received prior to the incident. V2 said, regarding V13 and V14, they no longer work here and facility has not been able to get in touch with them, they do not answer their phone. V2 said, the root cause of R2's injury was improper transfer. On 6/8/24 at 11:30 am V2 (DON) said the facility schedule for 4/26/24 shows V16 (CNA) as assigned to R2 but it was V14 (CNA) and she was training V13. On 6/8/24 at 12:32 V2 said, she did not fill out risk management regarding R2 and root cause was shifting of the hoyer pad, however she would not explain how that happened. On 6/10/24 V2 provided document stating V13 (CNA) started working in the facility on 4/24/24 and her last day was 5/21/24. Facility's time care report affirms V13 and V14 were on duty on 4/26/24. V12's (LPN) statement regarding R2 dated 4/30/24 documents in part: I (V12) was the nurse on duty. I was called to the room to assess patient after being transfer to bed via mechanical lift. Per cna's pt's foot hit footboard upon transferring to bed. Noticed no signs of pain/bruising/redness. Pt was continue to monitor throughout shift. V13's (CNA) statement regarding R2 dated 5/2/24 documents in part: V13 was training with another cna and we were putting resident to bed with a mechanical lift and she hit her foot on the bed. Cna went to get the nurse and then I helped cna finish getting resident comfortable in bed. V14's (CNA) statement regarding R2 dated 4/30/24 documents in part: I (V14) worked with R2 on 4/26. As me and another cna were putting her back to bed with a mechanical lift. The mechanical pad shifted as we were lowering her down to bed and her foot hit the foot board. Resident did not show any signs of pain. I assisted her with ADL's (activity of daily living) and made her comfortable for the night. R2's care plan documents in part: R2 Requires use of full body lift for transfer. Diagnosis includes: impaired mobility, generalized weakness (Date Initiated: 08/27/2021, Revision on: 06/08/2024) Interventions: Full body lift with 2 person assist for all transfers (Date Initiated: 08/27/2021, Revision on: 06/08/2024). Ensure the full body lift legs are adequately spread for increased base of support (Date Initiated: 08/27/2021, Revision on: 06/08/2024), Ensure resident is in the center of the full body lift pad before beginning transfer (Date Initiated: 08/27/2021, Revision on: 06/08/2024), Staff to support [NAME] body and legs during full body lift transfer (Date Initiated: 08/27/2021, Revision on: 06/08/2024). Facility policy Transfers- Manual Gait Belt and Mechanical Lifts (Effective Date: 11-28-12, Revisions: 1-19-18) documents in part: Purpose: In order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use Mechanical lifting devices for the lifting and movement of Residents. Guidelines: 1. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. 2. Staff responsible for direct resident care will be trained in the use of mechanical lifting devices annually and as needed. Refer to Manufacturer ' s Guide for proper instructions for use of equipment for transfer and weighing. 40515 On 6/8/2024 at 11:45am V18 (LPN) stated, when there is a fall or injury we have to document in the electronic medical record and complete risk management section. We get a statement from the CNA and follow the fall protocol, we document in the medical record. There is a lot of documentation that we have to do if there is a fall. We call the doctor, the POA, and the DON. On 6/8/2024 at 11:56am surveyor continued interview with V18 and asked V18 if a resident sustains an injury when the CNA is using a mechanical lift, what is supposed to occur. V18 stated, the CNA has to tell the nurse right away. The nurse has to come and assess right away and make sure the resident if okay and safe. I would have the resident put back in the bed or stop the transfer depending on my assessment. I would do a full body assessment, get vitals, contact the doctor, family and DON. I would have to get a statement from the CNAs that were there, follow the fall policy, and fill out the risk management information which is in the computer. There is also a fall packet with questions that have to be completed. The nurse has to be involved in assessing the resident, documenting in the nurses note, notify the doctor, and family member. The DON has to be notified for any resident that has a fall, injury or abuse. Surveyor asked V18 what is the purpose of having 2 people present when using a mechanical lift. V18 stated, to make sure the resident does not get injured and does not fall. One person controls the mechanical lift and the other person makes sure the resident does not sustain any injury like hit their arm, leg or head. We know how to transfer because of the colored dot on the door by the residents name. On 6/8/2024 at 12:16pm surveyor