Every finding on record at Kensington Place NRSG & Rehab

Based on observation, interview, and record review, the facility failed to obtain and administer a routine medication (zolpidem) for one resident (R3) out of four residents reviewed for medications, in a total sample of four.Findings include:On 08/11/2026 at 11:45 AM, R3 stated she is at the facility for food, medications, and sleep. R3 stated she did not receive her zolpidem the previous evening because it was not available. R3 stated she takes zolpidem to help her sleep, describing it as a relaxer, and reported difficulty sleeping, including tossing and turning for hours.On 08/11/2026 at 11:58 AM, V6 (Licensed Practical Nurse) reported that the facility maintains an emergency medication box, located on this floor in the medication room. V6 stated it is important to administer medications as ordered by the resident's physician to maintain the resident's treatment routine and prevent disruption of their clinical care. V6 reported that medications should be reordered as soon as the last row of the bingo card is reached, as the card indicates when reordering is required.On 08/11/2026 at 12:50 PM, V9 (Registered Nurse) stated medications are usually reordered when three to four pills remain in the bingo card and that the physician is contacted if a new prescription is needed. V9 stated she was the nurse for R3 in the evening R3 did not receive zolpidem. She reported the medication supply was depleted and she informed R3. V9 stated she had not worked on that floor the previous days. She reported she checked the emergency medication box but found no zolpidem, then contacted the physician, who stated he would send a new prescription. V9 stated she forgot to document the communication and did not recall the physician's name.On 08/11/2026 at 1:04 PM, V10 (Licensed Practical Nurse/Wound Care) searched for R3 in the automated dispensing cabinet (ADC) and had to add R3's name, date of birth , and room number. V10 stated that when a medication is unavailable in the ADC, its name appears greyed out. V3 stated that zolpidem was not greyed out, indicating it was available, and reported that two 5 mg (milligram) tablets would be needed to meet R3's 10 mg ordered dose.On 08/12/2026 at 1:32 PM, V3 (Director of Nursing) stated regarding R3's medication issue, V3 stated the nurse should have called the pharmacy, checked the emergency (convenience) box, notified the physician, and documented the situation. She stated the pharmacy delivers medications between 9:00 p.m. and 10:00 p.m. daily. V3 stated nurses typically reorder when the third pill remains and follow up with the pharmacy the next day if the medication has not arrived. If a new prescription is required, the physician is contacted to send one directly to the pharmacy.R3's MDS/Minimum Data Set Section C dated 06/20/2026 documents that R3 has a BIMS/Brief Interview for Mental Status score of 14/15, indicating that R3 is cognitively intact.R3's-controlled substance receipt/record/disposition form for zolpidem 10 mg documents that on 08/09/2026 at 9:00 p.m., one tablet was administered and the remaining inventory was recorded as zero tablets.R3's medication flowsheet/medication administration record dated 08/10/2026 reflects zolpidem documented as administered.An undated facility document lists medications available in the automated dispensing cabinet system, including zolpidem tartrate 5 mg tablets.Facility document dated March 2022 documents in part, medication administration policy. Medications not received and/or from a pharmacy and/or not administered within twenty-four (24) hours from the ordered time to be administered will be considered a medication incident. The attending physician shall be notified and a facility designated from initiated.

Based on observations, interviews and record reviews, the facility failed to monitor the temperature in the walk-in refrigerator cooler; failed to ensure food in the freezer is 6 inches off the floor; failed to label prepared foods; failed to test and record dishwasher sanitation; and failed to clean kitchen equipment used to prepare food. These failures have the potential to cause foodborne illnesses for all 139 residents receiving oral nourishment in the facility. Findings include: On 7/10/26 V4 (Dietary Supervisor) presented a list of 139 residents who were receiving an oral diet in the facility. On 7/10/26 at 9:15 am, a tour was conducted with V4 (Dietary supervisor) and observed the following findings: On 7/10/26 at 9:20 am, V5 (Dietary Aide) working in the dishwashing room, running the dishwasher machine. Surveyor asked V5 where is the dishwasher test strip logbook? There was no sheet in the dishwasher test strip logbook. Surveyor asked V5 where the test strip was that was run today? V5 stated, I did not run a test strip today. A test strip is supposed to be run first before running loads in the dish machine to make sure the dishes are being sanitized. I already ran three loads today. That's on me, I just didn't do it.On 7/10/26 at 9:25 am, V4 (Dietary Supervisor) stated, We do not have the dishwasher logbook. I have not seen any books since I have been here. I've only been here for some weeks. A test strip should have been run before the dishes were washed in the machine.On 7/10/26 at 9:27 am, kitchen stove was noted dirty with a dried brown substance on it. V4 (Dietary Supervisor) stated, This stove does not look clean. This could cause cross contamination if not cleaned. The stove should be cleaned weekly. V4 said to V6 (Dietary Aide) The stove needs to be cleaned weekly. V6 stated, Weekly, why not daily?On 7/10/26 at 9:29 am, surveyor checking inside the walk-in refrigerator cooler with V4 (Dietary Supervisor). V4 could not locate the thermometer inside the cooler. Turkey and bologna sandwiches in a clear sandwich bag noted on a tray in the cooler with no dates. Hotdogs noted in a clear open packet not dated. On 7/10/26 at 9:31 am, V6 (Dietary Cook) stated, I made the sandwiches today and there should have been dates on the sandwiches to know first in and first out. The dates should be on the sandwiches to know if the food is old because someone can get sick with old food. On 7/10/26 at 9:33 am, kitchen freezer noted with boxes of chicken breast tenders and a box of fish on the floor. V4 Dietary Supervisor stated, There should be no boxes on the floor, because of cross contamination.Facility document titled Temperature Log - Cooler reviewed for the month of June 2026. There were missing temperature checks from June 17th to June 31st. There were no temperature checks for the month of July 2026. Facility's policy titled, Dishwasher Procedure undated documents in part, Policy: To prevent food borne illness, all dish wares will be cleaned in the dish machine. Policy Specifications: Before dishes are washed, the sanitation temperature or level of chemical sanitizer in the dish machine should be tested with the correct test strip. Test strips should be done a minimum of once a day before dishes are washed.Facility's policy titled, Labeled and Dating foods dated 2017, documents in part, Policy: To decrease the risk of food borne illness and provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded.Facility's policy titled, Expired and Outdated Food Policy dated January 2026, documents in part, 1. Purpose: To established a standardized procedure for identifying, labeling, dating, monitoring, and discarding expired and outdated food and beverage items within the dietary department, in order to prevent the service of unsafe food, reduce the risk of foodborne illness, and maintain compliance with federal and state food safety requirements. 5. Labeling and Dating: 1. PHF/TCS (Potentially hazardous Food/ Time- Temperature Control for Safety) food stored in refrigeration or freezer units shall labeled with the item name and dated with the date received, opened or prepared. 2. Refrigerator temperatures shall be maintained at or below 41 degrees Fahrenheit and freezers at or below 0 degrees Fahrenheit, verified and logged daily with an internal thermometer. 3. Foods shall be stored covered, off the floor. Facility's job description titled, Dietary Aide undated, documents in part, Duties/ Responsibilities/Function: Follow all dietary policies and procedures. This includes, but not limited to, proper sanitation procedures, proper food and chemical storage procedures, operation of facility equipment (dishwasher, stove, oven) .cleaning procedures, dish temperature or chemical monitoring log, monitoring refrigerator and freezer temperatures.Facility's job description title, Food Service Supervisor undated, documents in part, Duties/ Responsibilities/Function: Supervise and direct all food service component. This includes, but not limited to, proper sanitation procedures proper food and chemical storage procedures, proper operation of facility equipment (dishwasher, stove, oven) .cleaning procedures, dish temperature or chemical monitoring log, monitoring refrigerator and freezer temperatures.

Based on observation, interview, and record review the facility failed to ensure that one resident (R10) who depends on staff's assistance for ADL (Activities of Daily Living) care received incontinence care. This failure affected one (R10) out of three residents reviewed for quality of care.Findings include:R10's Face Sheet documents that R10 has diagnoses which includes but not limited to rheumatoid arthritis, dementia, epilepsy, anemia, osteoarthritis, delirium, spinal stenosis, depressive disorder, anxiety disorder and paranoid schizophrenia.R10's Brief Mental Status Interview (BIMS) dated 6/15/26 shows a score of 3, which indicates that R10 has severe cognitive impairment. A review of the Minimum Data Set (MDS) dated [DATE], Section GG, indicates R10 is dependent on staff for toileting needs. Additionally, Section H shows R10 has bowel and bladder incontinence.On 6/29/26 at 1:12 pm R10 was observed lying in bed. Surveyor asking R10 questions about R10's incontinence needs, and R10 saying one word, Yes, repeatedly; appears confused. Requested for incontinence check for R10. V7 (Licensed Practical Nurse/LPN) entered the room to clean R10, and surveyor noted R10's brief soiled with a brown substance. R10's bed pad that he was lying on (underneath R10's soiled brief) was saturated with a wet yellow substance.On 6/29/26 at 1:22 pm, V18 (Certified Nursing Assistant, CNA) stated the following, I last changed (R10's) brief at 9:30 am. I laid him back down in bed at 10:30 am and at that time, he (R10) said that he wasn't wet. That was the last time that I checked him. We are supposed to round every two hours for incontinent care and as needed.On 6/29/26 at 1:24 pm, V7 (Licensed Practical Nurse, LPN) stated the following, (R10) had a bowel movement, but I cleaned him now. I'm not sure how long he was soiled. If a resident is not cleaned in a timely manner, it could lead to skin breakdown. CNAs are expected to make rounds every 2 hours and as needed.On 6/30/26 at 1:45 pm, V2 (Director of Nursing/DON) stated that CNAs are expected to make rounds every two hours and as needed. They must check incontinence briefs and change them if they are soiled. If a resident is not cleaned in a timely manner, it could lead to skin breakdown.R10's care plan dated 11/14/25 documents in part: Restorative care plan: R10 is incontinent of bowel and bladder. Goal-R10 will maintain/improve level of continence.R10's care plan dated 5/20/26 documents in part: R10 is at risk for pressure injury related to decreased mobility and self-performance, weakness, incontinence, confusion and fluctuating appetite. Approach-Keep clean and dry as possible. Minimize skin exposure to moisture.The facility document, dated January 2026, titled Incontinence care policy noted in part: It is the policy of this facility to effectively manage urinary and bowel incontinence. If resident is incontinent, the facility implements interventions and services based on realistic goals to prevent urinary tract infections and to restore as much normal bladder function as possible. if the resident does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a check and change strategy. A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. Incontinence care should be individualized at night in order to maintain comfort and skin integrity and minimize sleep disruption. The primary goals are to maintain dignity and comfort and to protect the skin.The facility document, dated January 2026, titled activities of daily living policy noted in part: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.The facility document, undated, titled Job Description of Certified Nursing Assistant, noted in part: Assist residents to and from bathroom, offers bedpans, and keeps incontinent residents clean at all times, changing linens as often as necessary. Encourages showers and all self-help measures and activities.

Based on observations, interviews and record review, the facility failed to follow their medication administration policy for one resident (R1) of three reviewed in a sample of four.Findings include:R1 medical condition on current face sheet includes but not limited to Shortness of breath, chest pain, Hypertensive heart disease without heart failure. MDS section C-Functional abilities dated 01/22/2026 document R1's Brief Interview for Mental Status (BIMS) as 15/15, indicating R1 has intact cognitive abilities. On 04/11/ 2026 at 10:26AM, R1 was observed laying in bed with oxygen via nasal cannula set at 4L/min. R1's nebulizer machine was observed on his bedside table. R1 stated he administers his nebulizer treatments to himself. R1 showed surveyor two nebulizer vials (Albuterol Sulfate Inhalation Solution, 0.63mg/3mL). R1 stated he asked the nurse to give him the Nebulizers vials this morning so he can administer nebulizer treatments to himself throughout the day. I will take it at 2:00PM. I take it every four hours. I gave myself one treatment earlier at 10:00AM.On 04/11/2026 at 12:02PM, V8 (Licensed Practical Nurse-LPN) stated she follows physician orders when administering medications to residents. V8 stated R1 told her he administers to himself nebulizer treatments his own. This morning, she gave R1 vials of Nebulizers to administer to himself later. R1 has a nebulizer machine in his room. I don't sit there and monitor him. V8 looked at R1's Physician Order Sheet (POS) and stated R1 does not have orders to self-administer nebulizer treatments.V8 stated she should not have left the nebulizer treatments with R1 without a doctor's orders. R1 can misuse the treatments which can cause drug intoxication and affect his breathing. V8 stated nurses should always follow physician orders. V8 should have called R1's physician for self-administer of nebulizer treatments.On 04/11/2026 at 1:22PM, R1 showed V3 (Director of Nursing) and surveyor two vials of nebulizer treatments. His nebulizer machine was observed on his bedside table. R1 stated V8 gave him the vials this morning so he can administer to himself the nebulizer treatments every four hours throughout the day. V1 stated medications are not supposed to be left with a resident because other residents can have access to it. R1 can take more medication than he is supposed to which can cause drug overdose or serious allergic reactions. R1 can misuse the medication. A physician's order is required for a resident to self-administer medications. The resident is evaluated and educated on self-medication administration for safety of resident and other residents. V3 stated nurses do not give orders or diagnosis residents. Nurses follow doctor's orders and instructions. Giving a resident medication to keep in their room without a physician order is acting above a nurse's scope of practice. R1's POS dated 03/12/2026 documents:-albuterol sulfate solution for nebulization; 0.63 mg/3 mL; amt: 1 vial; inhalation Every 4 Hours - PRN; PRN 1, PRN 2, PRN 3, PRN 4, PRN 5, PRN 6.-ipratropium-albuterol solution for nebulization; 0.5 mg-3mg (2.5 mg base)/3 mL; amt: 1 (Amount 1).Inhalation. Four Times A Day; 06:00 AM, 12:00 PM, 05:00 PM, 09:00 PMReview of R1's POS does not document orders for R1 to self-administer medications.Medication Administration Policy dated March 2022 documents:1.Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates.23. Residents who indicate a desire to self-administer medications will be assessed by the interdisciplinary care plan team using an assessment tool. Assessment results will be provided to the physician for approval. Residents will be allowed to self-administer medications only when the attending physician has written as order. Self-administered medications use and response will be monitored by licenses nurses.

