Every finding on record at Joliet Living & Rehab Center

Based on observation, interview, and record review, the facility failed to properly label/date/seal/store/defrost/discard food items and make safe sanitizer solution for food preparation surfaces in the facility kitchen. This applies to all 99 residents residents that receive oral nutrition and food prepared in the facility kitchen.Findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 6/9/26 documents that the total census was 99 residents. On 6/9/26 at 10:40 AM, V11 (Dietary Manager) said the facility does not have any NPO (Nothing By Mouth) residents; all 99 residents eat from the facility kitchen.On 6/9/26 starting at 9:36 AM, the facility kitchen was toured, and the following was found:Sitting out on kitchen counter:1. 2 frozen turkeys sitting in a silver basin on counter. Not under running water.Per V10 (Cook) the turkeys are being thawed for tomorrow's lunch.In the refrigerator in the Dry Storage Room:2. A 1 gallon bag with separated red sauce with water in the bottom of bag, dated 5/22/26. No label on bag.3. A Styrofoam container with scrambled eggs, potatoes, and corn bread in it. No label or date on container.4. Half an avocado that is mushy and dark brown. No label or date.5. A large partially eaten sesame bread loaf with numerous fuzzy green spots on it.It appears the refrigerator in the dry storage room has both resident and staff food in it. There are multiple resident food items in the refrigerator- cottage cheese containers, tzatziki sauce containers, and bags of pita bread. On 6/9/26 at 10:14 AM, V11 (Dietary Manager) said resident and staff food should not be stored together.In Cooler #2 in Kitchen:6. An unopened smoked turkey ham deli meat with a handwritten sticker on it reading 5/26. There was no manufacturer expiration date on the deli meat wrapper. Sticker did not say use by, received on, or defrosted on date. V11 said she was not sure what the expiration date was of the item.In Milk Cooler in the Dry Storage Room:7. Five half pint (236mL/milliliter) whole milk cartons with best by date of 6/8/26.In the Dry Storage Room:8. Seven 46 fluid ounce cartons of pineapple juice with best if used by date 3/19/26.9. A 3kg (kilogram) can of salsa gran [NAME] de queso para nachos on circulation rack with multiple large dents in can.10. A visibly soiled scooper stored on top of sugar bin. [NAME] food residue noted on the scooper and the top of the sugar bin was contaminated with dust and crumbs/food debris.11. An opened 2.125lb carton of fresh cut hashbrowns. Not sealed, open to contaminants.12. An opened 32-ounce bag of pure cane sugar. Not sealed, open to contaminants.13. An opened 80-ounce bag of old-fashioned grits. Not sealed, open to contaminants.14. An opened resealable gallon sized bag labeled cinnamon. Not sealed, open to contaminants.15. 2 opened 16 ounce boxes of corn starch. Not sealed, open to contaminants.16. An opened resealable gallon sized bag labeled baking powder. Not sealed, open to contaminants.In the 3-door freezer in the Dry Storage Room:17. A bag oof 8 meat patties, not sealed. No label or date.18. 4 medium sized packages of unlabeled and undated meat logs in a medium sized silver bin.In the Reach in Freezer Chest in the Dry Storage Room:19. 9 breadsticks, no label or date with visible freezer burn.20. An opened large plastic bag of 20+ frozen cookie dough cookies, not sealed.21. A bag of freezer burned lima beans with no label or date.22. At 10:34 AM, V11 (Dietary Manager) tested the quat (quaternary) sanitation bucket in main kitchen. QT-10 Hydrion testing strip showed the quat sanitizer measured over 500 ppm (parts per million). V11 said it's too high and took the bucket over to the sink and added water to it. V11 then retested the sanitizer solution again and it was still showing over 400ppm.23. At 10:36 AM, V11 tested another quat sanitation bucket sitting in the 3-compartment sink. Testing strip showed too high again, over 400ppm.On 6/10/26 at 12:51 PM, V11 said all food items in the facility kitchen need to be labeled and dated for food quality and safety; therefore, staff know what is safe to serve to the residents. V11 said all opened food items in the kitchen need to be tightly resealed to keep all pests, dust, and debris contaminants from crawling or getting into the food item and spoiling it. V11 said meat should be thawed by placing it in the refrigerator 2 days before meal is scheduled and if that 48 hour time frame is missed, the meat should be thawed under cool running water. V11 said meat should never be thawed on the counter at room temperature because it can go bad/become contaminated and make residents sick if served. V11 said dented cans should be removed from circulation because of the risk of botulism to the residents if served. V11 said scoopers should be stored covered in a drawer or hanging on a specified hook. V11 said a soiled scooper stored on top of a contaminated food container is a concern because of the risk of cross contamination to the container of food the scooper is used for. V11 said juice with a best if used by date from March is expired and should've been discarded so it is not given to the residents with the possibility of making them ill. V11 said if milk is not served by its best by date, it should be discarded so it is not served to the residents with the possibility of illness from consuming spoiled milk. V11 said resident and staff food should not be stored in the same refrigerator because of the risk of cross contamination and resident illness passed from staff to resident. V11 said freezer burned items should be removed from storage because air has gotten to the food item and it could be spoiled. V11 said a safe sanitizer level for the facility's sanitizer buckets is 200ppm and if the sanitizer strips are measuring too high, there can be resident poisoning from food contamination after being prepared on a surface that was cleaned with the sanitizer. On 6/11/26 at 1:42 PM, V11 said if a sanitizer bucket is tested and is measuring too high, it needs to be dumped out and re-made.The facility's policy titled, Food Storage (Dry, Refrigerated, and Frozen) copyright 2020 states, Guideline:.Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded.c. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration.f.wrap foods properly. Never leave any food item uncovered and not labeled.e.discard damaged cans. F. Dented cans are set aside in a separate area of the storeroom to avoid using them.The facility's policy titled, Labeling and Dating Foods copyright 2017 states, Policy: To decrease the risk of food borne illness and to provide the highest quality, foods are labeled with the date received, the date opened, and the date y which the item should be discarded.The facility's policy titled, Refrigerated Food last revised 5/20/14 states, .Refrigerated Potentially Hazardous Food (PHF) or Time/Temperature Controlled for Safety (TCS) foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date.Use By Date Recommendations chart shows unopened packaged lunch meat should be used by the manufacturer's expiration date.The facility's policy titled, Storage of Frozen Foods last revised 5/20/14 states, .Procedure:.If taken out of original container, food is tightly wrapped and labeled with the name of the item and use by date.The facility's provided documentation regarding QT-40 testing strips states, follow manufacturer's dilution instructions carefully and the standard acceptable range for food safe surfaces is generally 200-400ppm. The MSDS (Material Safety Data Sheet) for Lemon NutraQuat Disinfectant Cleaner dated 6/10/11 states, May be irritating to eyes, skin, gastrointestinal tract, and respiratory system. Ingestion: Can cause gastrointestinal irritation, swelling of the larynx, difficulty breathing, circulatory shock, and/or convulsions.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, and comfortable environment by failing to identify and correct environmental concerns in resident rooms. This applies to 6 residents (R98, R69, R55, R33, R73, R3) reviewed for environmental safety in a sample of 20. Findings include: 1.On 6/11/2026 at 10:29 AM, an inspection of R98's room was conducted with V5 (Maintenance Director). An air vent located in the floor near the window was observed with water actively flowing within the vent shaft in a horizontal direction. The concrete vent shaft was also observed with a thick black substance along the interior surface. R98's MDS (Minimum Data Set) dated 5/5/2026 showed R98 was cognitively intact. On 6/11/2026 at 10:35 AM, R98 stated he had reported concerns regarding the vent for approximately two months, shortly after admission to the facility on 4/22/2026. R98 stated the air coming from the vent was stinky like sewage and worsened at night. R98 stated the vent did not adequately cool the room and described the room as musty. R98 further stated the condition made it difficult for him to breathe. R98 stated V5 did not assess the concern until 6/10/2026, during the survey. 2. R69's MDS dated [DATE] showed R69 was cognitively intact. On 6/11/2026 at 10:44 AM, R69, R98's roommate, stated the air vent in their room emitted air that smells bad and smells like mold. R69 said air flowing through the vent worsened the condition by making the room environment feel moist. R69 stated the moisture made the room uncomfortable, caused their sheets to become damp, and caused papers in the room to become soggy. R69 further stated the moist air causes mildew in the room. R69 said he reported the concern to V1 (Administrator) around March 2026. R69 further stated V5 did not assess the concern until 6/10/2026, during the survey. 3.On 6/11/2026 at 10:54 AM, an inspection of R55's room was conducted with V5. An air vent located in the floor near the window was observed with water actively flowing within the vent shaft in a horizontal direction. The concrete vent shaft was also observed with a thick black substance along the interior surface. R55's MDS dated [DATE] showed R55 was cognitively intact. On 6/11/2026 at 10:56 AM, R55 stated the issue had been present for years and that he had repeatedly informed V5 that the previous maintenance staff periodically siphoned water from the vent shaft and drained it out the window. R55 further stated he was concerned the water would accumulate, overflow from the vent, and seep into his room. 4. On 6/11/2026 at 10:59 AM, an inspection of R33's room was conducted with V5. An air vent located in the floor near the window was observed to have a wet concrete vent shaft. Stagnant water was observed at the base of the shaft, along with a brown mud-like substance coating the bottom surface. The shaft walls were also observed with a thick black substance along the interior surface. R33's MDS dated [DATE] showed R33 was cognitively intact. On 6/11/2026 at 11:01 AM, R33 stated, There's always been water- everybody knows about it, referring to staff members and residents. R33 stated the water in the vent caused the air in the room to smell bad and feel muggy due to moisture in the air. 5. On 6/11/2026 at 11:04 AM, an inspection of R73's room was conducted with V5. An air vent located in the floor near the window was observed to have a wet concrete vent shaft. Stagnant water was observed at the base of the opening, along with a brown mud-like substance coating the bottom surface. The shaft walls were also observed with a thick black substance along the interior surface. R73's MDS dated [DATE] showed R73 was cognitively intact. On 6/11/2026 at 11:05 AM, R73 stated the issue had been present for years. R73 stated air flowing through the vent pushed foul-smelling odors into the room. R73 described the condition as icky and stated the water and vent were both dirty. R73 stated she had reported the concern to facility management in the past. R73 further stated that the previous maintenance staff used to drain water from the vent shaft through a hose directed out the window. 6.On 6/11/2026 at 11:08 AM, an inspection of R3's room was conducted with V5. An air vent located in the floor near the window was observed to have a wet concrete vent shaft. Stagnant water was observed at the base of the shaft, along with a brown mud-like substance coating the bottom surface. The shaft walls were also observed with a thick black substance along the interior surface. R3's MDS dated [DATE] showed R3 was cognitively intact. On 6/11/2026 at 11:09 AM, R3 stated the issue had been recurring, with the most recent occurrence approximately three days prior. R3 stated water would seep through the vent and spill onto the floor near her bed. R3 further stated the water made the floor slippery. On 6/11/2026 at 11:55 AM, V12 (CNA-Certified Nursing Assistant) stated the water accumulation issue in the vents had been present for years. V12 stated R98 had been adamantly voicing concerns regarding the vent and water accumulation issue for several weeks. V12 stated, Everybody knows about it, and indicated staff and management were aware of the concern. V12 further stated R98 made a big fuss regarding the issue on 6/10/2026, which prompted facility staff to address the water accumulation. V12 stated she had been employed at the facility for over a decade and was aware the concern had been discussed among staff and management. On 6/11/2026 at 1:08 PM, V5 (Maintenance Director) stated he became aware of the water accumulation issue in the vent shafts on 6/10/2026. V5 stated he learned of the concern after R69 reported an odor coming from the vent. V5 stated he inspected the vent and did not detect an odor; however, he observed water within the vent shaft. V5 stated he drained water from the vent shaft on 6/10/2026. V5 stated he had not inspected the vent shafts prior to 6/10/2026. V5 stated he believed the water accumulation was a new issue because he had never previously been informed of the concern. V5 stated he did not know the source of the water and was unsure whether the vent shafts were connected. V5 further stated he did not have manufacturer information or guidance regarding the HVAC system. V5 stated, There shouldn't be water in the vent. On 6/11/2026 at 12:59 PM, V13 (Regional Maintenance Director) stated V5 first brought the water accumulation issue in the vent shafts to his attention on 6/10/2026. V13 stated he inspected the vent shafts on 6/10/2026 and pumped water from the shafts. V13 stated he was unsure of the source of the water and stated, There shouldn't be water in air vents. V13 stated he had never previously been informed of concerns regarding water accumulation in the vent shafts. V13 stated he expects V5 to notify him immediately of maintenance issues that V5 is unable to resolve. V13 further stated water accumulation in vent shafts presents a safety risk because standing water can promote the growth of bacteria and potentially mold. On 6/11/2026 at 12:43 PM, V2 (DON-Director of Nursing) stated she had not received complaints regarding water accumulation in the vent shafts during her five years at the facility. V2 stated she did not know the source of the water. V2 stated a previous maintenance employee had used a pump to remove water from the vent shafts; however, she was unsure of the frequency or schedule of the pumping. V2 stated water accumulation in the vent shafts could present respiratory and infection control concerns. V2 stated the condition could contribute to respiratory symptoms and promote the growth of mold and mildew. On 6/11/2026 at 2:00 PM, V1 (Administrator) stated R69 informed her of water accumulation in the vent shaft sometime in April or May 2026. V1 stated she did not personally observe the condition; however, she reported the concern to V5 (Maintenance Director). V1 stated she did not know the source of the water. V1 further stated she did not realize the condition was as extensive as observed during the survey because V5 had informed her he was working on the issue. Review of V5's Maintenance Worksheets from February 2026 through June 2026 showed no documented concerns, inspections, work orders, or corrective actions related to water accumulation in air vent shafts. Review of a Resident Concern/Grievance Form submitted by R98 and dated 6/10/2026 stated, I've reported a number of times about there being no air condition in my room today, it's over the 90s in my room which puts my lift at risk due to the fact of me having high blood pressure . (quoted as written). Review of the facility policy titled Homelike Environment Policy, revised February 2025, stated the facility's department directors and staff will provide residents with a safe, clean, and comfortable environment that emphasizes person-centered care, resident comfort, independence, and personal needs and preferences. The policy further stated environmental interventions include maintaining cleanliness and order and providing comfortable temperatures. Review of the facility's policy titled Maintenance Service, revised January 2025, stated maintenance personnel are responsible for maintaining the building in good repair and free from hazards. The policy further stated maintenance department functions include maintaining the heating and cooling system, plumbing fixtures, wiring, and other building systems in good working order.

