Every finding on record at Foster Health & Rehab Center

Based on observation, interview and record review, the facility failed to ensure full privacy by assigning two residents of different genders (R4, R6) of four reviewed a shared bathroom without adequate privacy safeguards or consent in a sample of seven.Findings include:R4's medical diagnosis in current face sheet includes but not limited to metabolic encephalopathy, anoxic brain damage, not elsewhere classified, dysphagia, unspecified, major depressive disorder, single episode, unspecified, bipolar disorder, unspecified MDS (Minimum Data Set) section C-Cognitive Patterns dated May 8, 2026, document R4's Brief Interview for Mental Status as 15/15 indicating R4 has intact cognitive abilities.R6's medical diagnosis in current face sheet includes but is not limited to major depressive disorder, recurrent, mild, generalized anxiety disorder, unspecified atrial fibrillation. MDS (Minimum Data Set) section C-Cognitive Patterns dated May 1, 2026, document R6's Brief Interview for Mental Status as 15/15 indicating R6 has intact cognitive abilities. On July 7/07/2026 at 11:00AM, R4 was observed sitting on her bed. R4 stated she has hearing difficulties. R4 wears hearing aids and stated she reads lips to understand what people are saying to her. R4 stated she goes to the bathroom next to her room. R4 stated she forgets to lock it sometimes. R4 stated she does not know if the residents in the adjourning room were male or female. R4 did not answer further questions.R4's bathroom was observed to connect to a male room. Observed locks on the inside of the bathroom. No locks were observed on doors on the room's side leading into the bathroom.On July 7, 2026, at 10:38AM, R6 was observed in his room sitting on the bed. R6 was alert and oriented to person, place, time and situation. R6 stated he shares a bathroom with female residents in the next room. R6 stated it is not comfortable because R4 sometimes forgets to lock the bathroom door leading to R6's room. R6 always knocks on the door before going into the shared bathroom but R4 does not always answer when R6 knocks. R6 stated he opens the door slowly just to check and see if R4 is using the bathroom. R6 stated he has opened the bathroom door and seen R4 using the bathroom. R6 stated this makes him very uncomfortable. R6 stated he wished the room sharing the bathroom with him was for male residents. That way he would not feel uncomfortable.On 07/07/2026 at 10:49AM, V2 (Assistant Administrator) and surveyor toured R4 (female) and R6 (male) shared bathroom. Observed a lock on both doors on the inside of the bathroom. No lock was observed on the outside of the doors leading to the residents' rooms. V2 stated it could be a problem. If R4 and R6 forget to lock the bathroom door leading to the other room, the resident in the other room does not walk in while the other resident is using the bathroom, the resident using the bathroom would not feel very good being exposed to another resident of opposite gender.On 07/07/2026 at 11:12AM, V1 (Administrator) stated the shared male /female (Jack/[NAME]) style is only temporary until a bed can be open in another room to separate R4 and R6 who are using a shared bathroom accessible from both rooms. V1 stated a resident can feel ashamed if the resident forgets to lock the bathroom door and a resident of opposite gender opens the bathroom door when in use. V1 stated the bathroom has a lock from inside the bathroom on both doors leading to resident room. There is no lock on the side of the resident's room before getting into the bathroom. Residents can walk through the bathroom into each other's room. It is not an ideal situation. Male and female residents should not have access to each other's room for safety reasons.On 07.07.2026 at 12:49PM, V5 (Certified Nursing Assistant -CNA) stated R4 and R6 have a connecting bathroom. R4, R5 are females' residents, R6, R7 are male residents. When a resident from either room is using the bathroom, they should remember to lock the door that connects the bathroom to the other resident's room to prevent an opposite sex resident from accidentally walking in other resident using the bathroom. They can walk in on each other when they are not dressed. This can cause emotional distress. Male and female residents are not allowed to go into each other's rooms unless they're a couple.R4's care plan dated 5/10/2024 documents: R4 has an ADL (Activities of Daily Living) self-care performance deficit d/t (Due to) impaired cognition.R4's census documents R4 has been in current room since 3/21/2026.Foster Shared-Bathroom Policy dated 12/1/2025 documents:-Privacy Measures: Physical or procedural protection ensuring residents can use the bathroom without exposure or intrusion.- Residents must be able to lock the door independently, unless contraindicated by care plan.Resident Rights Policy - Long-Term Care & Skilled Nursing Facility dated 12/1/2025 documents:Resident Rights Right to dignity, respect, and freedom from abuse or neglectFacility floor plan documents R4 and R6's rooms share a bathroom

Based on observation, interview and record review, the facility failed to publicly post the complete mandated staffing data regarding the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care on each shift daily at the beginning of each shift. This had the potential to affect all 35 residents who resided in the facility at the time of the survey.On 1/12/2025 at 9:16 am, Staff schedule posted on wall across from the 1st floor nursing station with schedule for the 3 shifts but not the daily staffing log posted with the census and total hours worked for licensed and unlicensed personnel. On 1/13/2026 at 9:21 am, No Daily Staffing Posting visible to the public by the nurse's station or secretary desk near the entrance door posted. Staffing Schedule posted with no resident census documented. On 1/14/2026 at 9:27 am, No Daily Staffing Posting visible to the public or residents by the nurse's station or secretary desk near the entrance door posted. Staffing Schedule posted with no resident census documented. On 1/14/2026 at 1:14 pm, V3 (Director of Nursing) stated V13 (Staffing Scheduler) is responsible for posting the daily staffing posting. V13 stated the daily staffing schedule has the am, pm, and night shifts, Certified Nurse Aides along with escorts schedule daily. V13 stated the Daily Staff Posting does not consist of the number of hours licensed and non-licensed staff providing direct care to residents to provide public information to the residents and public is not posted on the Daily Staffing Posting. V13 stated she (V13) is aware of the staffing form the surveyor is referring to and the facility does not post a Daily Staffing Posting. On 1/14/2025 at 1:33 pm, V13, Activity Director and staffing Scheduler stated the daily staffing posting is posted across from the nursing station in a locked glass case. The daily staffing posting contains the nurse for each shift and the CNA scheduled for each shift. We have never done it like that. We don't do that, but the census is on our schedule, but the hours worked by every licensed and unlicensed personnel providing direct care to the residents is not. On 1/14/2026 at 1:55 pm, V2 (Assistant Administrator) provided an email documenting the facility does not have a policy on Daily Staffing Posting.

Based on observation, interview, and record review the facility failed to follow facility policy to check the refrigerator temperature 2 times daily and at routine intervals throughout the same twenty-four-hour period, failed to maintain a tracking log on the freezer, refrigerator, and walk-in cooler, and label open foods with an open and expiration date. This failure has the potential to affect all 35 residents in the facility. On 1/12/2026 at 9:27 am, Surveyor observed the following during the initial kitchen observation:Coleslaw opened with an open date of 12/18/2025 and no label with expiration date.Freezer contains the following foods opened with label indicating the expiration date:English muffins open date is 12/31 with no year and no expiration date.All diced chicken with open date of 12/31 with no year and no expiration date.Pizza Puffs open with no open or expiration date.Broccoli cuts opened 1/8 with no year and no expiration date.Ground Beef Patties opened 1/8 no year and no expiration date.Observed freezer, refrigerator, and walk-in cooler with no temperature tracking log. Freezer, refrigerator, and walk-in cooler has a January calendar with a temperature recorded each day from 1/1/2026 to 1/12/2026.On 1/12/2026 at 9:48 am, V4 (Dietary Cook) stated when the kitchen receives food, it is labeled with the open date and because the food is cooked so fast, the dietary staff does not label the food with an expiration date. V4 stated the pizza puffs are not dated because they are for the staff. On 1/12/2026 at 10:56 am, V5 (Dietary Supervisor) stated the foods in the freezer, refrigerator, and walk-in cooler have their own expiration dates printed on the box and the pizza puffs are for the whole facility including staff with no open or expiration date. V5 stated the pizza puffs in the freezer along with apple juice and orange juice in the refrigerator with no open dates are a violation. V5 stated he (V5) has all the recorded expiration dates of the foods on the [NAME] Food Services (GFC) invoice form, and he conducts a monthly audit of all the food in the freezer, refrigerator, and walk-in cooler. V5 stated the purpose of food labeling and storage is to prevent foodborne illness. V5 stated the January calendar posted on the refrigerator, freezer, and walk-in cooler are the recorded temperatures for the day and the temperature is tracked and recorded daily.On 1/15/2026 at 3:34 pm, V1 (Administrator) verified the freezer, refrigerator, and walk-in cooler was not checked two times daily; stated using a monthly calendar is a kitchen thing when it comes to recording temperatures; the personal refrigerator temperature log was made personally by her (V1); and the purpose of temperature tracking is to prevent food poisoning. Facility Policy titled Labeling and Dating of Foods date 2021 documents, in part, to decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded. Facility Policy titled Storage of Refrigerated Foods with a Revision date of 2017 documents, in part, Air temperature inside the refrigerator is checked and recorded twice daily. The reading on both external and internal thermometers is recorded.

Based on observations, interviews and record review, the facility failed to follow their policy and did not provide clean, comfortable, and homelike environment by ensuring the bathroom sink is clean and free off blockage for four residents (R7, R8, R13 and R21); failed to ensure the room ceiling is free of water stains and not leaking for six residents (R7, R8, R13, R14, R21 and R32) and failed to provide a double door for a closet for one resident (R31). These failures affected seven residents reviewed for homelike environment in the final sample of 33 residents.Findings include: On 1/12/2026 at 10:10 the V1 (Administrator) stated that the census is 35 residents living in the facility. On 1/12/2026 at 11:50 AM in R13 and R21's room, observed a shared bathroom sink filled halfway with standing water. The bathroom sink was observed to be clogged and the water in the sink was not draining. The bathroom was observed to have additional entrance/exit door for the room next to R13 and R21's room and it appears to be joined bathroom for two resident rooms, therefore a total of four residents are sharing the same bathroom. R13 stated, that the clogged sink has been an issue for a while and that the facility is aware of the problem, but not really repairing it. R13 stated that maintenance comes and quickly release the standing water but not repairing the pipes or the actual problem that causes the sink to get clogged up all the time. R13 also confirmed that the bathroom is shared between R13, R21, R7 and R8. R21 stated, that the bathroom sink is always clogged up and it looks bad. On 1/12/2026 at 11:56 AM, observed in R7 and R8's room the entrance door to the shared bathroom and R8 stated, that the bathroom sink is terrible and smells bad sometimes, and that the bathroom sink is always clogged up and has standing water. R8 stated that R8 does not like using that bathroom and R8 would rather use another bathroom in the hallway or when R8 goes out on pass he uses the bathroom outside. R8 said, that R8 told V2 (Assistant administrator), and the facility came and tried to repair the sink, but it keeps getting clogged up and the water does not go down. Observed standing water in R8's bathroom sink that is still in the same level as a previous observation from R13 and R21's room six minutes prior. On 1/12/2026 at 12:25 PM, V2 (Assistant Administrator) stated, that the maintenance director is a part time employee and not present in the facility at times but comes in when called to perform repairs. On 1/12/2026 at 12:42 PM, R7 stated, that the shared bathroom in R7's room has always had a clogged-up sink, and the water does not go down the drain. R7 stated, that this problem is ongoing for a while, maybe more than a few months and that the maintenance tried to repair the problem but did not repair the pipes or the cause of the sink getting clogged up. R7 stated, that the sink is dirty looking, and that the bathroom smells bad sometimes and that the bathroom is shared with three other residents. R7 and R8 both stated that they do not put food or other items down the sink drain and that the problem with the sink clogged up has been reported multiple times to the assistant administrator. On 1/12/2026 at 1:17 PM, V11 (Registered Nurse/RN) stated that V11 has not heard any complaints from R13 or R21 about the bathroom sink. On 1/12/2026 at 1:17 PM, V7 (RN), stated, that V7 is not aware of any complaints from R7 and R8 related to a clogged-up sink in the bathroom. On 1/12/2026 at 1:19 PM, V2 (Assistant Administrator) stated, that V2 is not aware of clogged up sink in R7, R8, R13 and R21's bathroom. On 1/12/2026 at 1:20 PM, observed with V2 (Assistant Administrator) R7, R8, R13 and R21's bathroom sink and V2 confirmed that there was standing water in the sink. V2 stated, that the sink appears to be clogged up and the water is not draining down. V2 stated, that the sink should not have standing water. V2 said, that the maintenance already repaired the sink in the past, but V2 said that the sink must have had clogged up again. V2 stated that V2 will notify the maintenance to come and repair. V2 stated that when a repair is reported to the staff member, the staff should notify V2 and then V2 fills out the repair log and contacts the maintenance. On 1/12/2026 at 1:30 PM, V9 (Certified Nursing Assistant/CNA) stated that V9 was aware of the problem with the sink being clogged up in R21's room and reported the issue to V2 and that the maintenance repaired the sink a while ago, but V9 was not sure when exactly. V9 stated that V9 is not aware of new problem with R21's bathroom sink since the maintenance performed repairs. On 1/13/2026 at 10:30 AM, V12 (CNA/Activities Aide) stated, that V12 is aware of the problem with clogged sink in R7's bathroom, and that the maintenance came and repaired it already. On 1/13/2026 at 12:47 PM, observed R7, R8, R13 and R21's bathroom sink still clogged up, the maintenance removed the middle part of the drain stopper, but when the faucet turned on, and water came down the sink, the water was observed to sit in the drain and backed up to the sink. On 1/13/2026 at 1:27PM V3 stated, that if there is maintenance needed to be performed, the CNAs or nurses will report to V2 (Assistant of Administrator) and then V2 sends a text message or calls V8 (Maintenance Director). V3 stated that V3 is aware of R7, R8, R13 and R21's complaining about their bathroom sink clog up all the time and said, that the maintenance repaired the sink sometime last week. V3 stated, that the facility should keep maintenance logs or sheets with documentation of performed repairs. On 1/13/2026 at 6:06 PM, V8 (Maintenance Director) stated, that V8 is a part time employee of the facility and has been working there for five years. V8 stated, that the facility keeps maintenance logs in a book and that when V8 completes repairs, the maintenance sign in sheet is filled out and V8 signs the sheet. V8 does not have assistants, housekeepers could help with small tasks, but usually if any repair is needed, the nurses or the CNAs report to V2 (Assistant of Administrator) and then V2 text or call V8 to come to the facility and perform the repair. V8 stated, that on 1/12/2026 in the afternoon, the sink in R7's bathroom was unclogged. V8 stated, that V8 performed multiple repairs on that sink, but it keeps getting clogged, V8 thinks that residents wash maybe food or other items down the drain and that is why the sink gets clogged. V8 is aware of this problem and stated, that on 1/12/2026 V8 went to facility and repaired the clogged-up sink in R7's bathroom. V8 stated, that resident rooms should have a homelike environment, should be clean and comfortable. On 1/14/2026 at 10:15 AM, observed in R13's room, large brown stain on the ceiling. The stain was oblong/rectangle shape, brown and right above R13's bed. R13 stated, that R13 just noticed the stain today, and said that it could be because of the snow, the roof leaked. R13 stated, that the building is old, and a water stain was in the room before and the facility just patches the area but does not repair the roof. Observed at that time two additional smaller brown stains on R21's ceiling above R21's bed. Both stains were round, brown and a coffee cup size. Observed above R21's head of the bed on the ceiling, a large white patched up area, rectangular shape, and size of a letter page. On 1/14/2026 at 1:12 PM, V2 (Assistant Administrator) stated, that the resident's room should be clean, safe, comfortable and should have a homelike environment. On 1/14/2026 at 1:45 PM, in R7, R8, R13 and R21's bathroom, observed again, a sink full of standing water, not flowing down the drain. The bathroom was noticed to have a damp smell at the time of observation. R13 stated, that the large brown stain on the ceiling was noticed today by R13 and that the facility's roof needs repairs, because R21 had a leaky ceiling in the past and the facility patched it, but the ceiling still leaks water when raining or snowing outside. On 1/14/2026 at 2:07 PM, V1 (The Administrator) stated, that the facility does not employ a full-time maintenance, the facility staff gets notified about repairs needed and then the assistant of administrator calls the maintenance director and writes repairs to the maintenance on a form and places the form in the maintenance logbooks. V1 stated, that once V8 (Maintenance Director) completes repairs, V8 signs the form as completed. V1, also stated, that the administration is aware that, the facility has a leak on the roof, and is currently waiting for better weather, so V8 (The maintenance director) could go up on the roof and assess for repairs. V1 stated, that the resident's room ceiling and walls should not have stains, and the room should be safe, clean, comfortable and a provide a home-like environment atmosphere. V1 stated, that if the celling is actively leaking, the facility would move resident to another room. Facility's document titled Foster Repair Log showed in part on 1/12/2025, 10/27/2025, 10/28/2025, 12/1/2025, 12/10/2025, 12/15/2025 and 12/30/2025 description of repairs needed for R7, R8, R13 and R21's bathroom sinks due to clogged up drain. Facility's document titled Facility Repair Log Policy (12/1/2019) documents in part that the purpose is to ensure repairs are made to maintain a comfortable environment for residents, staff, and visitors and that if repairs are needed, the staff should fill out the Repair Log form that is kept at the nursing station and the form should be submitted to the Administrator. R14 has a Brief Interview of Mental Status score of 15. R32 has a Brief Interview of Mental Status score of 15. On 1/12/2026 at 11:47am surveyor observed a large round brown stain on the ceiling above R32's bed. There was also a beige color piece of the ceiling hanging over R32's bed. On 1/12/2026 at 11:50am R32 stated his only issue was the ugly leaking ceiling and that his bed and belongings get wet when it rains. R32 stated he has to move the bed further away from the wall to prevent him (R32) from being rained on. On 1/12/2026 at 2:01pm V8 (Maintenance Director) stated the roofing people came out in December, but it was icy and dangerous and they have not come back yet. On 1/14/2026 at about 11:15am R14 stated that when it rains R32 does get wet and we have to move R32's bed further away from the wall to prevent him (R32) from getting wet. On 1/14/2026 at about 12:15pm V2 (Assistant Administrator) stated that V8 would have not called someone to fix the leak and if so it would have been the HVAC people. On 1/15/2026 at 3:40pm via email V2 stated to clarify, no repairs were completed on the roof because during the month of December, unfortunately, the weather produced safety hazards, like ice for example, which prevented maintenance or any personnel to gain access to the roof. Foster Repair Log documents, in part, Date Reported: 1/6/2026 for room [ROOM NUMBER] and Description of Repairs needed: ceiling water leak/roof. Observed R31's has a double door vertical closet with one closet door missing and the second closet door is detached and placed in the 1st closet space leaning against the inside of the cabinet space. Reviewed the Maintenance Log dated 6/1/2025 to 1/12/2026 with no repair log documentation of R31's closet doors in need of repairs. On 1/12/2026 at 1:55 pm, V8 (Maintenance Director) stated he (V8) was informed R31's closet doors were off the hinges yesterday and will be repairing the doors. On 1/13/2026 at 9:38 am, R31's closet doors remained in disrepair. On 1/14/2026 at 9:50 am, R31's closet doors remained in disrepair. Facility's document titled Maintenance Director – Long Term Care Facility (Undated) showed in part, that Maintenance Director is responsible for ensuring safety, functionality and regulatory compliance of the facility and performing preventive maintenance, responding to repair requests, and supporting a safe and comfortable environment for residents and staff. The documents also showed in part, that the maintenance director should perform building maintenance and repairs including but not limited to plumbing and carpentry and should document maintenance activities and repairs according to facility's policy. Facility's document titled Job Description – Assistant Administrator (Undated) showed in part that the Assistant Administrator reports directly to the Administrator and assists in the day-to-day functions of the facility and that responsibilities include but not limited to ensuring that each resident's right is strictly enforced. Facility's document titled Accommodation of Needs and Homelike Environment Guideline (10/2025) showed in part, that the facility should provide reasonable accommodation of resident needs and preferences and that resident have the right to retain a homelike environment and that the facility should provide a safe, clean, comfortable, and homelike environment. The document further shows that the environment includes but not limited to resident's rooms and bathrooms and that homelike environment should de-emphasize the facility's character of the setting as much as possible to support a homelike environment. The document also showed in part that the resident's environment would be maintained a homelike manner. Facility's document titled Resident Rights Guideline (10/2025), showed in part, that the facility should provide environment where residents exercise their rights every day and that the facility would treat every resident with respect and dignity in environment that promotes maintenance and enhancement of resident's quality of life. Document showed in part, that the resident has the right to reasonable accommodation of their needs and the right to a safe, clean, comfortable, and home-like environment.