Based on observation, interview and record review, the facility failed to provide comfortable and safe temperature levels for the residents by not following their policy to maintain consistent temperatures at 71 degrees or greater. This failure affected all 147 residents that reside at the facility.Findings include:On 01/20/26 at 11:05am, R7 stated that it has been cold in the facility for a few days. R7 stated that a guy came and put plastic on his window, but he was still cold. R7 stated that he has 4 blankets covering him. Surveyor observed R7 with 4 blankets. On 01/20/26 at 11:14am, the surveyor observed V3 (Maintenance Supervisor) use a handheld infrared thermometer to check random room temperatures in multiple areas. Observed thermometer readings of 55.4 degrees Fahrenheit in room [ROOM NUMBER]xx, 58.8 degrees Fahrenheit in room [ROOM NUMBER]yy, 62 degrees Fahrenheit in room [ROOM NUMBER]zz. On 01/20/26 at 11:14am, V3 (Maintenance Supervisor) stated that he was first informed about the facility being cold on Sunday 01/18/26. V3 stated that he came to the facility on [DATE] and placed plastic on some of the resident windows. V3 stated that he did not do temperature checks on Sunday when he came into the facility. V3 stated that he came back to the facility on Monday 01/19/26 and began placing plastic on the remaining windows. V3 stated that the temperature in the building should be at least 71 degrees Fahrenheit. V3 stated that it is not okay for the residents to be cold. V3 stated that he made a call to the service company on Monday 01/19/26 and did not hear back from them. V3 stated that he informed the administrator on Monday 01/19/26 that the building was cold. V3 stated that on Tuesday 01/20/26, the administrator authorized him to place an emergency call to the boiler service company. On 01/20/26 at 11:33am, the surveyor entered the 2nd floor nursing unit and instantly felt a cold chill. Surveyor observed V3 (Maintenance Supervisor) use handheld infrared thermometer to check random room temperatures in multiple areas of the 2nd floor nursing unit. Observed thermometer readings of 68.2 degrees Fahrenheit in the 2nd floor long hallway, 63.9 degrees Fahrenheit in room [ROOM NUMBER]xx, 59.7 degrees Fahrenheit in room [ROOM NUMBER]yy.On 01/20/26 at 12:57pm R3 stated that he has been cold for two days. R3 stated that he is uncomfortable and would like the room temperature to be warm.On 01/20/26 at 1:02pm R1 stated that the facility has been cold for a few days, and the facility is not doing anything about the cold. On 01/20/26 at 1:11pm V10 (Registered Nurse/RN) observed sitting at the 3rd floor nurse's station with a winter coat and hat on. V10 stated that he is cold. V10 stated that he first felt the cold temperature in the building on Monday 01/19/26. V10 stated that he did not inform anyone when he felt the cold temperatures and he just gave his residents extra blankets. V10 stated that the residents still complained about being cold, so he had them to put on hoodies and jackets and provided more blankets for those residents that were still complaining about the cold temperature.On 01/20/26 at 1:56pm V8 (Refrigeration Technician) stated that for the facility to achieve the desired temperature of 71 degrees, the facility would have to have an additional heat source.On 01/20/26 at 2:14pm surveyor observed V3 (Maintenance Supervisor) use handheld infrared thermometer to check random room temperatures in multiple areas of the 1st floor nursing unit. Observed thermometer readings of 68.5 degrees Fahrenheit in room [ROOM NUMBER]xx, and 67.1 degrees Fahrenheit in room [ROOM NUMBER]yy.On 01/20/26 at 2:41pm V1 (Administrator) stated that she was first notified of the building being cold on Tuesday 01/20/26. V3 stated that she informed maintenance to contact the service company to check the boiler. V1 stated that she told the DON (Director of Nursing) to make sure that all the windows were closed and that the plastic placed on the windows were still up. On 01/21/26 at 10:45am surveyor observed V3 (Maintenance Supervisor) use handheld infrared thermometer to check random room temperatures in multiple areas of the 1st, 2nd and 3rd floor nursing units. Observed thermometer readings of 64.9 degrees Fahrenheit on 3rd floor long hallway, 64.9 degrees Fahrenheit in room [ROOM NUMBER]ww, 64.0 degrees Fahrenheit in room [ROOM NUMBER]tt, 66.7 degrees Fahrenheit in room [ROOM NUMBER]zz, 63.9 degrees Fahrenheit in room [ROOM NUMBER]yy, 66.9 degrees Fahrenheit in room [ROOM NUMBER]xx, 65.7 degrees Fahrenheit in room [ROOM NUMBER]ww.On 01/21/26 11:40am V7 (DON) stated that she was first made aware of the facility being cold on Sunday 01/18/26. V7 stated that she received a phone call from V15 (Licensed Practical Nurse/LPN) stating that it was cold in the building. V7 stated that she informed V1 (Administrator) of the phone call from V15 (LPN). V7 stated that she does not know what action was taken after she informed V1 (Administrator). V7 stated that she instructed her staff to make sure that all the windows were closed and to hand out extra blankets to any resident that was complaining of being cold. V7 stated that she does not know what the temperature of the building should be. On 01/21/26 at 12:55pm V2 (Assistant Administrator) stated that she was first made aware of the building being cold on Monday 01/19/26. V2 stated that she did not have an actual temperature gun to check the temperature of the facility, that she just felt the coldness in the air. V2stated that they are trying to figure out what else they can do to decrease the cold temperature in the building. V2 stated that V3 (Maintenance Supervisor) was instructed to put plastic over the air conditioning (A/C) units and to place blankets over the windows.On 01/21/26 at 2:41pm surveyor observed V2 (Assistant Administrator) use handheld infrared thermometer to randomly check temperatures throughout the building. Observed thermometer readings of 68 degrees Fahrenheit in room [ROOM NUMBER]ss, 67 degrees Fahrenheit in room [ROOM NUMBER]ww, 66.5 degrees Fahrenheit in room [ROOM NUMBER]rr, 69 degrees Fahrenheit in room [ROOM NUMBER]zz, 66 degrees Fahrenheit in room [ROOM NUMBER]yy, and 67-degrees Fahrenheit in room [ROOM NUMBER]pp. Surveyor observed plastic coverings to windows and A/C wall units.Facility's undated policy titled Residents' Rights for People in Long-Term Care Facilities documents in part, Your rights to safety: . Your facility must be safe, clean, comfortable and homelike. Your rights as a citizen and a facility resident: . You have the right to complain to your facility and to get a prompt response.Facility's undated policy titled Extreme Weather Temperature Policy documents in part, Policy: it is the policy of this facility to maintain indoor temperatures in the range of 71 to 81 degrees Fahrenheit. Interventions will be promptly implemented to protect residents' health and safety when temperatures fluctuate outside the accepted range.

Based on observation, interview and record review the facility failed to distribute and serve food to two residents (R1 and R6) in accordance with professional standards for satisfactory food consumption. This failure affected two residents reviewed for dietary services.Findings include:R1's medical diagnoses include but are not limited to type 2 diabetes mellitus, lymphedema, acquired absence of left leg below knee, acquired absence of right leg below knee.R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R1's cognition is intact.R6's medical diagnoses include but are not limited to chronic obstructive pulmonary disease, hypertensive heart disease without heart failure, mild cognitive impairment of uncertain or unknown etiology.R6's MDS dated [DATE] has a BIMS score of 14, indicating R6's cognition is intact.On 01/20/26 at 12:29pm observed R1 and R6's lunch trays delivered to their bedside.On 01/20/26 at 12:30pm observed V12 (Dietary Manager) take temperature of R1' and R6's lunch meal tray. R1 and R6's pork shoulder meat temperature 96.6 degrees Fahrenheit. On 01/20/26 at 12:33pm V12 (Dietary Manager) stated that the food temperature should be at least 145 degrees Fahrenheit. V12 stated that she has been informed by the residents that they receive cold food. V12 stated that she has had to come to the nursing units to assure that the resident meal trays were passed out in a timely fashion. V12 stated that no one wants to eat cold food unless the food is supposed to be served cold. V12 stated that she confirms that the resident trays that were tempted were cold.On 01/20/26 at 12:44pm V11 (Certified Nursing Assistant/CNA) stated that residents have complained about receiving cold food. V11 stated that if the resident complains about their food being cold, she warms their food in the microwave. V11 stated that she also informs the dietary staff that the resident food was cold. V11 stated that residents are still upset after she warm their food up in the microwave because they want the food to already be hot. V11 stated that they are now trying to pass the meal trays in the dining area and the resident rooms at the same time so that none of the meal trays are cold.On 01/20/26 at 1:02pm R1 stated that the food he receives is served cold. R1 stated that the facility tells him to have the CNA (Certified Nursing Assistant) to warm up his food, and he feels that the food should be served hot and he should not have to have it warmed up. On 01/21/26 at 11:40am V7 (Director of Nursing/DON) stated that dietary did speak to her about having her staff to pass the meal trays as soon as they come up to the unit.V7 stated that they have come up with a system so that someone is in the dining area passing out meal trays and someone is also passing trays to resident rooms at the same time.Facility's policy titled Food Preparation and Service review dated 07/2025 documents in part, Policy statement: Food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: Food Preparation, Cooking and Holding Temperatures and Times: 1. The dander zone: for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. 3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF (potentially hazardous foods) must be maintained below 41 degrees Fahrenheit or above 135 degrees Fahrenheit. 6. Previously cooked food must be reheated to an internal temperature of 165 degrees Fahrenheit for at least 15 seconds.

Based on observation, interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R9) of 10 residents reviewed for abuse. This failure resulted in R10 hitting R9 on the face in the dining room, resulting in R9 sustaining superficial scratches to R9's face.Findings Include: R9's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Cerebrovascular disease, type 2 diabetes mellitus without complications, idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, unspecified, hyperlipidemia, hypertensive heart disease without heart failure, gastro-esophageal reflux disease without esophagitis, history of falling, benign prostatic hyperplasia without lower urinary tract symptoms. Minimum Data Set Section (MDS) section C (dated Sep.10, 2025) documents that R9 has an Interview for Mental Status (BIMS) score of 12, indicating that R9's cognition is intact. Care plan (dated 07/02/2025) documents that R9 is potentially at risk for abuse/neglect secondary to moderate physical deficits and soft-spoken communication. Recently, he was involved in an incident where he was not the aggressor. R9 is alert and able to verbalize needs.R10's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Parkinson's disease without dyskinesia, without mention of fluctuations, schizoaffective disorders, chronic obstructive pulmonary disease, unspecified, bipolar disorder, Hypertensive heart disease with heart failure. Minimum Data Set Section (MDS) section C (dated 10/22/2025) documents that R10 has an Interview for Mental Status (BIMS) score of 13, indicating that R10's cognition is intact. Facility Final Incident Investigation Report (dated 07/08/2025) documents in part: On 07/02/2025 at approximately 3:20PM, R10 was observed to strike R9 while in the basement dining area. Staff intervened and immediately separated the residents. Body assessments conducted for R9 and R10. R10 reported no pain and injury. R9 denied pain but was observed with 2 superficial scratches on face. Emergency contacts for R9 and R10 notified. R9 alleged R10 got out of his wheelchair and became aggressive towards him. R9 alleged he was stationary in the basement dining area when R10 came towards him, stood up from the wheelchair and came at him. R9 denied any precipitating factors. Residents who witnessed the incident indicated that R10 became aggressive towards R9. A resident alleged observing R10 trying to get past in between R9 and another peer who were sitting at the table in the basement dining area. R10 stood up and became aggressive towards R9. Abuse Prevention Policy (revised 10/2022) states in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish to a resident. Resident Rights Policy (revised 11/2018) states in part: Your rights to safety- You must not be abused, neglected, or exploited by anyone- financially, physically, verbally, mentally or sexually. On 09/30/2025, surveyor was conducting a facility reported incident related to resident-to-resident abuse, that occurred on 07/02/2025. On 9/30/25 at 2:42 PM, R9 observed sitting in his motorized wheelchair in his room. Surveyor conducted an interview with R9. R9 stated, R10 hit me because R10 was trying to get by. R10 and I were in the cafeteria. I was in my wheelchair. R10 was in his wheelchair. It was not enough space for R10 to get by. R10 put his hand on my chair. I went to move R10's hand. R10 stood up and struck me in the face. I was not injured and R10 was not injured. I did not go to the hospital. R10 went to the hospital for psychiatric evaluation. I feel safe in the facility.On 9/30/25 at 2:34 PM, surveyor conducted an interview with resident, R10. R10 stated, I ain't been fighting with nobody. Ain't nobody hit me. I ain't hit nobody. I stay in my room watching television. I feel safe in the facility.On 12/10/2025 at 10:55AM, V1 (administrator) stated, On 07/02/2025, it was reported that at 3:20PM, R10 was observed hitting R9 in the face, in the dining room. Staff intervened immediately and separated R10 from R9. The nurses completed body assessment on both residents. R10 had no pain or injury. R9 had a superficial scratch on his face. Both R9 and R10's physicians and emergency contacts were made aware of the incident. The police were called, and a report was filed. R10 was petitioned and sent out to the hospital for psychiatric evaluation. R9 was provided first aide for the scratch on his face. The issue started because both residents are in wheelchairs. R10 was trying to get by and could not, and that's how the incident started. R10 became frustrated because he could not get by and struck R9 in the face. R9 and R10 have not had any incidents prior to the physical altercation. R9 and 10 did not have other incidents after the altercation. R9 and R10 both feel safe in the facility.On 12/11/2025 at 9:48AM, V18 (psychiatric rehabilitation services coordinator) stated, On 07/02/2025, I was coming out of the office in the basement, and I heard a commotion coming from the big dining room. I went inside the dining room to see what the commotion was, and I saw that the certified nursing assistants already separated R9 and R10. R10 became furious and he was saying that R9 needs to get out of his way. Where they were sitting, there is a lot of residents in wheelchairs and R10 was trying to get by but couldn't. R10 became frustrated and R10 hit R9 in the face. I saw R9 with a scratch on his face, which was a result of being struck in the face by R10. R9 did not attempt to strike R10 back. R10 was placed on 1 to 1 supervision and R10 was sent out to the hospital for psychiatric evaluation.R9's Progress Note (dated 07/02/25) documents, It was reported that resident had an unprovoked altercation with one of his peers. Resident has 2 scratches to his lower right cheek. Resident stated that the other resident scratched him in the face for no reason. The scratches cleansed with normal saline and left open to air, no bleeding noted. Physician notified. No new orders given. V/S 98.1-78-18-132/77, O2 sat 98% on room air. Will continue to monitor.R9's Progress Note (dated 07/02/25) documents, 1:1 VISIT TOPIC: Well-being Check. Writer met with resident in an effort to process event and to assess resident's mood/behavior. Educated the resident on importance of verbalizing any concerns immediately to staff for intervention/support. Processed with resident event; he reported no additional concerns and presented with adequate mood and stated feeling okay but verbalized feeling somewhat upset by event. Feelings/concerns were validated, resident reported no concerns. Resident was alert and oriented x3. PLAN: Continue to be available to resident as appropriate.R10's Progress Note (dated 07/02/2025) documents, It was reported by social service that resident had and altercation with another resident and the other resident sustained scratches to his face. Resident received delusional and uncooperative with social services as to what led up to the altercation. Physician called and order given to send resident to community hospital emergency room with a petition.R10's Progress Note (dated 07/02/2025) documents, Ambulance called for transport with ETA (estimated time of arrival) 30-40 minutes. Nursing report given to registered nurse at community hospital emergency room. Sister of resident was notified that resident will be sent to community hospital. Resident remains on the unit at this time.R10's Progress Note (dated 07/03/2025) documents, Resident has been admitted DX (diagnoses): aggressive behavior.