Based on observation, interview, and record review, the facility failed to ensure safe smoking practices for residents. This applies to 5 of 5 residents (R23, R17, R68, R88, R56) reviewed for safety and supervision in a sample of 20. The findings include: 1. On 06/10/26 at 1:40 PM, R23 was on the smoking patio during a smoke break. R23 was holding a lighter and smoking a cigarette. R17 and R68 walked up to R23 and R23 lit R17 and R68's cigarette. At 1:48 PM, R23 did not return the lighter to the staff and went back inside the facility. On 06/11/26 at 10:31 AM, R23 was holding the lighter, smoking a cigarette on the smoking patio. R88 walked up to R23 and R23 lit his cigarette for him. On 06/11/26 at 10:45 AM, V7 (CNA/Certified Nurse Assistant) said none of the residents were allowed to light each other's cigarettes. On 06/11/26 at 10:51 AM, V8 (CNA) said none of the residents were allowed to light other residents' cigarettes as it was a hazard. V8 said there should be two staff present during smoking break, one staff member to light the cigarettes and the other to monitor the residents. On 06/11/26 at 10:55 AM, V9 (RN/Registered Nurse) said she believed lighting other residents' cigarettes was not allowed. On 06/11/26 at 1:27 PM, V1 (Administrator) said residents were not supposed to have their own lighters and they should only be provided during the smoke break. V1 said the residents should not be lighting other residents' cigarettes as it was a safety concern. R23's face sheet showed he was admitted to the facility with diagnoses including schizoaffective disorder bipolar type, asthma, and nicotine dependence. R23's Smoking Safety Risk Assessment was last completed on 12/09/26. On 06/11/26 at 3:13 PM, V18 (Regional Nurse Consultant) said the Smoking Assessments needed to be completed quarterly. 2. R56's Face Sheet shows the following diagnoses: paranoid schizophrenia, generalized anxiety, and major depressive disorder. On 6/9/26 at 11:48 AM, 2 lighters were observed on the shelf above R56's bed. R56's Smoking Safety Risk assessment dated [DATE] states he has potential for causing injury to self or others from smoking in unauthorized areas or careless use of smoking materials, has a history of hazardous behavior (i.e., smoking in unauthorized areas or careless use of smoking materials, sustaining burns, fire starting), and he may not be capable of handling/carrying ANY smoking materials. Assessment also shows R56 has been known to trade smoking materials. On 6/11/26 at 2:05 PM, V1 (Administrator) said R56 cannot keep or handle his own smoking materials. V1 said it is a risk for R56 to have lighters in his room because he could attempt to smoke in an unauthorized area/inside the facility and start a fire. The facility policy titled, Facility Smoking Safety Policy last revised 2026 states, Policy Objective: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident.Guidelines: 1.The organization has the right to enforce a policy prohibiting residents from keeping any smoking materials in his/her possession for health, safety and security reasons.5. It is against facility policy to give away, sell, share, trade smoking materials or light another resident's cigarette.Consequences of non-compliance.4.The facility recognizes the potential harm that may result from careless, hazardous smoking and has implemented this policy to maintain a safe living environment.

Based on interview and record review the facility failed to ensure behavioral psych services were provided to a resident with mental health diagnoses.This applies to 1 of 3 residents R78 reviewed for mental health services in a sample of 20. The findings include:On 06/09/2026 at 11:02 AM, R78 said he does not participate in behavioral health programs. R78 stated he graduated from mental health programs at another facility and was not signed up for any programs in the current facility.On 06/10/2026 at 3:16 PM, V16 Social Services Director stated R78 attends outpatient psychosocial rehabilitation and R78 was not signed up for any in-house programs. V16 stated she did not have any documentation or progress notes related to his participation in the outpatient community psychosocial rehabilitation services, but she has been requesting them to send her documentation. V16 stated the receptionist keeps a record of when R78 leaves the facility for his community programs.On 06/11/2026 at 2:12 PM, V17 Receptionist stated R78 has not gone out for any community mental health programs. R78 goes out to church, walks and on pass with his family. On 06/11/2026 at 3:00 PM, V15 Community Rehab and Counseling Operations Manager stated their program provides behavioral health counseling for groups and individual counseling. They offer activities such as arts & crafts, chair yoga and games that helps with mental stimulation, interpersonal skills and build confidence. The program also gives residents the opportunity to share their emotional troubles. V15 stated R78 has never attended their outpatient program. V15 stated he received the referral from V16 Social Services Director on April 13, 2026, but the transportation was never arranged.The facility sign out sheets and pass forms were reviewed January 2026 to survey date no documentation of outpatient community programs was provided.R78 diagnoses includes paranoid schizophrenia and bipolar disorder current episode depresses. R78's care plan includes R78 has a problem with depressed mood that is evidenced by an increased PHQ (Patient Health Questionnaire), prolonged periods of sadness, fluctuations in mood behavior and affect and loss of interest / enjoyment in activities and negatively affect overall thinking, feeling, and interaction with self and the people and objects in the environment. Intervention includes encouraging R78 to express feelings and thoughts, and outline factors that contribute to depression while supporting me holistically and maintaining my safety. Refer to psychiatry and psychotherapy services. R78 is minimally involved in the life of the facility and demonstrates limited social interaction. Solicit activity program ideas from the resident on a regular basisThe facility-provided chart of programs that residents are registered for listed R78 as having psychosocial rehabilitation services in the community. No documentation was provided for any other rehabilitation services being provided to R78.The facility Psychiatric Rehabilitation Services Policy dated 12/2025 states it is the philosophy of this facility to offer mentally ill residents consistent, therapeutic and productive interventions. These interventions are designed to help each resident acquire the behaviors necessary to function with as much self determination and independence as possible in the lease restrictive environment. The long-term objective is to help the person achieve his / her highest potential by challenging himself / herself physically, mentally, emotionally, culturally, socially and spiritually.

Based on observation, interview, and record review, the facility failed to provide foot care to a resident dependent on staff to cut his toenails. This applies to 1 of 1 (R9) reviewed for podiatry in a sample of 20. The findings include: On 06/09/26 at 10:10 AM, R9 was lying in bed, and his toenails were 0.5 inches long on both feet and were curling over his toes. R9 said he told the staff a month ago he needed his toenails trimmed by the podiatrist, but no one had come to trim his toenails. At 12:19 PM, R9 said it hurt him to wear his sneakers because his toenails were too long in them. On 06/10/26 at 10:02 AM, R9's toenails were still 0.5 inches long and curling over his toes. R9's big toe on his right foot was thick. On 06/11/26 at 10:36 AM, R9's toenails remained long. On 06/11/26 at 10:45 AM, V7 (CNA/Certified Nurse Assistant) said she had not seen R9's toenails but no one's toenails should be curling over their toes. V7 said the residents with long toenails needed to be put on the list to be seen by the foot doctor. On 06/11/26 at 10:51 AM, V8 (CNA) said the CNAs do not cut the residents' toenails. V8 said the residents' toenails needed to be checked on shower days, even if the residents were independent. V8 said the residents' toenails should not be curling over their toes. V8 said if she saw that, she would notify the nurse and get the resident on the podiatrist list. On 06/11/26 at 10:55 AM, V9 (RN/Registered Nurse) said none of the CNAs had mentioned any concerns regarding R9's toenails. V9 said the residents' toenails should be short. V9 said if residents needed their toenails cut, they should be put on the podiatry list. On 06/10/26 at 10:07 AM, V14 (Podiatrist) said if a resident's toenails are curling over, they need to be cut, and he would need to see the resident for it. V14 had a list of residents to be seen, and R9 was not on the list. R9's face sheet showed he was admitted to the facility with diagnoses including type 2 diabetes mellitus, hypertensive heart disease without heart failure, morbid obesity, localized edema, vitamin D deficiency, and chronic pain. R9's Physician Order Sheet had an order dated 01/18/26 which showed May see podiatrist to eval and treat as indicated. R9's MDS (Minimum Data Set) dated 03/31/26 showed R9 was cognitively intact. R9's Diabetes Mellitus Care Plan dated 03/31/26 showed to Provide foot care on a regular basis and observe for skin changes. The facility's Resident Fingernail/Toenail Care policy dated 01/26 showed Activity of daily living is important for maintaining resident's cleanliness, proper hygiene and dignity.Resident needing toenail care/trimming, will be performed by outside Podiatrist. Staff will identify resident that is need of toenail care service during daily ADL care. If resident is identified as needing podiatry services, resident will be placed on Podiatrist list.

Based on observation, interview and record review, the facility failed to provide a functional and comfortable bathroom.This applies to 3 of 3 residents, R27, R110 and R103, reviewed for environmental concerns in a sample of 20. Findings include:On 06/09/2026 at 10:47 AM, R103 stated his room was tacky and raggedy. There are cracks in the floor, and the shower doesn't work. R103 stated he's had to go to another unit to shower because his shared bathroom shower hasn't worked for some time and it's been reported. The shared shower of R27, R103 and R110 was missing one of two shower knobs, the tub spout was turned sideways, the doorway was missing the transition leaving a void between the bathroom tile and the bedroom tile, there was broken tile, and the door jamb was rusted with chipped paint. On 06/10/2026 at 3:21 PM the shared bathroom of R27, R103 and R110 had not been repaired.On 06/10/2026 at 3:23 PM, R10 stated he has had to go to another unit in the facility to shower because the shower in his shared bathroom did not work. R10 stated he informed a CNA (Certified Nursing Assistant) a few days ago that it was out of order, but he didn't remember the CNA's name.On 06/10/2026 at 3:34 PM R27 stated he had been showering on another unit in the facility. R27 stated the shared shower had been broken for a few days. R27 stated he had not reported the broken shower to any staff because he was present when R110 reported it to staff, but he did not know the staff person's name.On 06/10/2026 at 3:06 PM, V3 CNA stated R103 goes to another unit to shower every day for some time. V3 stated she had been assigned to R103's unit but she was unaware of a problem with the shower.On 06/10/2026 at 3:12 PM, V4 CNA stated R27, R103 and R110 share the bathroom between their two rooms. V4 stated R103 showers on another unit every day. V4 stated if anything is broken or there is a problem in the residents' room, they will report it to us or the nurse, and it is written on the maintenance log. Residents have also written repair request on the maintenance log themselves. V4 stated when staff are aware of a repair need it is to be reported to maintenance.On 06/11/2026 at 9:09 AM, V5 Maintenance Director stated he does regular room inspections. V5 stated facility supervisors, activity aids and residents will notify him of repair needs. V5 stated the shower has been out of service for a few days already. V5 stated he did not know how long the tile had been cracked, the transition missing or how long the door jamb had been rusted.The facility policy Maintenance policy dated January 2025 states the maintenance department is responsible for maintaining the building, grounds and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to maintaining the building in good repair and free from hazards.

Based on interviews and record reviews, the facility failed to ensure residents were treated in a respectful and dignified manner when they searched the residents' room without them present. This failure applies to 1 of 4 residents (R1) reviewed for resident rights. The findings include:R1 is a [AGE] year-old male with diagnoses history of paranoid schizophrenia, bipolar disorder, and post-traumatic stress disorder, who was admitted to the facility June 1, 2023. On April 28, 2026 at 10:42 AM, R1 said his room was searched randomly and he was not present during the search, nor did he give permission for his room to be searched. R1 said during this inspection, his jacket was lying on his bed, and they searched his jacket pocket. Grievance form, dated April 20, 2026, showed R1 reported concerns regarding having his room searched without him being present. On April 28, 2026 at 12:08 PM, V3 (Psychosocial Rehabilitation Services Coordinator) said she searched R1's room on April 20, 2026, as a random room check. V3 said she searched R1's room by herself and R1 was not present during the search. The facility's Inspection Policy, received April 28, 2026, showed: When searching a resident's room, belongings, and/or clothing; Resident must be present during room search; A residents' pockets may be checked, but the resident must be the one to conduct the search by turning pockets inside out.