Based on observations, interviews and record review, the facility failed to follow their policy and did not monitor resident's personal refrigerators by providing a refrigerator temperature log for two residents (R6 and R28) and failed to document and record daily refrigerator temperatures for two residents (R16 and R21). These failures affected four residents reviewed for personal food policy in the final sample of 33 residents.Findings include:On 1/12/2026 at 10:10 the V1 (Administrator) stated that the census is 35 residents living in the facility.On 1/12/2026 at 11:54 AM, observed R21's personal refrigerator with a log attached on the side of the refrigerator, blank, with no recorded temperatures or documented checks of the refrigerator. The Log only showed a month of January, and dates preprinted on the log, with slots next to each date for AM and PM time, temperature checks and initials of person performing the task.On 1/12/2026 at 12:10 PM, V6 (Certified Nurse's Assistant/CNA) stated that the resident's refrigerator checks, and temperature logs should be completed by the dietary department.On 1/12/2026 at 12:10 PM in R16's room, observed a personal refrigerator, in working order with temperature log attached on the refrigerator. Observed on the log under 1/5/2026 slot, recorded temperature of 36 degrees with initials. No time recorded and no other slots were filled out for the rest of the month.On 1/12/2026 at 12:12 PM, in R28's room, observed a personal refrigerator, in working order, with no temperature log attached. No temperature log was observed in the room. On 1/12/2026 at 12:17 PM, V11 (Registered Nurse/RN), stated that the dietary manager comes and checks the refrigerators and should document temperatures on the attached logs. V11 said that the nurses check the medication refrigerator in the nurse's station only and that the dietary department is responsible for the residents' refrigerators checks.On 1/13/2026 at 10:15 AM, in R6's room observed a personal refrigerator, in working order, with no temperature log attached. No temperature log was observed in the room. On 1/13/2026 at 10:38 AM, V12 (CNA/Activity Aide) stated that the dietary services are responsible for checking personal refrigerators in the resident rooms and should provide temperature logs for each refrigerator. V12 also said, that the refrigerators, when checked, the temperatures should be recorded on the temperature logs.On 1/13/2026 at 12:45PM, observed in R16's room, a personal refrigerator, in working order with temperature log attached on the refrigerator. Observed on the log under 1/5/2026 slot, recorded temperature of 36 degrees with initials. No time recorded and no other slots were filled out for the rest of the month. No additional details about refrigerator checks were documented since 1/12/2026 observation.On 1/13/2026 at 12:46 PM, observed in R28's room, a personal refrigerator, in working order, with no temperature log attached. No temperature log was observed in the room. On 1/13/2026 at 12:48 PM, observed R21's personal refrigerator with a log attached on the side of the refrigerator, blank, with no recorded temperatures or documented checks of the refrigerator. The log was observed to be the same as from the observation on 1/12/2026.On 1/13/2026 at 12:52 PM, V7 (RN), stated, that the dietary takes care of checking the refrigerators in the resident rooms and V5 (Dietary Manager) is the responsible party for the refrigerator logs updates.On 1/13/2026 at 1:10 PM, V5 (Dietary Manager stated that checking temperatures and maintaining resident's personal refrigerators is V5's responsibility. V5 stated, that each resident's refrigerator should have a temperature log attached and visible on the fridge. V5 stated, that the temperature logs should be filled out daily or weekly, depending on if the resident has food inside. V5 stated, that V5 follows a list that has the residents with the refrigerators on it and if the refrigerator should be checked daily or weekly. V5 further said, that the temperature logs should be marked with the temperature and V5's initials. V5 stated that the residents that do not have food in the personal refrigerator, would get the refrigerator checked once a week and the residents that store food in their refrigerators, would be checked daily. V5 also stated, that to prove that V5 checked the resident refrigerator, the log would have be filled out with the temperature and V5's initials next to the date that the check was performed. V5 stated that working refrigerators, even if not filled with food items, should have temperature logs attached to the fridge and temperatures checked. V5 said that the temperature log should have a month, date, temperature measurement and initials filled on the log. V5 then stated, that V5 works five days a week and on the weekend, when off, there is nobody performing the task of checking the resident personal refrigerators. V5 stated, that V5 is not aware of logs missing or not filled in and that V5 usually checks the refrigerators closer to end of V5 shift. V5 stated, that V5 checked all the refrigerators and temperature logs on 1/12/2026.On 1/13/2026 at 1:20 PM, during tour of the unit with V5 (Dietary Manager), observed with V5 in R16's room a personal refrigerator with temperature log not filled out completely. The temperature log had a check for 1/5/2026 with temp of 36F with V5's initials and no other check documented. V5 stated, that the temperature log should be filled out for every check performed and V5 guessed that V5 missed recording of the checks that V5 performed.On 1/13/2026 at 1:21 PM, during tour of the unit with V5 (Dietary Manager), observed with V5 in R28's room a personal refrigerator with no temperature log on the fridge or nearby. V5 stated that the refrigerator should have a temperature log attached.On 1/13/2026 at 1:22 PM, observed with V5 (Dietary Manager) in R21's room, a personal refrigerator with temperature log that has no temperature checks documented on any of the dates. Observed a blank temperature log. V5 stated that the temperature log should be filled out when checked and the temperatures should be recorded.On 1/13/2026 at 1:25 PM, V2 (Assistant Administrator) stated that the personal resident refrigerator logs are V5's (Dietary Manager) responsibility, and that V2 is not sure how often the refrigerator temperature logs should be checked and filled out. V2 stated that the temperature logs should be attached on the refrigerator and should be filled out with date checked, the temperature and initials of person that checked the refrigerator.On 1/13/2026 at 1:27 PM, V3 (Director of Nursing/DON) stated, that the kitchen staff should check all resident's personal refrigerators daily and all the refrigerators should have temperature logs attached and temperatures recorded on the logs. V3 stated that the personal refrigerators should be checked for expired items and inspected for proper working condition to prevent foodborne illness spread.Facility's document titled Temp Log-Cooler (Undated), showed in part instructions for filling out the log. The document showed in part, that the temperatures for each refrigerator/cooler in the department should be recorded on the temp-log and the record should include, time and temperature and initials and it should be performed twice a day (AM and PM). V5's (Director Manager) personal refrigerator checks list of residents that should have refrigerators checked daily and checked weekly, showed in part that R16 and R21's refrigerators should be checked weekly and R6's refrigerator should be checked daily. R 28's refrigerator is not on the list.Facility's document titled Refrigerators (Resident) Policy for Maintaining and Cleaning (11/2025) documents in part, that the dietary staff is responsible for ensuring that resident's refrigerator is working and clean and that dietary department is responsible for monitoring resident's refrigerator on daily basis. The policy documents in part that the resident's refrigerator temperature should be taken and recorded daily, and that the dietary manager should record the temperatures of each refrigerator.Facility's document titled Use and Storage of Foods Brought into the Facility Policy(10/24/2024) , documents in part, in section 10 that facility staff will monitor resident personal refrigerators. In section 13a, the policy shows that all refrigerators should have their temperatures recorded daily.Facility's document titled Food Brought in by Family or Visitors Personal Refrigerators (2017), documents in part that personal refrigerator temperatures are maintained at 41F or below and refrigerators should be cleaned regularly to maintain a safe and sanitary condition for food storage.Facility's document titled Food Service Supervisor Job Description (4/14) showed in part, that the supervisor overseas general operation of dietary department and maintains records of food, refrigerator and freezer temperatures and gathers nutritional data from residents and manages storage of food and equipment.Facility's document titled Job Description - Assistant Administrator (Undated) showed in part that the Assistant Administrator reports directly to the Administrator and assists in the day-to-day functions of the facility and that responsibilities include but not limited to ensuring that each resident's right is strictly enforced.

Based on observation interview and record review, the facility failed to complete a new pre-admission screening and resident review (PASSR) when a new mental health diagnosis is identified. This failure affects 1 resident (R2) out of a sample of 35.R2's Face Sheet dated 1/14/2026 has an admission date of 11/28/2023 and has a diagnosis of Schizophrenia with a diagnosis date 12/6/2024.On 1/13/2025 at 12:32 pm, reviewed R2's Preadmission Screening and Resident Review Level I Notice of Outcome dated September 6, 2024, which documents No Level II required- No SMI (Serious Mental Illness) or ID (Intellectual Disability).R2's Minimum Data Set Section C dated 12/5/2025 documents a BIMS (Brief Interview of Mental Status) score of 10.R2's Minimum Data Sheet section D (Mood) dated 12/5/2025 documents a severity score of 12.R2's care plan dated 12/6/2024 documents, in part, a focus for psychotropic medication (Quetiapine) to help alleviate/manage symptoms related to diagnosis of Schizophrenia and Delusional Behavior. Date Initiated: 12/06/2024 Created on: 12/15/2024R2's Physician Order Report dated 1/15/2026 does not document any medications for Schizophrenia.On 1/14/2025 at 12:41 pm, V2 (Assistant Administrator) stated he (V2) believes a Preadmission Screening and Resident Review (PASARR) Level II should be done if a resident has a diagnosis or a new serious mental health illness to ensure the facility can provide the appropriate services to the resident in a long term care facility; should be doing another PASARR Level II if the resident has a new serious mental health illness; he (V2) put every resident in assessment pro and this will trigger a PASARR if one is needed; verified R2 has a new serious mental illness of Schizoaffective Disorder diagnosis on 12/2024 after his (R2's) PASARR Level 1 was completed 9/6/2024; coordinating when a resident is diagnosed with a new serious mental illness and submitting a new level I PASARR in assessment pro to trigger a level II is something the facility needs to get better at.On 1/14/2025 at 1:19 pm, V10 (Psychosocial Rehabilitation Social Services Director-(PRSD) stated he (V10) is not responsible for completing Preadmission Screening and Resident Review's at this facility, the V2 (Assistant Administrator) is responsible.Facility Policy titled Preadmission Screen and Resident Review (PASRR) Policy and Procedure (ILLINOIS) documents, in part:#7. If a resident has a change in status, a new PASRR Level I should be completed in Assessment Pro. Reasons for status change may include, but not limited to:Increased behavioral, psychiatric, or mood related symptoms.f. Resident was not previously identified to require a Level II, and it appears that the referral source may not have appropriately completed screening information.

Based on interview and record review the facility failed to refer one resident (R1) for rescreening to the state agency for Preadmission Screening and Resident Review (PASRR). This deficient practice affected one resident (R1) in a total sample size of 33 residents.Findings include:R1 was admitted on [DATE].R1 has a Brief Interview of Mental Status score of 09 that indicates moderate cognitive impairment. R1 has a diagnosis of but not limited to Dementia, Schizophrenia, Depression, and Bipolar disorder.R1's Interagency Certification of Screening Results dated 2/15/2020 documents, in part, Screening indicated nursing facility are appropriate. R1's Obra-I Initial Screen dated 2/15/2020 documents, in part, based upon all information and data available to me for this person there is a reasonable basis for suspecting DD or MI: NO.On 1/14/2026 at 1:45pm, document reviewed that R1 was admitted on [DATE] with an Obra screening, but there was no PASARR level 1 completed when MAIXMUS took over 2023. On 1/14/2026 at about 11:00am V2 stated that we don't have a PASRR level 1 for R1 because he came in with an Interagency Certification of Screening Results.Facility Policy states, Prior to admission and upon any changes in status, residents will be screened for a known or suspected diagnosis of severe mental illness to ensure resident is appropriate for nursing facility services and to incorporate treatment recommendations into the resident's care plan, and prior to or upon admission and with any status change, Preadmission Screen and Resident Review Level 1 Screen through Maximus Assessment Pro.

Based on observation, interview, and record review the facility failed to provide full visual privacy to ensure resident privacy and dignity. This failure has the potential to affect 1 resident (R10) in a sample of 33.Surveyor observed R10 was missing a privacy curtain, but the curtain track and hooks remained attached to the ceiling in R10's room.On 1/12/2026 at 11:39 am, R10 stated he has not had a privacy curtain since he was admitted 10 months ago due to issues with his hip. R10 stated he receives physical therapy during the week. R10 stated he is taking blood thinners for his heart, makes his own choices, participates in activities, rights are respected, feels safe in the facility, food is good, and received snacks. R10's Face sheet dated 1/14/2026 documents a diagnosis of but not limited to Unspecified Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Essential Hypertension, Other Low Back Pain, Other Acute Kidney Failure, Dislocation of Left Ankle Joint, Manic Episode, Severe with Psychotic Symptoms, Muscle Weakness, and Difficulty in Walking.R10's Minimum Data Set BIMS (Brief Interview Mental Status) Score is a 15 which is an indication of an intact cognition.On 1/12/2026 at 11:58 am, V1 (Administrator) stated the curtains were taken downstairs and are cleaned by a special company. V1 stated the curtains are removed if they become dirty or soiled. V1 stated she (V1) does not have substitution curtains to hang to provide privacy until the curtains are picked up for cleaning and returned to the facility by a special company. On 1/13/2026 at 9:36 am, R10's privacy curtain remains missing. On 1/14/2026 at 9:47 am, R10's privacy curtain remains missing.On 1/14/2026 at 3:00 pm, V15 (Housekeeping) stated staff lets maintenance know when the curtains need cleaning; maintenance removes the curtains; and the laundry lady cleans the curtains. V15 stated the purpose of privacy curtains is to maintain a resident's privacy. Facility Policy dated 11/2025 title Privacy Curtain Policy documents, in part, to ensure resident privacy and dignity through the appropriate use, maintenance, and cleaning of privacy curtains within the skilled nursing facility.

Based on observation, interview and record review the facility failed to secure the call light device for one resident (R12). This failure has the potential to affect one resident (R12) out of a sample size of 33 residents. Findings include:R12 has a diagnosis of but not limited to Spastic Diplegic Cerebral Palsy, Major Depressive Disorder, Chronic Idiopathic Constipation and Retention of Urine.R12 has a Brief Interview of Mental Status score of 15.R12's Call Light Evaluation dated 12/04/2025 documents, in part, Can the resident use the call light: Yes.On 1/12/2026 at 11:14am surveyor observed R12's call light string hanging from the wall behind the bed not within reach of R12. The call light string is stuck on something so surveyor could not pull it free.On 1/12/2026 at 11:15am R12 stated that she would have to lower the bed and find the call light string to activate the call light, but she is not able to reach at this time.On 1/12/2026 at 11:47am V6 (Certified Nursing Assistant) stated the call light string should be within reach of the resident.On 1/14/2026 at about 1:30pm observed R12's call light hanging from the wall and not within reach.On 1/14/2026 at 1:30pm V11 (Registered Nurse) stated call lights should be within reach of the residents.On 1/14/2026 at 1:40pm V3 (Director of Nursing) stated call light devices should be within reach of the resident at all times and the purpose is for the resident to be able to let us know when they need something.Call light policy with a reviewed dated of 11/2025 documents, in part, be sure call lights are placed within reach of residents who can always use it.Undated job description for Certified Nursing Assistant documents, in part, provide for resident comfort by utilizing resources and materials, answering call lights and requests.