Based on interview and record review, the facility failed to prevent resident to resident physical abuse for one of four residents (R2) reviewed for abuse in a total sample of nine residents. Findings include: R1's Face sheet documents R1 is a [AGE] year-old admitted to the facility on 2.12.2013, with diagnoses including but not limited to: Cerebral palsy, Schizoaffective disorders, Hypertensive Heart disease without Heart failure, and Gastro-Esophageal Reflux disease without Esophagitis. R1's MDS *-Minimum Data Set (MDS) dated 5.6.2025 documents R1 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R2's Face sheet documents R2 is a [AGE] year-old admitted to the facility on 2.6.2024, with diagnoses including but not limited to: Type 2 Diabetes Mellitus with unspecified complications, Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety; Hypertensive Heart disease with Heart failure, and Chronic Obstructive Pulmonary disease. R2's MDS *-Minimum Data Set (MDS) dated 3.31.2025 documents R2 is moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 9 out of 15. The Illinois Department of Public Health Final Investigation report completed on 4.25.2025, documents in part, on 3.19.2025 (4.19.2025) staff observed R1 tap R2's face. R2 stated while he was waiting for the smoke break, he was sitting quietly in the basement dining room. R1 approached him and hit him without provocation. He denied any precipitating factors. R1 reported to staff that R2 called him an inappropriate name. Body assessment of both residents was conducted. R2 was observed with superficial scratch under his eye which healed with no complications. (Local police department) was contacted. R1 was sent to (local hospital) for psychiatric evaluation. On 6.25.2025, at 2:41 PM, R1 said, R2 swore at me a lot. I got angry, and I hit him in the face with my right fist. I went to the hospital for fighting, they (facility) sent me. It happened in the basement dining room. Now, I would tell a worker if someone was swearing at me, I wouldn't hit them. On 6.26.2025, at 10:15 AM, V4 (CNA-Certified Nursing Assistant) said, I was up on the first floor. I was alerted by a housekeeper that R1 and R2 were fighting. When I got to the basement, I saw R1 hitting R2 in the face. We separated the residents. R2 went back to his unit, and we kept R1 downstairs for approximately 10 minutes. R1 said R2 was messing with me and calling me b*****s. On 6.26.2025, at 10:21 AM, V5 (Housekeeper) said, I was downstairs cleaning the day room. I was in the hallway; I heard some chaos. I went into the day room and saw R1 and R2 fighting. When I looked, I saw R1 with a can of soda hitting R2 in the head. I tried to get between them. R1 wouldn't stop. I went upstairs to get some help. V4 and V10 (PRSA-Psychiatric Rehabilitation Services Aide) responded. On 6.26.2025, at 10:59 AM, R4 said, when I came downstairs, I saw R1 with his arm around R2's neck, punching R2 in the face. On 6.26.2025, at 11:23 AM, R5 said, they (R1 and R2) had a fight. I saw R1 punching R2 in the face and R1 was stepping on R2's feet. I don't know how it started. On 4.19.2025, (no time), R2's Witness Statement documents in part, I was in the basement lunchroom and R1 started to hit me for no reason. I had said nothing to him. R2 denies saying anything prior or having any conflict with peer. R2 stated he was just sitting waiting for smoke break. R2 was not in the facility during the survey. On 4.22.2025, (no time), R6's Witness Statement documents in part, I just saw (R1) hit (R2) in his face. I didn't hear what was said between them. That's all I saw. On 4.22.2025, (no time), R7's Witness Statement documents in part, I don't know (how) it started, but (R2) must've said something, he (R1) was p****d and snuck up on the side and hit him (R2). On 4.22.2025, (no time), R8's Witness Statement documents in part, It happened in the big room in the basement. They (R1 and R2) had a discussion with each other, don't know what about, maybe something about the vending machine. (R1) hit (R2) afterwards. On 4.24.2025, (no time), R9's Witness Statement documents in part, (R1) was just all riled up and was sitting in the basement. R1 just walked up to him (R2) and just hit (R2). (R2) was sleeping in the wheelchair doing nothing. (R2) hit (R1) back though. On 4.24.2025, (no time), V10's Witness Statement documents in part, The housekeeper came and got us (CNAs). We ran downstairs and heard yelling. I saw (R1) hit (R2). We immediately separated both of them. (R1) said that (R2) wouldn't leave me alone, he called me a b****. On 4.19.2025, at 10:37 AM, R1's progress note documents in part, 7:00 AM-3:00 PM writer was told R2 was observed exhibiting aggressive behavior to R1 while off the unit. On 4.19.2025, at 5:37 PM, R1's progress note documents in part, 3:00 PM-11:00 PM, (R1) has been admitted to (local hospital) with the admitting diagnosis: Aggressive Behavior and Schizoaffective Disorder. R1's Petition for Involuntary/Judicial admission (dated 4.19.2025) documents in part: -Emergency inpatient admission by certificate. The Respondent is currently detained in a mental health facility or hospital. -Person continues to be subject to involuntary admission on an inpatient basis. -R1 is a person with mental illness who: because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another person in physical harm or in reasonable expectation of being physically harmed; a person with mental illness who: because of his or her illness is unable to provide for his or her basic physical needs so as to guard himself or herself from serious harm without the assistance of family or others, unless treated on an inpatient basis; a person with mental illness who: refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his or her illness is unable to understand his or her need for treatment; and if not treated on an inpatient basis, is reasonably expected based on his or her behavioral history, to suffer mental or emotional deterioration and is reasonably expected, after such deterioration, to meet the criteria of either paragraph one or paragraph two above. (Is) in need of immediate hospitalization for the prevention of such harm. -Patient shows increase agitation, hyper verbal behaviors. Patient showing signs of aggression. Patient cannot be redirected at this time. On 4.19.2025, at 10:45 AM, R2's progress note documents in part, 7:00 AM-3:00 PM, Writer was told R2 was seated in the basement dining area when R1 began to exhibit aggressive behavior towards R2. R2 was removed from dining area and separated to ensure safety and assessed for any bruising, swelling and pain. Writer observed a scratch under his right eye. Basic first aid was applied. Abuse Policy (Reviewed 1.18.2024) documents in part, this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.

Based on observation and interview the facility failed to clean the lint screen thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 127 residents that reside in the facility. Findings include: On 04/29/25 at 11:07am, a large amount of lint is observed in all three of the dryers covering the lint trap catcher and the base of the dryers located in the facility's laundry area. Also observed a large amount of lint on the floor surrounding the three dryers. On 04/29/25 at 11:07am V11 (Housekeeping Supervisor) stated that he cleans the lint traps every three days. V11 stated that there is a loose wire in one of the dryers and the repair guy is coming to fix the wire. V11 stated that he is unable to physically move the dryers to clean around them and will do so when the repair guy comes to fix the dryer. V11 stated that it is important to clean the dryer's lint traps and surrounding areas because they are fire hazards and could cause a fire. On 05/01/25 at 12:56pm V1 (Assistant Administrator) sent an email that stating, There is no policy for the Lint Traps and there is no specific policy for the laundry area.

Based on observation, interview and record review the facility failed to wear personal protective equipment (PPE) while performing gastrotomy (G-tube) care for one resident (R104) on enhanced barrier precautions (EBP). This failure affected one resident (R104) in a total sample size of 54 residents. The facility also failed to do hand hygiene while performing laundry duties. This failure has the potential to affect all 127 residents residing in the facility. Findings include: 1. On 4/28/25 at 10:28 am, R104 observed in bed with a tube feeding pump hanging on a pole with a piston syringe for a G-tube. R104 stated that R104 went back to the hospital recently to have R104's G-tube replaced, and R104 pointed to R104's covered stomach saying that the G-tube is clamped now. An Enhanced Barrier Precautions (EBP) sign is observed visibly posted on R104's room door. On 4/29/25 at 10:41 am, R104 observed in bed with a tube feeding pump hanging on a pole with a piston syringe for a G-tube, and R104's G-tube is clamped. An EBP sign is observed visibly posted on R104's room door. On 4/30/25 at 10:15 am, V15 (Registered Nurse, RN) stated that R104 has a G-tube. This surveyor requested to view R104's G-tube site and for placement check. An EBP sign is observed visibly posted on R104's room door. V15 did not put on a gown prior to R104's G-tube care. With gloves on, V15 pulled back R104's shirt and touched R104's G-tube dressing to show that it was intact. V15 removed the piston syringe from the plastic bag, removed the cap from R104's G-tube, and connected the piston syringe into R104's open G-tube port. V15 pulled back on the piston syringe for a gastric residual check for placement which revealed approximately 30 milliliters of stomach contents. While holding the G-tube connecting port and piston syringe with one hand, V15 removed the plunger from within the piston syringe with the other hand which opened the end of the syringe to allow for R104's gastric contents to flow slowly by gravity first into R104's G-tube and next into R104's stomach. V15 then disconnected the piston syringe from R104's G-tube connecting port and clamped R104's G-tube. V15 stated that R104's tube feedings and G-tube dressing change are done on the night shift. As V15 doffed gloves upon exiting R104's room, this surveyor pointed to R104's Enhanced Barrier Precautions sign. V15 stated that the purpose of residents on EBP is to protect the patient from us (staff). V15 stated that EBP applies to residents who have openings such as residents with G-tubes, indwelling urine catheters, and open wounds, and when staff are performing care related to these sites, staff wear gowns and gloves, despite V15 not donning a gown. V15 stated that wearing the gown and gloves will prevent transfer of contamination of microbes from V15's person, who provides care to other residents, and transferring the unknown microbes to the residents who have body openings like G-tubes. On 4/30/25 at 10:57 am, V4 (Infection Preventionist, Quality Assurance, RN) stated that the purpose of EBP is to protect them (residents) from us (staff). We use protection (PPE) on us for them (residents). V4 stated that EBP is for residents who receive treatments to open wounds, has a G-tube, indwelling catheter or surgical sites. V4 stated that EBP is for anywhere where microbes can get in. Transferred from person to person, from staff who is providing care to residents. V4 stated that EBP constitutes staff wearing a gown and gloves when performing direct care to these residents. When asked if a nurse is caring for a G-tube resident and opens the G-tube to check for G-tube placement, what PPE does the nurse need to be wearing, and V4 stated, Gown and gloves. The nurse needs to have the stuff on. Because that's going to expose contaminants to that area. We (staff) are considered dirty and contaminated. They (staff) should have PPE when they are messing with catheters or G-tubes. It can be possible harm to the patient by introducing microbes which cause infection. Facility sign posted on R104's door (undated) titled Enhanced Barrier Precautions documents, in part, Stop . Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities: . Device care or use: . feeding tube. R104's Face Sheet documents, in part, diagnoses of gastrostomy status, hypertensive hear disease, elevated white blood cell count, hypo-osmolality and hyponatremia, intestinal obstruction, chronic kidney disease, nausea with vomiting, anemia, hyperlipidemia, pelvic varices, and acquired absence of right leg above the knee. R104's Minimum Data Set (MDS), dated [DATE], documents, in part, that R104's Brief Interview for Mental Status (BIMS) score is 9 which indicates that R104 has moderate cognitive impairment. R104's Swallowing/Nutritional Status documents, in part, that R104 has a feeding tube (G-tube). R104's Physician Order Report, dated 4/28/25, documents, in part, an active orders (from 3/25/25) of enteral feeding general flush with water (150 milliliters, ml) every shift, and Jevity 1.2 at 75 ml/hour from 6 pm to 6 am. R104's Care Plan, start date of 2/7/25 and edited date of 2/13/25, documents, in part, a problem of R104 has a diagnosis of gastrostomy status with an approach of check placement and patency of feeding tube every 8 hours. Facility list (undated) titled Enhanced Barrier Precaution documents, in part, that R104 is on the EBP list which was provided to the survey team by V4 (Infection Preventionist/Quality Assurance Registered Nurse, RN). Facility policy dated 4/28/24 and titled Enhanced Barrier Precautions Policy documents, in part, Policy: Enhanced Barrier Precautions (EBP) is designed to reduce transmission of multidrug-resistant organisms (MDROs) and Extensively drug-resistant organisms (XDROs) in nursing homes. It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implement during high-contact resident care activities when caring for residents that have an increased risk of acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO or XDRO. Overview: The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of MDROs to employees hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids . Procedure: 1. Standard Precautions should always be applied to all residents at all times. 2. In addition to Standard Precautions, residents will be assessed to determine whether Contact Precautions or Enhanced Barrier Precautions will be implemented . 9. Personal Protective equipment is required for all staff providing high-contact resident care activities to include . vii. Device care or use: . feeding tube . 19. Enhanced Barrier Precautions are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device. Facility Job Description (undated) titled RN documents, in part Purpose: The primary purpose of this position is to: . Provide licensed nursing care to residents on assigned unit in accordance with current federal, state and local standards, guidelines and regulations . Duties/Responsibilities/Function: . 24. Ensure compliance with infection control standards. 50662 2. On 04/29/25 at 11:07am V11 (Housekeeping Supervisor) observed pushing soiled linen cart into the soiled linen area of the laundry room with his bare hands. V11 then observed removing items from the washing machine and touching multiple surfaces without performing hand hygiene. Observed soiled linen in the laundry chute that was not contained in a bag. On 04/29/25 at 11:07am V11 (Housekeeping Supervisor) stated that he should have performed hand hygiene after pushing the soiled linen cart and touching the clean items. V11 stated that the items that he removed from the washing machine were clean items and that he should not have touched them without washing his hands. V11 stated that soiled linen should not be in the laundry chute without a bag. V11 stated that the soiled linen should be contained in a bag to prevent contamination of other items. On 04/29/25 at 1:14pm V4 (Infection Preventionist/IP) stated that hand hygiene should be performed when moving from a dirty task to a clean task. V4 stated that the soiled linen cart is considered dirty, and hand hygiene should be performed after touching the cart. Facility's policy titled Handling of Contaminated Linen Policy dated 02/2014 documents in part, Policy To protect employees and residents from cross-contamination while handling contaminated linen .Policy Specifications: .2. Contaminated linen will be placed in a biohazard bag. Facility's policy titled Hand-Washing/Hand Hygiene Policy dated 03/2020 documents in part, Policy: It is the policy of the facility to assure staff practice recognized hand washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand rubs can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids .Policy Specifications: 1. All personnel shall be educated on recognized hand washing/hand hygiene procedures and shall follow such procedures .4. When hands are not visibly soiled, employees may use an alcohol-based hand rub containing at least 60% alcohol in all of the following situations . j. After handling used dressing, potentially contaminated equipment . l. After contact with potentially infectious material.