Based on interview and record review, the facility failed to provide residents the right to private visits when the facility rules for resident visitation changed preventing private room visits. This applies to 9 of 9 (R1, R19, R22, R23, R24, R25, R20, R6, R10) reviewed for residents' rights. The findings include:The facility's Resident Rights for people in Long-Term Care facilities showed the following: You have the right to private visits, unless your doctor has ordered limited visits for medical reasons. The facility's House Rules and Behavior Expectations agreement implemented on January 23, 2026, showed the following: 14 Residents are prohibited from going onto another unit/floor that he or she does not reside on. If you would like to visit with a co-resident, please use the dining room.1.On February 2, 2026, at 10:14 AM, R1 stated during a meeting a couple weeks ago, the facility took away her right to have friends and her boyfriend in her room. R1 stated they told everyone that they cannot have another resident in their room unless the other resident lives on the same wing of the facility. R1 stated V1 (Administrator) said if they wanted to visit each other, they could do so in the dining room. R1 stated she has a boyfriend who resides on a different wing of the facility, and they cannot be intimate because there is no privacy now. 2. On February 2, 2026, at 10:25 AM, R19 stated the new rule that you can't visit someone in their room unless they are on the same wing was a violation of his rights. R19 stated they told them last Friday, January 23, 2026, and it shook everyone up. R19 stated he has anxiety issues and this has increased his depression. We are all distant now. You can only go to the dining room to visit with friends who reside on other wings. R19 stated he doesn't like leaving his room.3. On February 2, 2026, at 10:54 AM, R22 stated the new rules are unconstitutional and a violation of his rights. R22 stated prisoners have more rights than we do. I can't play video games with my friends.4. On February 2, 2026, at 11:02 AM, R23 stated the new rules that impede the residents' rights. R23 stated her friends can't come and hang out. The new Chief Operating Officer started it when she came. R23 stated she is annoyed that now she can't see her friends in private. R23 stated she wants to have private time with her friends, and the facility has no other place they can go to have privacy.5. On February 2, 2026, at 11:07 AM, R24 stated she gets frequent headaches and likes to be in her room. R24 stated now her time is limited with her boyfriend because she doesn't like to go out in dining area a lot because of chronic migraine headaches.6. On February 2, 2025, at 11:24 AM R25 stated the new rules that they can't visit each other in the privacy of their rooms is a concern for her. R25 stated she has a boyfriend, and it is causing her more depression and anxiety, and it is a burden that she can't see her boyfriend in privacy of their room.7. On February 2, 2026, at 11:30 AM, R20 stated the facility prohibits them from visiting with friends in their rooms. R20 stated her boyfriend is on another wing. R20 stated it makes her mad that they took that right away from her. R20 stated her and her boyfriend love each other and can no longer see each other in private.8. On February 02, 2026, at 10:15 AM, R6 said approximately a week ago, the facility stopped allowing residents to have visits in their room; he can't have visits from his girlfriend or others, and this was done to attempt to catch residents smoking in rooms. R6 said this rule puts a damper on his social life, he feels caged in like a prisoner and feels depressed.9. On February 02, 2026, at 11:19 AM, R10 said approximately 2 weeks ago, the facility prohibited private visits and no longer allowing residents to engage in private relationship activities, this makes him feel like he's living in a prison.On February 2, 2026, at 10:48 AM, V12 (Certified Nursing Assistant) stated they started the new rule that residents can't go into each other's rooms if they don't live on the same wing. V12 stated residents were complaining.On February 2, 2026, at 12:13 PM, V1(Administrator) stated new rules were implemented on January 23, 2026, where the facility had residents sign a new agreement that said they are no longer allowed to have residents in their rooms unless they reside on the same wing of the facility. V1 stated they implemented the rules permanently to keep residents from smoking in their rooms. V1 stated after the implementation, a few coupled residents started to complain. V1 stated she told them that they would revisit the issue in a couple of weeks. V1 stated residents currently do not have a place where residents who reside on different wings can visit privately. V1 stated they can visit in the dining room. V1 stated 80 of the 92 residents have signed the new house rules and behavior expectations agreement. V1 stated number 14 of the House rules and behavior expectations was newly added and other rules were revised. V1 said the facility implemented the policy of prohibiting residents from visiting other residents' rooms if they do not reside on the same unit because it's easier to identify which residents are smoking in the facility and where they are smoking.On February 03, 2026, at 11:20 AM, V1 (Administrator) said other ways of addressing the behavior of resident's smoking in the facility include conducting room searches per their policies, increasing resident monitoring, and enforcing their smoking policy.

Based on interview and record review, the facility failed to investigate incidents and allegations of abuse and mistreatment of residents. This failure apples to 3 of 7 residents (R1, R2, and R7) reviewed for abuse in a sample of 7 residents. The findings include:R1 is a [AGE] year-old male with diagnoses history of Bipolar Disorder, Generalized Anxiety Disorder, and Suicidal Ideations, who was admitted to the facility 01/20/2016. On November 17, 2025 at 11:34 AM, R1 said V3 (Psychosocial Rehabilitation Services Aide) told him You're a dick, when R1 tried to apologize to V3 for a miscommunication from the day prior. R1 said he originally thought V3 was joking, however, when R1 looked at V3 and saw V3 wasn't laughing, he realized V3 wasn't joking. R1 said he reported the incident to V4 (Certified Nursing Assistant), who then informed V1 (Administrator). R1 said V3 has a military background and went on to question him about his military clothing, such as asking why R1 was wearing army clothing if he was in the Navy. R1 said he felt insulted by V3's behavior. R2 is a [AGE] year-old male with diagnoses history of Depressive Type Schizoaffective Disorder, and Generalized Anxiety Disorder, who was admitted to the facility 03/03/2014. On November 17, 2025 at 11:14 AM, R2 said he doesn't feel safe at the facility because staff have hurt him emotionally. An Abuse Investigation report shows V3 (Psychosocial Services Rehabilitation Coordinator/Assistant) was hired by the facility 09/17/2025. On 11/05/2025, V4 (Certified Nursing Assistant) reported to the Administrator R1 informed her V3 was verbally abusive to him by calling him a dick on 10/31/2025, and also during this time V4 received a report V3 was observed mocking R2 during smoke break, Upon further investigation, R1 and V3 were interviewed and confirmed the allegations, and V3 was terminated by the facility as a result. On November 17, 2025 at 3:01 PM, V4 (Certified Nursing Assistant) said she is the Resident's Ambassador and takes reports regarding negative staff or resident to resident interaction. V4 said R1 reported to her he didn't like V3 (Psychosocial Services Rehabilitation Coordinator/Assistant) because V3 called him a dick in a really loud tone and was offended. V4 reported this to V1 (Administrator). V4 said she then received another complaint later in the week from peers and other staff including V6 (Psychosocial Services Rehabilitation Coordinator/Assistant) that V3 was mocking R2 while wearing a bag over his head, which she also reported to V1. V4 said she had also received prior complaints from residents about V3 saying they don't like how he talks to them, and from staff reporting they did not like the tone in which V3 communicated towards the residents. V4 said she did not report this to the Abuse Coordinator as it was not severe enough, however, she spoke with V3 and gave corrective feedback explaining that the communication was not appropriate. V3 responded he didn't feel his communication was inappropriate and she continued explaining the communication was inappropriate for residents. V4 said on one occasion, she overheard a resident asking V3 not to talk to them in a certain tone. V3 apologized, and the issue seemed to be resolved, therefore, she did not provide V3 with any corrective feedback at the time. V4 said V3 would speak to residents in a playful and aggressive tone which some residents were confused by and expressed they didn't like. On November 18, 2025 at 1:39 PM, V7 (Psychosocial Rehabilitation Services Coordinator) said she observed V3 (Psychosocial Rehabilitation Services Aide) to be impulsive and easily agitated. V3 would become easily overwhelmed when approached by the residents and she would have to redirect him and educate him on remaining calm. Some of the staff expressed concerns with V3's behaviors regarding the residents. V7 said she did inform V5 (Psychosocial Rehabilitation Services Director) about concerns with V3's behaviors and advised he may need some additional coaching on how to work with the residents. On November 18, 2025 at 1:50 PM, V5 (Psychosocial Rehabilitation Services Director) said V7 (Psychosocial Rehabilitation Services Coordinator) informed her V3 (Psychosocial Rehabilitation Services Aide) may need more in-services about psychosocial practices because he doesn't listen to redirection and instead enforces what he thinks should happen. V5 said she and V1 (Administrator) followed up by educating and in-servicing V3 about how to talk to and approach residents. V5 said V3 would become easily frustrated when residents approached him for things and V3 became easily agitated when a lot of residents approached him at the same time and became overwhelmed. V5 said R7 reported to V8 (Activities Aide) that she didn't like the way V3 spoke to her when she asked V3 to take her to the bank and V8 also said R7 didn't like the tone in which V3 spoke to her during their interaction. On November 18, 2025 at 2:02 PM, V8 (Activities Aide) said back in early October, she was in the office with R7 and V3 (Psychosocial Rehabilitation Services Aide) and heard V3 briefly talking to R7 regarding assistance with banking. She then stepped away during this interaction and overheard V3 raise his voice to R7 while saying to R7 didn't I tell you I was going to help you. V8 said later in the day, R7 came to her and said V3 was yelling at her. V8 said during the conversation between R7 and V3, she overheard V3 saying, You can tell somebody else to take you to the damn bank. V8 said she informed V5 about this incident on the same day. V8 said V3 spoke really aggressive with the residents and on another occasion. She observed V3 exhibit a really aggressive demeanor with the residents, and she redirected and educated V3 about how to properly address the residents. On November 18, 2025 at 2:08 PM, V5 (Psychosocial Rehabilitation Services Director) said approximately in early October, V8 (Activities Aide) reported to her R7 didn't like the tone V3 (Psychosocial Rehabilitation Services Aide) used when speaking with her, and V3 was loud when speaking to R7. V5 said if V8 had communicated V3 was yelling at R7 she would have reported this immediately. V5 said V8 did not report to her V3 yelled or swore at R7. V5 said it is not ok for staff to become loud with the residents and if they are loud with the residents, she would report that to the Administrator and the Administrator would determine if it were abuse. However, she didn't report to V1 (Administrator) that V3 was loud with R7. V5 stated the next morning during morning meeting, she informed V1 about the information she received about the incident between V3 and R7. Abuse Investigation reports from October to November 2025 did not include a report for R7. On November 18, 2025 at 3:50 PM, V1 (Administrator) said she and V5 (Psychosocial Rehabilitation Services Director) had a conversation with V3 (Psychosocial Rehabilitation Services Aide) on 11/03/2025 regarding how he interacts with the residents. V1 said V3 had a short and dismissive way of speaking with the residents. V1 said the information reported to her by V5 during morning meeting regarding V3 and R7's interaction was not presented as abuse. If it was reported V3 was loud with R7, V1 would have spoken further with the residents and staff to determine if there was potential for abuse, and if it was discovered V3 was loud in a rude manner, then abuse would have been investigated, and V3 would have been suspended immediately pending the outcome of investigation. V1 said she wasn't aware V3 yelled and swore at R7. V1 said if a resident came to her and reported they didn't like how V3 was speaking with them, she would interview the resident to get further details, and if they expressed V3 was speaking to them in an unkind or disrespectful manner, she would have investigated this and sent V3 home. V1 said she should be informed of any allegation of potential abuse and all allegations should be investigated. V1 said V3 yelling and swearing at R7 should have been reported to her, and V4 (Certified Nursing Assistant) should have reported observing a resident telling V3 they didn't like the tone he was speaking to them with so this could be investigated. V1 said if she is not informed about incidents of abusive behavior, this causes all the residents to be at risk for abuse. The facility's Abuse Policy received 11/18/2025 states:The facility affirms the right of our consumers to be free from verbal abuse or mistreatment. This facility therefore prohibits abuse and mistreatment of consumers. The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse and mistreatment of consumers. This will be done by:Implementing systems to promptly and aggressively investigate all reports and allegations of abuse and mistreatment and making the necessary changes to prevent future occurrences.Filing accurate and timely investigative reports.Verbal Abuse is the use of oral or gestured language that willfully includes disparaging and derogatory terms to consumers or withing their hearing distance regardless of an individuals age, ability to comprehend, or disability.Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse or mistreatment. Upon learning of the report, the administrator or a designee shall initiate an incident investigation.Employees of this facility who have been accused of abuse or mistreatment of consumers will be removed from consumer contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse or mistreatment of consumer is unsubstantiated.All incidents will be documented, whether or not abuse or mistreatment occurred, was alleged or suspected.Any incident or allegation involving abuse or mistreatment will result in an investigation.When an allegation of abuse or mistreatment has been made, the administrator, or designee, shall notify Department of Public Health's regional office immediately. Public Health shall be informed that an occurrence of potential abuse or mistreatment has been reported to the administrator and is being investigated.