Based on interviews and record reviews, facility failed to follow their policy to protect the resident's right to be free from [A] verbal abuse by a staff member for one [R2] of four residents reviewed for abuse, [B] failed to provide the abuse training to the alleged perpetrator [V6] staff member, and [C] failed to follow their Abuse Prevention Program Policy and report an allegation of abuse within 2 hours of the incident to IDPH (Illinois Department of Public Health) for one [R2] of four residents reviewed for abuseFindings include:R2 has diagnosis not limited to Hyperlipidemia, Type 2 Diabetes Mellitus, Repeated Falls, Anxiety Disorder, Dysphagia, Major Depressive Disorder, Spinal Stenosis, Cervical Region, Pain, Low Back Pain, Fibromyalgia, Morbid (Severe) Obesity Due to Excess Calories, Generalized Anxiety Disorder. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.R2's Care Plan in part: R2's assessments reveal factors that may increase R2's susceptibility to abuse. R2 will be treated with respect, dignity, and resides in a facility free of mistreatment. The facility will assure that R2 is in a safe and secure environment, to ensure staff members are available to help and address concerns. Investigate statements/ allegations per facility protocol. R2's progress notes in part: 12/23/25 7:50 AM, Nurse Note: R2 was observed with a new onset of confusion, lethargy, and unable to recognize person, day or time. R2 is usually alert and oriented x4. Received order to send R2 to the emergency department. 12/23/25 at 2:08PM Nurse Note: R2 was admitted to the hospital with admitting diagnosis of altered mental status. On 12/23/25, R2 was sent and admitted to the hospital with a diagnosis of change in mental status. R2 was not available for interview.On 12/23/25 at 11:30 AM, V9 [Clinic Manager] stated, On 10/16/25, between 9AM to 10AM, R2 was in the medical clinic. R2's wheelchair had broken during transport to the medical clinic. R2's escort [V6], V10 [Medical Clinic Office Assistant] and I was at the desk, when V6 was asking if R2 can see the physician past R2's appointment time. I explained the appointment would have to be rescheduled. V6 said R2 had been waiting a long time to receive the appointment, then R2 replied 'No I haven't waited a long time', V6 proceeded and said to R2 'Shut the f_ _k up.' R2 did not say another word, he just looked downward. I then called the nursing facility and spoke with V5 [Office Manger] and V3 [Director of Nursing]. V3 was on speaker phone. I told V5 and V3 exactly what V6 told R2. Neither one [V5, V3] did not have anything to say. I decided to call IDPH, to report the verbal abuse I witnessed.On 12/23/25 at 11:40 AM, V10 [Medical Clinic Office Assistant] stated, I was at the desk when V6 [Escort] was asking if R2 could see the physician, because it took a long time to receive an appointment. When R2 said I haven't been waiting for long time, V6 turn to R2 and said, 'shut the f_ _k up.' R2 did not say another word, R2 got quiet and looked sad. Then V9 called and reported the incident to R2's nursing facility.On 12/23/25 at 1:50 PM, V6 [Escort] stated, I am not a certified nurse assistant. I am an escort. I go out with residents on appointments. I don't remember receiving abuse training. I do not know who the abuse coordinator is. I went out with R2 to his medical appointment in October. That was the day his wheelchair broke. I was at the desk with R2 and two other ladies. I was trying to get R2 seen by the physician while we were there, because it took a long time waiting to receive an appointment. I did not curse at R2. While I was speaking, R2 did cut me off, but I did not curse at R2.On 12/23/25 at 2:00 PM V5 [Office Manger], stated, I received a phone call from V9 [Medical Clinic Manager] and asked when R2's transportation will be there for pick up. Also, V9 said that V6 was rude to R2. That's all V9 said to me, she did not say how or what V6 did to R2. I did not believe V9, because I never heard V6 curse.Surveyor asked V5, why did she say she never heard V6 curse, did V5 say V6 cursed at R2?V5 stated, Oh yeah, I just told on myself, okay. V9 did say she heard V6 curse at R2 saying 'shut the f_ _k up'. I did not tell V3 [Director of Nursing], but I told V1 [Administrator] immediately. But V1 and I knew V6 did not curse at R2, because she is a good person, and we never heard V6 curse before, V1 and I did not believe V9.On 12/23/25 at 3:00 PM, V1 [Administrator] stated, V5 kept me informed about R2's broken wheelchair and transportation issues. V5 did not report R2 was verbally abused by V6 at his medical appointment, but I take full responsibility leave V5 and V3 out of this. I am the human resource director. I cannot locate V6's abuse training during orientation. I must have misplaced the abuse training. If I was made aware of the allegation, V6 would have been suspended immediately, reported to IDPH, and investigation would have occurred.On 12/24/25 at 10:10 AM, V1 stated [during telephone conversation], I called the hospital and spoke with R2. I asked R2 if V6 cursed at him, R2 said he did not know who V6 was. R2 was admitted to the hospital for altered mental status. Also, V5 told me she was confused during the interview, and she mistakenly said she told me V6 cursed at R2.On 12/26/25 at 11:30 AM, V1 stated, The abuse training orientation was verbal, I do not have any documentation that V6 received abuse training. I take full responsibility.Policy in part:Abuse and Prevention dated 1/3/25This affirms the right of our residents to be free from abuse. The facility is committed to protecting our residents from abuse by anyone including, but not limited to facility staff, and other residents. Abuse means any physical, mental, sexual, verbal inflicted upon a resident. Verbal abuse is the use of oral, written, gestured language that willfully includes disparaging and derogatory terms to the resident within in their hearing distance regardless of their age, ability to comprehend or disability. Employees: Orientation and training employees: Resident rights, resident needs, to prevent and report abuse. All employees will sign an Abuse Policy Employee Acknowledgement form. Employees are required to immediately report any occurrences of potential mistreatment they observed, hear about, or suspect to supervisor and or administrator. Reporting: Initial reporting of allegations shall be completed immediately upon notification of the allegation. The written report shall be sent to the Department of Public Health. Investigating: The administrator or designee will investigate the allegations and obtain a copy of any documentation related to the incident.

Based on interview and record review the facility failed to ensure a resident was properly assessed for the sizing of a wheelchair and failed to follow their Accident Incident/Fall Reporting Policy for one (R2) of three residents reviewed for wheelchair use.Findings Include:R2 has diagnosis not limited to Hyperlipidemia, Type 2 Diabetes Mellitus, Repeated Falls, Anxiety Disorder, Dysphagia, Major Depressive Disorder, Spinal Stenosis, Cervical Region, Pain, Low Back Pain, Fibromyalgia, Morbid (Severe) Obesity Due to Excess Calories, Generalized Anxiety Disorder. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.R2's Care Plan document in part: Problem: R2 is High risk for falls r/t (related/to) gait/balance problems. Interventions: Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. Problem: Resident has Alteration in mobility/ Transfer R/T fibromyalgia, repeated falls, weakness and Pain.On 12/23/25 at 11:15 AM V9 called the surveyor and said when R2 came to the hospital the care giver (V6 Escort Provider) said R2 fell out of the van when the driver made a sharp turn. R2's wheelchair had a broken armrest, wheel and the wheelchair was unstable so we could not move R2 inside. It was as if the wheelchair was too small and R2 needed a larger wheelchair. V7 (Activity Director/Certified Nurse Assistant) arrived with a wheelchair that was the same size. I am concerned with R2's wellbeing and R2 waited 8 hours before they sent a van to pick R2 up. Both a coworker and I witnessed it. The facility came on 2 separate occasions, with 2 separate rides and with the wheelchair that was too small. V6 stated the resident fell in the van when they were trying to get him out of the van. When R2 arrived at the clinic a code blue was called. R2 told me he fell immediately after they left the facility, was not strapped in and was laying sideways for the entire ride on the van's floor. My concern was R2 had fallen, and they let R2 stay on the floor of the van. I made the facility aware of the situation around 9-10 am and they were dismissive and argumentative.On 12/23/25 at 11:37 AM V10 (Office Assistant) said R2 was here 5-6 hours later when the facility finally picked R2 up.On12/23/25 at 10:17 AM upon entering R2's room surveyor observed a large wheelchair located near the foot of R2's bed with damage to the left armrest cushion. R2 had been transferred to the hospital due to altered mental status.On 12/23/25 at 10:17 AM R3 stated R2 said he used to have a different wheelchair. The wheelchair that R2 had was like that one near R2's bed but it was just smaller.On 12/24/25 11:00 AM V16 (Certified Nurse Assistant) stated I was one of the people that cleaned R2 up, put on his clothes and helped put him in the wheelchair. I don't know if they had to change R2 out of the chair because it did not fit on the transportation van. R2 usually stays in bed because he cannot stand and does not have weight bearing for his ankles. On 12/23/25 at 12:49 PM When asked did she escort R2 to his appointment on 10/16/25 V6 (Escort Provider) responded, I pushed R2 to the transportation van. R2 changed wheelchairs into a smaller wheelchair because the big boy wheelchair would not fit on the van's transportation wheelchair ramp. R2 mentioned they gave him a reduced wheelchair, smaller wheelchair so it could fit on the ramp into the medical van. The driver came out and pushed R2 up the ramp. The floor in the van was a plain floor with straps on the side, inside the spokes of the wheels of the wheelchair. I am not sure if the driver strapped R2 in because I was outside of the van and I was not paying that close of attention. As far as I am concerned the driver did everything I could have sworn. There was a long bench seat in the van, and I can't tell you if R2 was strapped in because I was sitting next to the driver. R2 is a big guy. The driver said if you like you can sit in the front passenger seat. I did not sit in the back on the bench seat because it was not enough room. I am glad I was not back there because R2 would have fell on me. The driver made a left turn and R2 fell. The wheelchair tilted sideways, and the wheels were in the air. R2 fell leaning towards the bench seat. I told the driver to pull over. The driver opened the door and R2 was facing the door behind the driver. The driver could not get R2 up and said he needed some help. R2 is alert and oriented x3. When we get to the clinic they came out and 911 was called. 911 used a sheet and blanket to get R2 up. R2 was uncomfortable because he was used to his own wheelchair. The wheelchair left wheel was bent in when R2 was tilted, that is why the driver could not get R2 back. The spinal people said you cannot push R2 to his appointment because they said it was unsafe to go to R2's appointment and they cancelled his appointment. The fire department, they were all over R2 and I was back where I could not see R2's position. I don't know how they got R2 out of the van. 911 put R2 back in the broken wheelchair, R2 was still sitting in his broken wheelchair, and we were sitting there forever waiting on another wheelchair. I called V1 (Administrator) to let her know the fire department handled that and let her know what happen. V7 (Activity Director/Certified Nurse Assistant) drove and brought a wheelchair from the facility, and they sent 2 men to take R2 out the broken wheelchair. One to 2 hours had gone by. It was about 5 hours before R2 went back to the facility. V5 (Office Manager) made an appointment for the medical van to come get R2 and I road back in the van with R2. R2 cannot stand.On 12/23/25 at 02:52 PM V11 (Registered Nurse) stated on 10/16/25 R2 went to the pain clinic for a usual appointment with transportation. R2 is a fall risk. In the middle of the day, I got call from administrator. R2 had a broken wheelchair, and they needed another wheelchair for him. The transportation driver made a sharp turn and R2 tilted. I got the information from the escort. We sent two certified nurse assistants with another wheelchair, to help R2 from the damaged wheelchair to another wheelchair.On 12/24/25 at 11:44 AM per telephone interview V17 (Registered Nurse) stated on 10/16/25 R2 came back from his appointment as usual at maybe 3 something. When a resident returns from an appointment we get the notes from the appointment. I was not aware of R2's incident and I am not aware of what kind of wheelchair R2 was in.On 12/23/25 at 03:09 PM V1 (Administrator) stated the escort (V6) was calling me about the incident. I had V5 (Office Manager) call the transportation company to report the incident and the driver. It was reported that V6 called and said the transportation driver made a sharp turn and the wheelchair tipped over. The driver got out the van to try to put the wheelchair back up straight. The nurse said V6 needed to call 911 to help assist R2 to another wheelchair. We had an uber to get R2 back to the facility. It was after 03:30 when they came back to the facility.On 12/23/25 at 01:33 PM V7 (Activity Director/Certified Nurse Assistant) stated R2's wheel on the wheelchair was broken. Management V1 (Administrator) wanted me to take another wheelchair to R2's appointment. It was said the clinic could not assist transferring R2, so me and 2 other Certified Nurse Assistants went with me. I drove my personal truck to take the wheelchair, and the two other certified nurse assistants rode in a different vehicle. I arrived first and once I got there; I tried to assist transferring R2 into the wheelchair, but R2 would not allow me to assist transferring him. R2 allowed the three of us to transfer him. R2 has a favorite wheelchair that is a standard size. It was a regular wheelchair that was broken. I was holding the chair as R2 was being transferred. We left after we transferred R2, and he had to be transported by transportation services back to the facility. They had to transport R2 because he cannot stand. R2 is very alert.On 12/23/25 at 01:48 PM V8 (Certified Nurse Assistant) stated The director of nursing and administrator called us and said we need to go assist R2. We met R2 in the wheelchair and they said R2's wheelchair was broken. V7 (Activity Director/Certified Nurse Assistant), V13 (Certified Nurse assistant) and I transferred R2 putting our arms under R2's armpit, lift, pivot and transfer R2 to the other wheelchair. It was a medium size wheelchair. R2 said thank God you all came. R2 is not able to stand or walk. We left after R2 was transferred to the other wheelchair.On 12/24/25 at 09:53 AM V13 (Certified Nurse Assistant) stated the administrator called us and told us we need to go transfer R2 into another wheelchair. Me and V8 (Certified Nurse Assistant) rode together and met V7 (Activity Director/Certified Nurse Assistant) there. R2 was transferred into the wheelchair that we went with. I don't remember the size of the wheelchair. They gave R2 a bigger wheelchair after the incident. We came back to the facility after R2 was transferred to the wheelchair.On 12/23/25 at 02:03 PM V5 (Office Manager) stated the incident with R2 happened in October, this person picked R2 up, took a sharp turn in the vehicle and R2's wheelchair tilted. The vehicle was wheelchair accessible because R2 could not transfer. That is the account I got from R2 and from V6 (Escort Provider) because I was not present. The clearest report was from R2 saying the driver made a sharp turn and the wheelchair fell over, the parking guy came to help and said let's call 911. After they ascertained the wheelchair was broken, the doctor would not see R2 because R2 could not be pushed in the wheelchair. V7 (Activity Director/Certified Nurse Assistant) went to take the new wheelchair that R2 could fit in and be wheeled back in.On 12/24/25 10:35 AM V14 (Certified Nurse Assistant) stated I helped transfer R2 into the bed from the wheelchair. The wheelchair R2 was in was a regular wheelchair. I am not sure what size the chair was that we transferred R2 from into the bed.On 12/24/25 at 11:50 AM per telephone interview V18 (Restorative Nurse) stated When I started working there, I did a reassessment if R2's wheelchair was suitable but there is no assessment for the wheelchair itself. With the assessment we check if the resident is suitable for a wheelchair, then measure one side to the other side of the hips. That determines what size wheelchair is needed. I cannot recall what size R2's wheelchair was in and never had to document the size of his or anyone's wheelchair. I am aware of the incident that happened 10/16/25. The director of nursing told me that they needed to order another wheelchair. They did not tell me that I needed to reassess R2.On 12/23/25 at 09:27 AM V3 (Director of Nursing) stated I have no incident reports in the past 3 months.On 12/23/25 at 02:20 PM V3 (Director of Nursing) stated I was not here when they called about the incident with R2. When I came in the building around 2 pm (Registered Nurse) called and told me what happened. R2 went on an appointment and his wheelchair broke. I asked did R2 fall and V6 (Escort Provider) said R2 leaned over but he did not fall. The wheelchairs wheel broke, and they needed people to take him another wheelchair so two certified nurse assistants had to take R2 a wheelchair. V7 (Activity Director/Certified Nurse Assistant) went with the two certified nurse assistants. A Risk management was not done because no one said anyone fell on the floor. The wheel popped and leaned so they had to transfer R2 from one wheelchair to the other. A change of plain is considered a fall. R2 said he did not like that wheelchair, he liked the other wheelchair. R2's appointment as cancelled and after R2 came back from the appointment he did not fit properly in the wheelchair. I can't remember what size the wheelchair was When the wheelchair wheel broke, they couldn't get R2 out, so they had to call 911 for assistance. My presumption is the wheelchair did not support R2's weight or they did not have R2 strapped in correctly. They had to bring another wheelchair because the wheelchair was broken, and they did not have another wheelchair available. I did a report, and we did incorrect stuff. I did not do an incident report, and I don't have anything documented. When called, the nurse should have made documentation, informed the director of nursing and medical doctor. I will take total accountability. There should have been risk management, interview the staff and anyone involved including 6 interviews, R2 should have been assessed when he got back in the building, assessed for 72 hours, a wheelchair should have been ordered in the proper size, a root cause analysis should have been done, restorative and the interdisciplinary team should have gotten involved. The Root cause is R2 needed a bigger wheelchair. How V6 reported the incident was so vague, I did not speak to anyone. We rescheduled the appointment. On 12/24/25 at 09:15 AM V3 (Director of Nursing) stated the wheelchair that broke, R2 had it for a long and it was a regular wheelchair in weight. Policy:Titled Accident Incident/Fall Reporting Policy revised 01/01/25 document in part: Any accident/incident will be reported immediately to the nurse or appropriate person designated to be in charge. A written report will be completed for anu individual (resident) involved in an accident or an incident while residing in the facility. Purpose: To ensure that accidents and incidents that occur with residents is identified, reported, investigated, and resolved. To provide a database to study the cause of accidents/incidents and to provide assistant in implementing corrective actions to prevent reoccurrence when possible. Procedure: 1. If a resident is involved in and accident/incident an immediate assessment of the resident will be completed. 2. The nurse responsible for the oversite and care of the resident will complete an incident/accident report. When possible, a descriptive statement will be obtained from the resident and any witnesses. (Utilize the witness statement form). 3. The nurse will notify the resident's attending physician/nurse practitioner. Any actions/communications are to be documented in the resident's medical record. 4. The surrogate or authorized representative is to be notified of the accident/incident. 5. Any accident/incident report, which has occurred, shall be reported to the nurse's manager on duty or designee. 6. An accident/incident report will be completed as soon as information is obtained. The report is to be completed as fully as possible before the nurse ends the shift. An exact description of the circumstances surrounding the incident/accident will be provided. Only facts will be documented. 7 The occurrence will be documented in the resident's medical record. Documentation in the medical record should include the following: Description of the occurrence, Physical and mental status of the resident, Time of physician notification and physician response/orders, Time of notification of the resident's family, guardian, or responsible party. 8. A complete incident/accident report will be submitted to the Director of Nurses or designee. 10. Documentation of the resident's physical and mental status will be completed each shift following the incident for a minimum of 72 hours or until the condition symptoms improve. Neuro-checks will be completed according to policy. 11. The occurrence is to be communicated shift to shift as part of the unit report until the resident is stabilized. 13. A thorough investigation will be completed within 5 business days. 14. Based on the results of the investigation, the resident care plan is revised as necessary to prevent or minimize further accidents/incidents when possible. 15. A complete investigation tool and other written information will be maintained with the incident report.