Based on interview and record review, the facility failed to complete an accurate facility assessment. This failure has the potential to affect all 127 residents that reside within the facility. Findings include: The facility provided census (4/28/2025) documents 127 residents reside in the facility. The facility assessment (4/25/25) documents the following inaccuracies, including but not limited to: 1) No staff, resident, or family names that participated in the development of the facility assessment (pg. 6) 2) 803 residents with Heart/Circulation conditions (pg. 8) 3) 447 residents with metabolic conditions (pg. 8) 4) 252 residents that have > 252 diseases (pg. 8) 5) 383 residents were in the facility from 3/1/2025 to 4/1/2025 (pg. 8) 6) (Facility) is unable to care for and/or accept residents with a primary diagnosis of mental illness (pg. 8) when page 7 identifies that the facility has a long term/Psych unit 7) Acuity (Pg. 9) lists the facility as (Another Facility) 8) Identifies that 95% of the facility population has care needs related to urinary incontinence/indwelling catheters (pg. 10) 9) 94% of the facility population has care needs related to impaired nutritional status (pg. 11) 10) 100% of the facility population has care needs related to pressure ulcers (pg. 11) 11) Lists the facility as (Another Facility) and has a 30% of the resident population of Polish decent (pg. 11). 12) Lists the facility as (Another Facility) (pg. 12) 13) Identifies the need for a dementia unit coordinator (pg. 15). There is no dementia unit identified within the facility. 14) The staffing plan identifies the facility as (Another Facility) and identifies that the facility needs 17 Registered Nurses, 8 Licensed Practical Nurses and 53 Certified Nursing Assistants 15) facility assessment does not describe the facility's recruitment and retention of staff initiatives 16) does not describe the facility's contingency staffing plans 17) does not identify QAPI (Quality Assuracnce Performance Improvement) training as required area of training. On 4/29/2025 at 12:11 PM, the facility assessment was reviewed with V1 (Assistant Administrator) and V43 (Nurse Consultant). V1 and V43 affirmed that the IDT (Interdisciplinary Team) participated in the development of the facility assessment. V43 stated that the facility assessment is important because it identifies care needs of the residents within the facility, dictates what the facility can and cannot accept, outlines staffing needs, etc. The inaccuracies identified were reviewed with V1 and V43 and V43 stated, these must be typos. V43 could not explain how or why (Another Facility) name and data was described within the facility assessment. V43 stated the two must have gotten jumbled up. V43 could not give a reason how the facility assessments got jumbled up as the other nursing home is not within their multi-facility oversight. V1 affirmed there was no other facility assessment for (Facility) and no other facility assessments were provided prior to the exit of the survey. Facility policy titled Facility Assessment Tool (undated) documents in part, Requirement Nursing facilities will conduct, document, and annually review a facility wide assessment, which includes both their resident population and the resources the facility needs to care for their residents.

Based on observation, interview, and record review, the facility failed to label and date an opened refrigerated food item; kitchen staff failed to perform appropriate hand hygiene in the kitchen; failed to sanitize the thermometer probe in between obtaining temperature readings of each hot food item; failed to properly clean food processor equipment; failed to allow food processor equipment to fully air dry before use; failed to ensure that kitchen staffs' personal belongings are not stored on kitchen equipment where resident food is prepared; and failed to ensure that kitchen staffs' food and drink items are not stored in the facility kitchen dedicated for resident food and drinks. These failures affect all 127 residents receiving oral diets in the facility. Findings include: On 4/28/25 at 9:35 am, during the initial tour of the facility kitchen's walk in refrigerator and freezer with V13 (Dietary Manager) and V16 (Cook), a 16.9 fluid ounce bottle of water (frozen) observed on the shelf inside the freezer. When asked if this is a water bottle for resident use, V16 stated, No. It's someone else's. In the walk in refrigerator, an opened package of bologna slices wrapped in clear plastic wrap is observe with no label or date. V16 stated that V16 is not sure when the bologna slices package was opened. Ten water bottles (16.9 fluid ounces) and two ginger ale bottles (20 ounce bottles) are observed on a shelf inside the walk in refrigerator. When asked who's water and soda bottles are these, V13 stated, Employees. Next to the water and soda bottles on the shelf, a gray grocery sack is observed. V13 retrieved this sack from the shelf and opened the grocery sack revealing an opened package of polish beef sausages (identified by V13). When asked is this for the residents' menu, V13 stated, No, it's someone's (staff) lunch. V13 stated that staff's food should not be stored in the residents' kitchen refrigerator. On 4/28/25 at 9:53 am, clean plate covers are observed stacked on the main food preparation (prep) table in the center of the kitchen. At the end of this food prep table (closest to the dishwasher room), an employee's cellular phone is observed connected to a phone charger cable plugged into the outlet at the end of the food prep table. This employee phone is next to the clean plate covers. On 4/28/25 at 11:45 am, the same employee's cellular phone is observed again on the food prep table connected to phone charger next to the clean plate covers. Also, a set of keys with 2 car fobs (on a key ring with a lanyard) is observed next to the phone. On 4/28/25 at 11:46 am, V16 (Cook) observed plating residents' lunch plates on tray line service at the main food prep table. V16, with gloved hands, is observed taking V16's left hand, and with the back of V16's left gloved hand, wipes V16's perspiration on V16's forehead. V16 then continues to plate the macaroni with meat sauce and hamburgers on buns on the resident lunch plates. No hand hygiene and glove change are performed by V16. On 4/28/25 at 12:48 pm, a condiment tray (open cart on wheels with bins of salt, peppers, sugars, and sweeteners) observed parked at end of the main food prep table. A blue tumbler cup with an open clear lid is observed on this cart. V19 (Cook) observed preparing peanut butter and jelly sandwiches and bologna sandwiches on the kitchen prep table. When asked whose tumbler cup is this, V19 stated, I (V19) don't know. V19 then calls out to the kitchen staff, Whose cup is on the cart? V21 (Dietary Aide) said that it was V20's (Dietary Aide) cup, and V21 walked over to remove V20's tumbler cup from the condiment cart out of the kitchen. V19 stated, No one should be drinking in here (the kitchen). On 4/28/25 at 12:49 pm, this surveyor pointed to the cellular phone and car keys observed on the same kitchen table that V19 is preparing food sandwiches on, asking whose personal items are these? V19 stated that V19 doesn't know whose they are. When asked are these personal items to be stored in the kitchen on the food prep table and the condiment cart, V19 stated, Not that I am aware of. On 4/29/25 at 9:21 am, for the puree food preparation, V16 (Cook) is observed with food supplies on the main kitchen prep table near the food processor and the covered meat slicer. V16 stated that V16 is going to be making pureed beef steaks and creamed corn. A music speaker, white and gray in color and cylindrical in shape, is observed on the kitchen prep table in between the food processor and the meat slicer. Another cellular phone is observed on top of the meat slicer ledge and is connected to a charging cable plugged into the outlet on the opposite end (closest to the 3 compartment sink) of the main kitchen prep table. V16 observed preparing the pureed beef patties in the food processor, and V16 transfers the pudding like consistency of pureed beef steak patties from the food processor base into a clean pan. On 4/29/25 at 9:26 am, V16 observed taking the used food processor base, cover and blade over to the small sink next to the oven and rinsed the food processor equipment under the running water. V16 then walked the 3 food processor items over to the 3 compartment sink and placed the blade in the wash compartment, next the rinse compartment and lastly the sanitize compartment. V16 placed the food processor blade on the counter next to the small sink to air dry. V16 returned to the wash basin of the 3 compartment sink, washed and scrubbed the food processor base and lid, and then moved the 2 items to the rinse compartment. V16 placed both items in the sanitizer compartment to dwell. V16 then removed paper towels from the dispenser to dry off V16's hands. V16 observed touching and moving the gray garbage can lid covering the garbage can to place the used paper towel in the garbage can. V16 did not perform hand hygiene after touching the garbage can lid. V16 next retrieved the food processor base and cover from dwelling inside the sanitize 3 compartment sink. While holding onto to the food processor base and cover, V16 shook these items in front of V16's body and picked up the blade from the small sink counter. V16 walked back over to the main food prep table where V16 assembled the base with the blade inside, and visible moisture droplets are observed on the food processor base. In addition, 2 pieces of beef steak patties residue is observed on the food processor base. V16 removed the creamed corn from the oven and ladled scoops of creamed corn into the dirty food processor base. V16 continued the puree preparation of the creamed corn via the same food processor equipment. After creamed corn puree preparation was completed, V16's cellular phone, which is on top of the covered meat slicer ledge, rings, and V16 answers the phone call. On 4/29/25 at 11:30 am, V16 is observed with an electric thermometer preparing to obtain temperatures of the hot foods assembled on the main kitchen table. V16 pulls the foil covers back from hot food items and begins taking food temperatures. V16 inserts the thermometer probe into the mashed potatoes which read 200 degrees Fahrenheit. V16 removes the thermometer probe from the mashed potatoes and does not sanitize the probe with alcohol pads. V16 then inserts the same thermometer probe into a beef patty for a reading of 185.6 degrees Fahrenheit. V16 removes the thermometer probe and residual white mashed potatoes are visible on the beef steak patty where V16 inserted the same electric thermometer. V16 stated that V16 uses the alcohol pads to clean off the thermometer probe so there's no cross contamination. V16 stated, I (V16) don't want each food going into a different food. V16 gave example of not wanting beef steak patty to go into this or that pointing to the mashed potatoes or creamed corn, despite mashed potato residual being visible on a beef steak patty. On 4/30/25 at 11:15 am, V13 (Dietary Manager) stated that kitchen staff are supposed to wash their hands, after put on their hair nets, enter the kitchen and go over and wash their hands. Anytime they go in and out of the kitchen, touch their nose or face with fingers. It doesn't matter how many times they go in and out of the kitchen, they have to wash their hands. V13 stated that if kitchen staff are wearing gloves, are serving food on the tray line, and wipe their sweat from their forehead with the gloved hand, then they must take off the gloves and wash their hands. Use paper towel and let hands dry and put on new gloves. V13 stated that purpose of kitchen staff performing hand hygiene is to keep hands sanitized and to keep down cross contamination so not everyone will get sick. V13 stated that after kitchen staff are touching their face with a gloved hand during tray line or touching the garbage lid and not washing their hands, Well that's just nasty and is cross contamination. V13 stated that kitchen staff should not keep their personal items, such as cellular phones, music speakers, keys, or drinking cups, in the kitchen. V13 stated that kitchen staffs' personal items are not supposed to be around food. This is where we prepare food for the residents. Their (staffs') personal items are not to be in there (kitchen) at all. V13 stated that it is not acceptable for kitchen staff to have personal items in the kitchen, not on the condiment cart, not on the prep table with everything that's in there. No. V13 stated that V13 will in-service kitchen staff, but they should know. When asked when should a food item that is opened and is refrigerated, what should be labeled on the plastic wrap covering, and V13 stated, The date when it's opened and when it expires. It depends on the item. V13 stated that if a food item is refrigerated and remains in refrigerator past the expiration date, then if it's served to residents, it can have a possible bad effect, food poisoning, diarrhea. When asked about the employees water and soda bottles observed in the refrigerator and freezer on 4/28/25, V13 stated that V13 normally comes in and checks the refrigerators on Monday mornings. V13 stated that V13 had just came in to the kitchen on Monday, when survey team entered, and wasn't able to do the check of the refrigerator and freezer. V13 stated that V13 will normally remove everything from Friday, Saturday and Sundays. Everyone don't do it, and I can't speak for them. I throw out the staff's stuff in the garbage. V13 stated that the polish beef sausage in the grocery bag in the refrigerator observed on 4/28/25 is not on the menu to be served to the residents. V13 stated, That wasn't supposed to be there. It was an employees' (food). V13 stated that kitchen staff can't keep their food in there (kitchen refrigerator). It's for the residents. It's not for the staffs' food. V13 stated that the process of kitchen staff obtaining temperatures of hot foods before tray line service is to open and use an alcohol wipe on the thermometer probe; allow to air dry; place the probe into one food item; read the electric thermometer; remove the probe; and clean and sanitize the thermometer probe with a fresh alcohol wipe; and allow to air dry before moving to the next food item. V13 stated that the purpose of using alcohol to clean the thermometer probe in between each food item is to keep it sanitized and not have food cross over to contaminate the other food. It's common practice. V13 stated that the process for the 3 compartment sink is there are separate wash, rinse and sanitize compartments. V13 stated that the kitchen staff are to remove food off the pan or equipment and scrub the item in the wash basin with warm water. V13 stated that the item is then placed in the rinse basin after washing and finally immersed in the sanitizing basin to dwell. V13 stated that the sanitizing compartment is a combination of bleach and water. V13 stated, Then (staff) put it on the counter by sink and let it sit there completely air dry. Do not dry with a towel. V13 stated that the purpose of allowing the pan or equipment to air dry completely and not use a towel to dry it, V13 stated that they don't want to transfer food products or lint from the towels onto the clean and sanitized pan. V13 stated that if the item is not completely air dried and there are visible droplets of moisture on the item after the 3 compartment sink process, V13 stated, Those droplets can get into the food. Droplets of bleach water. It would actually be like poisoning. There should be no droplets residual whatsoever after air drying is complete. V13 stated, They (staff) need to wait to let it dry. V13 stated that staff must redo the whole process (3 compartment sink process) from the beginning if food particles are visible on the item after staff washed, rinsed and sanitized it. V13 stated that this would be cross contamination. It's not supposed to happen. On 5/1/25 at 9:57 am, V32 (Registered Dietitian) stated that V32 is a contracted registered dietitian for the facility. V32 stated that V32 expects kitchen staff to properly label and contain open foods in the refrigerator when they are removed from their original containers. V32 stated, They are dated and are in container they are able to see through the front. V32 stated, The date they (staff) opened it (food) is what is to be labeled on the plastic wrap of an opened food item. V32 stated that when the kitchen staff are obtaining temperatures of hot foods, the purpose of sanitizing the thermometer probe with alcohol in between each hot food item is to prevent cross contamination. V32 stated that if kitchen staff are touching the garbage can lid with their hands, they should remove their gloves, wash their hands and reglove. Facility list reviewed shows all of the current residents receiving oral diets (dated 4/29/25), and V1 (Assistant Administrator) confirmed with survey team that the total resident census is 127 residents. Facility kitchen menu from 4/27/25 to 5/3/25 titled Week at a Glance for General Week 3 documents, in part, that for lunch on 4/29/25, lunch meal is country fried steak, garlic mashed potatoes, roasted corn, brown gravy and oatmeal raisin cookie. Facility kitchen policy dated November 16, 2017, and titled Safe Food Preparation and Handling documents, in part, Policy: Food will be prepared to conserve maximum nutritive value in a safe and sanitary environment. Policy Specifications: The following safe food preparation and handling practices will be followed: 1. Strict personal hygiene will be followed. Hands will be washed properly, frequently, and at appropriate times. Proper hand washing techniques will be used . If gloves are used, they will be single-use gloves . Regulatory guidelines will be followed. Facility kitchen policy (undated) titled Labeling and Dating Foods documents, in part, Policy: Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality product for the residents and minimize waste. Policy Specifications: . Refrigerator Stores: . Commercially processed foods that have been prepared and packaged by a food processing place will be labeled with the date it is opened. This will be discarded by the 3rd day or by 'Best Used By' date. Facility kitchen policy (undated) titled Storage of Refrigerated Foods documents, in part, Policy: Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality. Facility kitchen policy (undated) titled Manual Sanitizing in Three-Compartment Sink documents, in part, Policy: A sink with three compartments is used for manually washing, rinsing and sanitizing utensils and equipment that can be submerged. It may also be used for tableware. Procedure: Manufacturer's instruction on the wall poster above the three-compartment sink are followed. Three-Compartment Sink Manufacturer's Poster (undated) titled Three Sink Washing & Sanitizing documents, in part, the Wash Setup, Sanitize Setup, and the Washing Procedures. The Washing Procedures are as follows: 1: Thoroughly pre-scrape food soil into waste receptacle, 2: Place ware into detergent sink and wash with pad or brush, 3: After washing, dip ware into middle sink to thoroughly rinse, 4: After rinsing ware, submerge into sanitizer sink for at least 1 minute, 5: Once sanitized, remove ware from sink and place onto drain board to air dry. Facility kitchen policy (undated) titled Sanitizing Food Thermometers documents, in part, Policy: Food thermometers will be sanitized between taking food temperatures. Procedure: When taking food temperatures, use an alcohol swab to sanitized the thermometer in between taking the temperature of each food. Facility Job Description (undated) titled [NAME] documents, in part, Purpose: The primary purpose of this position is to: Prepare meals in accordance with recipes and written planned menus . Ensure that the kitchen is maintained in a clean, sanitary and orderly fashion. Ensure that 'safe food handling' procedures are being consistently maintained. Maintain all federal, state and local nutritional/dietary regulations . Qualifications & Essential Requirements: . Must possess sanitation certification . Duties/Responsibilities/Function: . Follow all dietary policies and procedures. This includes, but is not limited to, Proper sanitation procedures, proper food and chemical storage procedures, proper operation of facility equipment (dishwasher, stove, oven, etc {and the rest}) . cleaning procedures . hand washing and infection control compliance . monitor food preparation and tray line activity to assure that: foods are handled under 'safe food handling' techniques . Follow all safety rules and regulations. Follow all facility policies and procedures . Ensure compliance with infection control standards.