Based on interview and record review, the facility failed to prevent residents from verbal abuse from a staff member. This failure apples to 3 of 7 residents (R1, R2, and R7) reviewed for abuse from a sample of 7. The findings include:An Abuse Investigation report shows V3 (Psychosocial Services Rehabilitation Coordinator/Assistant) was hired by the facility 09/17/2025. On 11/05/2025, V4 (Certified Nursing Assistant) reported to the administrator R1 informed her V3 was verbally abusive to him by calling him a dick on 10/31/2025, and also during this time, V4 received a report V3 was observed mocking R2 during smoke break; upon further investigation, R1 and V3 were interviewed and confirmed the allegations, and V3 was terminated by the facility as a result.On November 17, 2025 at 3:01 PM, V4 (Certified Nursing Assistant) said she is the Resident's Ambassador and takes reports regarding negative staff or resident to resident interaction. V4 said R1 reported to her he didn't like V3 (Psychosocial Services Rehabilitation Coordinator/Assistant) because V3 called him a dick in a really loud tone and R1was offended, and V4 reported this to V1 (Administrator). V4 said she then received another complaint later in the week from peers and other staff including V6 (Psychosocial Services Rehabilitation Coordinator/Assistant) that V3 was mocking R2 while wearing a bag over his head, which she also reported to V1. V4 said she had also received prior complaints from residents about V3 saying they don't like how he talks to them and from staff reporting they did not like the tone in which V3 communicated towards the residents. V4 said she did not report this to the Abuse Coordinator as it was not severe enough, however, she spoke with V3 and gave corrective feedback explaining that the communication was not appropriate. V3 responded that he didn't feel his communication was inappropriate and she continued explaining that the communication was inappropriate for residents. V4 said on one occasion, she overheard a resident asking V3 not to talk to them in a certain tone. V3 apologized, and the issue seemed to be resolved, therefore, she did not provide V3 with any corrective feedback at the time. V4 said V3 would speak to residents in a playful and aggressive tone which some residents were confused by and expressed they didn't like. R1 is a [AGE] year-old male with diagnoses history of Bipolar Disorder, Generalized Anxiety Disorder, and Suicidal Ideations, who was admitted to the facility 01/20/2016. On November 17, 2025, at 11:34 AM, R1 said V3 (Psychosocial Rehabilitation Services Aide) told him You're a dick, when R1 tried to apologize to V3 for a miscommunication from the day prior. R1 said he originally thought V3 was joking, however, when R1 looked at V3 and saw that V3 wasn't laughing he realized V3 wasn't joking. R1 said he reported the incident to V4 (Certified Nursing Assistant) who then informed V1 (Administrator). R1 said V3 has a military background and went on to question him about his military clothing, such as asking why R1 was wearing army clothing if he was in the Navy. R1 said he felt insulted by V3's behavior. R2 is a [AGE] year-old male with diagnoses history of Depressive Type Schizoaffective Disorder, and Generalized Anxiety Disorder, who was admitted to the facility 03/03/2014.On November 17, 2025 at 12:41 PM, R6 said he had observed V3 (Psychosocial Rehabilitation Services Aide) to at times slip and swear in the presence of residents.On November 18, 2025 at 9:48 AM, R5 said he recalls V3 (Psychosocial Rehabilitation Services Aide) being verbally abusive in the way he would tell residents to shut up and overheard him talking badly about residents with other residents. He did not report this behavior to staff.On November 18, 2025 at 1:39 PM, V7 (Psychosocial Rehabilitation Services Coordinator) said she observed V3 (Psychosocial Rehabilitation Services Aide) to be impulsive and easily agitated. V3 would become easily overwhelmed when approached by the residents and she would have to redirect him and educate him on remaining calm. Some of the staff expressed concerns with V3's behaviors regarding the residents. V7 said she did inform V5 (Psychosocial Rehabilitation Services Director) about concerns with V3's behaviors and advised he may need some additional coaching on how to work with the residents. On November 18, 2025 at 1:50 PM, V5 (Psychosocial Rehabilitation Services Director) said V7 (Psychosocial Rehabilitation Services Coordinator) informed her V3 (Psychosocial Rehabilitation Services Aide) may need more in-services about psychosocial practices because he doesn't listen to redirection and instead enforces what he thinks should happen. V5 said she and V1 (Administrator) followed up by educating and in-servicing V3 about how to talk to and approach residents. V5 said V3 would become easily frustrated when residents approached him for things and V3 became easily agitated when a lot of residents approached him at the same time and become overwhelmed. V5 said R7 reported to V8 (Activities Aide) that she didn't like the way V3 spoke to her when she asked V3 to take her to the bank and V8 also said R7 didn't like the tone in which V3 spoke to her during their interaction. On November 18, 2025 at 2:08 PM, V5 (Psychosocial Rehabilitation Services Director) said approximately in early October, V8 (Activities Aide) reported to her R7 didn't like the tone V3 (Psychosocial Rehabilitation Services Aide) used when speaking with her and V3 was loud when speaking to R7. V5 said if V8 had communicated V3 was yelling at R7 she would have reported this immediately. V5 said V8 did not report to her V3 yelled or swore at R7. V5 said it inot ok for staff to become loud with the residents and if they are loud with the residents, she would report that to the Administrator and the Administrator would determine if it were abuse, however, she didn't report to V1 (Administrator) that V3 was loud with R7. V5 stated the next morning during morning meeting she informed V1 about the information she received about the incident between V3 and R7. Abuse Investigation reports from October to November 2025 did not include a report for R7.On November 18, 2025 at 3:50 PM, V1 (Administrator) said she and V5 (Psychosocial Rehabilitation Services Director) had a conversation with V3 (Psychosocial Rehabilitation Services Aide) on 11/03/2025 regarding how he interacts with the residents. V1 said V3 had a short and dismissive way of speaking with the residents. V1 said the information reported to her by V5 during morning meeting regarding V3 and R7's interaction was not presented as abuse. If it was reported V3 was loud with R7, V1 would have spoken further with the residents and staff to determine if there was potential for abuse and if it was discovered V3 was loud in a rude manner, then abuse would have been investigated and V3 would have been suspended immediately pending the outcome of investigation. V1 said she wasn't aware V3 yelled and swore at R7. V1 said if a resident came to her and reported they didn't like how V3 was speaking with them, she would interview the resident to get further details, and if they expressed V3 was speaking to them in an unkind or disrespectful manner, she would have investigated this and sent V3 home. V1 said she should be informed of any allegation of potential abuse and all allegations should be investigated. V1 said V3 yelling and swearing at R7 should have been reported to her and V4 (Certified Nursing Assistant) should have reported observing a resident telling V3 they didn't like the tone he was speaking to them with so this could be investigated. V1 said if she is not informed about incidents of abusive behavior, this causes all the residents to be at risk for abuse. The facility's Abuse Policy received 11/18/2025 states:The facility affirms the right of our consumers to be free from verbal abuse or mistreatment. This facility therefore prohibits abuse and mistreatment of consumers. The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse and mistreatment of consumers. This will be done by:Identifying occurrences and patterns of potential mistreatment.Immediately protecting consumers involved in identified reports of possible abuse or mistreatment.Implementing systems to promptly and aggressively investigate all reports and allegations of abuse and mistreatment and making the necessary changes to prevent future occurrences.Filing accurate and timely investigative reports.Verbal Abuse is the use of oral or gestured language that willfully includes disparaging and derogatory terms to consumers or withing their hearing distance regardless of an individuals age, ability to comprehend, or disability.Employees are required to report any incident, allegation or suspicion of potential abuse or mistreatment they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. Reports will be documented, and a record kept of the documentation.Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse or mistreatment. Upon learning of the report, the administrator or a designee shall initiate an incident investigation.Employees of this facility who have been accused of abuse or mistreatment of consumers will be removed from consumer contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse or mistreatment of consumer is unsubstantiated.All incidents will be documented, whether or not abuse or mistreatment occurred, was alleged or suspected.Any incident or allegation involving abuse or mistreatment will result in an investigation.When an allegation of abuse or mistreatment has been made, the administrator, or designee, shall notify Department of Public Health's regional office immediately. Public Health shall be informed that an occurrence of potential abuse or mistreatment has been reported to the administrator and is being investigated.

Based on interview and record review, the facility failed to report incidents and allegations of abuse and mistreatment of residents. This failure apples to 3 of 7 residents (R1, R2, and R7) reviewed for abuse in a sample of 7 residents. The findings include:R1 is a [AGE] year-old male with a diagnoses history of Bipolar Disorder, Generalized Anxiety Disorder, and Suicidal Ideations who was admitted to the facility 01/20/2016. On November 17, 2025 at 11:34 AM, R1 said V3 (Psychosocial Rehabilitation Services Aide) told him You're a dick, when R1 tried to apologize to V3 for a miscommunication from the day prior. R1 said he originally thought V3 was joking, however, when R1 looked at V3 and saw V3 wasn't laughing, he realized V3 wasn't joking. R1 said he reported the incident to V4 (Certified Nursing Assistant) who then informed V1 (Administrator). R1 said V3 has a military background and went on to question him about his military clothing, such as asking why R1 was wearing army clothing if he was in the Navy. R1 said he felt insulted by V3's behavior. R2 is a [AGE] year-old male with a diagnoses history of Depressive Type Schizoaffective Disorder and Generalized Anxiety Disorder who was admitted to the facility 03/03/2014. On November 17, 2025 at 11:14 AM, R2 said he doesn't feel safe at the facility because staff have hurt him emotionally. An Abuse Investigation report shows V3 (Psychosocial Services Rehabilitation Coordinator/Assistant) was hired by the facility 09/17/2025. On 11/05/2025, V4 (Certified Nursing Assistant) reported to the Administrator R1 informed her V3 was verbally abusive to him by calling him a dick on 10/31/2025, and also during this time, V4 received a report V3 was observed mocking R2 during smoke break. Upon further investigation, R1 and V3 were interviewed and confirmed the allegations and V3 was terminated by the facility as a result. On November 17, 2025 at 3:01 PM, V4 (Certified Nursing Assistant) said she is the Resident's Ambassador and takes reports regarding negative staff or resident to resident interaction. V4 said R1 reported to her he didn't like V3 (Psychosocial Services Rehabilitation Coordinator/Assistant) because V3 called him a dick in a really loud tone and was offended. V4 reported this to V1 (Administrator). V4 said she then received another complaint later in the week from peers and other staff including V6 (Psychosocial Services Rehabilitation Coordinator/Assistant) that V3 was mocking R2 while wearing a bag over his head, which she also reported to V1. V4 said she had also received prior complaints from residents about V3 saying they don't like how he talks to them, and from staff reporting they did not like the tone in which V3 communicated towards the residents. V4 said she did not report this to the Abuse Coordinator as it was not severe enough, however, she spoke with V3 and gave corrective feedback explaining that the communication was not appropriate. V3 responded he didn't feel his communication was inappropriate and she continued explaining that the communication was inappropriate for residents. V4 said on one occasion, she overheard a resident asking V3 not to talk to them in a certain tone. V3 apologized, and the issue seemed to be resolved, therefore, she did not provide V3 with any corrective feedback at the time. V4 said V3 would speak to residents in a playful and aggressive tone which some residents were confused by and expressed they didn't like. On November 18, 2025 at 1:39 PM, V7 (Psychosocial Rehabilitation Services Coordinator) said she observed V3 (Psychosocial Rehabilitation Services Aide) to be impulsive and easily agitated. V3 would become easily overwhelmed when approached by the residents and she would have to redirect him and educate him on remaining calm. Some of the staff expressed concerns with V3's behaviors regarding the residents. V7 said she did inform V5 (Psychosocial Rehabilitation Services Director) about concerns with V3's behaviors and advised he may need some additional coaching on how to work with the residents. On November 18, 2025 at 1:50 PM, V5 (Psychosocial Rehabilitation Services Director) said V7 (Psychosocial Rehabilitation Services Coordinator) informed her V3 (Psychosocial Rehabilitation Services Aide) may need more in-services about psychosocial practices because he doesn't listen to redirection and instead enforces what he thinks should happen. V5 said she and V1 (Administrator) followed up by educating and in-servicing V3 about how to talk to and approach residents. V5 said V3 would become easily frustrated when residents approached him for things, and V3 became easily agitated when a lot of residents approached him at the same time and become overwhelmed. V5 said R7 reported to V8 (Activities Aide) that she didn't like the way V3 spoke to her when she asked V3 to take her to the bank, and V8 also said R7 didn't like the tone in which V3 spoke to her during their interaction. On November 18, 2025 at 2:02 PM, V8 (Activities Aide) said back in early October, she was in the office with R7 and V3 (Psychosocial Rehabilitation Services Aide) and heard V3 briefly talking to R7 regarding assistance with banking. She then stepped away during this interaction and overheard V3 raise his voice to R7 while saying to R7 didn't I tell you I was going to help you. V8 said later in the day, R7 came to her and said V3 was yelling at her. V8 said during the conversation between R7 and V3, she overheard V3 saying, You can tell somebody else to take you to the damn bank. V8 said she informed V5 about this incident on the same day. V8 said V3 spoke really aggressive with the residents and on another occasion. V8 observed V3 exhibit a really aggressive demeanor with the residents, and she redirected and educated V3 about how to properly address the residents. On November 18, 2025 at 2:08 PM, V5 (Psychosocial Rehabilitation Services Director) said approximately in early October, V8 (Activities Aide) reported to her R7 didn't like the tone V3 (Psychosocial Rehabilitation Services Aide) used when speaking with her, and V3 was loud when speaking to R7. V5 said if V8 had communicated V3 was yelling at R7 she would have reported this immediately. V5 said V8 did not report to her V3 yelled or swore at R7. V5 said it is not ok for staff to become loud with the residents, and if they are loud with the residents, she would report that to the Administrator and the Administrator would determine if it were abuse. However, she didn't report to V1 (Administrator) that V3 was loud with R7. V5 stated the next morning during morning meeting, she informed V1 about the information she received about the incident between V3 and R7. Abuse Investigation reports from October to November 2025 did not include a report for R7. On November 18, 2025 at 3:50 PM, V1 (Administrator) said she and V5 (Psychosocial Rehabilitation Services Director) had a conversation with V3 (Psychosocial Rehabilitation Services Aide) on 11/03/2025 regarding how he interacts with the residents. V1 said V3 had a short and dismissive way of speaking with the residents. V1 said the information reported to her by V5 during morning meeting regarding V3 and R7's interaction was not presented as abuse. If it was reported that V3 was loud with R7, V1 would have spoken further with the residents and staff to determine if there was potential for abuse. If it was discovered V3 was loud in a rude manner, then abuse would have been investigated and V3 would have been suspended immediately pending the outcome of investigation. V1 said she wasn't aware V3 yelled and swore at R7. V1 said if a resident came to her and reported they didn't like how V3 was speaking with them, she would interview the resident to get further details, and if they expressed V3 was speaking to them in an unkind or disrespectful manner, she would have investigated this and sent V3 home. V1 said she should be informed of any allegation of potential abuse and all allegations should be investigated. V1 said V3 yelling and swearing at R7 should have been reported to her and V4 (Certified Nursing Assistant) should have reported observing a resident telling V3 they didn't like the tone he was speaking to them with so this could be investigated. V1 said if she is not informed about incidents of abusive behavior, this causes all the residents to be at risk for abuse. The facility's Abuse Policy received 11/18/2025 states:The facility affirms the right of our consumers to be free from verbal abuse or mistreatment. This facility therefore prohibits abuse and mistreatment of consumers. The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse and mistreatment of consumers. This will be done by:Implementing systems to promptly and aggressively investigate all reports and allegations of abuse and mistreatment and making the necessary changes to prevent future occurrences.Verbal Abuse is the use of oral or gestured language that willfully includes disparaging and derogatory terms to consumers or withing their hearing distance regardless of an individuals age, ability to comprehend, or disability.Employees are required to report any incident, allegation or suspicion of potential abuse or mistreatment they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. Reports will be documented, and a record kept of the documentation.Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse or mistreatment. Upon learning of the report, the administrator or a designee shall initiate an incident investigation.Employees of this facility who have been accused of abuse or mistreatment of consumers will be removed from consumer contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse or mistreatment of consumer is unsubstantiated.All incidents will be documented, whether or not abuse or mistreatment occurred, was alleged or suspected.When an allegation of abuse or mistreatment has been made, the administrator, or designee, shall notify Department of Public Health's regional office immediately. Public Health shall be informed that an occurrence of potential abuse or mistreatment has been reported to the administrator and is being investigated.