Based on interview and record review, the facility failed to update a resident care plan as exacerbation of neurological symptoms began to occur. This failure affected 1 (R3) resident reviewed for care plan in the total sample of 5 residents. Findings include: On 05/05/2025 at 2:20pm, V2 (Director of Nursing) stated R3 was doing spastic movement of her upper extremities, flexion and extension. R3 never had this jerking movement before. It was as if she was trying to get out of her chair. It was just severe so we put her on 1:1 supervision. If you (staff) were with her, there is no spastic movement but as soon as you (staff) leave, R3 would have spastic movements of both her upper and lower extremities. I really think her cerebral palsy is exacerbating. There is a change on her baseline signs and symptoms. The exacerbation of R3's symptoms should be care planned. It is a problem that we need to focus on, we have to create a goal and add interventions. R3's careplan for cerebral palsy and spastic movement was not updated with new interventions. R3's careplan should be revised to include new interventions. I (V2) will update it today. R3's Admission Record documented that R3's diagnoses (include but not limited to) cerebral palsy, metabolic encephalopathy, and reduced mobility. R3's (02/14/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-Term memory Ok: 1 Memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. Section I0020. Indicate primary medical condition. 07. Other neurological conditions. I0020B. primary Medical Condition. Cerebral Palsy. R3's care plan (date initiated: 05/05/2023) documented, in part The resident has an alteration in musculoskeletal status r/t (related to) hx (history) of muscle wasting and atrophy, spasticity and involuntary/impaired movements of the limbs and trunk d/t (due to) Cerebral Palsy. Date Initiated: 05/05/2023. Revision on: 05/05/2025. Revision by: V2 (Director of Nursing). Give medication as prescribed. Date Initiated: 05/05/2025. Created on: 05/05/2025. Created by: V2 (Director of Nursing). Neurology/Psychiatrist referral PRN. Date Initiated: 05/05/2025. Created on: 05/05/2025. Created by: V2 (Director of Nursing). Of note, revision was made on day one of survey. The (10/20/2024) Care plans, comprehensive Person Centered documented, in part Policy Statement: A comprehensive, person-centered careplan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and implementation. 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas. 13. Assessments of the resident are ongoing and care plan are revised as information about the residents and the resident's condition change.

Based on observation, interview and record review, the facility failed to protect residents' rights to be free from mental and physical abuse for 1 out of 4 residents reviewed for abuse. This failure does not conform with facility's abuse policy and affected one resident (R1), who experienced hair pulling by another resident (R2), resulting in R1 expressing anguish, fear for her safety, and danger of harm. Findings include: R1 is [AGE] years old, initially admitted at the facility on 04/11/2022. R1's diagnosis includes visual impairment, anoxic brain damage, bipolar disorder, and depression. R1's BIMS (Brief Interview of Mental Status) dated 10/03/2024 is 15 out of 15 indicating that R1's cognition is intact. On 12/17/2024 at 12:16 PM, R1 was seen inside her room alert and verbally able to express her thoughts well during conversation. R1 stated last Sunday (12/15/2024) while she was walking in the hallway, R2 grabbed her ponytail again. R1 showed her back hair that was long. R1 stated that R2 grabbed her hair multiple times in the past. R1 said, R2 constantly abused me, and I don't feel safe. R1 stated that she is visually impaired and does not have peripheral vision, and that it is hard for her to see R2 when coming from her side. R1 pointed to the stick that she uses to guide her when she walks. R1 stated that pulling of her hair also happened in the smoking area when R2 grabbed her ponytail, and that staff did not monitor R2 because R2 was in the smoking area although R2 does not smoke. R1 stated that R2 was able to go inside her room around 12:15 AM and that made her (R1) scared of her safety. R1 stated that there are two (2) other residents, R3 and R4, that had also experienced physical aggression from R2. R1 stated that she spoke to V5 (Social Service Worker) about being transferred to another facility last October or November, but nothing has been done. R1 said, I spoke to V5 the social worker, who told me, this is his (V5) exact words, bear with us, we are trying to find another place for her (R2). R1 stated that she has been in the facility for three (3) years, and she does not feel safe. Behavioral notes dated 12/15/2024 written by V6 (Registered Nurse) documents R2 pulled R1 hair that led to R1 yelling towards R2. Similar incident also happened on 11/01/2024 as recorded on R2's behavioral notes by V8 (Licensed Practical Nurse) that documents R2's physically aggressive and that R2 assaulted R1 by pulling her hair. Another incident note by V8 dated 10/23/2024 documents that R2 went inside the room of R1 at 12:08 AM. R1 was noticeably shaking and stated, I don't feel safe here with this woman still here. Why is she in my room? Why? I've been attacked by her several times. I don't want her killing me before they realize she is not supposed to be here. On 12/17/2024 at 01:40 PM, R3 was seen alert and able to express her thoughts within topic during conversation. R3 confirms that R2 hit her back multiple times, punching with her fist behind her (R3) head, (R3 made a punching motion behind the right side of her back). R3 said that she turned to R2, and R2 just laughed. Per R3, staff allowed R2 to do those things, and she (R3) just keep distance with R2, as long as R2 keep distance from her. Behavioral notes dated 07/22/2024 by V9 (Registered Nurse) documents that in the dining room, R2 hit R3 and threw milk on R3's face. R2 is [AGE] years old, initially admitted at the facility on 05/25/2024. R2's diagnosis includes restlessness and agitation, schizophrenia, bipolar disorder, major depressive disorder. R2's BIMS (Brief Interview of Mental Status) dated 09/05/2024 is 09 out of 15 indicating R2's cognition is moderately impaired. On 12/17/22024 between 12:05 PM to 03:20 PM R2 was seen in the hallway, sitting on a chair, and wandering. Every time R2 goes to a specific direction, facility staff goes to redirect. It takes multiple staff to monitor and/or redirect R2. R2 was not able to be redirected at times. On 12/17/2024 at 02:50 PM, V1 (Administrator) stated that another incident happened over the weekend, on Saturday (12/14/2024), when R2 pulled R1's ponytail. According to V1 none of the facility staff told her about what happened and that V6 (Registered Nurse) was expected to report to her (V1) any incident or allegation of abuse. V1 states that the facility does not have any designated abuse coordinator during the weekend because she still accepts calls. When she came on Monday (12/16/24), before she left for the day, R1 told her about the incident that R2 pulled her hair. V1 said, that was the time I knew that R2 pulled the hair of R1. V1 then said that she did a grievance form for R1. V1 was asked why she did not do a reportable after she knew what happened between R1 and R2. V1 replied that abuse incident or allegation needs to be reported immediately or within 2 hours upon knowing of the incident. Since the incident happened on 12/14/2024, it was too late to report and investigate. V1 stated that the incident that happened on 12/14/2024 between R1 and R2 was abuse, because R1 does not like what was being done to her. V1 states that the act of R2 to R1 causes an effect on R1, physically or mentally. Per V1 one on one monitoring to R2 is ongoing and R2's transfer to the hospital for a psych eval will take place when there is an available bed. V1 stated that currently R2 is being monitored one on one, and arrangement is being made to transfer R2 to the hospital for psych evaluation. V1 was informed that based on documentation in R2's behavioral notes the incident of R2 pulling R1's hair happened on Sunday, 12/15/2024 (same as R1's statement) not Saturday (12/14/2024). V1 said that she will correct her documentation. On 12/17/2024 at 03:49 PM, V6 (Registered Nurse) stated that the incident between R1 and R2 on 12/15/24 happened around 09:30 AM, the time she was passing medication. V6 stated that she heard R1 yelling. V6 said, I saw R1 behind R2 and R1 said R2 pulled my hair. So, I just did 1 on 1 monitor. I need to report, I knew R1 was telling the truth, but I forgot to tell. V6 stated she just documented the incident and did not report to her supervisor. Per V6 abuse incidents need to be reported immediately but forgot to report it. V6 stated that abuse happened when R2 pulled the hair of R1, and it needs to be reported immediately. Per V6 the CNA (Certified Nursing Assistant) assigned to R2 was attending to another resident during the incident. On 12/18/2024 at 09:37 AM, V3 (Director of Nursing) stated that incidents like pulling of R1's hair will affect R1 mentally. V3 said, If I were in her (R1) shoes, I will feel scared too. V3 stated that it may lead to more aggressive actions than pulling of hair. V3 reviewed the full care plan of R1, and after review, V3 said, I don't see anything that addresses abuse incidents. V3 said that the care plan should be done for both because both residents (R1 and R2) are affected. R1's care plan does not address R2's aggressive behavior towards R1. V5's (Director of Social Services) psychosocial notes do not document any of R1's incidents with R2. On 12/18/2024 at 12:06 PM, V5 (Director of Social Services) stated that all of his notes are under psychosocial and were written in general. V5 was asked about R1's psychosocial notes and why all the notes do not address any incidents from R1's encounter with R2. V5 stated that the last time he saw R1 was 11/7/2024 and there were no particular concerns for R1. V5 was asked about addressing the abuse incidents that R1 encountered in the care plan's intervention to prevent further abuse from occurring. V5 stated that since R1 is not at risk for doing abuse or does not participate back during a physical aggression, a general statement of at risk of abuse behavior was placed. V5 was asked if interventions were placed in R1's care plan would it help to prevent another incident of abuse from happening. V5 did not directly answer the question. V5 stated that if he only knew R1 felt unsafe or scared, he would go out of his way to transfer R1 into another facility. V5 was informed that the incidents of R1 and R1 expressing feelings of unsafety and fear were documented in the behavioral notes and were readily accessible. V5 did not comment. V5 was asked how he would feel if the same thing happened to him. V5 stated that he would be scared too, and added, Next time I will do better. Abuse Policy dated 01/04/2024, reads: This facility affirms the right of the residents to be free from abuse. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of the residents. This will be done by establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. Identifying occurrences and patterns of potential mistreatment. Immediately protecting residents involved in identifying reports of possible abuse.

Based on observation, interview, and review of records the facility failed to identify and provide behavioral services to 1 (R1) out of 4 residents reviewed for all services provided by the facility. These failures do not conform with facility's Behavioral Assessment, Intervention, and Monitoring policy and affected 1 resident (R1) who expressed anguish, fear of her safety, and danger from harm. Findings include: R1 is [AGE] years old, initially admitted at the facility on 04/11/2022. R1's diagnosis includes visual impairment, anoxic brain damage, bipolar disorder, and depression. R1's BIMS (Brief Interview of Mental Status) dated 10/03/2024 is 15 out of 15 indicating that R1's cognition is intact. On 12/17/2024 at 12:16 PM, R1 was seen inside her room alert and verbally able to express her thoughts well during conversation. R1 stated last Sunday (12/15/2024) while she was walking on the hallway, R2 grabbed her ponytail again. R1 showed her back hair that was long. R1 stated that R2 grabbed her hair multiple times in the past. R1 said, R2 constantly abused me, and I don't feel safe. R1 stated that she is visually impaired and does not have peripheral vision, and that it is hard for her to see R2 when coming from her side. R1 pointed to the stick that she uses to guide her when she walks. R1 stated that pulling of her hair also happened in the smoking area when R2 grabbed her ponytail, and that staff did not monitor R2 because R2 was in the smoking area although R2 does not smoke. R1 stated that R2 was able to go inside her room around 12:15 AM and that made her (R1) scared of her safety. R1 stated that there are two (2) other residents, R3 and R4, that had also experienced physical aggression from R2. R1 stated that she spoke to V5 (Social Service Worker) about being transferred to another facility last October or November, but nothing has been done. R1 said, I spoke to V5 the social worker, who told me, this is his (V5) exact words, bear with us, we are trying to find another place for her (R2). R1 stated that she has been in the facility for three (3) years, and she does not feel safe. Behavioral notes dated 12/15/2024 written by V6 (Registered Nurse) documents R2 pulled R1 hair that led to R1 yelling towards R2. Similar incident also happened on 11/01/2024 as recorded on R2's behavioral notes by V8 (Licensed Practical Nurse) that documents R2's physically aggressive and that R2 assaulted R1 by pulling her hair. Another incident note by V8 dated 10/23/2024 documents that R2 went inside the room of R1 at 12:08 AM. R1 was noticeably shaking and stated, I don't feel safe here with this woman still here. Why is she in my room? Why? I've been attack by her several times. I don't want her killing me before they realize she is not supposed to be here. On 12/17/2024 at 01:40 PM, R3 confirms that R2 hit her back multiple times, punching with her fist behind her head (R3 made a punching motion behind the right side of her back). R3 said that she turned to R2, and R2 just laughed. Per R3, staff allowed R2 to do those things. R3 states she (R3) just keeps distance with R2, as long as R2 keeps distance from her. Behavioral notes dated 07/22/2024 by V9 (Registered Nurse) documents that in the dining room, R2 hit R3 and threw milk on R3's face. R2 is [AGE] years old, initially admitted at the facility on 05/25/2024. R2's diagnosis includes restlessness and agitation, schizophrenia, bipolar disorder, major depressive disorder. R2's cognition is moderately impaired with BIMS (Brief Interview of Mental Status) of 9 dated 09/05/2024. On 12/17/24 between 12:05 PM to 03:20 PM R2 was seen in the hallway, sitting on a chair, and wandering. Every time R2 goes to a specific direction, facility staff goes to redirect. It takes multiple staff to monitor and/or redirect R2. R2 was not able to be redirected at times. On 12/17/2024 at 02:50 PM, V1 (Administrator) stated that another incident happened over the weekend, on Saturday (12/14/2024), when R2 pulled R1's ponytail. According to V1 none of the facility staff told her about what happened and that V6 (Registered Nurse) was expected to report to her (V1) any incident or allegation of abuse. V1 stated that the incident that happened on 12/14/2024 between R1 and R2 was abuse, because R1 does not like what was being done to her. V1 states that the act of R2 to R1 causes an effect on R1, physically or mentally. V1 was informed that based on documentation in R2's behavioral notes the incident of R2 pulling R1's hair happened on Sunday, 12/15/2024 (same as R1's statement) not Saturday (12/14/2024). V1 said that she will correct her documentation. On 12/18/2024 at 09:37 AM, V3 (Director of Nursing) state that incidents like pulling of R1's hair will affect R1 mentally. V3 said, If I were in her (R1) shoes, I will feel scared too. V3 stated that it may lead to a more aggressive actions than pulling of hair. V3 reviewed the full care plan of R1, and after review, V3 said, I don't see anything that addresses abuse incidents. V3 said that care plan should be done for both because both residents (R1 and R2) are affected. R1's care plan does not address R2's aggressive behavior toward R1. V5's (Director of Social Services) psychosocial notes do not document any of R1's incidents with R2. On 12/18/2024 at 12:06 PM, V5 (Director of Social Services) stated that all of his notes are under psychosocial and were written in general. V5 was asked about R1's psychosocial notes and why all the notes do not address any incidents from R1's encounter with R2. V5 stated that the last time he saw R1 was 11/7/2024 and there were no particular concerns for R1. V5 was asked about addressing the abuse incidents that R1 encountered in the care plan's intervention to prevent further abuse from occurring. V5 stated that since R1 is not at risk for doing abuse or does not participate back during a physical aggression, a general statement of at risk of abuse behavior was placed. V5 was asked if interventions were placed in R1's care plan would it help to prevent another incident of abuse from happening. V5 did not directly answer the question. V5 stated that if he only knew R1 felt unsafe or scared, he would go out of his way to transfer R1 into another facility. V5 was informed that the incidents of R1 and R1 expressing feelings of unsafety and fear were documented in the behavioral notes and were readily accessible. V5 did not comment. V5 was asked how he would feel if the same thing happened to him. V5 stated that he would be scared too, and added, Next time I will do better. Behavioral Assessment, Intervention and Monitoring policy dated 01/04/2024, reads: Under general guidelines, behavior is the response of an individual to a wide variety of factors. These factors may include psychosocial, emotional, psychiatric, or environmental causes. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including emotional, psychiatric and/or psychological stressors for example anxiety; and/or fear. Under management, the interdisciplinary team will evaluate behavior symptoms in the resident to determine the degree of severity, distress, and potential safety risk of the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice.