Based on interview and record review, the facility failed to ensure that all kitchen staff have active food handler certifications to provide safe and competent food and sanitation service to residents which has the potential to affect all 127 residents receiving oral diets in the facility. Findings include: On [DATE] at 2:25 pm, this surveyor requested V16 (Cook), V21 (Dietary Aide), V29 (Dietary Aide), and V31's (Dietary Aide) food handler certifications. V13 confirmed in viewing the kitchen employee schedule ([DATE]) provided to survey team that there are 10 kitchen employees (excluding V13) working all shifts in the facility kitchen. On [DATE] at 10:00 am, V13 stated that V13 requested the food handler certifications from V21, and (V21) hasn't responded and (V29) started (V29's certification test) today but can't pay for it until tomorrow. On [DATE] at 11:15 am, V13 stated that of the 4 kitchen staffs' (V16, V21, V29 and V31) food handler certificates not yet presented to this surveyor, both V16 and V31 were taking the food handler tests today. V13 stated that V16 and V31 informed V13 that both of their previous food handler certificates were expired. V13 stated that it's the kitchen employees' responsibility to maintain a current food handler certification. V13 stated that in different facility kitchens that V13 has worked in, all kitchen staffs' food handler certificates are posted in the kitchen. V13 stated that the dietary manager can then see when they are expiring and can give reminders to the staff. V13 stated, But they are not posted here (facility). V13 stated that the kitchen staff must have an active food handler certification; It's part of their union hand book to be certified to work in the facility. V13 stated that the importance of having an active food handler certification is so they (kitchen staff) will know what they can and can't do for cross contamination. To know what the law is. This is these people's (residents') home. We are making their food in the kitchen, and it can affect any resident eating from this kitchen. On [DATE] at 1:18 pm, V13 stated that the kitchen staffs' roles are broken up by the title and shift of cook and dietary aides. V13 stated that there are two shifts for cooks, one that starts the early shift at 5:00 am, which is V16; and the other cook's shift is 11:30 am to 8:00 pm. V13 stated that dietary aides have shifts from 6:00 am to 2:30 pm, 6:30 am to 3:00 pm, 11:30 am to 8:00 pm, and 4:00 to 8:00 pm. V13 stated that they have on cook working on each of the two cook shifts. V13 stated that two dietary aides work between the two early shifts (6 am-2:30 pm; 6:30 am-3:00 pm); two dietary aides work on the 11:30 am to 8:00 pm shift and one dietary aide from the 4:00 to 8:00 pm on 3 to 4 days a week. V13 stated, We need at least the 2 dietary aides and one cook per shift. V13 presented this surveyor with the kitchen job descriptions saying that the shifts listed are for the dietary aides, and the other one is for the cook. On [DATE] at 1:51 pm, V13 presented copy of V31's food handler certificate which was completed on [DATE]. V13 stated, (V31) did it today. On [DATE] at 2:15 pm, V13 stated that V13 does not keep or catalog the kitchen staffs' food handler certificates, and that V13 doesn't really know who maintains copies of the kitchen staffs' food handler certificates. V13 stated that this surveyor can check with V1 (Assistant Administrator) for the remaining kitchen staffs' food handler certificates. On [DATE] at 9:19 am, when requesting for food handler certificates for V16, V21, V29 and V31 prior to [DATE], V1 (Assistant Administrator) stated that V1 was going to speak with V13 about the food handler certificates. On [DATE] at 10:48 am, this surveyor received V16's food handler certificate, dated [DATE]. On [DATE] at 11:26 am, this surveyor received V31's food handler certificate, dated [DATE]. On [DATE] at 11:34 am, this surveyor received an email notice from V13 documenting the following, The following employees don't have their Food Handler Certification. (V21)-Dietary Aide. (V29)-Dietary Aide. Employee facility list documents, in part, the hire dates of the following kitchen staff: V16 on [DATE]; V21 on [DATE] (rehire date); V29 on [DATE]; and V31 on [DATE]. V16 (Cook) and V21 (Dietary Aide) certificates document, in part, that their food handler certificates for Employee Food Safety Course and Exam were completed on [DATE]. On [DATE] at 9:57 am, V32 (Registered Dietitian) stated that that the kitchen staff should have, at a minimum, a current food handler certification. V32 stated that the importance of all kitchen staff having a current food handler certification is to ensure the overall residents' safety and having no cross contamination in the kitchen. Facility kitchen employee schedule, dated [DATE], documents, in part that there are 10 kitchen employees (excluding V13, Dietary Manager). During facility kitchen tours on [DATE] and [DATE], this surveyor observed V16, V21 and V31 working, and V29 was scheduled on the 4 - 8 pm shift on [DATE]. Facility list reviewed shows all of the current residents receiving oral diets (dated [DATE]), and V1 (Assistant Administrator) confirmed with survey team that the total resident census is 127 residents. Facility Job Description (undated) titled [NAME] documents, in part, Purpose: The primary purpose of this position is to: Prepare meals in accordance with recipes and written planned menus . Ensure that the kitchen is maintained in a clean, sanitary and orderly fashion. Ensure that 'safe food handling' procedures are being consistently maintained. Maintain all federal, state and local nutritional/dietary regulations . Qualifications & Essential Requirements: . Must possess sanitation certification. Facility Job Description (undated) for the Dietary Aide, 6 am to 2:30 pm shift, documents, in part, a timed list of job responsibilities which include set up coffee and start coffee machine, setup juice and milk, start tray line, call the dietary line, help other dietary aides, wash dishes, and sweep and mop. Facility Job Description (undated) for the Dietary Aide, 6:30 am to 3 pm shift, documents, in part, a timed list of job responsibilities which include prepare dessert, help cook on line, setup tray line and milk, call the tray line, help other dietary aides, wash dishes, and sweep and mop. Facility Job Description (undated) for the Dietary Aide, 11:30 am to 8:00 pm shift, documents, in part, a timed list of job responsibilities which include help on line, supplement setup (for 10 am, 2 pm and 7 pm), start dessert (follow all recipe), set up cart for dinner (salt, pepper, sugars), do juice for breakfast, prepare sandwiches for snacks, and setup for dinner meal. Facility Job Description (undated) for the Dietary Aide, 4 pm to 8 pm shift, documents, in part, a timed list of job responsibilities which include pour juice for breakfast (follow menus as to what juice to pour, spread sheet book), help cook on line, wash dishes, and sweep and mop.

Based on observation, interview and record review, the facility failed to post required staffing information in a high visibility area. This failure affects all 127 residents that reside within the facility. Findings include: The facility census for 4/28/2025 documents 127 residents reside within the facility. On 4/28/2025 at 11:19 AM, surveyor requested the daily staffing posting for the facility. V1 (Assistant Administrator) grabbed a document (titled Nursing Schedule) that was observed on top of the ledge of the 1st floor nurse's station, facing the ceiling (not visible to residents). V1 affirmed this was the document that the facility uses to post the staffing information. V2 (Director of Nursing) affirmed that this posting is kept at the nurse's station. The facility provided document from V1 titled, Nursing Schedule (dated 4/28/2025), does not document the following required information: A) Facility Name B) The total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants directly responsible for resident care per shift C) Resident census. Facility policy titled Posting Direct Care Daily Staffing Numbers documents in part, Policy Statement Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents . At the beginning of each shift facility shall post the nurse staffing data as required by state and federal regulations.

Based on interview and record review, the facility failed to complete performance evaluations for certified nursing assistants and failed to ensure 12-hours of in-servicing was completed for certified nursing assistants annually. This failure affects all 127 residents that reside within the facility. Findings include: Record review of facility provided census (4/28/2025) documents that 127 residents reside in the facility. On 5/1/2025 at 9:51 AM, annual performance evaluations and documentation of in-servicing for the last year was requested for V18 (Certified Nursing Assistant/CNA) and V27 CNA. No annual performance evaluation documentation was received prior to the end of the survey. The facility provided in-servicing documents titled CNA (Certified Nursing Assistant) Competency Checklist for V18 and V27 does not document training/in-servicing, nor the hours (time) it took to complete this competency. On 5/1/2025 at 1:26 PM, V4 (Registered Nurse, Infection Preventionist/Quality Assurance Nurse) affirmed that V4 is responsible for educating and in-servicing the staff within the facility. V4 stated that V4 was told by V1 (Assistant Administrator) that the facility does not complete performance evaluations because of the union contract but that the surveyor would have to verify with V1. V4 stated that V4 was unsure how many hours of in-servicing certified nursing assistants were required annually and stated, I think maybe 20 or so?. V4 affirmed that the process for training CNAs is a skills fair where they come in to get checked off on skills competency. V4 stated that the skills fair takes about 6 hours or so. Additional in-servicing documents were requested to verify how many hours of in-servicing V18 and V27 received within the last year. V4 stated, I don't think we have any documentation on our in-service forms that document how long each training occurred. V1 stated to V4, we need to start tracking that from now on. No further in-servicing records were provided during the survey that affirms V18 or V27 received at least 12 hours of in-servicing within the last year. On 5/1/2025 at 1:49 PM, V1 (Assistant Administrator) affirmed that the facility does not complete performance evaluations for certified nursing assistants. V1 explained, due to the union contract, we are unable to complete performance evaluations. All pay increases have already been decided in the contract. On 5/1/2025 at 3:47 PM, V1 stated that there is no facility policy for annual performance reviews for certified nursing assistants. The facility assessment dated [DATE] documents in part, . Required in-service training for nurse aides. In-service training must: - Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year . - address areas of weakness as determined in nurse's aides performance reviews and facility assessment and may address the special needs of residents as determined by facility staff .

Based on interview and record review, the facility failed to ensure all staff were trained on Quality Assurance (QA)and Performance Improvement (QAPI). This failure affects all 127 residents that reside within the facility. Findings include: Record review of facility provided census (4/28/2025) documents that 127 residents reside in the facility. On 4/28/2025 at 10:52 AM, V44 (Housekeeper) stated that V44 did not know what QAPI was and had never received training on QAPI. On 4/28/2025 at 11:14, V26 (Registered Nurse) stated that V26 was unsure what QAPI or QA was. V26 could not recall when the last time V26 was in-serviced on QAPI. On 4/29/2025 at 12:11, V1 (Assistant Administrator) stated, we do train on QAPI, like we just got done training everyone on handwashing. The line staff get training on hire. When asked if the floor staff get trained on QAPI, V1 replied they don't participate in the QAPI meeting. V43 (Nurse Consultant) and V1 (Administrator) were unsure if it was a requirement that all staff receive QAPI training. V43 stated, I will have to check on that. On 4/30/2025 at 10:32 AM, V4 (Registered Nurse, Infection Preventionist/QA Nurse) affirmed that V4 is responsible for the QAPI programming in the facility. V4 affirmed that the purpose of QAPI is to improve systems and identify/correct deficient practices within the facility. V4 stated that the facility had not completed all staff QAPI training but was currently working on it. V4 provided a document titled IN-SERVICE TRAINING REPORT that indicated QAPI training began on 4/29/2025, after the survey had begun. Record review of facility assessment (4/16/2025) does not identify that the staff require training on quality assurance and performance improvement (QAPI).