Based on observation, interview, and record review, the facility failed to protect two residents from abuse by not implementing interventions regarding repeated behavioral concern and a resident complaint. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in a sample of 10. The finding includes: According to the Electronic Medical Record (EMR), R1 is a [AGE] year-old female with diagnoses including, but not limited to, mood disorder, depression, anxiety, morbid obesity, and chronic pain. The Minimum Data Set (MDS), dated [DATE], showed R1 is cognitively intact and exhibits verbally threatening behaviors on an almost daily basis. R1 also demonstrated depressive moods. The EMR of R2 showed R2 is a [AGE] year-old female with diagnoses of schizoaffective disorder, post-traumatic stress syndrome (PTSD), anxiety disorder, bipolar disorder, and morbid obesity. The MDS, dated [DATE], showed R2 is cognitively intact and experiences depressive moods. The facility incident report, dated May 28, 2025, documented a verbal and physical altercation between R1 and R2 at approximately 5:45 PM during dinner. According to the report, R1 was walking with her dinner tray when R2 struck her. R1 reported that while seated, R2 began yelling at her, calling her derogatory names. R1 responded by striking R2, resulting in R2 sustaining multiple facial scratches. R1 sustained facial redness. First aid was provided to R1 and R2. Both residents were sent to the hospital for psych evaluation and treatment and returned to the facility a week later. Dining Room Configuration with V1 (Administrator) on June 13, 2025, at 11:00 AM showed the following identified seating arrangements: -R1 was seated at (table #) with R7 and R8. -R2 was at (table #) with R3, R5, and R10. -V4 (Psychosocial Rehabilitation Services Aide/PRSA) was monitoring the dining room, positioned approximately 6 feet from R1 and 12 feet from R2. On June 13,2025 at 11:41 A.M., R1 stated she walked to a table to hand her tray to R10. Upon returning to her table, R2 began yelling and cursing at her. R1 said she used her walker as a barrier and punched R2's face. R1 added V4 was nearby, but intervened only after the physical altercation had begun. On June 13,2025 at 11:50 A.M., R2 validated receiving facial scratches from R1 during the incident. R2 added she expressed irritation at R1 for repeatedly placing trays on their table for R10 to dispose of. R2 admitted to initiating the confrontation by yelling, then physically engaging R1 by pulling her hair before V4 intervened. On June 13,2025 at 12:10 P.M., R5 validated annoyance shared by (table #) residents regarding R1's tray-dropping behavior. R5 said R10 had reported these concerns to V3 (PRSD/Psychosocial Rehabilitation Coordinator), but no changes or interventions were implemented. On June 13,2025 at 12:20 P.M., R3 and R6 confirmed witnessing the verbal exchange and subsequent physical altercation. On June 13,2025 at 1:52 P.M., V5 (Certified Nurse Assistant/CNA) stated the issue with R1 placing trays at (table #) had been ongoing for over a week prior to the incident. V5 added residents at (table #) were upset with R1's behavior of dropping her meal tray. On June 13,2025 at 12:30 P.M., V4 (PRSA) acknowledged being informed by V3 about complaints regarding R1's behavior, but did not intervene until the physical altercation began. On June 13,2025 at 1:26 P.M., V3 (PRSD) confirmed receiving R10's complaint prior to the incident but failed to document or implement any intervention, deferring discretion to V4. On June 13,2025 at 1:45 P.M., V2 (Director of Nursing) stated V3 should have acted on R10's complaint to prevent escalation. V2 added V4, being an aide, is not qualified to plan behavioral interventions. On June 13,2025 at 1:50 P.M., V1 stated she was unaware of the complaints before the incident. V1 said V3 should have addressed the concern to ensure timely intervention. V1 acknowledged the situation could have been easily resolved if addressed proactively. A review of EMRs, progress notes, and care plans for R1, R2, and R10 revealed no documentation of interventions or care strategies to address R1's behavior, despite voiced concerns. The facility's abuse prevention policy, dated March 2022, states: This facility affirms the right of our consumers to be free from verbal, physical . abuse. The facility therefore prohibits abuse In order to do so, the facility has attempted to establish a consumer-sensitive and consumer-secure environment Consumer concerns will be recorded, reviewed, addressed, and responded to . An essential element of consumer satisfaction is a timely response back to the concerns expressed.

Based on interview and record review, the facility failed to follow their water management program and identify areas where control measures are needed and assess how much of a risk those hazardous conditions pose. This affects all 88 residents residing in the facility. Findings include: The CMS (Centers for Medicare and Medicaid Services)-671 Long Term Care Facility application for Medicare and Medicaid, dated May 12, 2025, showed the total census of 88 residents. The facility's Water Management program stated the facility will do the following: 1. identify building water systems for which Legionella control measures are needed. 2. Assess how much risk the hazardous conditions in those water systems pose. On May 14, 2025 at 1:25 PM, it was requested from V1 (Administrator),V6 (Maintenance Director), V15 (Regional Maintenance) all information regarding their water management plan, Legionella, and other waterborne pathogens plan, their water management assessment, and any evidence of measures used to prevent Legionella. On May 14, 2025 3:32 PM, V1, V6, and V15 acknowledged and clarified information given to the surveyor, and all stated they had no other information to give surveyor for their water management program. The information that was provided included a log for room water flushing in rooms that are unoccupied for 72 hours or more, a water management program policy, and two mobile phone screen shots of the logged water flushings of unoccupied rooms. V15 stated the water flushing they are doing are considered their assessment, and that is all we have to do. V1 and V15 stated they do not have any assessment in writing or otherwise to show what the facility's risks for Legionella are, or what their control measures are based on those identified risks. V15 stated other than the logs and the water management program policy, they do not have anything more to present to the surveyor. Nowhere in the facility's water management program policy and the flushing logs was there an identification of the building's water systems for which Legionella control measures, nor an assessment of how much risk the hazardous conditions in those water systems pose. The facility's water management program policy refers one to see diagram in Figure A (attach appropriate drawing). However, there was no such Figure A drawing attached.

Based on record review and interview, the facility failed to provide residents or residents' representatives their written bed hold and return policy prior to hospitalization . This applies to 4 of 4 residents (R23, R38, R72, R78) reviewed for hospitalization s in the sample of 18. The findings include: 1. R38 has multiple medical diagnoses including type 2 diabetes mellitus without complications, hypothyroidism, unspecified, constipation, unspecified, extrapyramidal and movement disorder, unspecified, hypertensive heart disease without heart failure, schizoaffective disorder, bipolar type, Ogilvie syndrome, based on the face sheet. Progress notes from November 2024 to present shows that R38 was sent to the hospital multiple times for different reasons. On November 17, 2024, he was sent to the hospital for acute left lateral fracture of the 4th, 5th, 6th, and 7th rib, with 5% pneumothorax. On December 20, 2024, he was sent for abnormal result of KUB (Kidney, Ureter, Bladder) test, and on January 2, 2025, he was admitted to the hospital for UTI (Urinary Tract Infection). Further review of R38's records showed that there was no documentation provided to R38 or R38's representatives about the bed-hold and return policy prior to hospital transfer. 41855 2. R23's EMR (Electronic Medical Record) showed R23 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder depressive type and primary insomnia. R23 was admitted to the hospital on March 13, 2025. R23's MDS (Minimum Data Set) dated April 15, 2025, showed R23 was cognitively intact. R23's progress note written on March 12, 2025, at 1:49 PM, showed R23 was agitated and throwing things in his room. He was refusing to shower and told the staff to drop dead. R23 was making derogatory statements to staff, he was resistant to redirection, and his agitation was increasing towards staff. Progress note dated March 13, 2025, at 12:09 PM, showed R23's aggressive behavior continued to escalate towards staff. R23 was informed that due to his non-compliance with taking his medications and aggressive behavior, the physician had given an order to have R23 sent to the hospital. R23 became upset and took a swing at the nurse, other staff members had to intervene and redirected R23. At 1:17 PM, the progress note showed the ambulance arrived at 12:45 PM and took R23 to the hospital. R23's records were reviewed and there was no documentation that R23 or his representative had received in writing the facility's bed-hold policy. 3. R72's EMR showed R72 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder bipolar type, PTSD (Post Traumatic Stress Disorder), anxiety, moderate intellectual disabilities, and bipolar disorder current episode depressed severe with psychotic features. R72's MDS dated [DATE], showed R72 was cognitively intact. R72's progress note written on May 9, 2025, at 12:27 PM, showed R72 was being sent to the hospital for trying to harm herself and others. Staff attempted to get a pen away from R72, she was forcefully trying to stab staff. R72 was taken to another room, nurse called physician, and an order was given to send R72 to the local hospital for evaluation and treatment. R72's records were reviewed and there was no documentation to show that the facility had provided the resident or her representative with written notice of the bed-hold policy. 4. R78's EMR showed R78 was admitted to the facility on [DATE], with diagnoses that included anxiety, schizoaffective disorder bipolar type, and alcohol abuse uncomplicated. R78's MDS dated [DATE], showed R78 was cognitively intact. R78's progress note written on May 9, 2025, at 10:13 AM, showed R78 was making delusional statements about it being her birthday and asking residents to sing happy birthday to her. R78 was observed crying and telling stories At 8:37 PM, R78's progress note showed the nurse had asked R78 to come take her medications and R78 replied, don't tell me what to do, I'm a pharmacy tech. At 10:54 PM, R78 was being verbally aggressive towards another resident and staff intervened by separating the two residents .the nurse asked R78 if she wanted her PRN (as needed) medication and R78 said, why don't you take it? At 11:23 PM, physician was called, and an order was given to have R78 sent to the hospital. R78 was admitted to the hospital on May 10, 2025. R78's record was reviewed and there was no documentation to show R78 or her representative had been provided in writing the bed-hold policy. On May 13, 2025, at 10:17 AM, V1 (Administrator) was asked to provide the bed-hold written documentation for R23, R38, R72, and R78. At 10:58 AM, V1 brought the policy for bed hold but admitted the facility was not completing the bed-hold forms for residents being transferred to the hospital. Facility provided their Bed Hold policy that was dated effective as of April 2020. The policy showed, Guideline: Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.