Based on interview and record review, the facility failed to follow its abuse policy of reporting incidents and/or allegations of abuse for 1 (R1) out of 4 residents reviewed for abuse. This failure affected 1 resident (R1) who experienced pulling of her hair by another resident (R2). Findings include: R1 is [AGE] years old, initially admitted at the facility on 04/11/2022. R1's diagnosis includes visual impairment, anoxic brain damage, bipolar disorder, and depression. R1's cognition is intact with BIMS (Brief Interview of Mental Status) of 15 dated 10/03/2024. On 12/17/2024 at 12:16 PM, R1 was seen inside her room alert and verbally able to express her thoughts well during conversation. R1 stated last Sunday (12/15/2024) while she was walking in the hallway, R2 grabbed her ponytail again. R1 showed her back hair that was long. R1 stated that R2 grabbed her hair multiple times in the past. R1 said, R2 constantly abused me, and I don't feel safe. R1 stated that she is visually impaired and does not have peripheral vision and it is hard for her to see R2 when coming from her side. R1 pointed to the stick that she uses to guide her when she walks. R1 stated that pulling of her hair also happened in the smoking area when R2 grabbed her ponytail. R1 stated that staff did not monitor R2 because R2 was in the smoking area although R2 does not smoke. R1 stated that R2 was able to go inside her room around 12:15 AM and that made her scared of her safety. R1 stated that there are two (2) other residents that R2 did some physical aggression, and these residents were R3 and R4. R1 stated that she spoke to V5 (Social Service Worker) about being transferred to another facility last October or November but nothings being done. R1 said, I spoke to V5 the social worker. Who told me, this is his (V5) exact words, bear with us, we are trying to find another place for her (R2). R1 stated that she has been in the facility for three (3) years, and she does not feel safe. Behavioral notes dated 12/15/2024 by V6 (Registered Nurse) documents R2 pulled R1's hair that led to R1 yelling towards R2. Similar incident also happened on 11/01/2024 as recorded on R2's behavioral notes by V8 (Licensed Practical Nurse) that documents R2's physically aggressive and assaulted R1 by pulling her hair. Another incident dated 10/23/2024 by V8 documents that R2 went inside the room of R1 at 12:08 AM. R1 was noticeably shaking and stated, I don't feel safe here with this woman still here. Why is she in my room? Why? I've been attacked by her several times. I don't want her killing me before they realize she is not supposed to be here. R2 is [AGE] years old, initially admitted at the facility on 05/25/2024. R2's diagnosis includes restlessness and agitation, schizophrenia, bipolar disorder, major depressive disorder. R2's cognition is moderately impaired with BIMS (Brief Interview of Mental Status) of 9 dated 09/05/2024. On12/17/24 between 12:05 PM to 03:20 PM R2 was seen in the hallway, sitting on a chair, and wandering. Every time R2 goes to a specific direction, facility staff goes to redirect. It takes multiple staff to monitor and/or redirect R2. R2 was not able to be redirected at times. On 12/17/2024 at 02:50 PM, V1 (Administrator) stated that another incident happened over the weekend, on Saturday (12/14/2024) when R2 pulled R1's ponytail. According to V1, none of the facility staff told her about what happened, and that V6 (Registered Nurse) was expected to report to her any incident or allegation of abuse. V1 stated that the facility does not have any designated abuse coordinator during weekend because she still accepts calls. V1 stated that when she came on Monday (12/16/2024) before she left for the day, R1 told her about the incident that R2 pulled her hair. V1 said, that was the time I knew that R2 pulled the hair of R1. V1 then said that she did a grievance form for R1. V1 was asked why she did not do a reportable after she knew what happened between R1 and R2. V1 replied that abuse incidents or allegations need to be reported immediately, or within 2 hours upon knowing the incident, and since the incident happened on 12/14/2024, it was too late to report and investigate. V1 stated that the incident that happened on 12/14/2024 between R1 and R2 was abuse, because R1 does not like what was being done to her, and the act of R2 to R1 causes an effect, physically or mentally. Per V1 one on one monitoring to R2 is ongoing and R2's transfer to hospital for psych eval will take place when there is an available bed. V1 stated that currently R2 is being monitored one on one, and arrangement is being made to transfer R2 to the hospital for psych evaluation. V1 was informed that based on documentation in R2's behavioral notes the incident of R2 pulling R1's hair happened on Sunday, 12/15/2024 (same as R1's statement) not Saturday (12/14/2024). V1 said that she will correct her documentation. On 12/17/2024 at 03:49 PM, V6 (Registered Nurse) stated that the incident between R1 and R2 happened on 12/15/24 around 09:30 AM, the time she was passing medication. V6 stated that she heard R1 yelling. V6 said, I saw R1 behind R2 and R1 said R2 pulled my hair. Per V6 the CNA (Certified Nursing Assistant) assigned to R2 was attending to another resident during the incident. V6 stated she just documented the incident and did not report to her supervisor. Per V6 abuse incidents need to be reported immediately but she forgot. V6 stated that abuse happened when R2 pulled the hair of R1, and it needs to be reported immediately. Abuse Policy dated 01/04/2024, reads: This facility affirms the right of the residents to be free from abuse. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of the residents. This will be done by immediately protecting residents involved in identifying reports of possible abuse. Employees are required to immediately report any occurrences of potential mistreatment they observe, hear about, or suspect to supervisor or the administrator. Initial report of allegations shall be completed immediately upon notification of the allegation. The written report shall be sent to the Department of Public Health. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation will be sent to the Illinois of Department of Public Health.

Based on interview and record review, the facility failed to follow its abuse policy on investigating incidents and/or allegations of abuse for 1 (R1) of 4 residents reviewed for the right to be free from abuse. This failure affected 1 resident (R1) who suffered hair pulling by another resident (R2). Findings include: R1 is [AGE] years old, initially admitted at the facility on 04/11/2022. R1's diagnosis includes visual impairment, anoxic brain damage, bipolar disorder, and depression. R1's BIMS (Brief Interview of Mental Status) dated 10/03/2024 is 15 out of 15 indicating that R1's cognition is intact. On 12/17/2024 at 12:16 PM, R1 was seen inside her room alert and verbally able to express her thoughts well during conversation. R1 stated last Sunday (12/15/2024) while she was walking in the hallway, R2 grabbed her ponytail again. R1 showed her back hair that was long. R1 stated that R2 grabbed her hair multiple times in the past. R1 said, R2 constantly abused me, and I don't feel safe. R1 stated that she is visually impaired and does not have peripheral vision, and that it is hard for her to see R2 when coming from her side. R1 pointed to the stick that she uses to guide her when she walks. R1 stated that pulling of her hair also happened in the smoking area when R2 grabbed her ponytail, and that staff did not monitor R2 because R2 was in the smoking area although R2 does not smoke. R1 stated that R2 was able to go inside her room around 12:15 AM and that made her (R1) scared of her safety. R1 stated that there are two (2) other residents, R3 and R4, that had also experience physical aggression from R2. R1 stated that she spoke to V5 (Social Service Worker) about being transferred to another facility last October or November, but nothing has been done. R1 said, I spoke to V5 the social worker, who told me, this is his (V5) exact words, bear with us, we are trying to find another place for her (R2). R1 stated that she has been in the facility for three (3) years, and she does not feel safe. Behavioral notes dated 12/15/2024 by V6 (Registered Nurse) documents R2 pulled R1 hair that led to R1 yelling towards R2. Similar incident also happened on 11/01/2024 as recorded on R2's behavioral notes by V8 (Licensed Practical Nurse) that documents R2's physically aggressive and assaulted R1 by pulling her hair. Another incident dated 10/23/2024 by V8 documents that R2 went inside the room of R1 at 12:08 AM. R1 was noticeably shaking and stated, I don't feel safe here with this woman still here. Why is she in my room? Why? I've been attack by her several times. I don't want her killing me before they realize she is not supposed to be here. R2 is [AGE] years old, initially admitted at the facility on 05/25/2024. R2's diagnosis includes restlessness and agitation, schizophrenia, bipolar disorder, major depressive disorder. R2's cognition is moderately impaired with BIMS (Brief Interview of Mental Status) of 9 dated 09/05/2024. On 12/17/24 between 12:05 PM to 03:20 PM R2 was seen in the hallway, sitting on a chair, and wandering. Every time R2 goes to a specific direction, facility staff goes to redirect. It takes multiple staff to monitor and/or redirect R2. R2 was not able to be redirected at times. On 12/17/2024 at 02:50 PM, V1 (Administrator) stated that another incident happened over the weekend, on Saturday (12/14/2024) when R2 pulled R1's ponytail. According to V1, none of the facility staff told her about what happened, and that V6 (Registered Nurse) was expected to report to her any incident or allegation of abuse. V1 stated that the facility does not have any designated abuse coordinator during weekend because she still accepts calls. V1 stated that when she came on Monday (12/16/2024) before she left for the day, R1 told her about the incident that R2 pulled her hair. V1 said, that was the time I knew that R2 pulled the hair of R1. V1 then said that she did a grievance form for R1. V1 was asked why she did not do a reportable after she knew what happened between R1 and R2. V1 replied that abuse incidents or allegations need to be reported immediately, or within 2 hours upon knowing the incident, and since the incident happened on 12/14/2024, it was too late to report and investigate. V1 stated that the incident that happened on 12/14/2024 between R1 and R2 was abuse, because R1 does not like what was being done to her, and the act of R2 to R1 causes an effect, physically or mentally. Per V1 one on one monitoring to R2 is ongoing and R2's transfer to the hospital for psych eval will take place when there is an available bed. V1 stated that currently R2 is being monitored one on one, and arrangement is being made to transfer R2 to the hospital for psych evaluation. V1 was informed that based on documentation in R2's behavioral notes the incident of R2 pulling R1's hair happened on Sunday, 12/15/2024 (same as R1's statement) not Saturday (12/14/2024). V1 said that she will correct her documentation. On 12/17/2024 at 03:49 PM, V6 (Registered Nurse) stated that the incident between R1 and R2 happened on 12/15/24 around 09:30 AM, the time she was passing medication. V6 stated that she heard R1 yelling. V6 said, I saw R1 behind R2 and R1 said R2 pulled my hair. Per V6 the CNA (Certified Nursing Assistant) assigned to R2 was attending to another resident during the incident. V6 stated she just documented the incident and did not report to her supervisor. Per V6 abuse incidents need to be reported immediately but she forgot. V6 stated that abuse happened when R2 pulled the hair of R1, and it needs to be reported immediately. Abuse Policy dated 01/04/2024, reads: This facility affirms the right of the residents to be free from abuse. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of the residents. This will be done by implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively and making the necessary changes to prevent future occurrences. Facility will appoint an investigator. Once an allegation has been made, the administrator or designee will investigate the allegation and obtain a copy of any documentation related to the incident. The final investigation will be completed within five working days of the reported incident. The final report shall include facts determined during the process of the investigation, review of medical records, personnel files, and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts.

Based on observation, interview, and record review, the facility failed to ensure food items were properly labeled, dated, and stored, failed to properly rotate food using First In, First Out (FIFO) guidelines, and failed to ensure kitchen staff were wearing appropriate hair coverings. These failures have the potential to affect all 38 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:38 AM, V13 (Dietary Manger) stated perishable items should be dated with the date it was prepared, a use by date and used within three days. V13 stated the kitchen staff follows the manufacturer label if there is a use by or best by dates printed on the product. V13 stated for shelf- items which need to be refrigerated after being opened such as salad dressing, mayonnaise, and sauces get labeled with a delivery date, an open date and a use by date which is within 30 days of the item being opened. V13 stated it is important for food items to be labeled and dated with opened and use by dates to prevent food-borne illness which could harm the residents. On [DATE] at 9:40 AM, observed the following items in the Walk-In Refrigerator: 1.) Opened 30-Fluid Ounce glass bottle Barbeque Marinade 50% full with manufacturer best by date [DATE] printed on the side of the bottle. No opened date labeled on the item. V13 stated the Marinade sauce was used on chicken served to the residents last week for a cookout. V13 viewed the best by date of [DATE] printed on the side of the bottle and said, I would still use this for residents because the vinegar inside it would kill any bacteria in the marinate. 2.) Opened 1-gallon Golden Italian Dressing labeled with an open date of [DATE]. Item was not labeled with a use by date. 3.) Opened 1-gallon Honey Mustard Dressing labeled with an open date [DATE]. Item was not labeled with a use by date. 4.) Opened 1-gallon Soy Sauce dated with an open date [DATE]. Item was not labeled with a use by date. 5.) Opened 1-gallon Mayonnaise dated with an open date [DATE]. Item was not labeled with a use by date. 6.) Opened 1-gallon Pickle Chips labeled with an open date [DATE]. Item was not labeled with a use by date. 7.) Opened 64-ounce plastic container Mayonnaise. Not labeled with an opened date. On [DATE] at 9:50 AM, V13 stated those items in the Reach-In Refrigerator not labeled are used so frequently that labeling them with a use by date is not necessary because V13 said, we go through the items quickly. On [DATE] at 9:55 AM, when touring the dry storage room, V13 stated all items must be labeled with a delivery date and the items are organized according to First In, First Out (FIFO). V13 stated FIFO means the newest or most recently delivered item is stored in the back and the oldest item is stored in the front. V13 stated this is important to rotate the food items so that the older items are used first. On [DATE] at 9:58 AM, observed the following items in the dry storage room: 1.) #10 can Dark Red Kidney Beans - not labeled with delivery date. V13 stated V13 knows when that was delivered but the delivery date should be written on the can. 2.) #10 can Diced Beets - not labeled with delivery date. V13 stated the delivery date should be written on the can. 3.) 5 of 6 - #10 cans Cut Waxed Beans labeled with delivery date [DATE] and 1 of 6 #10 can Cut Waxed Beans labeled with delivery date [DATE]. The can dated [DATE] was in the very back behind the cans dated [DATE]. V13 stated the can dated [DATE] should be in the front so it is used before the other cans dated [DATE]. 4.) Separate bins filled with Breadcrumbs, Farina, Parboiled Rice, Oatmeal, Flour, Sugar. None of the bins were labeled with the item name, open or use by dates. V13 stated since there are no labels on the bin items you cannot tell when they were opened and the potential problem with that is the kitchen could be using items over the expiration date without realizing it. On [DATE] at 10:06 AM, V13 stated spices are good for two years. Observed in the cook's prep station near the stove the following spices: 1.) Opened 10-ounce bottle titled Poultry Seasoning labeled with delivery date [DATE]. Not labeled with an open or use by date. There was no manufacturer's best by date printed on the bottle. 2.) Opened 8-ounce bottle titled Ground Sage labeled with delivery date [DATE]. Not labeled with an open or use by date. There was no manufacturer's best by date printed on the bottle. On [DATE] at 10:29 AM, observed V15 (PM Cook) in the kitchen organizing meal tickets. V15 had a mustache and beard which was not covered with a beard protector or any type of covering. V15 stated V15 is not wearing a beard protector over V15's beard right now because V15 is doing the meal tickets and emptying the garbage. V15 stated V15 only wears the beard protector when V15 is dealing with food, not necessarily every time V15 enters the kitchen. On [DATE] at 3:20 PM, observed V15 in the kitchen walking around food prep area in front of the oven with uncovered food on the stove. V15 stated V15 is preparing the food for the dinner meal tonight. V15 had a mustache and beard which was not covered with a beard protector or any type of covering. On [DATE] at 3:30 PM, V13 stated hair and beard restraints should be put on before crossing the threshold into the kitchen regardless of whether or not someone is handling food. V13 stated the kitchen is currently out of beard protectors and in the meantime, the kitchen is using the white hairnets in place of the beard protectors. V13 stated any facial hair needs to be covered regardless of the length. V13 stated the purpose of wearing hair coverings including beard protectors is to prevent hair from falling into the food because this would contaminate the food. V13 stated V15 is the only staff down in the kitchen right now and is the cook on duty so V15 is working with food and should have a beard protector or white hairnet over V15's beard. On [DATE] at 11:45 AM, V6 (Registered Dietitian) stated labeling and dating are important so the kitchen staff is aware of when a food item is expired so it is not served to the residents. V6 stated serving food after the best by or used by date to the residents could potentially cause an overgrowth in bacteria which could lead to food borne illness. V6 stated food items should have a receive date (delivery date), and then once opened labeled with an opened and a use by date or expiration date. V6 stated if the items are not labeled with an open or use by date the staff won't know when the items are no longer any good and when they should be discarded. Facility provided document titled, Diet Type Report dated [DATE] listing residents with their diet orders. There are no residents who are NPO (receiving nothing by mouth). V3 and V13 stated none of the residents living at the facility are NPO. Facility provided policy titled Employee Health & Personal Hygiene dated [DATE] which documents in part, hair restraints will be worn at all times. Beards should be well-trimmed and covered with an appropriate hair restraint. Facility provided V15's signed job description dated [DATE] which documents in part, hair covering must be worn while cooking or food handling. Any facial hair (beards) must be covered while in the kitchen. Facility provided policy titled, Date Marking and Labeling dated [DATE] which documents in part, 1.) All foods that are stored will be properly dated and labeled to ensure food safety. 2.) Date marking is an identification system that helps identify the name of the food, when the food was prepared and when it is to be discarded 3.) When to date mark: the food requires refrigeration, a commercially prepared food item is opened, when potentially hazardous (PHF/TCS) food are stored, when purchased, ready-to-eat foods are removed from their original packaging/container. 4.) When to discard refrigerated items that are opened must be discarded or used in 7 days, the item has expired according to the manufacturer's expiration date. Facility provided policy titled First In First Out (FIFO) dated [DATE] which documents in part the facility will follow safe food handling and storage practices and newly arrived food stock items will be placed at the back of the shelf and the older food items to the front of the shelf. The old stock items will be used first.