Based on interview and record review, the facility failed to ensure preadmission screening assessments were completed as needed for residents identified to have a mental illness. This failure affects 4 residents (R10, R33, R40, and R46) reviewed for pre-admission screening in the sample list of 54 residents. Findings include: 1. R10's face sheet documents, in part, admitted : 12/27/2024 05:15 PM (latest return); 09/21/2015 06:47 PM (current). R10's face sheet documents R10's diagnoses that include but are not limited to schizophrenia (date diagnosed [DATE]). R10's active order, start date 1/7/24, documents, in part, risperidone (antipsychotic) 2mg (milligram) orally twice a day. Review of R10's health records do not show that a Level I Pre-Admission Screening and Resident Review (PASARR) was completed for R10. 2. R33's face sheet documents, in part, admitted : 02/11/2023 06:53 PM (latest return); 07/07/2010 12:01 AM (current). R33's face sheet documents R33's diagnoses that include but are not limited to schizophrenia (date diagnosed [DATE]) and other schizoaffective disorders (date diagnosed [DATE]). R33's active orders documents, in part, risperidone (antipsychotic) start date 3/14/25, 0.25mg at bedtime. Review of R33's health records do not show that a Level I Pre-Admission Screening and Resident Review (PASARR) was completed for R33. On 4/29/25, surveyor asked for the employee responsible for the completion of PASARRs and V1 (Administrator) referred V25 (Business Office Manager/Admission Director). On 4/29/25 at 10:41am, V25 (Business Office Manager/Admission Director) said, I am not the only one responsible for the PASARRs. (V3 (SSD/Social Services Director)) has a part too. (R10) and (R33) never had an initial PASARR done. Not sure why. Yes, everyone needs an initial PASARR screening. Before the resident come here, the place the resident is coming from submits the PASARR and we (facility) get the results. It (PASARR) tell us (facility) if the resident is appropriate for our facility. I don't know. This (PASARRs) is new to me. PASARRs identify if our facility is an appropriate setting for the incoming resident. PASARR II identifies residents that have dementia, schizophrenia, things like that. I give (V3) the information on the resident and (V3) enters the information. I think certain diagnoses would trigger a PASARR II to be done. (V3) and myself collaborate. On 4/30/25 at 10:40am, V3 (SSD/Social Services Director) said, I (V3) don't collaborate with anyone for the PASARRs. The only thing I (V3) do is put in the information from the MATRIX to determine if the level of nursing care is appropriate. PASARR II is for psychosis and IOP (Identified Offenders Program). PASARR II is for diagnoses like schizophrenia and Bipolar. New diagnoses of schizophrenia and Bipolar would need a new submission for a PASARR II if a PASARR was already done. On 4/30/25 at 11:36am, V25 (Business Office Manager/Admission Director) said, I (V25) did speak with (agency that completes PASARR screenings) and they had me submit for R10 and R33 to have PASARR screenings done. Facility policy titled, PASSAR Guideline, revised date 11/2017, documents, in part, The objective of the PASARR guideline is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals identified. PROCEDURE 1. Admission and Readmission The facility will participate in or complete the Level I screen for all potential admissions regardless of payer source to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. b. Based upon the Level I screen, if an individual is determined to meet the above criterion, the facility will not admit an individual, the facility will refer the potential admission to the State PASARR representative for the Level II screening process. c. Upon completion of the Level II screen, the facility will review the screen recommendations and determine the facility's ability to provide the specialized services outlined. Admission decision will be determined and notification to the State PASARR representative, resident and resident representative will be completed. d. Readmission i. The PASARR screening process will not apply to those identified individuals, who after being admitted to the facility, were transferred for an acute care stay . iv. The facility will refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a level II review upon a significant change in status assessment to the State PASARR representative . Facility policy titled, Residents' Rights for People in Long-term Care Facilities, revision date 3/17, documents, in part, safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Your facility must make reasonable arrangements to meet your needs and choices. 51772 3. R40's Face Sheet documents a diagnosis of Hypertension, Major Depressive Disorder, Dementia, Psychotic Disturbance, Schizophrenia, and Gastro-esophageal reflux disease. R40's Minimum Data Set, dated dated dated [DATE], Section C documents in part, A Brief Interview Mental Status score of 6 which is indicative of cognitive impairment. R40's Minimum Data Set, dated dated dated [DATE], Section D Mood documents in part, a Mood Total Severity Score of 12 which is indicative of Moderate Depression. On 04/30/25 at 10:40 AM, V25, (Business Office Manager-(BOM) stated V25 called Maximus about R40 regarding a Preadmission Screening and Resident Review (PASARR) because R40's admitted was in 2008 when the requirement was just an Omnibus Budget Reconciliation Act of 1987. V25 stated Maximus informed V25 that a (PASARR) should have been submitted when Maximus took over. V25 stated that nobody ever submitted it to Maximus, so V25 submitted R40's PASARR. V25 stated V25 enters the data and then social service enters the resident's history. V25 stated now V25 knows that when a resident have a psychiatric diagnosis, the PASARR Level I will trigger a PASARR Level II. On 04/30/25 at 11:11 AM, V3, (Social Services Director-(SSD), stated the business office does the Preadmission Screening and Resident Review (PASARR). V3 stated Yes, every resident should have a PASARR completed if the resident has a mental health diagnosis. V3 stated when residents go out to the hospital, residents may be diagnosed with a new mental health diagnosis. V3 stated in the case of a new mental health diagnosis, V25, (Business Office Manager-(BOM) completes the PASARR and both V3 and V25 play a part tag teaming on it. V3 affirmed R40 should have a PASARR I and a PASARR II. 45346 4. On 04/29/2025 at 10:30am surveyor requested R46's PASARR (Preadmission Screening and Resident Review) from the facility staff. On 04/29/2025 at 10:55am V25(Business Office Manager/ Admissions Director) stated I work with the Social Services Director to do the PASARRs for residents. V25 stated the PASARR is used to identify what type of facility the resident goes to, to make sure the resident is in the appropriate setting. V25 stated R46 came to this facility in 2019, R46 did not have a PASARR. V25 stated I spoke with the state agency representative regarding R46's PASARR. The state agency representative informed me to start a PASARR Level I for (R46).

Based on interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice. The facility failed to vaccinate eligible residents with the pneumococcal vaccine. The facility failed to document the refusal and/or the benefits and side effects in the resident's electronic medical records. This deficient practice affected 9 residents (R21, R25, R33, R39, R64, R68, R69, R102, R115) sampled in a total sample size of 54 and has the potential to affect all eligible residents that reside at the facility. Findings include: Review of records for R21, R25, R33, R39, R64, R68, R69, R102, and R115 from admitted s to 04/30/25 have no findings of documentation of pneumococcal vaccine offering or education of the vaccine. Review of physician orders for R21, R25, R33, R39, R64, R68, R69, R102 and R115 from admission to 04/30/25 show no orders for pneumococcal vaccination. Immunization records for R21, R25, R33, R39, R64, R68, R69, R102 and R115 has no current pneumococcal vaccination listed. On 04/29/25 at 11:30am V4 (Infection Preventionist/IP) stated that pneumococcal vaccines are offered to residents upon admission and during influenza season. V4 stated that she does not have proof of offering the residents the pneumococcal vaccine besides the undated and incomplete consent forms. V4 stated that she does not usually document the resident's refusal for vaccination in the resident's chart. V4 stated that she does not know why she did not add the date or finish filling out the vaccination forms. Facility's policy titled Pneumococcal Vaccine dated 11/2009 documents in part, All residents will be offered the Pneumovax (Pneumococcal vaccine) to aid in preventing pneumococcal infections .Policy Interpretation and Implementation .1. Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumovax (pneumococcal vaccine), and when indicated, will be offered the vaccination withing thirty days of admission to the facility unless medically contraindicated for the resident has already been vaccinated .3. Pneumococcal vaccinations will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician approved pneumococcal vaccination protocol. 4. Residents/representatives have the rights to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. Facility's policy titled Infection Control Policy dated 06/2020 documents in part, Objective: The facility's written program is for the implementation of systems that provide a safe, sanitary and comfortable environment and helps prevent the development and transmission of communicable diseases and infections. The facility's infection control program include: 1. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for residents, staff, visitors and other individuals providing services based upon the facilities assessment in conjunction with hazards and vulnerability analysis that is consistent with national standards. Policy is reviewed annually . 15. The facility maintains procedures for managing outbreaks of infection and pandemics. The facility will follow guidance as provided by the Local Health Department, State Regulatory and/or Communicable disease division, CMS (Centers for Medicare and Medicaid Services) and CDC (Centers for Disease Control) . 19. The facility maintains a program of immunizations for residents to include pneumonia and influenza immunization programs . 24. The facility appoints an Infection preventionist (IP) who is responsible for coordinating the infection control program . a. The IP will be an advocate for each resident to monitor that standards of practice to prevent and control infections is carried out.

Based on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 4 out of 18 residents who are prescribed controlled substances from the second-floor long hall medication cart. Findings include: On 04/29/2025 at 1:26 pm, review of the 2nd Floor long hall medication cart with V15 (RN/Registered Nurse) surveyor observed the Controlled Substances Check Form for April 2025. The Nurse's Initials On box was left blank for April 17, 2025 (3-11 shift). The Nurse's Initials Off box was left blank for April 17, 2025(11-7 shift). The Nurse's Initials Off box was left blank for April 20, 2025 (11-7 shift). The Nurse's Initials On box was left blank for April 21, 2025 (3-11 shift). The Nurse's Initials On box was left blank for April 23, 2025(3-11 shift). The Nurse's Initials On box was left blank for April 26, 2025 (3-11 shift). The Nurse's Initials Off box was left blank for April 26, 2025 (11-7 shift). The Nurse's Initials On box was left blank for April 27, 2025(7-3 shift). The Nurse's Initials On box was left blank for April 27, 2025 (3-11 shift). The Nurse's Initials Off box was left blank for April 27, 2025 (3-11 shift). The Nurse's Initials Off box was left blank for April 27, 2025(11-7 shift). The Nurse's Initials On box was left blank for April 28, 2025 (3-11 shift). The Nurse's Initials Off box was left blank for April 28, 2025 (11-7 shift). The blank spaces on the facility's-Controlled Substances Check Form indicate the controlled substances were not reconciled at the end and beginning of the shift on the specified days. On 4/29/2025 at 1:26pm V15 stated the shift-to-shift controlled substances check form is used by the nurses to count the narcotics. V15 stated two nurses are to count the narcotics together, the nurse going off the shift and the nurse coming on the shift. V15 stated both nurses are to make sure the count of the narcotics is correct and document their initials on the form if the narcotic count is correct. On 4/30/2025 at 12:07am V2 (DON/Director of Nursing) stated the Controlled Substances Check Form is used to verify the count for the narcotics is correct. V2 stated the nurse coming on shift and the nurse leaving the shift are to count the narcotics together and sign off on the Controlled Substances Check Form that the count of the narcotics is correct. V2 stated it is my expectation that two nurses (the incoming nurse and the outgoing nurse) are counting the narcotics and initialing the Controlled Substances Check Form indicating that the count of the narcotics is correct. The facility's policy dated 05/24 and titled Controlled Drug Policy and Procedure which documents in part, 1. Controlled drugs, as determined by the facility, are counted every shift by the nurse reporting on duty with the nurse reporting off-duty. 3. The controlled drug checklist must be signed by the nurse coming on duty and going off duty to verify that the count of all controlled drugs is correct, if used at facility discretion. The facility's undated Registered Nurse job description which documents in part, underneath Duties/ Responsibilities/Function: 11. Ensure that appropriate documentation/charting is completed as required and in accordance with established policies and procedures. 14. Ensure that narcotic records are accurate for your shift. Immediately notify the DON/ADON (Director of Nursing/Assistant Director of Nursing) of any identified drug discrepancies. The facility's undated Licensed Practical Nurse job description which documents in part, underneath Duties/ Responsibilities/Function: 10. Ensure that appropriate documentation/charting is completed as required and in accordance with established policies and procedures. 13. Ensure that narcotic records are accurate for your shift. Immediately notify the DON/ADON (Director of Nursing/Assistant Director of Nursing) of any identified drug discrepancies.

Based on observation, interviews and record review, the facility failed to maintain confidentiality of personal and medical information for two residents (R225 and R69) out of the 54 residents reviewed for privacy and confidentiality of records. Findings include: 1. On 4/28/2025 at 10:05am R225 observed in room, lying in the bed. R225 stated I came to this facility on Thursday (4/24/2025) from the hospital. Observed a white band on R225 's left wrist. R225 stated this is the band I had at the hospital. R225 stated none of the staff have asked me if I wanted the band removed. Observed the following information documented on R225 's white wrist band: MRN# (medical record number), AD (admitted ): 04/13/2025, and R225's date of birth. R225's Face sheet which documents in part, last qualifying hospital stay: 04/13/2025-04/24/2025. 2. On 4/28/2025 at 10:35am R69 observed lying in bed watching television. Observed a white band on R69's right wrist. R69 stated I went to the hospital about two months ago. R69 stated this is the band I got in the hospital. Observed the following information documented on R69's white band: Name, DOB (date of birth), admitted : 3/19/25, MD (medical doctor's name). R69's Face sheet which documents in part, last qualifying hospital stay: 3/19/2025-03/26/2025. On 4/28/2025 at 10:45am V15 (RN/Registered Nurse) stated the nurses are responsible for removing the hospital bands when the resident is admitted back into the facility. V15 stated the purpose of removing the band is due to HIPPAA (Health Insurance Portability and Accountability Act) concerns. On 4/30/2025 at 12:05pm V2(DON/Director of Nursing) stated there is no time frame for the removal of a resident's hospital band once the resident is admitted into this facility. V2 stated the resident must request for the hospital band to be removed. V2 stated the hospital bands usually have the resident's name, date of birth, and clinical number on them. V2 stated the purpose of removing the resident's hospital band once the resident is admitted back into this facility is to prevent giving out the resident's information. V2 stated this (resident continuing to wear the hospital band once admitted back into the nursing facility) is a HIPPA (Health Insurance Portability and Accountability Act) issue. The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities policy presented by the facility, which documents in part, you have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private.

Based on observation, interviews, and record review the facility failed to protect the resident's right (R2) to be free from physical abuse by another resident (R1) out of six residents reviewed for abuse in the sample. This failure resulted in R2 sustaining a laceration to the right center of the head requiring four sutures to close the wound. Findings include: R1's medical record face sheet documented that R1 was admitted on [DATE] and latest admission was on 10/25/24. Listed diagnoses includes but not limited to type 2 diabetes mellitus with other specified complications, other schizoaffective disorders, and other symptoms and signs involving appearance and behavior. R1's MDS (Minimum Data Set) dated 08/28/24 section C scored R1's BIMS (Brief Interview for Mental Status) as 15 indicating that R1 is cognitively intact. R1 care plan for aggression documented that R1 has history of demonstrating aggressive behaviors that can exacerbate at times due to instability to R1's mental illness. R1 as a history of being physically aggressive at times. R2's face sheet showed documentation that R2 was admitted [DATE] with listed diagnoses that includes but not limited to schizoaffective disorder, psychosis, and major depression disorder, type 2 diabetes mellitus with other specified complications, headaches. R2's medical record care plan for abuse showed R2 is potentially at risk for abuse/neglect secondary to diagnosis of schizoaffective disorder, psychosis, and major depression disorder. R2's (MDS) dated [DATE] scored R2's BIMS as 13 indicating that R2 is cognitively intact. R2's medical record Progress Notes dated 10/18/24 timed 10:58pm showed documentation that R2 returned to the facility, from (local hospital) via ambulance with 4 (four) sutures on the right center of the head. R2's emergency room discharge paper dated 10/18/24 presented showed that R2 was seen and attended to for acute head injury. On 10/31/24 at 12:46pm, R1 noted in the room sitting on the bed with a liquid filled plastic coffee cup, R1 was unable to recollect what happened on 10/18/24. R1 was just talking about something irrelevant to a question that was asked. On 10/31/24 at 12:48pm, R2 was observed in bed, R2 stated that I did not do anything to (R1). (R1) came to the bathroom and hit me in my head with a shoe and a cup. (R1) wanted to kill me. I was in pain. Blood everywhere. I have been living in this place for 3 years and (R1) wanted to take me out. R1's facility witness statement dated 10/18/24 timed 1:05pm documented in part that R1 stated that R2 was disrespectful and opening things that don't belong to R2, bothering R1, throwing cup of water at R1, and expressing delusional thinking of R2 doing things to her hair and putting things in her scalp. On 10/31/24 at 12:50pm, V6, Licensed Practical Nurse/LPN, stated that I was in the nursing station charting and I heard a loud yelling noise coming from the common bathroom on the 3rd floor. I got up to see (R2) standing by the sink brushing (R2)'s teeth because (R2) had toothpaste on the mouth and holding the hand over the head with blood. There was a plastic coffee cup on the floor in the bathroom. I had (R1) go to the room and (R2) was brought to the nurse's station with (R2)'s head leaking (bleeding) blood with a small laceration noted on top of (R2)'s head. When asked whether V6 heard or saw both resident arguing, V6 stated I was busy with my (assigned) residents. I did not see or hear any verbal arguments. When asked about how often rounds are made, V6 stated that we are supposed to make rounds every two hours. I have my own residents. V6 stated the assigned nurse (referring to V5, LPN) was not on the floor at the time of incident. V6 stated V5 was on lunch break. On 10/31/24 at 2:57pm, V12 ADON (Assistant Director of Nurse's) stated that the incident between R1 and R2 on 10/18/24 is considered as abuse. On 11/06/24 at 2:30pm, V13 (Physician) stated that it is an occurrence in many places with this type of population to act out, start fights. They are psyche patients but don't get me wrong they (residents) need to be monitored and separated from each other. V13 stated, I don't want any laceration, and (R1) hitting (R2) in the head can cause a bleeding into the brain and the patient (resident) die. The facility Abuse policy presented with revised date of 1/18/2024 documented that the facility affirms the right of the residents to be free from abuse. The purpose of the policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, and mistreatment of residents.