asked V20 (CNA) if she had training on how to use mechanical lift. V20 stated, yes we have to use 2 people, put a pad underneath and lift mechanical lift. One person does the mechanical lift and the other person makes sure the resident does not move because the resident's head could get hit or legs. If the resident falls or gets injured when using the mechanical lift, I call the nurse and let them know what happened. I have to tell the nurse what happened because we are supposed to let the nurse or supervisor know what happened. The nurse will come and check the resident and does an assessment and will ask the resident of they are okay and I follow the directions of the nurse. On 6/8/2024 at 12:51pm surveyors asked V1 about the incident that occurred on 4/26/24. V1 stated, we talked to both CNAs, but they did not tell us everything. V1 stated V13 (CNA) and V14 (CNA) received discipline after the 4/26/24 incident and were in-serviced, but shortly after that they both quit so the discipline did not mean anything. Surveyor asked if they have been able to get in touch with V13 or V14. V1 stated, no. On 6/8/2024 at 1:02pm V19 stated, when a resident falls or is injured when using a mechanical lift, the nurse has to assess the patient, check range or motion, do vital signs and head to toe assessment, call doctor, if the resident is on blood thinners, the resident will be sent to the hospital, call family. We have to fill out risk assessment and complete the fall protocol and document in nursing notes what happened. Surveyor asked if the nurse is required to document in the medical record. V19 stated, Yes, if not documented, it was not done. We have to also notify DON, supervisor, and family. Surveyor attempted to call V13 and V14 on 6/8/2024 without a response. During the course of the survey, V13 and V14 failed to returned surveyor's call. During course of survey, facility did not produce any evidence/documentation regarding staff training/education regarding the use of mechanical lift/injury prevention.

Based on observations, interviews and record review, the facility failed to protect a cognitively impaired resident from physical and emotional abuse by a staff member who forcefully pushed the resident in her wheelchair and shouted at the resident out of frustration which caused the resident to be fearful of the staff member, emotionally distraught and intimidated; and facility failed to follow their policy on abuse prevention. This failure affected one (R81) of 5 residents reviewed for abuse from a sample of 37 residents. Findings include: R81 is a [AGE] year-old female with birth date of [DATE]. She admitted to the facility on [DATE] and has a past medical history not limited to Weakness, Lack of Expected Normal Physiological Development in Childhood, Non-ST Elevation Myocardial Infarction, Syncope and Collapse, and Difficulty in Walking. On [DATE] at 11:54 AM while outside of R81's room, surveyor overheard V8 (Certified Nursing Assistant/CNA) being verbally abusive to R81 regarding a telephone cord being tangled up in her wheelchair. Surveyor then observed V8 (CNA) forcefully push R81, who was seated in her wheelchair, from next to her bed forward towards the room door. V8 (CNA) then said loudly and with continued frustration, I'm still trying to get the cord untangled, went behind R81's wheelchair, then proceeded to lift the wheelchair from behind and turned it so R81 was now facing the doorway. Surveyor observed R81 at this time while sitting near doorway and she appeared frightened. At 11:57 AM, V8 (CNA) then moved R81 from the area near the doorway back to the area next to her bed. Upon leaving R81's room, when asked if staff should talk to a resident in that manner with such frustration, V8 (CNA) said no and I'm sorry. V8 (CNA) was informed that she should apologize to the resident and not to the surveyor. V8 again apologized to surveyor but did not observe V8 (CNA) apologize to R81. At 11:58 AM, surveyor reported incident to V9 (Licensed Practical Nurse) who was working on the unit. At 12:15 PM, observed V8 (CNA) assisting other staff members pass lunch trays on this same unit. On [DATE] at 12:22 PM, V1 (Administrator) said abuse protocol is for the alleged perpetrator to be removed immediately. V1 then said regarding the alleged incident with V8 (CNA), that she was just told about it and V8 is now gone. At 1:21 PM, V1 (Administrator) provided R81's initial abuse report submitted to the department that indicated surveyor reported V8 seemed frustrated and was not speaking to R81 appropriately. Report stated that V8's (CNA) statement was taken but was not included within the report. Received V8's statement from V1 (Administrator) which indicated V8 was having a hard time getting cords loose from R81's wheelchair. Statement also indicated