Based on observation and interview the facility failed to have window screens in resident's rooms. This applies to 5 of 5 residents (R30, R66, R74, R77 and R80) in the sample 18. The findings include: 1.R80's quarterly MDS (Minimum Data Set), dated March 21, 2025, showed R80 was cognitively intact. On May 13, 2025 at 9:11 AM, R80 stated the window in her room does not have a screen. On checking R80's window in her room, it did not have a screen. The window was partially (about 4 inches) opened on the right side. R80 stated she had slid the inner panel sideways as far as it would go. A wooden block at the left side was inside the ledge of the window that prevented sliding the panel to open the window further. R80 stated V6 (Maintenance Director) applied the wooden block to prevent residents from opening the window completely and jumping out. R80 stated when V6 applied the wooden block on April 23, 2025, she had told him about the missing screen, and he did nothing about it. R80 remarked it is warm at the facility, and therefore she opens the window to let in some fresh air. R80 remarked without a screen on the window, anything can fly in through the open window. On May 13, 2025 at 11:53 AM, V6 stated he thought that none of the windows in the facility had any screens since he started working at the facility three years ago. V6 also verified he had applied a wooden block in R80's window panel to prevent the window being opened completely, as there has been concerns regarding the same. On May 14, 2025 starting at 2:23 PM, during tour of the resident rooms in all the wings of the facility, the absence of window screens was seen in multiple rooms, including some that were warped, and others with ripped mesh, and V6 was made aware of the same. 2. R77's Annual MDS, dated [DATE], showed R77 was cognitively intact. On May 14, 2025 at 2:51 PM, R77's room window did not have a window screen, and it was partially open. R77 stated he would like a screen, as he is concerned with flies coming in all the time. 3. R74's quarterly MDS, dated [DATE], showed R74 was cognitively intact. On May 14, 2025 at 2:53 PM, R74's room window was also partially open and did not have a window screen. R74 stated without the screen, moths fly in all the time, and he is worried a bird might fly in. R74 stated he likes to open the window to get some fresh air. 4. R66's quarterly MDS, dated [DATE], showed R66 was cognitively intact. On May 14, 2025 at 2:57 PM, R66's room window did not have a window screen, and the screen was seen lying on the grass outside the window, with broken edges and the mesh ripped up in shreds. R66 stated the screen fell over more than two weeks ago, and was already ripped up. 5. R30's quarterly MDS, dated [DATE], showed R30 was cognitively intact. On May 14, 2025 at 3:03 PM, R30's room window had no window screen, and R30 stated he would like to have a screen, as he sometimes opens the window for fresh air. On May 13, 2025 at 11:58 AM, V1 (Administrator) stated the facility does not have a policy that shows requirements for window screens. V1 stated she is of the impression the facility did have screens on all the windows in the (unknown) past, and the residents would take them off or punch holes in them, so the facility did not re-install them.

Based on observation, interview, and record review, the facility failed to provide behavioral health services to residents with SMI (severe mental illness). This applies to 2 of 3 residents (R76 and R81) reviewed for behavioral health services in the sample of 18. The findings include: 1. R76 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder and attention deficient hyperactivity disorder, based on the face sheet. R76 was under [AGE] years old. R76's annual MDS (Minimum Data Set), dated February 10, 2025, showed R76 is cognitively intact. The MDS showed the resident has no functional impairments in range of motion. Further review of the MDS showed R76 requires supervision with all his ADLs (activities of daily living). The same MDS showed R76's primary SMI (Serious Mental Illness) diagnosis is schizophrenia, and the resident is on antipsychotic medication. R76's PASRR (Pre-admission Screening and Resident Review) Level II, dated September 11, 2024, showed R76 needs programs that teach the resident daily living skills needed to be independent, such as grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of living environment. R76's PASRR summary of findings showed R76 needs to have meetings with a psychiatrist or social worker. R76's PASRR Level II, dated December 27, 2024, recommended rehabilitation supports, such as pharmacotherapy, life skills programs, and psychotherapy. The PASRR also showed R76 should have programs that teach the resident daily living skills needed to be independent, such as grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of living environment. It was mentioned in the PASRR summary report the PASRR should be incorporated in R76's plan of care, and the staff should be aware of the services required for R76. R76's active care plan, dated June 17, 2024, showed R76 has hallucinations related to mental illness. The same care plan showed several interventions including encouraging the resident to participate in activities, coping skills, and symptom management groups. On May 12, 2025, at 11:06 AM, R76 was lying in bed and had his covers on him. He said he does not attend any in house and/or outpatient programs because he does not want to. He stated his plan was to stay in the facility long-term. He said his plan for the day was to eat and take naps. On May 13, 2025, at 9:31 AM, R76 was sleeping in bed. At this time, there was an exercise activity going on in the dining/activity area. R76's quarterly risk of self-harm assessment, dated May 7, 2025, showed the resident has self-destructive behavior. R76's social service progress notes from December 2024 to May 14, 2025, showed the resident attended only two groups, which were money management and sexual health group. Each group lasted 30 minutes. R76 attended money management group on March 8, 2025, and attended the sexual health group on February 20, 2025. It was documented in the social service notes that R76 actively participated in the money management group and verbalized understanding of the topics discussed in the sexual health group. Based on the above information, R76 had received a total of one hour of mental health/behavioral health services from December 2024 to May 14, 2025. The facility presented a list of groups/programs with a list of participants, and R76's name was not on the list for the following groups: symptom management, home and self-care, and social skills/basic conversation. On May 13, 2025, at 11:04 AM, V4 (Psychiatric Rehabilitation Service Director/PRSD) stated R76 refused to go to one-on-one sessions, groups, or activities. On May 13, 2025, at 2:12 PM, V4 (PRSD) stated based on R76's level of functioning assessment dated [DATE], the resident can benefit from the following groups: symptom management, home and self-care, and social skills/basic conversation. V4 stated R76 refused to attend any of the above-mentioned groups. R76 also refused one-on-one sessions with the counselor, PRSD, and PRSC (Psychiatric Rehabilitation Service Coordinator). On May 14, 2025, at 10:17 AM, V4 stated there was no documentation in R76's records with regards to one-on-one sessions offered and the resident's refusal for one-on-one sessions to address his behavioral health needs. 16746 2. R81 had multiple diagnoses including schizoaffective disorder depressive type (principal diagnosis), major depressive disorder, generalized anxiety disorder and disorganized schizophrenia, based on the face sheet. R81 was under [AGE] years old. R81's quarterly MDS, dated [DATE], showed the resident is cognitively intact. The MDS showed R81 had no functional limitation in range of motion, and he required supervision to moderate assistance from the staff with his ADLs. Further review of the MDS showed R81's primary SMI diagnosis is schizoaffective disorder. R81's PASRR summary of findings, dated March 20, 2025, showed the resident has serious mental health condition. The PASRR findings showed in-part, A nursing home will be able to provide you with the care you need and make sure your mental health needs are being met. It also showed R81 met the nursing facility level of care. The PASRR summary of findings listed multiple services and/or supports needed to be provided to R81, under rehabilitative services including, Development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self-determining including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment. The screening documented the above service and/or support was selected because, In the nursing facility, you could benefit from strengthening your independent living skills so you can return to the community when able. The same PASRR summary of findings showed under rehabilitative services, Individual, group and family psychotherapy. R81's PASRR service matters summary report ,dated May 1, 2025, showed multiple rehabilitative supports recommended for the resident as a routine nursing facility services including, Development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self-determining including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment and Individual, group and family psychotherapy. On May 12, 2025 at 10:52 AM, R81 was inside his room; he was alert and oriented. R81 stated he attends only one in-house group called money management. R81 said group is held three times per week for about 20 minutes each group session. R81 stated he also talks 1:1 to the psychosocial person once a week. According to R81, he stays inside his room most of the time, and would only come out of his room to eat at the main dining room, and to smoke during the scheduled times. R81 added he also does not attend any activities at the facility. On May 13, 2025 at 9:30 AM, R81 was inside his room, playing with his computer. At 2:40 PM, R81 was sleeping in his bed inside his room. R81's quarterly substance use assessment, dated February 26, 2025, showed the resident had history of alcohol, marijuana, and heroin use. R81's quarterly treatment motivation assessment, dated February 26, 2025, showed the resident is Somewhat willing to work on treatment plan. R81's quarterly discharge potential assessment, dated February 26, 2025, showed the resident's overall goal established during the assessment process was, Expects to be discharged to the community. Review of the facility's list of groups/programs showed that R81 was scheduled to participate/attend the money management group every Tuesdays, Wednesdays and Thursdays from 6:00 PM through 6:30 PM. R81 was not listed on any other group/program scheduled by the facility. On May 13, 2025 at 9:30 AM, the facility was asked to provide all the group/program attendance sign-in sheet for R81 from March through May 2025. The facility presented R81's group attendance sign-in sheet for the months of April and May 2025 for the money management group. The group attendance sign-in sheet showed R81 attended the money management group only three times on April 30, May 1 and May 7, 2025. On May 13, 2025 at 2:23 PM, V4 (PRSD) stated based on R81's discharge potential assessment, the resident expects to be discharged to the community, and based on R81's latest level of functioning assessment, dated February 26, 2025, the resident would benefit from money management group, home and self-care group, and symptom management group to support his behavioral and mental health and be able to facilitate re-integration to the community. However, according to V4, R81 only attends the money management group, because he (R81) is interested in it, and refused to attend the home and self-care group and symptoms management group. V4 was asked why R81's name was not listed as a scheduled participant in the facility's list of groups/programs for home and self-care and symptom management. According to V4, R81's name was not listed because he does not attend the said groups/programs anyway. On May 13, 2025 at 2:46 PM, V7 stated she is the PRSC for R81. V7 stated for R81's mental health rehabilitative service, the main focus is to attend symptom management/coping skills group and home and self-care/life skills for ADLs (activities of daily living), but the resident refused to attend, and also had refused to have a one on one meeting to discuss his behavior and mental health. According to V7, R81 had attended money management group, but was not sure how often. V7 added R81 at times would attend activity, and the resident prefers to stay in his room and play with his computer. V7 stated she has a problem motivating R81 to attend his focus groups. V7 stated R81's goal is to eventually be discharged to the community, however, because of poor to no group attendance, it is hard to reintegrate the resident to the community. On May 13, 2025 at 3:12 PM, V4 (PRSD) stated after reviewing R81's electronic records from January through March 2025, there was no documentation to indicate the resident attended any group/program offered by the facility, except on February 20, 2025. V4 stated the February 20, 2025 group that R81 attended was the sexual health and hygiene, and the group lasted for only 30 minutes. V4 acknowledged that based on R81's attendance information from January through May 7, 2025, R81 had attended only two hours of the group/program that was provided at the facility, three times for the money management group (each lasting for 30 minutes) and once for the sexual health and hygiene group (lasting for 30 minutes). On May 14, 2025 at 9:47 AM, group exercises were going on inside the main dining room, and R81 was not present. At 9:51 AM, R81 was standing inside his room. The resident stated he does not want to attend the group exercises that were going on. R81 also stated he does not have any plans for the day, and would just be staying in his room to play with his computer. R81 was asked why he does not want to attend symptom management group and home and self-care group. R81 responded he does not like the groups, and it does not interest him. On May 14, 2025 at 10:16 AM, V4 (PRSD) stated there is no documentation from January through May 14, 2025 of any one on one meeting with the PRSD or the PRSC to discuss R81's mental health and refusals to attend the assessed groups/programs that could support his mental health service/care.

Based on interview and record review, the facility failed to prevent resident to resident abuse. This applies to 2 of 2 (R9 and R17) reviewed for abuse in the sample of 18. The findings include: R9's face sheet shows R9 is [AGE] years-old, and has multiple diagnoses including paranoid schizophrenia. R9's most recent Minimum Data Sheet (MDS) assessment indicates R9 is cognitively intact. R17's face sheet shows he is [AGE] years-old, and has multiple medical diagnoses including unspecified schizophrenia, and generalized anxiety disorder, with a MDS assessment indicating moderately impaired cognition. R17's active care plan shows R17 has history of aggressive behavior and has exhibited verbally/physically abusive behavior related/manifested by being challenged by mental illness, ineffective coping mechanisms, poor verbal skills and inability to express self in more appropriate language. Incident report, dated May 1, 2025, at approximately 3:30 PM, documents while watching a movie in the dining/day room, V4 (Psychiatric Rehab Service Director/PRSD) witnessed R17 reaching out and touching R9's arm. V4 walked over to remind R17 not to touch anyone, however, R9 immediately reacted by grabbing R17's hand and kneeing R17 in his abdomen. V4 immediately responded, however, R17 lost his balance and fell to the floor. Nurses immediately assessed R9 and R17. R17 reported he hit his head, and his ribs hurt. R9 reported his left upper arm was hurting, as R17 hit him there. R9's and R17's primary physicians and psychiatrist were notified of the incident, and both residents were sent to the hospital for further evaluation. On May 12, 2025, at 10:58 AM, R9 said he was in the dining/day room watching a movie. R9 was sitting beside R17, and for no reason, R17 became agitated while he (R17) was talking to himself. R17 started punching him lightly on his left arm repeatedly. At first R9 tried to ignore R17, until he noticed the punches were becoming harder. R9 did not say anything because that was R17's behavior. When R17 stood up suddenly, R9 grabbed R17's hand, then he turned and kneed R17 in the abdomen. R9 did not get the chance to tell staff because R17 started punching him stronger. R9 retaliated so R17 would stop what he was doing. On May 14, 2025, at 12:45 PM, R17 stated he hit R9 a little bit, then R9 hit him in the abdomen and chest. On May 12, 2025, at 10:56 AM, V9 (Certified Nursing Assistant/CNA) said, (R9) was a nice person, usually he was calm and cooperative, but he doesn't like being touched. The resident whom he attacked kept touching him. R9 informed her that R17 grabbed him, so he (R9) pushed R17. On May 13, 2025, at 1:56 PM, V4 (Psychiatric Rehab Service Director/PRSD) stated the residents were watching a movie when the incident happened. V4 stated she saw R17 lean over R9, and R9 suddenly pushed R17. V4 stated during her interview of R9 and R17, R9 said R17 punched his arm, and then he grabbed R17 and kneed him in the abdomen. R17 fell on the floor. R17 admitted to punching R9. According to V4, R17 was socially inappropriate, (R17) likes touching people, and sometimes he would butt in to people's conversation without being invited, and is intrusive. While (R9) doesn't talk much, he keeps to himself, but he participates in all activities. During her (V4) interview of R17, the resident said he fell on his buttocks, but did not hit his head. 911 was called, both residents were sent to the hospital for further medical evaluation. On May 13, 2025, at 4:38 PM, V11 (Certified Nursing Assistant/CNA) and V12 (CNA) stated the incident happened beginning of the evening shift. V11 said she was coming out from the C-hallway, and did not witness the incident. V11 saw R17 was already on the floor, and she ran towards the day room; activity staff and V4 (PSRD) were already by R9 and R17. On May 14, 2025, at 10:46 AM, V13 (RN/Registered Nurse) stated she and the other nurses were at the nurses' station when the incident happened. V13 was charting/writing her documentation. According to V13, R17 punched R9 on the left shoulder/arm, and R9's reaction was to knee R17 in the abdominal area, which led to R17 falling on the floor. On May 14, 2025, at 3:03 PM, V17 (Psychiatric Rehab Service Assistant/PRSA) stated she was at the conference room getting ready for the smoke break, preparing the cigarettes and lighters of the residents. She did not see the incident, but heard the commotion. She went to the day area immediately, and she saw R9 being escorted to the nurses' station, while R17 was on the floor.