Based upon record review and interview the facility failed to ensure that one of three residents (R2) in the sample remained free from physical abuse and failed to assess (R1) prior to hospital transfer. On 11/9/22, R1 struck R2 in the eye. R1 sustained a fracture of the right 5th distal metacarpal and R2 sustained discoloration to the right eye. Findings include: The initial facility incident report states on 11/10/22 at approximately 8:45am, staff observed (R2) with discoloration to right eye. When asked what occurred (R2) alleged (R1) hit her on 11/10/22 afternoon [per R2's 11/10/22 statement the incident occurred 11/9/22 after lunch]. She (R2) is just now reporting it to staff. Body assessment was conducted by Nurse on duty. R1 was observed with discoloration to right eye. [R2's physical assessment is excluded]. The final facility incident report states (R1) was sent to the hospital for psychiatric evaluation. (R1) initially denied the allegation however when staff visited (R1) in the hospital she admitted to hitting (R2). R2's diagnoses include schizophrenia and hearing loss. R2's (10/27/22) BIMS (Brief Interview Mental Status) determined a score of 15. On 12/21/22 at 12:27pm, surveyor inquired about R2's means of communication. V4 (Social Service) stated, She can't talk. She uses sign language or writes things down. Surveyor inquired about the (11/9/22) altercation. R2 wrote down (R1's name) she was bossy then motioned that she was struck in the right eye. On 12/21/22 at 1:47pm, surveyor inquired about the (11/9/22) incident which occurred between R1 and R2. V12 (Licensed Practical Nurse) stated, I was making rounds and I noticed (R2's) eye so I wrote to her could you tell me what happened to her eye. Her (R2) reply to me was (R1) had hit her (R2) in the eye the night before. I called the doctor and informed him what had happened and received orders to transfer (R1) out. I did assessments on (R2) to see if she was having blurred vision or pain. Surveyor inquired if V12 assessed R1 prior to transfer. V12 responded, No. R1's (11/10/22) hospital history & physical states patient presents from nursing home after having a confrontation with another resident where she reports that she punched a person in the face with her right hand. Complains of painful swelling to the (right) hand 5th metacarpal region. R1's (11/30/22) BIMS (Brief Interview Mental Status) determined a score of 15. R1's (11/10/22) right hand x-ray states there is an acute boxer's fracture of the right 5th distal metacarpal. There is mild to moderate volar angulation of the distal fracture fragments. There is soft tissue swelling. On 12/22/22 at 10:55am, surveyor inquired about potential harm to a resident that gets struck in the eye. V13 (Medical Director) stated, The potential harm is blindness if somebody gets hit, its injury to the eye (if you want to take it to the extreme level) to a minor thing being an abrasion. It depends how hard they got punched or where they got punched. The (11/22/17) abuse prevention policy states residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment.