Based on observation, interview and record review, the facility failed to handle linen in a manner to prevent cross contamination, failed to conduct an annual review of its infection control policy and procedures, failed to post Enhanced Barrier Precautions (EBP) signage outside 2 residents (R21, R38) rooms with active wounds, and failed to have measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. These failures could potentially affect all 38 residents residing in the facility. Findings Include: R21's Treatment Administration Record (TAR) dated 9/1/24 to 9/30/24 shows R21 has venous wound of the left lateral leg with daily treatment. Progress note dated 10/10/24 documents in part: R21 on ABT Doxycycline 100mg PO bid x 10 days wound infection on the left leg. R38's TAR dated 10/1/24 to 10/31/24 shows R38 has treatment to lower legs every shift for skin infection. On 10/08/24 10:48 AM, R21 is obserevd lying in bed with left leg wound. No signage of EPB on R21's door. On 10/08/24 10:46 AM, R38 is observed in bed with skin peeling on both legs. No enhanced barrier precaution (EBP) signage on R38's door. On 10/08/24 at 10:50 AM, V4 (Registered Nurse/RN) stated that Enhanced Barrier Precautions (EBP) signage should be posted outside the door of any resident with wounds, Feeding tube, Foley Catheter, and central line. V4 stated it is important to have EBP signage to ensure that staff are wearing the necessary Personal Protective Equipment (PPE) required before providing care for R21 and R38. 10/08/24 at 12:13 PM, surveyor V3 (Director of Nursing/Infection Preventionist) observed R21 and R38's door without the EBP signage. V3 stated that R21, and R38 have wounds, there should be a EBP signage by the door to alert staff to know the type of PPE to wear before providing care to R21, and R38. V3 stated that not having the signage by R21, and R38's door, is a potential for transmission of infection. On 10/08/24 at 12:08 PM, surveyor reviewed the water management area with V16 (maintenance Director). Surveyor asked V16 for measures in place to prevent the growth of Legionella. V16 stated V16 is not sure, and V16 could not provide any documentation. V16 stated V16 will ask V1. On 10/09/24 at 1:01 PM, V1(Administrator) stated that Legionella is checked yearly, and V1 has not checked for Legionella this year. V1 stated that the last time the water was checked for Legionella was 1/11/23 which is over one year. V1 stated that V1 will call the company to come over later. V1 stated that failure to perform an annual check for Legionella, is a potential for waterborne infection. V1 stated that the infection control policy is reviewed or revised yearly, but V1 provided surveyor undated infection policy. V1 stated that the date should have been November 2023, but it was an oversight. On 10/08/24 at 12:53 PM, the laundry room was obsereved with V7 (Laundry/Housekeeping Aide). Surveyor observed V7 pick up the dirty mop from the laundry room without wearing a pair of gloves, and V7 used the same dirty hand to pick up clean resident gowns from the folding table. V7 stated that V7 is sorry because, V7 forgot to sanitize V7's hand before picking up the clean gowns from the folding table. Surveyor asked V7 if the clean gowns are now contaminated and should be rewashed. V7 responded yes. On 10/08/24 at 12:58 PM, the chute was observed with V7, surveyor observed V7 walking in the hallway with a dirty pair of gloves. Surveyor asked V7 if the dirty gloves can result in spreading of bacteria. V7 responded Yes. On 10/09/24 at 1:10 PM, V3 stated that it is the expectation of V3 that staff will wear a pair of gloves to pick up a dirty mop and perform hand hygiene before handling clean gowns or clean linen. V3 stated that the potential problem of handling clean gowns with a dirty hand may result in spreading of bacteria. V3 stated that, no staff should be wearing gloves when walking in the hallway to prevent the spread of infection. The facility policy titled Hand Hygiene dated 12/17/19 documents read in part: Hand hygiene is the single most efficient means of preventing the spread of infection. The facility policy titled Linen Handling dated November 2023 documents read in part: Wash hands after handling soiled linen and before handling clean linen. The facility policy titled Enhanced Barrier Precautions (EBP) dated 3/21/24 documents read in part: Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required Personal Protective Equipment (PPE). The facility policy undated, titled Infection Control and Procedure. A copy of EBP documents read in part: Wear gloves and a gown for wound care, any skin opening requiring a dressing.

Based on interview and record review, the facility failed to complete MDS (Minimum Data Set) assessments using CMS - specified Resident Assessment Instrument (RAI) process within the regulatory timeframes. This failure can potentially affect 13 (R1, R6, R9, R13, R17, R21, R23, R26, R27, R30, R33, R34, R38) out of 26 residents reviewed for resident assessment. The findings include: On 10/09/24 02:30 PM Surveyor reviewed the following MDS assessments and showed the following: 1. R1 Quarterly MDS dated [DATE] showed completion date on 9/27/24. 2. R6 Quarterly MDS dated [DATE] showed completion date on 9/19/24. 3. R9 Quarterly MDS dated [DATE] showed completion date on 9/26/24. 4. R13 Quarterly MDS dated [DATE] showed completion date on 9/26/24. 5. R17 Quarterly MDS dated [DATE] showed completion date on 9/19/24. 6. R21 Quarterly MDS dated [DATE] showed completion date on 9/26/24. 7. R23 Quarterly MDS dated [DATE] showed completion date on 9/30/24. 8. R26 Quarterly MDS dated [DATE] showed completion date on 9/27/24. 9. R27 Quarterly MDS dated [DATE] showed completion date on 9/19/24. 10. R30 Quarterly MDS dated [DATE] showed completion date on 9/19/24. 11. R33 Quarterly MDS dated [DATE] showed completion date on 9/26/24. 12. R34 Quarterly MDS dated [DATE] showed completion date on 9/30/24. 13. R38 Quarterly MDS dated [DATE] showed completion date on 9/30/24. On 10/10/24 at 10:14am V17 (MDS/Care Plan coordinator, LPN-Licensed Practical Nurse) stated she has been working in the facility for 2 years. MDS is an assessment to determine resident's ADL (activities of daily living), cognitive function, urinary / bowel function, current diagnosis, medication use, skilled therapy, and any falls. She said they follow RAI (Resident Assessment Instrument) guidelines including timeframe of every MDS assessment which are admission, annual, quarterly, and significant change. Quarterly ARD (Assessment Reference Date) is set every 91 days or prior from the last ARD. Completion date should be 14 days from the ARD. If not following the RAI guidelines required timeframe there would be problem with acceptance of the MDS assessment and it can potentially affect the care of the resident. Reviewed EHR (electronic health record) with V17 for the following residents: R6's Quarterly MDS ARD was on 7/24/24 and was completed on 9/19/24. V17 said R6's MDS assessment should have been completed 8/7/24. R38's Quarterly MDS ARD 8/21/24 was completed on 9/30/24. V17 sated R38's MDS assessment should have been completed 9/4/24. She said the MDS assessments have a late completion date. V17 stated she has been sick and maybe did not lock the assessment within the timeframe stated by RAI guideline. CMS'S (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 manual dated October 2024 page 2-17 documented in part: Quarterly (Non-Comprehensive) MDS Completion Date (Item Z0500B) No Later Than ARD + 14 calendar days.

Based on interview and record reviews, the facility failed to complete the comprehensive Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 13 (R31, R11, R32, R4, R2, R35, R37, R5, R12, R19, R15, R24, R20) out of 26 residents reviewed for comprehensive resident assessments. Findings Include: On 10/09/24 at 2:27 PM, record reviews of the following Minimum Data Set (MDS) assessments revealed the following: 1. R31's Annual MDS assessment with assessment reference date (ARD) of 5/29/24, date signed assessment as complete on 7/15/24. 2. R11's Annual MDS assessment with ARD of 10/29/23, date signed assessment as complete on 12/3/23. 3. R32 Annual MDS assessment with ARD of 7/18/24, date signed assessment as complete on 9/19/24. 4. R4's Annual MDS assessment with ARD of 7/25/24, date signed assessment as complete on 9/19/24. 5. R2's Annual MDS assessment with ARD of 4/26/24, date signed assessment as complete on 7/1/24. 6. R35's Admission MDS assessment with ARD of 5/5/24, date signed assessment as complete on 7/18/24. 7. R37's Admission MDS assessment with ARD of 5/15/24, date signed assessment as complete on 7/21/24. 8. R5's Annual MDS assessment with ARD of 5/15/24, date signed assessment as complete on 7/2/24, and care areas completed on 7/10/24. 9. R12's Annual MDS assessment with ARD of 11/29/23, date signed assessment as complete on 1/25/24. 10. R19's Annual MDS assessment with ARD of 11/5/23, date signed assessment as complete on 12/24/23. 11. R15's Annual MDS assessment with ARD of 5/16/24, date signed assessment as complete on 7/2/24, and care areas completed on 7/10/24. 12. R24's Annual MDS assessment with ARD of 10/19/23, date signed assessment as complete on 11/16/23. 13. R20's Annual MDS assessment with ARD of 5/15/24, date signed assessment as complete on 7/11/24. On 10/10/24 at 10:14 AM, V17 (Licensed Practical Nurse MDS/Care Plan Coordinator) stated [V17] follows RAI guidelines including timeframe of every MDS assessment which are admission, annual, quarterly, and significant change. V17 stated that Admission MDS ARD is set within 14 days from admission and completed 14 days from the ARD. Example if resident is admitted today 10/10/24, ARD should be set within 10/10 to 10/23/24. Care Area Assessments (CAA) completed by the 14th day from admission. Transmission is within 14 days from the completion date. V17 stated that Annual MDS ARD is set every year and should be completed 14 days from the ARD. Chapter 2 of the RAI (October 2024) manual page 17 titled RAI OBRA-required Assessment Summary indicates that Admission MDS assessment's completion date is no later than the 14th calendar day of the resident's admission, and the Annual MDS assessment's completion date is no later than 14 days from the ARD.