Based on observation, interview, and record review, the facility failed to have podiatry services provide foot care and treatment. This applies to 1 of 3 residents (R1) reviewed for podiatry services. The findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses which included schizoaffective disorder, attention deficit hyperactivity disorder, obesity, and tinea unguium. R1's MDS (Minimum Data Set), dated 02/10/25, showed R1 was cognitively intact. The same MDS showed R1 required supervision or touching assistance with ADL's (Activities of Daily Living). On 04/23/25 at 2:00 PM, R1 was wearing black slippers. R1's toenails on his left foot were long, black, and curled in a downward position. R1's toenails on his right foot were long. R1 stated the last time he had his toenails clipped by the podiatrist was six months ago. R1 stated he told the program manager that he needed his toenails clipped. R1 stated he was on the list to see the podiatrist in March. R1 stated the podiatrist came and did not see him. R1 stated he wants his toenails clipped. On 04/24/25 at 12:03 PM, V1 (Administrator) stated R1 should have been provided with podiatry care. R1's toenails should not be long, hard, and discolored, and without care. On 04/24/25 at 1:16 PM, V4 (Director of Nursing) stated the podiatrist came to the facility on [DATE]. V4 stated R1 did not see the podiatrist on that day. V4 stated they did not have documentation showing R1 refused to be seen. V4 stated the facility should have made sure R1's toenails were clipped, if that meant sending him to a podiatrist outside of the facility. The facility's podiatry list showed R1 was added to the podiatry list on 03/03/25 to have his toenails trimmed. The facility was unable to provide documentation of R1 being seen in 03/2025 by the podiatrist. The facility's Podiatry Services policy, effective date 03/2021, showed The facility will make available podiatry services to all residents. Comprehensive foot care by a podiatrist includes prevention of infections and trimming of mycotic/ingrown toenails .

Based on interview and record review, the facility failed to protect a resident's rights to be free of sexual and physical abuse. This applies to 3 of 4 residents (R2, R3, and R4) reviewed for sexual and physical abuse. The findings include: R2 was admitted to the facility on [DATE] with multiple diagnoses which included post-traumatic stress disorder, schizoaffective disorder, anxiety, and borderline personality disorder. R2's MDS (Minimum Data Set), dated 02/13/25, showed R2 was cognitively intact. R3 was admitted to the facility on [DATE] with multiple diagnoses which included schizoaffective disorder, post-traumatic stress disorder, anxiety, insomnia, psychoactive substance use, depression, and seizures. R3 was discharged from the facility on 04/07/25. R4 was admitted to the facility on [DATE] with multiple diagnoses which included primary insomnia, schizoaffective disorder, bipolar disorder, cannabis use. R4's MDS, dated [DATE], showed R4 was cognitively intact. The facility's 04/05/25 Report to IDPH (Illinois Department of Public Health) showed R2 reported to the PRSC (Psych Rehab Services Counselor) that R3 touched her inappropriately by grabbing her left breast. R2 reported she kicked R3 after he touched her inappropriately, and he left the room. The police were called and arrived at the facility on 04/05/25 at 6:40 PM. The conclusion for final report: the facility believes that due to (R3's) diagnoses of severe mental illness, including schizoaffective disorder bipolar type, paranoia with accusatory statements, mixed with being intoxicated, the facility believes that (R3) was unable to control his impulses and proceeded to touch (R2) inappropriately. The facility's 04/07/25 Report to IDPH showed during an interview regarding a previous incident, R2 stated that she slapped her boyfriend, another resident (R4) on 04/05/25, because he didn't protect her from another peer who was inappropriate with her (R3). (R4) confirmed he was slapped, but stated that it didn't hurt. No injuries noted and (R4) denied pain. Resident declined police intervention. The MD (Medical Doctor) was notified with no new orders. The Final Report showed R4 declined police intervention. Conclusion for Final Report: the facility believes that due to (R2's) diagnoses of severe mental illness, including borderline personality disorder and bipolar disorder, mixed with being intoxicated, and angry and hurt from being violated, she reacted in an emotional manner and slapped her boyfriend. On 04/23/25 at 2:45 PM, R2 stated on 04/05/25, it was her birthday. She took a ride share to (retail store) and purchased an alcoholic beverage. R2 stated she wanted to turn up for her birthday with her boyfriend (R4) and her friend (R3). They all went outside and were drinking the alcoholic beverage. R2 and R4 went to R4's room. R2 stated they were lying in the bed. R2 stated she was tipsy, and they were not asleep. R2 stated R3 walked into the room and was talking with R4. R2 stated she was wearing headphones, so she did not hear what they were talking about. R2 stated R3 walked up to her and put his hand under shirt and grabbed her left breast. R2 stated she kicked R3 to move him away from her. R2 stated R3 walked towards her again, so she kicked him once again. R2 stated she thought R4 gave R3 permission to touch her, so she smacked R4. R2 stated she left the room and reported the incident to psych social staff. R2 stated the police were called and came to the facility. On 04/24/25 at 10:30 AM, R4 stated on 04/05/25, he and R2 were outside hanging out. R4 stated R3 came outside with them. R4 stated he and R2 went back inside to his room. R4 stated they were lying in the bed, and R3 came in the room. R4 stated he was rubbing on R2's stomach because she did not feel good. R4 stated R3 walked over and put his hands under R2's shirt and grabbed her breast. R4 stated R2 kicked R3 after he grabbed her breast. R4 stated R2 got mad at him and slapped him because R2 thought he let R3 grab her breast. R4 stated, I did not have a conversation with him and did not tell him he could do that. On 04/24/25 at 12:03 PM V1 (Administrator) stated all residents should be free from abuse and should feel safe in the facility. The facility's Abuse policy, effective date 12/2024, showed, The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals .

Based on observation, interview, and record review, the facility failed to maintain a residents room in good repair. This applies to 1 of 3 residents (R1) reviewed for physical environment. The findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses which included schizoaffective disorder, attention deficit hyperactivity disorder, obesity, and tinea unguium. R1's MDS (Minimum Data Set), dated 02/10/25, showed R1 was cognitively intact. R1's Progress Note, dated 02/13/24 at 9:52 AM, showed, It was brought to writers attention that there was a hole in the wall by the resident's bed. Writer approached resident about the said behavior and incident and was educated that vandalizing facility property is not acceptable and will be held accountable. On 04/23/25 at 2:00 PM, R1 was in his room, sitting on the side of the bed. R1 was alert and oriented x3. R1 had a large piece of plywood on the wall next his bed. R1 stated he accidentally kicked the wall a year ago while he was sleeping. R1 stated the plywood has been there for a year. R1 stated the facility told him that they were going to repair it, but not when. On 04/24/25 at 9:20 AM, V6 (Maintenance Director) stated the plywood on the wall in R1's room measured 3 feet x 2 inches. V6 stated the plywood has been on the wall in R1's room since 02/13/24. V6 stated the hole has not been repaired in 14 months, due to him overlooking it. V6 stated the hole should have been repaired over a year ago. On 04/24/25 at 12:03 PM, V1 (Administrator) stated, (R1) punched a hole in the wall in his room on 02/13/24. The hole should have been fixed. It should not have been left with plywood on the wall for over a year. (R1) could get an injury from the plywood that is on the wall. The facility's Maintenance policy, effective date 04/2020, showed, The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to: Maintaining the building in good repair and free from hazards. Establishing priorities in providing repair services.