V8 could not recall speaking inappropriately to R81, but was probably speaking loudly because she could not hear R81. On [DATE] at 1:55 PM, interviewed R81 in her room. When asked if she had ever experienced poor staff treatment and/or abuse prior to today, R81 said I just wanted to get it done. Then added, I was scared of that one that was in here, there's one that always yells but so long as they help me, I'm not going to say anything. At 2:03 PM, R81 who appeared frustrated added if they want to yell, then I just let them go ahead and yell. On [DATE] at 2:15 PM, V1 (Administrator) said that she knows V8 (CNA) from a previous facility and V8 personally took care of her loved ones. V1 added that she knows V8 talks loudly because she is hard of hearing but has never know of V8 (CNA) to speak in this alleged manner. Reviewed V8's personal file which showed a physician assessment dated [DATE] that documented, patient denies any hearing loss. Reviewed V8's (CNA) training logs that showed she last completed abuse and neglect training on [DATE]. On [DATE], reviewed R81's MDS Section C - Cognitive Patterns dated [DATE] that showed her Brief Interview for Mental Status (BIMS) score was 11 out of 15 which indicated moderate cognitive impairment. Also reviewed R81's current plan of care which did not show an implemented care plan to prevent R81 from being abused. On [DATE] at 11:21 AM, when talking with R81 regarding the incident with V8 (CNA) from previous day, R81 said they come in and don't tell us who they are. They make me want to not care anymore. On [DATE] at 11:31 AM, V12 (Licensed Practical Nurse) said she started working at facility one month ago and completed abuse training during her orientation. When asked to name specific types of abuse, V12 said verbal, financial, and physical are the only ones I know of. On [DATE] at 01:39 PM, V19 (Certified Nursing Assistant) said she had just completed abuse training a week ago. When asked to name specific types of abuse, V19 said verbal, physical and that's all I know of. On [DATE] at 01:49 PM, V20 (Certified Nursing Assistant) who was assigned to the 400 unit said, her last abuse in-service was last night and types of abuse are verbal, sexual, physical, and abuse done to others. Reviewed Facility Reported Incident Final Abuse Reports for the last year until present and noted the following: On [DATE], a male (deceased ) resident complained of being physically abused by a certified nursing assistant. Report indicated the staff member was interviewed and denied physically abusing the resident. The allegation of physical abuse was not substantiated by V1 (Administrator). Reviewed resident's MDS Section C - Cognitive Patterns while at facility dated [DATE] that showed his Brief Interview for Mental Status (BIMS) score was 11 out of 15 which indicated moderate cognitive impairment. On [DATE], a surveyor reported an allegation of verbal abuse made by R75's spouse. Report indicates the residents involved were not interviewed due to cognition and the staff member involved denied verbally abusing any resident during her interview. The allegation of verbal abuse was not substantiated by V1 (Administrator). On [DATE], when interviewed by a surveyor about an incident that occurred on [DATE], R37 said she was verbally and physically abused by V28 (Certified Nursing Assistant). R37 then stated that she was informed V28 was no longer employed at the facility. Report indicated the facility attempted to contact V28 for an interview but was unable to reach her. The allegation of verbal and physical abuse was not substantiated by V1 (Administrator). R37's Brief Interview for Mental Status (BIMS) score dated [DATE] showed 14 out of 15 which indicated no cognitive impairment. On [DATE], R37 complained of being physically abused by a certified nursing assistant. Report indicated the staff member was interviewed and denied physically abusing R37. The allegation of physical abuse was not substantiated by V1 (Administrator). On [DATE], R29 (hospitalized since [DATE]) complained of being verbally abused by a certified nursing assistant. R29's Brief Interview for Mental Status (BIMS) score dated [DATE] showed 15 out of 15 which indicated no cognitive impairment. Report indicated the staff member was interviewed and denied verbally abusing R29. The allegation of verbal abuse was not substantiated by V1 (Administrator). On [DATE] at 09:50 AM, V1 (Administrator) was interviewed by the survey team regarding the outcome of her abuse investigations reviewed during survey. When asked how V1 concluded the allegations were all unsubstantiated, including those allegations made by residents who were cognitively intact, V1 (Administrator) said it's their word versus the staff because that's how I was trained. On [DATE], V1 provided