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff and failed to follow their medication policy to ensure residents received essential medications to treat their medical conditions as ordered by their physician. There was no nurse on duty to pass medications in the entire facility and as a result, 37 residents (R1- R37) did not receive their scheduled medications on 06/05/2023 and 06/06/2023 on the evening shift (3:00 PM - 11:00 PM). These failures have the potential to cause negative medical outcomes for all 37 residents. This was identified as an Immediate Jeopardy situation which began on 06/05/2023. On 07/28/2023 at 10:00 am, the Administrator was notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 08/11/2023. However, the deficiency remains at the second level until the facility determine the effectiveness of the implementation of the removal plan. Findings include: Facility's punch timecards from 06/04/2023 to 06/10/2023 documents in part: No nurse on 06/05/2023 from 5:00 PM to 11:00 PM. Review of Medication Administration Audit Report (06/05/2023 and 06/06/2023) indicated all 37 residents did not receive scheduled medications for both days during the 3pm to 11pm shift. R1's Facesheet documents in part: fibromyalgia, low back pain, anxiety disorder, spinal stenosis, cervical region, pain, unspecified, morbid (severe) obesity due to excess calories, major depressive disorder, recurrent, unspecified, hyperlipidemia, unspecified, type 2 diabetes mellitus without complications, repeated falls, and dysphagia, oropharyngeal phase. On 06/29/2023 at 11:29 am, R1 stated, On 06/05/2023 and 06/06/2023, there was no nurse on duty at all, and I did not receive my medications. I have a lot of pain because I had a neck surgery and I have other medical problems that cause me a lot of pain. During those dates there were shifts that I did not receive my medications, which includes Morphine. I have extended release Morphine that is scheduled, and I have fast acting Morphine that is also scheduled, and I did not receive either of them. Those shifts when there was no nurse to pass medications, I was in a lot of pain. My pain was at an 10/10. If I don't take my pain medications when it is scheduled, the pain builds up and it becomes intolerable. Those two days that I did not receive my pain medications, my pain got so bad that it caused my anxiety to get worse. I cannot tolerate the pain when it builds up due to missed pain medications. Them not having a nurse to pass medications happens often. This is not the first time there was no nurse on duty to pass medications. The staffing in this facility is an issue. It's 11:30 am, and I still did not receive my scheduled 9:00 am medications, and of course I am in pain and I am uncomfortable. I never receive my 9:00 am medications on time. It's always given to me late, usually around noon time. R1 also stated the facility has not been consistent about his wounds. The day there was no nurse in the facility, no one changed my wounds then. I am not sure if it is getting better. I have expressed my concerns regarding not receiving my medications to the Social Services Director and the Administrator, but nothing is done. It's the same problem every day. I have told them many times about my concerns with the medication administration. The last time I expressed my concerns to the Administrator and Social Services Director was two weeks ago, when I did not receive my scheduled medications during two shifts on 06/05/2023 and 06/06/2023. My concerns were not addressed by the administration. R2's Facesheet diagnoses documents in part: displaced subtrochanteric fracture of left femur, subsequent encounter for closed fracture, gastrointestinal hemorrhage, cerebral infarction, malignant neoplasm of colon, diverticulosis of large intestine without perforation or abscess, and pain. On 06/29/2023 at 10:00 am, R2 stated, I did not receive my medications in beginning June. There wasn't a nurse on shift on one of the days, first week of June. I did not receive my Norco that night which led me to have 8 out of 10 pain. R3's Facesheet diagnoses documents in part: rheumatoid arthritis, essential (primary) hypertension, other osteoporosis without current pathological fracture, acute embolism and thrombosis of unspecified deep veins, dementia with behavioral disturbance, bipolar disorder, anxiety disorder, gastro-esophageal reflux disease without esophagitis, and chronic kidney disease. On 06/29/2023 at 10:30 am, R3 stated, On 06/05/2023 there was no nurse working on the night shift. I normally receive Tramadol for pain two times a day. When I did not get it in the evening, I wheeled up front to ask the nurse. That's when someone told me that were was no nurse working. My pain was so bad that night. It went up to an 8 out of 10. R4's Facesheet diagnoses documents in part: epilepsy, post-traumatic stress disorder, and major depressive disorder. On 07/06/2023 at 10:24 am, R4 stated, There was a date in beginning June when there wasn't a nurse on shift to give me my medications, especially my pain medications. I was in a lot of pain. When I don't get my pain medications, my pain goes up to a 9. R6's Facesheet diagnoses documents in part: fracture of lower end of left femur, subsequent encounter for closed fracture, arthritis, fracture of left acetabulum, subsequent encounter for fracture, severe sepsis with septic shock, paraplegia, pressure ulcer of left heel, stage 3, pressure ulcer of other site, stage 3, non-pressure chronic ulcer of unspecified part of right lower leg with necrosis of muscle, methicillin resistant staphylococcus aureus infection as the cause of diseases, pain in leg, history of pulmonary embolism, atrial fibrillation, displaced apophyseal fracture of right femur, subsequent encounter for closed fracture, and acute embolism and thrombosis of other specified deep vein of right lower extremity. On 07/06/2023 at 10:30 AM, R6 stated, No one administered my medications or changed my wounds sometime in June when there was no nurse. During that time, they missed my pain medications and my wound treatment. I am always in pain and it is a lot of pain and at that time my pain went up to a 12 out of 10. R5's Facesheet diagnoses documents in part: arthritis, morbid (severe) obesity, chronic obstructive pulmonary disease, acute hematogenous osteomyelitis, cellulitis of right lower limb, osteoarthritis, anemia, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, gastro-esophageal reflux disease, lymphedema, chronic kidney disease, and atherosclerotic heart disease of native coronary artery. On 07/06/2023 at 11:00 am, R5 stated, I did miss my medications sometime in June. I was in a lot of pain when I missed my medications. I don't think there was a nurse around that time and my pain went up to a 6 out of 10. R32's Facesheet diagnoses documents in part: chronic obstructive pulmonary disease, hyperlipidemia, gastro-esophageal reflux disease, major depressive disorder, and conversion disorder with seizures or convulsions. On 07/26/2023 at 10:51 am, R32 stated, There was time in June where there was no nurse. I did not gets pain medications and when the facility misses my medications, I get this aching pain all over my arms and it goes up to 9 out of 10. R30's Facesheet diagnoses documents in part: cerebral infarction, traumatic subdural hemorrhage without loss of consciousness, type 2 diabetes mellitus, and cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery. On 07/26/2023 at 10:55 am, R30 stated, I receive blood thinner medications, blood pressure medications. I receive blood thinner medications at night. My blood thinner medication is a shot, and that I get the shot at night. On 06/05/2023 when there was no nurse to give me my medications; I missed my Lovenox shot. R34's Facesheet diagnosis documents in part: anoxic brain damage, cardiac arrest due to other underlying condition, cerebral infarction, dysphagia, and acute respiratory failure with hypoxia. On 07/26/2023 at 11:01 AM, R34 stated, There was a time in June where there was no nurse on duty. Those two nights I couldn't sleep because at night I take my sleeping medications. On June 5th and June 6th, I did not receive my sleep medications, and so I couldn't sleep those nights. I went up to the nurse's station to ask the nurse for my medication, but there was no nurse. R26's Facesheet diagnosis documents in part: iron deficiency anemia, lymphedema, traumatic subdural hemorrhage without loss of consciousness, and low back pain. On 07/26/2023 at 11:09 am, R26 stated, There were some occasions where the facility misses my medications. I take blood pressure medications, sugar cholesterol and pain medications. When they miss my medications, I have pain all over my body. It's an aching pain and goes up to at least a 5 out of 10. R23's Facesheet diagnoses documents in part: osteoarthritis of hip, cellulitis of right lower limb, major depressive disorder, anxiety disorder, chronic pancreatitis, and other chronic pain. On 07/26/2023 at 11:37 am, R23 stated, I take Gabapentin for nerve pain. I get that every 8 hours; at 6:00 am, 12:00 pm, and 8:00 pm. If I miss my medications, then my pain goes up to a 3 out of a 10. R21's Facesheet diagnoses documents in part: depression, iron deficiency anemia, tachycardia, bipolar disorder, anxiety disorder, schizophrenia, and gastro-esophageal reflux disease without esophagitis. On 07/26/2023 at 11:46 am, R21 stated, There was a time on June 5th and June 6th, where there was no nurse. I was irritated because there was no one to give me my medications. R22's Facesheet diagnoses documents in part: cerebral infarction, wernicke's encephalopathy, cerebral infarction due to occlusion or stenosis of small 05/15/2023 secondary-6 admission artery, and hypertension. On 07/26/2023 at 11:54 am, R22 stated, There was no nurse for two shifts in the beginning of June. I missed my pain medication, blood pressure medication. It was very irritating. R13's Facesheet diagnoses documents in part: spondylosis, gout, Parkinson's disease, type 2 diabetes mellitus, leiomyoma of uterus, hydronephrosis with renal and ureteral calculous obstruction, dysphagia following cerebral infarction, cerebral infarction due to unspecified occlusion or stenosis of cerebral artery, schizoaffective disorder, and epilepsy. On 07/26/2023 at 11:58 am, R13 stated, I asked for pain medications but they never gave it to me. I had pain in my stomach on both sides. When I don't receive my pain medications my pain is a 10/10. R24's Facesheet diagnoses documents in part: acute respiratory failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, heart failure, essential (primary) hypertension, hypothyroidism, atherosclerotic heart disease of native coronary artery, cardiac pacemaker, malignant neoplasm of pancreas, and migraine. On 07/26/2023 at 12:05 pm, R24 stated, There was a time in June when I missed my pain medications. I have pancreatitis so I have sharp excruciating pain on the side of my abdomen. The pain goes up to a 10/10 if I do not receive pain medications. R10's Facesheet diagnoses documents in part: other specified arthritis, chronic obstructive pulmonary disease, angina pectoris, bipolar disorder, acute respiratory failure with hypoxia, heart failure, and tachycardia. On 07/26/2023 at 12:16 pm, R10 stated, There was no nurse on June 5th and June 6th. That day they failed to give me my Norco for my arthritis and neuropathy. It was an aching and burning pain all over my body. I also do use oxygen. My pain was at a 10 out of a 10. R8's Facesheet diagnoses documents in part: other specified arthritis, multiple sites, type 2 diabetes mellitus without complications, and acute kidney failure. On 07/26/2023 at 12:23 PM, R8 stated, There was no nurse on 06/05/2023 and 06/06/2023. During that time, they missed all my medications. I was very upset. R27's Facesheet diagnoses documents in part: chronic obstructive pulmonary disease, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery, essential (primary) hypertension, and dementia. On 07/26/2023 at 12:40 pm, R27 stated, I did not get any medications this morning. When I do not get my medications, my legs ache from the hips downt to my ankle. My pain is at a 9 out of 10, 10 being the worst pain possible. R29's Facesheet diagnosis documents in part: schizoaffective disorders. On 07/26/2023 at 12:46 pm, R29 stated, I have been admitted to the facility since May 30th. There was no nurse June 5th and June 6th. I was worried because there was no one to run the place. R31's Facesheet diagnoses documents in part: other specified arthritis, traumatic subarachnoid hemorrhage without loss of consciousness, benign prostatic hyperplasia with lower urinary tract symptoms, unspecified dementia, Alzheimer's disease, atherosclerotic heart disease of native coronary artery, heart failure, chronic kidney disease, benign prostatic hyperplasia without lower urinary tract, major depressive disorder, hypothyroidism, hyperlipidemia, and essential (primary) hypertension. On 07/26/2023 at 12:48 pm, R31 stated, I take pain medication for my knees. The pain can get really bad if I don't get it. R37's Facesheet diagnoses documents in part: schizophrenia, type 2 diabetes mellitus, arthritis, acute kidney failure, chronic pain, neurocognitive disorder with lewy bodies, type 1 diabetes mellitus, vitamin d deficiency, essential (primary) hypertension, and prolapse of vaginal vault after hysterectomy. On 07/26/2023 at 12:53 pm, R37 stated, When I do not get my medications, my foot starts to ache and my pain is at a 4 out of 10. R12's Facesheet diagnoses documents in part: unspecified fracture of t11-t12 vertebra, subsequent encounter for fracture, chronic obstructive pulmonary disease, rheumatoid arthritis, fracture of third lumbar vertebra, atherosclerotic heart disease of native coronary artery, schizoaffective disorder, anemia, bipolar disorder, and anxiety disorder. On 07/26/2023 at 12:55 pm, R12 stated, There was a time on 06/05/2023 and 06/06/2023, where there was no nurse. I felt anxious and terrible because there was no nurse to give me medications at the facility. On 07/26/2023 at 1:15 pm, R6 stated, The nurse sometimes does my wounds. There were two dates in June where there was no nurse. During that time, they missed giving me my medications and missed doing my wound care treatments. I am in pain all the time and when I miss my pain medication, the pain gets to a 12 out of 10. On 06/29/2023 at 11:49 am, V3 (Licensed Practical Nurse) stated, The facility has only one nurse on duty, and I feel like there should be 2 nurses. If one nurse calls off and does not show up, then there is no nurse on duty to pass the medications to the residents. The facility needs more nurses and more Certified Nursing Assistants. It's 11:49 (am), and I am still not done passing medications. It is impossible for 1 nurse to pass all the medications to the residents on time. It's impossible to pass the scheduled medications on time to all the residents because there are 38 residents. I have not given (R1's) medications to (R1) yet. I am running behind. On 06/29/2023 at 1:00 PM, V1 (Administrator) stated, There is supposed to be one nurse per shift, with 4 Certified Nursing Assistants from 7:00 am to 3:00 pm, 3 certified nursing assistants from 3:00 pm to 11:00 pm, and 1 Certified Nursing Assistant from 11:00 pm to 7:00 am. There was no nurse on 06/05/2023 from 05:00 pm till 11:00 pm. There was no Director of Nursing during this time either. The Director of Nursing is part time. (V2, Director of Nursing) works Tuesday, Thursday and Saturday from noon till 10:00 pm. On 06/30/2023 at 12:05 pm, V5 (Primary Care Physician) stated, The facility made me aware that there was no nurse to administer medications on 06/05/2023 and 06/06/2023. What can you do? On 07/28/2023 at 9:37 AM, V1 (Administrator) stated, I was notified by the DON that she was going to be leaving early that day to her appointment. I did not ask the Director of Nursing to come back when the staff nurse called in. Facility's Staffing Policy (05/25/23) documents in part: It is the policy of this facility to minimum staffing ratios of 3.8 hours of nursing and personal care each day for each for each resident needing skilled care and 2.6 hours of nursing and personal care for each resident needing intermediate care are met. Nurse Managers may be required to work the nursing units when necessary. Facility's Nursing Shortage Policy (11/2022) documents in part: It is the responsibility of the Director of Nursing to ensure that the facility always has nursing coverage. The Director of Nurses will call all in-house nurses to obtain coverage. The Director of Nurse will cover the shift if need a charge nurse. The surveyor confirmed through observation, interview, and record review the facility took the following actions to remove the Immediate Jeopardy: 1. V1 (Administrator) re-educated V2 (Director of Nursing) and V6 (Assistant Administrator) on the facility's staffing policy. V1 stated V2 assisted V1 with reinstating the policy which requires all employees to call off at least 4-hours prior to their scheduled shift. V1 stated the staff have been in-serviced on the staffing policy requirements and in an event, staff do not follow the 4-hour rule, that employee will get disciplined. V1 stated employees must call the facility and inform the nursing supervisor on duty when not able to work their scheduled shift, and the supervisor will contact the Director of Nursing and the Administrator and/or the Assistant Administrator. V1 stated in the event a nurse calls and coverage is not able to be found, the Director of Nursing will cover that shift, to prevent the occurrence of the facility not having any nursing coverage, and to assure that all the residents will receive their medications as well as medical care and treatments. V1 stated V7, the nurse who worked a shift on 06/06/2023 and failed to administer medications, was terminated on 07/03/2023. V1 stated V2 will make regular daily rounds to ensure the residents are receiving their medications and treatments as scheduled. V1 stated V2 will develop the staffing schedule every two weeks and cover any shifts that are in need of coverage. V1 stated the facility implemented the changes and will continue to monitor the effectiveness of their implementation to provide the residents with the highest quality of care possible. 2. V2 (Director of Nursing) stated the facility has reinstated the staffing policy, which requires all employees to provide notice of at least 4 hours prior to scheduled shift, in the event of a call off. V2 stated all employees in the facility have been in-serviced on the staffing policy, and who the employee should notify when calling off a scheduled shift. V2 stated during a call off, the employee must call the supervisor on duty to notify that the employee will not be able to work a scheduled shift at least 4 hours prior to the start of shift, and the supervisor will notify the Director of Nursing and the Administrator/Assistant Administrator. V1 stated all efforts will be made to find Nursing/Certified Nursing Assistant coverage. V2 stated in the event that coverage is not able to be found, V2 will cover the shift. V2 stated V2 is performing daily rounds with the residents to ensure that all residents are receiving the scheduled and prn medications, as well as the necessary medical care and treatments. V2 stated the daily rounds will allow V2 to assure that the plan of correction is in place, and the residents are receiving the best care possible. 3. V6 (Assistant Administrator) stated an in-service was provided to all staff on the need to immediately report to the supervisor on duty when an employee will not be able to work a scheduled shift. V6 stated all employees must give at least a 4-hour notice when calling off a scheduled work shift. V6 stated all employees who do not follow that policy will be written up, and if an employee violates that policy 3 times, that employee will be terminated. V6 stated the Director of Nursing will work a shift to cover a nursing staffing need when a replacement nurse is unattainable. V6 stated the Director of Nursing will make daily rounds to ensure all the residents are receiving the required medications and medical care.V6 stated staff members will be contacted by phone if not scheduled to work, when a nurse or a Certified Nursing Assistant is needed when a staffing shortage occurs. V6 stated when the regular employees are not able to cover the shift, then V1 and V6 will contact a staffing agency for staffing coverage. 4. V4 (Social Service Director) stated V4 is making frequent rounds to identify residents who have concerns with their care, and V4 will collaborate with V2 (Director of Nursing) to provide solutions to the resident's medical/medication concerns. V4 stated staff have been in-serviced on the enforcement of the staffing policy requiring employee call off notification of 4 hours prior to a scheduled work shift. V4 stated all residents are receiving their daily medications and V4 has not received any concerns from the residents pertaining to medical care and medications. 5. V3 (Licensed Practical Nurse) stated V3 has been in-serviced by V2 (Director of Nursing) pertaining to the staffing policy, and V3 understands V3 must notify the supervisor on duty at least 4 hours when not able to work a scheduled shift. V3 stated V3 will stay to cover a shift when the replacement nurse calls off, until the administration will find a nurse to relieve V3. V3 stated at the end of V3's shift, V3 will not leave the facility until a nurse arrives to relieve V3 from duty. 6. V7, the nurse who worked the evening shift on 6/6/23, was terminated and no longer works in the Facility. 7. A work schedule was developed by the Director of Nursing for each shift every two weeks. The work schedule provided to all staff at the time it is finalized. 8. The facility implemented a policy requiring all staff members to notify their immediate supervisors at least 4 hours before their shift begins if any changes are required to work schedule. Immediate supervisors are required to inform the Director of Nursing who will adjust the work schedule to assure there is sufficient coverage at all times in accordance with Facility policy. 9. The facility developed a policy to assure nursing coverage on each shift. The Director of Nursing, Administrator, or Assistant Administrator will check at the beginning of each shift to assure a nurse is on duty. If no nurse is on duty, the Director of Nursing or the Administrator will call all other nurses on their list to fill that shift. If no nurse is available, agencies will be called in accordance with Facility Nurse Staffing Policy. If no other nurse is available, the Director of Nursing will be the nurse on duty for whatever time period is required. 10. The Administrator and Director of Nursing will review staffing schedules daily, taking the needs of residents into account. 11. The Director of Nursing began conducting daily rounds to assure compliance with incontinence care, feeding, grooming and personal care. A Quality Assurance audit tool entitled Resident Care Compliance will be used for this. Any irregularities will be corrected as soon as possible, and trends reported to the Quality Assurance Committee. This began 08/01/23 and will continue 11/01/23, or until no patterns of noncompliance are found. If no patterns of noncompliance are found, audits will be done on a weekly basis thereafter. Based on observation, interview, and record reviews conducted on 08/15/2023, the facility completed all measures on the abatement plan. Therefore the abatement plan could be approved on 08/11/2023.

Based on interview and record review, the facility failed to ensure resident medications were administered according to physician orders on 06/05/2023 and 06/06/2023 for 6 (R1, R2, R3, R4, R5, and R6) out of 6 residents reviewed pain medication administration. This failure resulted in the residents experiencing pain score of 6 to 12, on a scale of 0 to 10. Findings include: 1. R1's Facesheet documents in part: fibromyalgia, low back pain, anxiety disorder, spinal stenosis, cervical region, pain, unspecified, morbid (severe) obesity due to excess calories, major depressive disorder, recurrent, unspecified, hyperlipidemia, unspecified, type 2 diabetes mellitus without complications, repeated falls, and dysphagia, oropharyngeal phase. Minimum Data Set (MDS) section C (dated 06/14/2023) scores R1 as 15, indicating R1 is cognitively intact. On 06/29/2023 at 11:29 am, R1 stated, On 06/05/2023 and 06/06/2023, there was no nurse on duty at all, and I did not receive my medications. I have a lot of pain because I had a neck surgery and I have other medical problems that cause me a lot of pain. During those dates there were shifts that I did not receive my medications, which includes Morphine. I have extended-release Morphine that is scheduled, and I have fast acting Morphine that is also scheduled, and I did not receive either of them. Those shifts when there was no nurse to pass medications, I was in a lot of pain. My pain was at an 10/10. If I don't take my pain medications when it is scheduled, the pain builds up and it becomes intolerable. Those two days that I did not receive my pain medications, my pain got so bad that it caused my anxiety to get worse. I cannot tolerate the pain when it builds up due to missed pain medications. Them not having a nurse to pass medications happens often. This is not the first time there was no nurse on duty to pass medications. The staffing in this facility is an issue. It's 11:30 am, and I still did not receive my scheduled 9:00 am medications, and of course I am in pain and I am uncomfortable. I never receive my 9:00 am medications on time. It's always given to me late, usually around noon time. R1 also stated the facility has not been consistent about his wounds. The day there was no nurse in the facility, no one changed my wounds then. I am not sure if it is getting better. I have expressed my concerns regarding not receiving my medications to the Social Services Director and the Administrator, but nothing is done. It's the same problem every day. I have told them many times about my concerns with the medication administration. The last time I expressed my concerns to the Administrator and Social Services Director was two weeks ago, when I did not receive my scheduled medications during two shifts on 06/05/2023 and 06/06/2023. My concerns were not addressed by the administration. 2. R2's face sheet documents R2 is a [AGE] year-old with diagnoses including but not limited to: displaced subtrochanteric fracture of left femur, gastrointestinal hemorrhage, urinary tract infection, cerebral infarction, malignant neoplasm of colon, resistance to multiple antimicrobial drugs, diverticulosis of large intestine without perforation or abscess without bleeding, and pain unspecified. MDS section C (dated 06/06/2023) scores R2 as 10, indicating R2 is moderately cognitively impaired. On 06/29/2023 at 10:00 am, R2 stated, I did not receive my medications in beginning June. There wasn't a nurse on shift on one of the days, first week of June. I did not receive my Norco that night, which led me to have 8 out of 10 pain. 3. R3's Face Sheet documents R3 is a [AGE] year-old with diagnoses including but not limited to: Rheumatoid Arthritis, Morbid Obesity, Essential (Primary) Hypertension, Muscle Weakness (Generalized), Peripheral Vascular Disease, Osteoporosis Without Current Pathological Fracture, and Major Depressive Disorder. MDS section C (dated 06/17/2023) scores R3 as 15, indicating R3 is cognitively intact. On 06/29/2023 at 10:30 am, R3 stated, On 06/05/2023, there was no nurse working on the night shift. I normally receive Tramadol for pain two times a day. When I did not get it in the evening, I wheeled up front to ask the nurse. That's when someone told me that were was no nurse working. My pain was so bad that night. It went up to an 8 out of 10. 4. R4's Facesheet diagnosis documents in part: epilepsy, post-traumatic stress disorder, and major depressive disorder. MDS section C (dated 05/15/2023) scores R4 as 15, indicating R4 is cognitively intact. On 07/06/2023 at 10:24 am, R4 stated, There was a date in beginning June when there wasn't a nurse on shift to give me my medications, especially my pain medications. I was in a lot of pain. When I don't get my pain medications, my pain goes up to a 9. 5. R6's Face Sheet documents R6 is a [AGE] year-old with diagnoses including but not limited to: Paraplegia, Severe Sepsis with Septic shock, Arthritis Multiple Sites, Pressure Ulcer of Left Heel Stage 3, Pressure Ulcer of Other Site Stage 3, Impacted Cerumen Bilateral, Visual Loss, Pain in Leg Unspecified, Localized Edema, Essential (Primary) Hypertension, and Unspecified Atrial Fibrillation. MDS section C (dated 04/19/2023) scores R6 as 13, indicating R6 is cognitively intact. On 07/06/2023 at 10:30 am, R6 stated, No one administered my medications or changed my wounds sometime in June when there was no nurse. During that time, they missed my pain medications and my wound treatment. I am always in pain and it is a lot of pain, and at that time my pain went up to a 12 out of 10. 6. R5's Face Sheet documents R5 is a [AGE] year-old with diagnoses including but not limited to: Unspecified, Arthritis, Multiple Sites, Essential (Primary) Hypertension, Chronic Obstructive Pulmonary Disease, Acute Hematogenous Osteomyelitis, Cellulitis of Right Lower Limb, Osteoarthritis, Anemia, Acute on Chronic Combined Systolic and Diastolic (Congestive) Heart Failure. MDS section C (dated 06/01/2023) scores R5 as 15, indicating R5 is cognitively intact. On 07/06/2023 at 11:00 am, R5 stated, I did miss my medications sometime in June. I was in a lot of pain when I missed my medications. I don't think there was a nurse around that time and my pain went up to a 6 out of 10. Facility's Medication Administration Audit Report for 06/05/2023 to 06/06/2023 documents in part: - R1's Lyrica scheduled on 06/05/2023 at 05:00 PM and morphine scheduled on 06/05/2023 at 09:00 PM were not administered. R1's Lyrica scheduled on 06/06/2023 at 05:00 PM and morphine scheduled on 06/06/2023 at 09:00 PM were not administered. - R3's Tramadol for pain, scheduled on 06/05/2023 and 06/06/2023 at 05:00 PM, was not administered. - R4's Tramadol for pain, scheduled on 06/05/2023 and 06/06/2023 at 08:00 PM, was not administered. - R5's Norco for pain, scheduled on 06/05/2023 and 06/06/2023 at 08:00 PM, was not administered. - R6's Morphine Sulfate for pain, scheduled on 06/05/2023 and 06/06/2023 at 09:00 PM, was not administered. - All 37 residents in the facility, did not receive medications on 06/05/2023 from 05:00 PM to 11:00 PM and on 06/06/2023 from 04:00 PM to 11:00 PM. On 06/29/2023 at 3:14 PM, V2 (Director of Nursing) stated, Morphine is a medication used for pain. If residents miss their dose of morphine, they can have more pain and lead to emergency such as respiratory distress. If their level of pain is really high, the resident can have high levels of anxiety. If a resident has two doses of morphine and misses both doses over two days, the resident can start having withdrawal symptoms. If medication administration was not documented then the medication administration is not done. It is very important for our nurses to administer medications at the correct time and document it right after. On 06/29/2023 at 1:00 PM, V1 (Administrator) stated, There is supposed to be one nurse per shift with 4 certified nursing assistants from 7:00 AM to 3:00 PM, 3 certified nursing assistants from 3:00 PM to 11:00 PM and 1 certified nursing assistant from 11:00 PM to 7:00 AM. There was no nurse on 06/05/2023 from 05:00 PM till 11:00 PM. There was no Director of Nursing during this time either. The Director of Nursing is part time. V2 (Director of Nursing) works Tuesday, Thursday and Saturday from noon till 10:00 PM. On 07/28/2023 at 9:37 AM, V1 (Administrator) stated, On 06/05/2023, I was notified by the Director of Nursing (DON) that she was going to be leaving early that day for her appointment. I did not ask the DON to come back to the facility after the appointment when the staff nurse called in and there was no nurse coverage. I was trying to find a nurse to come in, and I sent out a blast via text to try and find someone to come in, but I was not able to find a nurse. There was no nurse on duty on 06/06/2023 as well. Quality Assurance in Medication Administration Policy (undated) documents in part: The medication must be administered in accordance with the written orders of the physician. Therefore, medication administration record (M.A.R) must be used while passing the medications.