1) Based on observation, interview and record review the facility failed to ensure staff disinfected glucose monitoring machines (glucometer) after resident use to prevent the spread of a blood borne pathogens. This applies to 6 of 6 residents (R1,R4,R5,R8, R9,R11) reviewed for blood sugar monitoring in the sample of 24, and 22 residents in the supplemental sample (R25 through R46). R4, R11, R30, R38, and R35 were identified by the facility as having infectious blood borne diseases. An Immediate Jeopardy (IJ) was identified on 4/29/14 at 11:20 AM when E6 (RN) failed to disinfect glucometer after use on R26. E2 (Director of Nursing) and E8 (Director of Operations) were notified of the Immediate Jeopardy 4/29/14 at 5:00 PM. Although the immediacy was removed on 4/29/14 at 8:00 PM, the facility remains out of compliance at a level 2 due to the need to evaluate the implementation of the training provided to staff. The findings include: On 4/29/14 at 11:20 AM during the 11:00 AM blood glucose checks, E6 (RN) carried a uncovered plastic box, containing a glucometer, alcohol prep pads, and lancets from inside nurse's station to R26's room. R26 was lying in her bed. E6 donned a pair of gloves, cleansed R26's finger with alcohol prep pad, pricked R26's finger, placed blood glucose strip in glucometer and obtained blood drop. E6 then proceeded to wipe the glucometer with an alcohol wipe, place the glucometer back in the plastic box along with soiled gloves rolled inside out. E6 then washed her hands and returned to nurse ' s station, and then disposed of the gloves. R26's [DIAGNOSES REDACTED]. On 4/29/14 at 11:25 AM, E6 called R27 into the nurse ' s station to obtain a blood glucose check. When R27 entered nurse ' s station, R27 was observed with blood oozing from open sores on forehead, dried blood on right side of neck and blood stains to R27's shirt and sweat pants. R27 also had dried blood under his finger nails and hands. E6 proceeded to remove glucometer from plastic box, wipe the glucometer with alcohol prep pad, and then placed the glucometer on top of the document shredder with no barrier in place. E6 then placed blood glucose strip in glucometer and pricked R27 ' s finger and obtained the blood drop. E6 removed glucose strip from glucometer, removed soiled gloves with strip wrapped inside and disposed of gloves. E6 placed the glucometer back on top of the document shredder, washed her hands and then wiped the glucometer edges and screen with alcohol prep pad and placed glucometer back into the plastic box. R27 was allowed to leave the nurse ' s station without washing his hands or E6 cleansing R27's forehead area. E6 stated when asked why R27 had blood on his head and hands, "he always is scratching his head, we have him wash his hands and he starts scratching his head again." R27's [DIAGNOSES REDACTED]. On 4/29/14 at 11:45 AM, E7 (LPN) called R25 into the nurse ' s station for a blood glucose check. E7 removed glucometer from an uncovered plastic box and placed the glucometer on top of the paper shredder (without barrier). E7 then donned on a pair of gloves, placed glucose test strip in glucometer, wiped R25's finger with alcohol pad and pricked R25's finger. E7 then placed glucometer back on top of the paper shredder. E7 then grabbed the container of disinfectant towel with bleach, removed the towel wiped the glucometer for 20 seconds and then disposed of the towel. E7 then placed the glucometer back in the plastic box and then washed her hands. At 11:56 AM E7 called R28 into the nurse ' s station for a blood glucose check and used the alternative machine previously used by E6 (Nurse). E7 donned on gloves, wiped glucometer with alcohol pad, and pricked R28's finger and then placed glucometer back on top of the paper shredder. E7 wearing same gloves, picked up glucometer again, placed it on a paper towel and wiped the edges and screen for 10 seconds. The glucometer was then placed back in plastic box. E6 and E7 stated on 4/29/14 at 12:30 that they only use two glucometers for blood glucose checks for all resident requiring blood glucose monitoring. E6 was asked how often the glucometer is cleaned E6 responded "we ' ll probably before use and you can wipe with the alcohol wipes in between." E6 went on to add that E2 (Director of Nursing) had advised them use alcohol wipes for cleaning. E7 stated the glucometer should be cleaned with the disinfectant cloth after use and wet for 45 seconds. E2 stated on 4/30/14 at 12:00 PM "I never had told anyone to use alcohol wipes to cleanse the glucometer. I did not know that this was their practice." On 4/29/14 at 4:03 PM, E10 (nurse) stated that she will be doing blood sugar monitoring to the residents. E10 stated the facility uses one glucometer for the residents in the C-wing, D-wing and E-wing (even rooms only). E10 took out a glucometer from an uncovered plastic box that was stored on top of the nursing station counter and wiped the glucometer with an alcohol prep pad and placed this machine directly on top of the nursing station counter (without any barrier). R4 has among his multiple diagnoses, Infectious Blood Borne Disease and has a physician's orders [REDACTED]. E10 then, pricked R4's finger, obtained blood and measured R4's blood sugar with gloved hands. After this procedure, E10 wiped the used glucometer with an alcohol prep pad and placed the glucometer directly on top of the nursing station counter (without any barrier). E10 then, recorded the results of R4's blood sugar level in the MAR (Medication administration Record) and proceeded to prepare R38 for blood sugar monitoring. When E10 stated that she was ready to prick R38's finger to obtain blood, E10 was stopped and was asked how the glucometer should be disinfected in between resident use. E10 responded that she uses the alcohol prep pad to clean the glucometer in between residents use. E10 was asked if she is aware of R4 ' s [DIAGNOSES REDACTED]. E10 stated that she is not aware of this. E10 then looked at R4's MAR and stated that R4 has a [DIAGNOSES REDACTED]. After checking R4's diagnosis, E10 was then observed wiping the same glucometer using a disinfectant towel with bleach for 10 seconds (the machine was not visibly wet) and placed the glucometer directly on top of the nursing station counter (without any barrier). The disinfectant towel with bleach directions shows the following, "wipe surface with towel until completely wet, let stand for 1 minute." When E10 stated that she was ready to prick R38's finger to obtain blood, E10 was stopped and was told that the when she wiped the glucometer for 10 seconds, the machine was not visibly wet. E10 then re-wiped the glucometer for 1 minute (the machine was visibly wet). The facility identified 28 residents with [DIAGNOSES REDACTED]. (R1, R4, R5, R8, R9, R11, R25 through 46). The facility identified 5 of these 28 residents (R4, R11, R30, R38, and R45) with infectious blood borne diseases. Facility Blood Glucose Machine Policy dated 5/ states: All residents requiring blood glucose monitoring will have a clean machine for testing. Equipment: Blood glucose machine PDI sani-cloth wipes or Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant wipes Procedure: -Before and after each use clean/disinfect outside of the meter with PDI Super Cloth wipes or Clorox Healthcare Hydrogen Peroxide Disinfectant wipes. -Treated surface of the blood glucose monitoring machine must remain visibly wet for full 2 minutes. Use additional wipes if needed to assure continuous 2 minutes wet contact time. Let air dry (for PDI wipes). If using Clorox Healthcare Peroxide Cleaner Disinfectant wipes, allow 30 seconds wet contact time and allow to air dry. -Surface of Blood Glucose Monitoring Machine, if visibly soiled need to physically clean to remove gross soil with one wipe and then a second wipe to disinfectant the surface. -Wash and dry hands thoroughly after procedure. The cleaner disinfectant towels with bleach provided by the facility Through observation, interview and record review the surveyor confirmed that the facility took the following steps to remove the immediacy of the situation. 1. The facility has taken the following actions concerning the alleged deficiency identified in the immediate jeopardy: a. Before the start of their shift all nurses will be educated on proper disinfection of the Ultra Track accucheck machine, until 100 percent compliant. b. The facility will have two accuchecks monitors for each nurse. One will be disinfecting, while the other will be available for use. c. Tomorrow 4/30/14, our vendor will provide 28 new Ultra Track accucheck machines for the 28 residents with blood disorders, Each of the 28 residents will have their name on the individual machine. The facility will provide a list in the MAR of residents who will have the own machine. All disinfectant procedure will continue to be used on the individual accuse machines. d. The Blood Glucose Machine Disinfecting policy and procedure was updated to reflect the correct disinfecting product. 2. The facility will ensure all nurses will properly disinfect the accucheck machine before and after each use to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of disease and infection. 3. The following measure have been taken to ensure that proper practices continue: a. The nurses will be and continue to be educated on the following: 1. Disinfecting the accucheck 2. Blood glucose monitor will be disinfected before and after each individual use. 3. Use the facility recommended disinfectant towel with 1:10 dilution of bleach (DISPATCH DISINFECTION TOWEL WITH BLEACH). 4. Moistened wipe must have 2 minutes wet contact with the accucheck over the blood glucose machine over it entire surface, being careful not to get liquid inside the screen.) 5. Allow to dry. 4. The Director of Nursing or designees will monitor continued compliance via the following Quality Improvement programs: a. A QA tool has been developed to monitor the disinfection of the accucheck machine, once per day. b. The facility will hold a QA meeting in May 2014. c. The results of the monitoring completed under this POC are submitted to the QA/QI Committee for review and follow-up. 2. Based on observation, record review and interview,the facility failed to prevent potential cross contamination of body fluids from one resident to others in the faciity. R27 was noted with dried blood on his hands and nail and with open wounds to his face and scalp. This applies to 1 resident (R27) in the supplemental sample reviewed for infection control. The findings include: R27's [DIAGNOSES REDACTED]. On 4/29/14 at 11:10 AM, R27 was observed at a long table in dining room during activities. R27 was playing the card game 21 and also playing with plastic chips. R27 had blood oozing from open sores on his forehead and scalp. R27 also had dried blood on both hands, under his fingernails and dried blood smears on clothing. At 11:25 AM was called into medication room/nurses station by E6 for accucheck with blood on head and hands. R27 was allowed to leave the medication room without washing his hands or E6 cleaning the blood off R27's forehead. R27 returned to the table at 11:30 AM where where he had been seated, picked up his cards and plastic chips and returned the items back to E12 (Activity Director). The items were commingled with the other playing cards and plastic chips returned from other residents. On 4/29/14 at E11 (activity director) provided a list which identified 19 other residents involved in the same activity. On 5/01/14 at 11:45 AM was asked how often the facility cleans activity equipment used by residents. E11 stated they once a week the plastic chips and any other object is put in a bucket of [MEDICATION NAME] alcohol/water and rinsed. R27's care plan goals for resisting care initiated 7/18/13 through 7/7/14 document "the resident will comply with care, specifically with regard to following nursing recommendation to refrain from picking at his scalp (7) days per week. Interventions include: evaluate when the best time of day is to provide care. Provide care consistent with (R27) 'schedule" based on when resident is most calm/relax. R27's care plan interventions dated initated 7//7/13 through 7/7/14 for excoriation to his face and scalp due to eczema and picking at his skin includes "Avoid scratching and keep hands and body parts from excessive moisture. Encourage R27 to stop scratching when observed." E2 (DON) stated 5/5/14 at 2:00 PM that R27's hands and forehead should be washed on an "as needed basis." Facility Procedure for Cleaning All Equipment states: 1) All equipmnet handled by residents such as bingo chips, checker pieces, chess pieces, dominios, Chinese checkers are cleaned with an alcohol solution one time a week. If required all above parts are cleaned as needed. 2) Popcorn machine cleaned before and after every use cleaning procedure is vinegar and water. 3) All ball equipment is cleaned weekly or as needed. 4) All other activity materials usd are cleaned weekly or as needed.

Based on observation, record review and interview the facility failed to obtain order clarification and failed to follow physician order [REDACTED]. This applies to 1 of 14 residents (R11) reviewed for use of [MEDICAL CONDITION] medications in the sample of 24. This failure resulted in R11's verbalization of hearing voices and wanting to hurt someone. The findings include: During the initial tour of the facility held on 4/28/14 at 10:30 PM, R11 stated that the nurses are not giving her [MEDICATION NAME] medication. Per R11 because she had missed more than 5 days of the [MEDICATION NAME] medication, she is starting to hear voices. R11's annual MDS (Minimum Data Set) dated 4/11/14 shows a BIMS (Brief Interview for Mental Status) score of 15, indicating that the resident is cognitively intact and would only require supervision with all ADL's (Activities of Daily Living). R11's POS (Physician order [REDACTED]. The POS showed multiple orders which included, Quetiapine ([MEDICATION NAME]) 400mg, 1 tablet by mouth every 12 hours which was started on 4/4/13. The same POS showed an order to "discontinue [MEDICATION NAME] 400mg PO q 12 hours" and a handwritten physician order [REDACTED]." R11's Psychiatric progress notes dated 4/11/14 showed, "Hallucinations: Present," "Delusions: Present," "Patient is: Deteriorated." The same progress notes showed, "increase [MEDICATION NAME] 400mg in morning & 500mg at bed time to treat her depression and [MEDICAL CONDITION]." R11's MAR (Medication Administration Record) for "[MEDICATION NAME] 400mg PO (by mouth) q (every) 9 AM. showed an encircled nurses initial on 4/26/14 and an N/A (Not available) printed on 4/27/14 and 4/28/14. The same MAR for "[MEDICATION NAME] 500mg PO at HS (bedtime) showed nurses initials on 4/15/14, 4/19/14, 4/20/14 and 4/24/14 and N/A printed on 4/13/14 and 4/27/14. A copy of the above MAR was requested on 4/28/14 at 11:30 AM and upon review of the copy that was given, the previously initialed [MEDICATION NAME] 500mg at HS on 4/15/14, 4/19/14, 4/20/14 and 4/24/14 were encircled, which was different from the original MAR that was earlier reviewed. On 4/28/14 at 12:00 PM, E2 (Director of Nursing) was informed of the discrepancies between the original review of the MAR and the copy that was provided to the State Agency. On 4/28/14 at 12:30 PM, E2 stated that he talked to E7 (Nurse) about the discrepancies. Per E2, E7 admitted encircling her initials for [MEDICATION NAME] 500mg at HS for 4/15/14, 4/19/14, 4/20/14 and 4/24/14 after it was reviewed and before copying the MAR for the State Agency. E2 stated that an encircled initial in the MAR meant that the medication was not given to the resident. Per E2, R11 never received the ordered [MEDICATION NAME] 500mg at HS, since it was ordered on [DATE], because the pharmacy never delivered the said medications because it needed clarification. According to E2, no one followed up with regards to clarifying the [MEDICATION NAME] order until 4/28/14. In an interview held on 4/30/14 at 11:12 PM, E7 stated that R11 did not received the [MEDICATION NAME] 500mg at HS on 4/15, 4/19, 4/20 and 4/24/14, because the medication was not available in the facility. E7 also stated that she gave R11's last [MEDICATION NAME] 400mg on 4/25/14 at 9 AM (last tablet in the medication card) and when she came back to work on 4/28/14, the [MEDICATION NAME] 400mg was not available in the medication cart because pharmacy did not refill. In an interview held on 4/30/14 at 2:25 PM, Z3 (Pharmacist) stated that when the physician changed the order for R11's [MEDICATION NAME] from 400mg every 12 hours to [MEDICATION NAME] 400mg every AM and [MEDICATION NAME] 500mg at HS on 4/10/14, this exceeded the recommended dose of the medication. Per Z3, the pharmacy did not send the new order of [MEDICATION NAME] but instead, sent a communication to the facility on [DATE], to verify the order before the [MEDICATION NAME] medication could be dispensed. According to Z3, the facility did not respond so, another communication was sent to the facility on [DATE] to obtain physician clarification of the [MEDICATION NAME] order. Per Z3 the facility only responded on 4/28/14 with new order for [MEDICATION NAME] 400mg twice daily. Z3 stated that after receiving this order (order does not exceed the recommended dose), the pharmacy delivered the medication, the evening of 4/28/14. The above information showed that R11 did that receive the ordered [MEDICATION NAME] 400mg at 9 AM for 3 days (on 4/26, 4/27 and 4/28/14) and the ordered [MEDICATION NAME] 500mg at HS was not verified with the physician and the resident did not received the [MEDICATION NAME] ordered for HS for at least 16 days (since ordered on [DATE] through 4/27/14). On 4/29/14 at 10:46 AM during group meeting with Z4 (program facilitator) , R11 verbalized, "I actually wanted to hurt somebody, because I was not given my [MEDICATION NAME] for so long." During the same group meeting, R11 stated that she started hearing voices and sees things she should not see, because she was not receiving her [MEDICATION NAME] medications. In an interview held on 5/5/14 at 10:15 AM, Z5 (Psychiatrist) stated that he ordered R11's [MEDICATION NAME] medications to be increased on 4/11/14 because the resident's depression and [MEDICAL CONDITION] had deteriorated and that some residents respond better if the [MEDICATION NAME] is increased to 900mg to 1200mg per day. Z5 stated that the facility nurse did not call him for any order verification for this medication nor was he notified that R11 was not receiving the [MEDICATION NAME] medication for days. According to Z5 he was only notified of the [MEDICATION NAME] dosage concerns on 4/28/14. Per Z5, R11 not receiving her [MEDICATION NAME] medications for multiple days and dosages, could have contributed to R11's further decline in mental status, depression and [MEDICAL CONDITION], especially if she had verbalized hearing voices and wanting to hurt someone.