final investigation report for R81 that did not indicate the result of investigation findings, whether abuse was substantiated or not. Report indicated surveyor reported to V9 (LPN) that V8 (CNA) was speaking loudly to R81 and indicated that V8 did not mean to sound frustrated she was trying to get her wheelchair untangled. Report also indicated V8 (CNA) was not frustrated with the resident but only with the cords restricting the wheelchairs mobility and that V8 did not intend to show any willful frustration towards R81. Report concluded with, the facility will do one on one abuse and customer service training with V8 prior to her return to work, will closely monitor V8 upon return by conducting random checks on residents she cares for. On [DATE] at 1:35 PM, requested R81's initial and most recent abuse/neglect screen and abuse care plan from V7 (Social Services Director) who said screenings should be completed upon admission, quarterly and with any allegations. At 2:39 PM V7 said the facility began screening residents for abuse or neglect and implementing abuse care plans as of [DATE]. At 2:44 PM, V7 (Social Services Director) said R81 was not screened for, or care planned for abuse upon her admission on [DATE]. V7 then provided R81's abuse/neglect screen dated [DATE] and abuse care plan with revision date or [DATE]. On [DATE] at 1:48 PM, when asked if there is required training to be the abuse coordinator, V1 (Administrator) said no, but I do yearly abuse training courses on-line. When asked when she last completed abuse training, V1 said I'll have to get back to you with the date. At 2:00 PM, V1 indicated her last abuse prevention and reporting training was completed on [DATE]. Reviewed Abuse Policy last revised [DATE] that showed the facility prohibits abuse and neglect by staff done by orientating and training employees on how to deal with stress and difficult situations. Policy defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means and provides examples of mental and verbal abuse include but not limited to yelling or hovering over a resident, with the intent to intimidate. Policy indicated under establishing a resident sensitive environment will be accomplished through: Resident Assessment: as part of the resident's life history on the admission statement, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary.

Based on observation, interview and record review, the facility failed to follow their policy on hand washing during food preparation and failed to properly wear hair nets during food preparation in the kitchen. This failure has the potential to affect all 97 residents who receive oral meals from the facility's kitchen. On 03/06/23 at 10:30 AM, during the kitchen observation, V17 Cook noted with a large amount of hair outside the back of her hair net while preparing food over the stove. V17 was inquired of her hair net. V17 Cook stated, Oh I thought it was all in. V17 Cook attempted to fix her hairnet by pushing the hair up into the net while standing at the stove and was instructed by V15 Dietary Manager to go over to the hand washing sink area away from the food. On 03/07/23 at 10:47 AM, V17 Cook observed touching the garbage can lid during preparation of pureed food. V17 Cook then rinsed her hands in the food preparation sink. V16 District Manager instructed V17 Cook to go to the hand washing sink. V17 Cook then rinsed her hands for less than 15 seconds and returned to preparing pureed food. V17 Cook was inquired of when to perform hand hygiene. V17 Cook stated, Sometimes I forget, it should be in the other sink. I should wash my hands for 15 seconds. V16 District Manager Yona Solutions stated, V17 only rinsed her hands off, she didn't wash her hands in it (food preparation sink). Dietary staff did not clean and sanitize the food preparation sink after V17 Cook rinsed her hands in it after touching the garbage can lid during puree food preparation. V17 Cook had previous in-service training for hand washing and infection control from 12/14/22, in-service training for infection control and hand washing from 1/18/2023. The Food & Nutrition Services Staff Attire Policy dated 9/1/21 states in part: Standard: All employees wear approved attire for the performance of their duties. Guidelines: 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. The Food & Nutrition Services Hand Washing Policy dated 9/1/21 states in part: Standard: Only wash your hands in sinks designated for handwashing. Do not wash your hands in utensil, food preparation or service sinks. 3. The entire process must last at least 20 seconds. 4. When to wash your hands, wash your hands as often as possible. It is important to wash your hands: -After handling soiled utensils and equipment. -As often as needed during food preparation and when changing tasks.