Based on interview, and record review, the facility failed to implement adequate fall prevention and monitoring for one resident (R1) of 3 residents reviewed for falls. This failure resulted in R1 sustaining a fall with bilater femur fracture requiring R1 to be hospitalized . Findings include: R1 is [AGE] year old individual, admitted to the facility on [DATE]. R1's Brief Interview for Mental Status (BIMS), dated 10/18/22, document R1 has BIMS score of 15/15. R1's Activities of Daily Living (ADL) Assistance, dated 11/9/22, documents R1 needs two person assistance and depends on staff for all ADL care. R1's Minimum Data Set (MDS) (7/22/2022) section G documents R1 is a total dependent resident and requires extensive assistance with a two person assist for Activities of daily living (ADL) care. Facility reported Incident report, dated 9/25/2022, documents R1 fell while ADL care was being provided, and R1 sustained a laceration to right (R) lower leg and R1 was transported to a community hospital nearby. Nursing notes, dated 9/25/2022, at 15:28 PM, document R1 fell off the bed unto the floor and blood was noted coming from a wound R1 sustained on the right leg. R1's medications document R1 was on blood thinners at the time of the fall. R1's hospital records, dated 9/25/2022, documents R1 presented to the hospital with Rt (right) knee laceration after mechanical after fall at the NH (Nursing Home), and x-ray showed R1 had active and healed fractures in both LLs (lower legs) On 11/12/2022 at 12:45 PM, V5 (Director of Nursing-DON) said R1 fell on a weekend as V6 (Certified Nurse's Assistant -CNA) was giving R1 a bath. V5 said V6 wanted to turn R1, and R1 was on one side of the bed, and V6 went to adjust the other side R1's bed, and R1's leg slid over R1's other leg, and R1 slid out of bed and fell out of bed. R1 then hit a bedside table and R1 landed on the floor. V5 said V6 yelled for assistance and V4(Licensed Practical Nurse-LPN) come to assist V4. V5 said V4 called the doctor and also called 911. V5 said, For residents who are immobile and are a two person assist, the staff are supposed to make sure there are two staff members when changing the resident. V5 said, What went wrong that day when R1 fell , was that V6 tried to bathe R1 by herself, and it did not go well. It was the carelessness of (V6) that day that contributed to (R1's) fall. V5 said there should be two CNAs assisting R1, because R1 is a big lady, and is dependent, and R1 needs a two person assist for safety issues. V5 said for residents who are totally dependent for Activities of Daily Living (ADLS), the facility requires these residents to be assisted by two staff members for safety purposes. V5 said, the point of taking care of residents is to provide a safe environment for our residents. On 11/12/2022 at 1:40 PM, V4 (Licensed Practical Nurse-LPN) said V4 was sitting by the nursing station on 9/25/2022 about 2:30 PM, getting report ready for the next shift, when V6(Certified Nurse's Assistant-CNA) shouted to V4 to go to R1's room. V4 said V4 rushed to R1's room and found R1 on the floor. V4 said V6 said V6 had just finished changing R1's incontinence pads, and V6 wanted to make the rest of R1's bed, when R1 slid down the bed and fell , hitting R1's bed side table. V4 said V4 observed R1 bleeding profusely, then asked the CNA what happened, and the CNA said, I was just done changing (R1), and I was repositioning (R1) back, and (R1) slipped out of the bed and fell . V4 said R1 is supposed to be attended to by two staff members. V4 said, I saw blood coming from (R1's) right leg, and it was a new skin tear, and it was bleeding a lot, so I called 911 and attended to (R1's) bleeding as I called the doctor. V4 said V7 (R1's physician) gave orders for R1 to be rushed to the emergency department immediately. V4 said V6 should have had two staff members in the room while changing R1. V4 said the CNAs know to check on the assignment sheet for the care and assistance each resident needs, and R1 is marked for two persons assist since R1 is a dependent resident for Activities of daily living (ADLs). V4 said, (V6) failed to protect (R1) because only one person was helping (R1) with ADL care, and this led to (R1) falling and getting injured. We failed to protect (R1). On 11/12/2022 at 2:06 PM, V6 (CNA) said on 9/25/2022, V6 was completing incontinence care for R1, and after V6 was done, V6 positioned R1 on the side and R1 was holding on to the side rail, and one of R1s leg was on top of the other leg, and as V6 was trying to go to the other side and bring R1 back on the other side of the bed, R1 started to slip and the momentum flipped R1 out of bed. V6 said R1's leg hit a table where R1 keeps R1 phone and communication device, and R1's leg was bleeding. V6 said V6 called out to the nurse to come to R1's room, and both V4 and V6 started to give R1 first aid while waiting for the ambulance to come. V6 said, I knew (R1) needs a two person assist, but everyone else was busy, so I went to provide care by myself. V6 said, Had I waited for another staff member to come assist me in changing (R1), this incident of (R1) falling out of bed would probably not have happened. Our goal is to keep residents safe. I did not keep (R1) safe on that day, because of my poor judgment. On 11/12/2022 at 2:31 PM, V7 (R1's physician) said V7 expects patients to be kept safe at the facility. V7 said if R1 was a two person assist for Activities of daily living (ADLs), then there should have been two staff members assisting R1 with ADL care. V7 said the fall R1 experienced could have been prevented if staff had followed the right ADL care protocol and had two staff members assisting R1, and R1 would not have suffered broken bones. V7 said R1's is not a good candidate for surgery per the orthopedic provider at the hospital, and R1's fractures will have to heal without surgery. Facility's Fall Protocol and Guidelines, no date, documents; Residents identified as a risk for fall will be placed on the Fall Prevention Program while in the facility.

Based on interview and record review, the facility failed to ensure that residents personal information was safeguarded from unauthorized disclosure without the resident's and/or the resident's representative's consent for four of four residents (R2, R3, R10, and R11) reviewed for privacy. This deficient practice resulted in residents' personal information being disseminated to unauthorized individuals. Findings include: On [DATE] at 9:37 AM, V16 (R1's Family Member) said, she had pictures V12 (CNA) provided to V16, including R3's personal information. V16 said she obtained R2's personal information, stating, I'm not gonna lie, I went behind the desk and got it. V16 provided pictures (undated) of texts that were sent to her by V12 (CNA). Included in these text messages is a picture of R3's information sheet that includes R3's demographics and the names of R10 and R11, with the message who died unclaimed. On [DATE] at 3:18 PM, V1 (Administrator) said R10 and R11 were former residents who passed away. On [DATE] at 1:29 PM, V17 (R3's Family Member) said, I received a random phone call from (V16). (V16) told me that (V12) gave her (V17) my brother's (R3) personal information, she even sent me a picture of his personal information (SSN, address, admission information referral, admitting physician, dated 7.23.21). (V16) should not have been provided with my brother's personal information. My brother is a very private person. Facility's undated HIPPA Compliance (Health Insurance Portability and Accountability Act, federal law that requires standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) form found in V13's employee folder states it is a condition of your employment with (facility) that you comply with the privacy of patient healthcare information. The form further states: 1. You will abide by the rules on the privacy and disclosure of healthcare information. 3. You will treat all patient healthcare information as private and confidential. V12's and V13's employee folders document both employees received this information upon hire.

Based on interviews and record reviews, the facility failed to supervise a resident (R1) while on the toilet for 1 of 4 residents reviewed for falls. This failure resulted in R1 falling and sustaining a head injury requiring emergency room care and two staples to R1's posterior head. Findings include: R1's face sheet has diagnoses include, but are not limited to: difficulty in walking, abnormalities of gait and mobility, history of falling, dementia and muscle weakness. All listed diagnoses have an onset date of 2018, and were present on admission. R1's Quarterly MDS (Minimum Data Set) Assessment, dated 4/15/2021, reads R1's cognitive skills for daily decision making are severely impaired. It also reads R1 requires extensive assistance with one person physical assist for toilet use and personal hygiene. R1's comprehensive care plan reads R1 is cognitively challenged, initiated 1/04/2021. R1 exhibits forgetfulness and confusion. R1 requires guidance and cues. R1 has impaired decision making, short and long term memory deficits. Cognitive skills for daily decision making is impaired. R1's comprehensive care plan also reads R1 is at risk for falls due to cognitive impairment, unsteady standing balance, unsteady balance during transitions and generalized weakness. Problem was initiated on 7/23/2020. It also reads R1 has impaired ability to ambulate due to generalized weakness, unsteady standing balance and cognitive impairment. Date initiated 7/23/2020. Interventions include Give hands on assist, Give verbal cues and Provide appropriate level of assistance to promote safety of the resident. All interventions were initiated 7/23/2020. Surveyor reviewed facility's 'Fall During Staff' report, dated 5/15/2021 11:37 AM, prepared by V10 (Nurse). Report reads: Called to shower room per CNA [Certified Nursing Assistant]. Resident observed with bleeding to back of head left side. Pressure applied bleeding stopped. Resident noted with small laceration to back of head. Surveyor reviewed facility's Incident Report Notification addressed to the Illinois Department of Public Health, dated 5/20/2021. Surveyor also reviewed V13's (Nurse) progress note dated 05/15/2021 at 3:52 PM. Resident returned from emergency room with two staples to R1's left middle posterior head. Staples in place for 7 days. On 6/16/2021 at 10:17 AM, surveyor interviewed V5 regarding the incident involving R1 on 5/15/2021. V5 stated V5 assisted R1 to the toilet in the shower room. V5 stated R1 was on a toileting program, and V5 wanted to toilet R1 prior to giving R1 a shower. At 10:18 AM, V5 asked surveyor to accompany V5 to the shower room to show surveyor the shower room setup, and demonstrate the events of the incident. Shower room is across the hall from R1's room. Shower room has a half separation wall parallel to the doorway to the hall. Immediately behind the half separation wall is the toilet. In front of the toilet is the shower. V5 stated V5 put R1 on the toilet and left V5 sitting on the toilet in the shower room. V5 then went around the separation wall to grab linens from the linen cart. V5 stated the linen cart was in the hallway but right at the doorway of the shower room. V5 stated when V5 returned to R1, R1 was sitting on the floor in between the toilet and the shower. V5 stated if it wasn't for the half separation wall, V5 would be able to see R1 from the linen cart. V5 stated V5 could not see R1 because the wall was dividing the doorway and the toilet. V5 stated V5 and V11 (Certified Nursing Assistant) assisted R1 up to the shower chair. V5 stated they both noted bleeding to the back of R1's head. On 6/17/2021 at 10:43 AM, surveyor interviewed V12 (Restorative Nurse). V12 stated R1 is confused and needs frequent redirection. V12 stated R1 should be supervised at all times, including during toileting. V12 stated staff should not put R1 on the toilet and leave R1 unsupervised. V12 stated that is unacceptable. V12 stated R1 can fall because R1 is a high risk for falls. V12 stated R1 has unsteady balance and is unaware of R1's safety needs. Reviewed V5's position contract and duties, signed 10/01/2019. It reads: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Facility policy titled 'Assessing Falls and Their Causes' reads: Preparation 1. Review the resident's care plan to assess for any special needs of the resident. . 3. Assemble the equipment and supplies as needed. It continues to read: 5. Residents must be assessed in a timely manner for potential causes of falls. 6. Relevant environmental issues should be addressed promptly.

Based on observation, interview and record review, the facility failed to ensure that residents are free of abuse, by failing to implement measures to protect a resident from resident-to-resident abuse, for one of three sampled residents (R1). As a result, R1 experienced psychosocial harm from being verbally and physically threathened by R2. Findings Included: R1 was a [AGE] year old resident, admitted to facility on 9/14/2018 with [DIAGNOSES REDACTED]. On review of the Minimum Data Set ((MDS) dated [DATE], the resident's mental status was intact, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. According to the MDS, the resident had no behavioral issues and able to ambulate independently. R1 was identified to have a history of drug abuse. R1 weighed 147 pounds and was 5 feet 7 inches tall. R2 was a [AGE] year old, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On review of the Minimum Data Set ((MDS) dated [DATE], the resident's mental status was intact, as noted in her Brief Interview for Mental Status (BIMS) score of 15 out of 15. She weighed 253 pounds and was 5 feet 9 inches tall. Her MDS did not address any behavioral issues; however her care plan noted behaviors of manipulative behavior expressed by anger and depression. On 2/13/2019 at 10:30 AM, R1 ambulated independently with steady gait in hallway. She was alert and oriented times three. There were three small areas of scab formation on the frontal side of the neck area. She began the conversation about the incident against her by R2 in a low toned manner. Her voice elevated and her hands began to shake. She said, I am so terrified of what happened that when I speak about it my anxiety is worse. Surveyor ended the conversation at that time. On 2/13/2019 at 11:30 AM, R1 said R2 came into her room on 1/27/2019 at around 5:30 PM-6:30 PM and dragged her out by her neck holding on to her hoodie until R1 was able to wiggle out of her hoodie and screamed as she ran back to her room. She said she ran outside, when she saw two officers come into the building. She said nothing was done to prevent another such situation. On 2/14/2019 at 10:24 AM, R1 explained what happened against her by R2. She said she was afraid of R2 since she was here at the facility and had reported to V1 (Administrator) on several occasions about little things like verbal abuse of R2 towards her. According to her, R2 continued with her behavior.R1 said she was so afraid of R2 that she did not sleep well and would place the nightstand behind the door of her room after 1/27/2019. R1 reported on Thursday (1/31/2019) after the incident, V1 and V8 (Owner) came into her room and told her they were trying to put R2 out of the building, but it was a process. On 2/14/2019 at 10:15 AM, R1 said on 2/2/2019 in the morning between the hours of 10:00 AM and 11:00 AM, R2 approached her outside of the facility and grabbed her arm so tight where the fistula for her [MEDICAL TREATMENT] was located, that her arm was sore for at least a week. R1 said she ran into the building screaming and the nurse called the police. She said she needs to speak with someone to get rid of the fear. On 2/14/2019 at 1:30 PM, R2 came to the facility and when R1 saw her, she ran in fear to V1's office who called the police. On 2/15/2019 at 10:45 AM, the surveyor called the local police department and confirmed that a call was made from the facility about residents fighting on 1/27/2019 at 7:00 PM and two officers came to the facility. On 2/14/2019 at 11:40 AM, V3 (Nurse) said R2 was always loud and aggressive and the staff had spoken with V1 (administrator) about her behavior but nothing was done. She (V3) said on 1/27/2019 she was on duty, but did not see or hear any altercation between R1 and R2. However, she said there was no intervention to prevent R2 from doing the same thing to R1 or any other resident. On 2/14/2019 at 11:55 AM, V2 (Director of Nursing/DON) said she was not aware of the incident of 1/27/2019, however, she said she knew about the incident on 2/2/2019 and R1 and R2 were scheduled to be sent out to community hospital for medical evaluation and psych evaluation respectively. V2 stated that R2 left Against Medical Advice (AMA) from facility on 2/2/2019. Facility's policy on Abuse dated 11/2017 documented, Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches and considering his or her safety as well as the safety of other residents. The facility will also take steps necessary to ensure the safety of residents. The facility policy also included, Any incident or allegation of abuse neglect, exploitation, mistreatment will result in an investigation. The facility was not able to present any documentation of an investigation. The policy also stated that, The facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal conviction. The facility was not able to provided evidence that a criminal background check was conducted.