Based on interview and record review, the facility failed to ensure that residents were free from physical abuse/assault from staff and fell ow residents. This failure affected four residents (R1, R5, R13, and R14) of six residents reviewed for physical abuse/assault. As a result, R14 sustained a facial and arm injury from a physical assault by staff. Findings include: 1. R14's Resident Face Sheet documents that R14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's BIMS (Brief Interview for Mental Status) dated 5/16/22 documents, in part, The BIM score is considered to be on a continuum with a score of 9 or less indicating some level of cognitive impairment and a 10 or greater being an indicator of intact cognitive function. R14 scored a 12. R15's BIMS dated 6/6/22 documents, in part, that R15 scored a 15. On 6/16/22 at 12:10 pm, the surveyor interviewed R15 (R14's roommate) regarding witnessing any physical abuse from staff upon R14. R15 stated, They beat each other up. They used their hands. R14 had blood all over R14's face from R14's eyes. R15 added that this incident occurred in the morning at the doorway of R14 and R15's room. On 6/16/22 at 2:40 pm, the surveyor conducted a phone interview with V13 (LPN/Licensed Practical Nurse) who stated, From what I can remember, (R14) was in a manic state. (R14) attacked me. I tried to redirect (R14), but (R14) scratched me under my eyeballs so I couldn't really see. V13 added, I was just trying to get away from (R14). I don't recall physically touching (R14). V13 stated that after V14 (CNA/Certified Nursing Aide) intervened, V13 left the unit and called the supervisor about the incident. V13 stated that V13 left the building at that time and, I haven't been back. The surveyor attempted to reach V14 for interview on 6/16/22 at 2:30 PM. Voicemail was left. Second attempt was at 2:47 PM with no answer and another voicemail was left. On 6/21/22 at 12:03 pm, V3 (Assistant Administrator) attempted to review the camera footage from 5/31/22 but was unable to locate the video stating, I don't know how to go back. I'm not good with electronics. V3 added that V3 believes the cameras only save recordings for 1-2 weeks. On 6/21/22 at 1:27 pm, the surveyor conducted a phone interview with R14 in the presence of V16 (the hospital social service staff member). R14 stated that on 5/31/22, R14 got up around 4 am to ask V13 for some Tylenol. R14 could not recall if V13 was asleep at the time but stated, V13 was all worked up about something. R14 stated that V13 told R14 to go back to the room and charged at me with a syringe and needle in V13's hand. When V13 did not back down, R14 and V13 got in a fist fight, per R14. R14 stated that V13 threw the first punch at R14's eyes, causing a scratch on the left eye that bled. R14 stated that I (R14) then scratched V13's face. Also, R14 stated that V13 took a Proceed with Caution sign and hit R14 over the head about 10 times. This statement corroborates the complainant's allegation that states the complainant witnessed V13 grabbing a 'Caution Floor is Wet' sign and started beating R14 with it. R14 added, I had a bruise to my right arm. It's still there. V16 was asked to confirm if the bruise is still there and stated, I see that there is something there, but I don't know what it is. Nor can I say that it is from the incident you are all talking about. On 6/22/22 at 2:00 pm, V11 (Social Services Director) stated that with any type of physical altercation (including resident to staff), a full body assessment should be completed for the resident. According to V11, there was no documentation, nor any resident or staff witnesses of R14 being injured by staff on 5/31/22. The surveyor inquired if hypothetically R14 was injured during this altercation, would that have to be reported as abuse? V11 replied, Yes, that would have to be reported by the nurse immediately because we have a two-hour window to submit a reportable to the state. On 6/22/22 at 4:18 pm, V19 MD (Medical Doctor/R14's Primary Physician) denied being notified of R14 sustaining any injury at the time that was notified that R14 attacked 11pm -7 am nurse (per nursing progress note dated 05/31/22), ordering R14 to be sent to the hospital for a psychiatric evaluation. Regarding taking care of psychiatric residents, V19 stated, You have to treat them as a human being. Stay calm. On 6/22/22, the surveyor attempted to reach V14 at 9:16 am and 10:26 am with no success. R14's ED (Emergency Department) Provider Report documented by V18 (ED Physician) documents, in part, History of Present Illness, Initial Comments: (R14) came from nursing home with agitation and aggressive behavior. (R14) was involved in an altercation with nursing staff and sustained injury to left facial region and also left forearm. (R14) states (R14) was pinched and poked . R14's hospital History and Physical dated 5/31/22 documented by V15 (Hospital Admitting Physician) documents, in part, History of present illness: (R14) seen in ER (emergency room ) room [ROOM NUMBER] with a hx (history) of aggressive behavior/agitation. (R14) reportedly had altercation with the nh (nursing home) staff resulting in physical injury to (R14's) face/arm. R14's ED (Emergency Department) Patient Notes documented by V17 RN (Registered Nurse) documents, in part, (R14) with dried blood on shirt and near left eye . R14's facility nursing progress noted dated 6/10/22 at 7:30 pm documents, in part, readmitted .Refuse Physical assessment noted facial redness . R14's Full Clinical/Body Observation dated 6/10/22 documents, in part, Skin: Describe any additional body marks: facial redness. A previous Full Clinical/Body Observation was documented on 05/06/22. R14's facility nursing progress note dated 6/14/22 documents, in part, (R14) has eye appointment .(R14) informed of appointment. R14's Abuse Risk Review dated 5/13/22 documents, in part, Section 1: Identify an areas of abuse the resident has experienced or may be at risk for: physical, verbal, mental; Does the resident have any of the following risk factors (select all that apply): confusion/disorientation, communication barriers, low self-esteem/self-worth. R14's care plan dated 3/10/22 documents, in part, R14 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approach: Assess if behavior endangers others, intervene if necessary; Avoid physical contact with R14; closely supervise R14; Assist R14 to identify effective coping mechanisms; Maintain a calm environment and approach to R14. The facility policy titled Abuse Prevention Policy dated February 2017 documents, in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Amd. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines). 2. On 5/31/22 at 10:20am, V3 (Assistant Administrator) presented the facility's initial and final incident reports dated 5/13/22 that were sent to the State Agency regarding the allegation that a staff member physically abused a resident. V3 explained that the staff (V10) was terminated. At this time, V3 presented V10's Employee File which was reviewed. According to the employee report dated 5/9/22, V10 was suspended pending the investigation. On 5/13/22, V10 was terminated due to the allegation of abuse being substantiated per the facility's investigation. The final facility incident report dated 5/13/22 documents, in part, Investigation completed. Writer interview staff and several resident as possible witnesses. As a result, the allegation was substantiated. R1 was physically attacked by staff. On 6/1/22 at 11:19 am, the surveyor inquired about the witness statements and pointed out the final incident report dated 5/13/22 to V11 (Director of Social Services) documenting, Writer interview staff and several residents as possible witnesses. V11 stated that there was only a staff member that witnessed the event. V11 added that the incident happened in the room when no other residents were present. Referring to the documented statement, V11 stated, That was a typo on my part. There were no resident witnesses. V11 stated that V12 LPN (Licensed Practical Nurse) told V12's supervisor that V12 witnessed the incident, but that V12 didn't talk to V11 directly. V11 looked through the incident report and stated, We're missing a statement from (V12). On 06/01/2022 at 1:43 PM, during an interview with R1 about the incident, R1 stated that there was no one in R1's room at the time of the incident. R1 stated that V10 was putting ice in the pitcher as R1 was standing in the doorway of R1's room. V10 then threw the ice at R1. R1 stated, I don't know what was on that man's mind. R1 stated that R1 then closed the door to R1's room and was holding the door with R1's foot when V10 pushed the door open and began to hit me with (V10's) fists on my face. R1 stated that R1's lip and mouth were bleeding but added that R1 was not taken to the hospital at that time. R1's MDS (Minimum Data Set) dated 2/2/22 documents R1 scored a 12 out of 15 on the BIMS (Brief Interview for Mental Status), indicating R1's cognition is moderately impaired. R1's Resident Face Sheet documents, in part, R1's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 2/3/22 documents, in part, Problem - Category: Psychosocial Well-Being - Trauma: R1's comprehensive assessment reveals a history of substance abuse/chemical dependency and suspected abuse and/or neglect or factors that MAY increase R1's susceptibility to abuse or neglect . Approach: Establish a psychosocial, therapeutic, milieu for R1. Observe R1 for signs of fear and insecurity during delivery of care. Take steps to calm R1 and help R1 feel safe. The facility policy titled Abuse Prevention Policy dated February 2017 documents, in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Amd. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines). 3. On 5/31/22 at 11:45 am, R5 (alleged victim) was observed to be calm and cooperative. R5 was interviewed regarding the incident of 5/4/22 with his roommate R4. R5 stated that R4 (alleged perpetrator) punched him (R5) on the left side of the cheek and his cheek was swollen, and they did an X-Ray on his (R5) cheek. R5 denied hitting R4 at any time and R5 explained that R4 was removed from the room, showing the surveyor the empty bed. R5's BIMS (Brief Interview for Mental Status) dated 12/3/2021 was 14 out of 15 (cognitively intact). Also, R4's BIMS Score dated 5/19/22 was 14 out of 15 (cognitively intact). On 5/31/22 at 12pm, the surveyor attempted to speak with R4, but R4 stated that he did not want to speak with the surveyor. R4's face sheet shows that R4 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's face sheet also shows a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/31/22 at 10:10 am, V3 (Assistant Administrator) presented the facility's preliminary and final investigation reports that were sent to the State Agency. These reports were both dated 5/4/22. The final investigation report states in part: On 5/4/22 at approximately 10am, (R4) became angry and punched (R5) in the face because he was talking too much. As a result, the allegation was substantiated. (R4) was having a psychotic episode, walked over to (R5) and punched him (R5) in the face. (R4) was sent to the hospital for psychiatric evaluation and (R5) was checked out by NOD (Nurse on Duty). X-Ray will be requested on left cheek area. R5's X-Ray report dated 5/14/22 (ten days later) states: Unremarkable facial bone series without obvious radiologic evidence of fracture. R4's progress notes dated 5/4/22 at 10:05 am written by V5 (LPN/Licensed Practical Nurse) states that R4 hit his roommate in the face with a closed fist. On 6/1/22 at 11:44 am, V11 (Director of Social Services) presented the social services progress notes for both R4 and R5 which were reviewed. 4. On 6/16//22 at 11:50 am, V3 presented the facility's investigation reports that were sent to the State Agency. These reports were dated 5/23/22. The final investigation report sent by V11 states in part that R12 struck R13 with open hand at the back of his (R13's) head, and that R12 was very delusional at the time of the assault. On 6/16/22 at 12:15 pm, R13 was interviewed regarding the incident of the alleged physical abuse by R12. R13 stated that R12 punched him (R13) at the back of the head, but that it was not too painful, and that the pain is no longer there. R13's BIMS (Brief Interview for Mental Status) dated 4/6/22 was 15 out of 15 (cognitively intact). On 6/16/22 at 1:44 pm, V11 stated that R12 was having a delusion and very symptomatic at the time R12 hit R13. At this time, V11 presented the social services progress notes and care plans for both R12 and R13. These were reviewed and show that R12 has a history of aggressive behavior and that R12 was sent to the hospital for psychiatric evaluation. MAR (Medication Administration Records) and POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based upon observation, interview and record review the facility failed to ensure that staff are aware of resident fall prevention interventions, failed to score fall risk assessments properly for (R1, R2, R3), failed to provide timely response to (R2's) call light, and failed to implement fall prevention interventions for three of three residents (R1, R2, R3) reviewed for falls. These failures resulted in R1 sustaining a (3/30/21) fall and laceration requiring 13 sutures. R2 sustained a (3/4/21) fall and abrasion with facial swelling/redness. R3 sustained a (3/9/21) fall and forehead skin tear. Findings include: 1)R1's diagnoses include dementia, [CONDITION(S)], weakness, and abnormalities of gait/mobility. The facility occurrence report affirms R1 fell on [DATE], 3/11/21 and 3/30/21. R1's (3/26/21) fall risk assessment determined a score of 7 (low risk) however history of falls in the last 3 months is marked no falls [1 or 2 falls was applicable] and for resident conditions Dementia was not selected [as warranted]. On 4/20/21 at 10:34 am, surveyor inquired if a resident recently fell should low risk for falls be concluded on the assessment V7 (Minimum Data Set Coordinator) stated I would put you at a high risk. R1's (3/30/21) occurrence report form states resident was observed on the floor of his room. Preventive measures at time of fall: low bed no. Resident was observed with a laceration to the back of his head. Resident returned to facility (from hospital) with 13 sutures to the back of his head. On 4/20/21 at 3:16 pm, surveyor inquired about R1's (3/30/21) fall V9 (LPN) stated We was making rounds and he was noticed on the floor at the side of his bed. His head was bleeding, I cleaned him up and noted that he had an opening to his head. Surveyor inquired if R1's bed was in low position prior to falling V9 responded He has a regular bed, he don't have an electrical bed and affirmed his bed was not low. R1's (4/5/21) care plan states resident has history of falling, preventive interventions include well-maintained footwear, bed in lowest position, and equip resident with device that monitors rising. On 4/19/21 at 10:22 am, R1 was observed lying in bed (raised above knee level). R1's bed was missing the crank (to lower it) and a bed alarm was not in use. He was wearing shoes (without socks) and the tongue of his right shoe appeared to be missing. Surveyor inquired about R1's fall prevention interventions V4 (CNA/Certified Nursing Assistant) stated We got to monitor him in the dayroom, make sure his shoes are tied and there's nothing on the floor that he can trip on. Surveyor inquired about R1's fall preventions while lying in the bed V4 responded We keep it as low as possible, so he won't be falling out. Surveyor inquired if R1's bed was in low position. V4 replied No, it's not low. This bed is broken. Surveyor inquired if R1 uses a device (and/or alarm) that monitors rising (as stated on his care plan). V4 stated Not that I know of. On 4/19/21 at 10:31 am, V5 (LPN/Licensed Practical Nurse) affirmed that she's assigned to R1. Surveyor inquired about R1's fall prevention interventions. V5 stated We closely monitor and provide supervision that's pretty much it. Surveyor inquired about R1's fall prevention interventions while lying in bed. V5 responded We try to encourage him to use the call light if he needs assistance. Surveyor inquired about the height of R1's bed. V5 responded That's as low as it can go. It don't have the cranks on it. Surveyor inquired about R1's device that monitors rising. V5 replied That would be considered a bed alarm and affirmed an alarm was not in use. Surveyor inquired about concerns with R1's shoes/footwear. V5 stated They not on properly with the tongue, the shoestring is actually wrong, he has no socks on. 2) R2's diagnoses include dementia, reduced mobility and absence of right/left leg (below knee). The facility occurrence report affirms R2 fell on [DATE] and 3/4/21. R2's (3/4/21) fall risk assessment determined a score of 7 (low risk) however history of falls in the last 3 months is marked no falls [1 or 2 falls was applicable], for medication use none of above was selected although antihypertensive, antipsychotic, & cathartic medications are prescribed, and for resident conditions Dementia was not selected [as warranted]. R2's (3/4/21) occurrence report form states writer was informed by CNA that resident was on the floor. Resident stated he was trying to get in his wheelchair and fell . Head to toe assessment reveals swelling above left eyebrow with small opening/blood noted, slight swelling on right eyebrow, redness under left eye, and small abrasion on bridge of nose. Preventive measures at time of fall: call light on. On 4/20/21 at 2:42 pm, surveyor inquired about R2's (3/4/21) fall. V5 (LPN) stated It was reported to me that he was on the floor he told me he was trying to get into his wheelchair and couldn't make it. The call light was on. R2's (4/13/21) care plan states resident is at risk for falling related to bilateral [CONDITION(S)], transfers without assist, and improper use of wheelchair. Preventive interventions include keep call light in reach at all times. Keep bed in lowest position. On 4/19/21 at 10:37 am, V5 (LPN) affirmed that she's assigned to R2. Surveyor inquired about R2's fall prevention interventions. V5 stated We closely monitor and supervise him and encourage him to use the call light. He tries to transfer without assistance. To my knowledge that's it [bed in lowest position was not inclusive]. R2's call light string was observed knotted up with his roommates call light (dangling from the wall) and out of reach. Surveyor inquired about concerns with R2's call light V5 stated The string is tangled up; it's not separated properly and affirmed it was out of reach. 3) R3's diagnoses include dementia, [CONDITION(S)], weakness, ataxia, and abnormalities of gait/mobility. The facility occurrence report affirms that R3 fell on [DATE] and 3/19/21. R3's (2/18/21) fall risk assessment determined a score of 6 (low risk) however contributing factors include impaired vision which was not selected [as warranted]. For medication use none of above was selected although hypoglycemic and antipsychotic medications are prescribed. R3's (3/9/21) occurrence report states nurse making rounds notice resident on the floor, lying on his back. Resident notice to have a 1-2-inch skin tear in the mid forehead. Preventive measure at time of fall: low bed no and alarm none. On 4/20/21 at 2:10 pm, surveyor inquired about R3's (3/9/21) fall. V6 (LPN) stated I was making rounds, he was on the floor in his bedroom on his back. He couldn't explain to me what happened. He had the call light intact (it wasn't on) but no bed alarm, and no low bed. R3's care plan includes (2/24/21) cognitive loss/dementia; provide cues and supervision. (2/26/21) Resident has history of falling. Equip resident with device that monitors rising. Keep bed in lowest position. Occupy resident with meaningful distractions (e.g.: music, crafts, etc.). Provide resident with safety device/appliance. On 4/19/21 at 10:44 am, R3 was observed standing idle between a table and chair (in the dining room). V6 (LPN) was present (behind the nurses' station) however provided no redirection and/or activities/distractions to R3. Surveyor inquired if R3 fell at the facility. R3 stated I do that every once and a while. I be walking and it just happens. I get dizzy and down I go. Surveyor inquired if he uses any devices R3 responded I used to but not anymore, I had a cane. Surveyor inquired if he was injured during recent fall R3 stated My head was busted. On 4/19/20 at 10:46 am, V6 affirmed she's assigned to R3. Surveyor inquired about R3's fall prevention interventions. V6 stated He's in the dayroom with staff monitoring. We assist him when he wants to go to the bathroom. Surveyor inquired if he uses any devices. V6 stated No, he does not. R3's bed was raised (above knee level) and a crank and/or remote (to adjust the bed) were not present. Surveyor inquired if V6 was able to lower R3's bed. V6 stated I don't see the remote and affirmed she could not. On 4/20/21 at 2:23 pm, surveyor inquired about potential harm to a resident that falls. V10 (Medical Director) stated A lot if they get a bleed in the brain, it's pretty bad. Unwitnessed falls can be dangerous if you don't see any injury, there could be sub-arachnoid hemorrhage. You can also break your neck, break your arm, or break your leg. The falls and fall risk managing policy & procedure (revised August 2008) states; the staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on observation, interview and record review the facility failed to provide supervision for a resident attempting to get up from bed unassisted and implement the use of a functioning bed or chair alarm for a resident at risk for falls. This failure applies to four of six residents (R1, R2, R5 and R6) reviewed for falls, in a sample of six. As a result, R1 who has a history of a fall, attempted to get out of bed unassisted and fell . R1 sustained a hip fracture. Findings Include: -R1's face sheet [DIAGNOSES REDACTED]. R1's fall risk observation dated 2/14/16 indicates that R1 was at high risk for falls with a score of 21. On 2/25/16 E7, Licensed Practical Nurse/Restorative Nurse stated that a score of 21 on R1's fall risk observation is considered high risk. R1's progress note dated 2/2/3/16 indicates that R1 was noted lying on the floor with left leg/hip under the right leg. R1's progress note indicates that R1 was admitted to a local hospital with the [DIAGNOSES REDACTED]. R1's facility incident report dated 2/23/16 indicates that R1 fell out of bed and was noted lying on the floor with left leg and hip under right leg. R1's report indicates that R1 was sent to the hospital with the [DIAGNOSES REDACTED]. R1's hospital radiology report dated 2/23/16 indicates that R1's hip x-ray was positive for an acutely displaced fracture of the subtrochanteric left femur with overriding of the fracture fragments. R1's fall care plan dated 1/21/16 includes an interventions for bed/chair alarm to alert staff to postural changes and ensure proper functioning of alarm devices. R1's statement of witness dated 2/23/16 from E5 Certified Nursing Assistant (CNA) indicates R1's room call light was activated and upon entering the room R1 was noted on the floor between his bed and his roommate's bed. R1's statement of witness dated 2/23/16 from R4 indicates R1 was trying to get out of bed and fell between R1 and R4's bed and the call light was activated for help. On 2/25/16 at 9:30 am R4 (R1's roommate) stated that R1 was trying to get up out of bed. R4 stated that shortly before R1 fell a nurse came into the room and told R1 to lay back down in bed because R1 was trying to get out of bed like he usually does. R4 stated that R1 laid back down in bed at the nurse request but started trying to get out of bed again after the nurse left the room. R4 stated that he observed R1 on the floor between R1 and R4 beds. R4 stated that R1 fell on the floor and was not on the floor mat when he fell . R4 stated that there was not an alarm sounding and he (R4) had to pull the call light to get help. On 2/25/16 at 10:27 am E5 CNA stated that she did rounds on R1 at around 11:35 pm and R1 was trying to get out of bed like he usually does and she instructed him to stay in bed. E5 stated that she responded to the call light in R1 and R4's room shortly after rounds and observed R1 on the floor between R1 and R4's bed. E5 stated that R1's leg didn't look normal. E5 stated that R1 was lying on the floor and there was not an alarm sounding in the room. E5 stated that R1 had one floor mat which was on the opposite side of the bed from which he fell . On 2/25/16 at 12:52 pm E6 Licensed Practical Nurse (LPN) stated that she was alerted by the CNA that R1 needed help. E6 stated that R1 was observed on the floor in an upright position. E6 stated that she did not hear an alarm sounding upon entering R1's room. On 2/29/16 at 9:00am Z1 (R1's Physician) stated he is aware of R1's fall and hip fracture. Z1 stated that R1 is not a candidate for surgery for [REDACTED]. Z1 stated that not all falls are preventable but preventative measures should be put in place to try and prevent accidents if a resident has dementia -R5's face sheet [DIAGNOSES REDACTED]. R5's fall risk observation assessment dated [DATE] documents R5 is at high risk for falls. R5's fall care plan dated 6/25/14 includes an intervention for bed and chair alarm. On 2/25/16 at 9:45am R5 was sitting in the 2nd floor dining room. R5 positioned in the wheel chair with an alarm device hanging off the back of the wheelchair. No wheelchair pressure mat was noted in place to connect to the alarm device. This device alerts staff if R5 is attempting to rise. E4 (Quality Assurance Nurse), who was present at the time of the observation stated, R5 is at high risk for falls. -R2's face sheet [DIAGNOSES REDACTED]. R2's fall risk observation assessment dated [DATE] documents R2 is at high risk for falls. R2's occurrence report dated 1/17/16 indicated R2 suffered a fall in the dining room. R2's report includes an immediate action to apply alarming wheelchair pressure mat. On 2/25/16 at 9:50 am R2 was in a chair while in the 2nd floor dining room. R2 had a safety helmet in place. R2 was observed with a chair alarm mat in place. The surveyor wanted to confirm if the alarm was working. E4 (Quality Assurance Nurse) assisted R2 to a standing position. However the alarm did not sound when R2 was assisted by E4 (Quality Assurance Nurse) to a standing position. E4 stated R2 is at high risk for falls. On 2/25/16 at 1:15 pm E7, Licensed Practical Nurse/Restorative Nurse stated that R2 should have a chair alarm as a care plan intervention. - R6's face sheet [DIAGNOSES REDACTED]. R6's fall risk observation dated 1/28/16 indicates that R6 is at high risk for falls. R6's fall care plan dated 9/5/15 includes an approach to apply bed/chair alarm to alert staff of postural changes. On 2/25/16 at 9:55 am with E4, R6 was observed sitting in the 2nd floor dining room with a chair alarm pad in place. R6's chair alarm failed to sound when assisted to a standing position by E4. On 2/23/16 at 1:15pm E7 Restorative Nurse stated care plans are updated 24 - 72 hours after a fall depending on the day of the incident. E7 stated that interventions are put in place immediately after a fall. E7 stated that R2, R5 and R6 should have chair alarms in place. E7 stated that R1 did not have an intervention for floor mats. E7 stated that R1 had the intervention for bed alarm just in case the nursing staff felt it was necessary to put interventions in place. E7 stated nursing staff often use safety alarms as an immediate intervention.

Based on interviews and record review, the facility failed to notify the physician of abnormal X-ray result and failed to notify the physician of critical high/low [MEDICATION NAME] level upon receipt from the laboratory for one of three resident (R1) reviewed for change in condition. This failure resulted in a R1 having a [MEDICAL CONDITION], and being sent the hospital for evaluation and assessed to have a [MEDICAL CONDITION]. Findings include: [MEDICATION NAME] level reference range is 10 - 20. 1/12/15 at 3:55am, R1's [MEDICATION NAME] level was 38.2 CH (critical high); this lab result was phoned and faxed to E12 RN (registered nurse) at 5:14pm on 1/12. 1/13/15 at 9:25pm, R1's [MEDICATION NAME] level was 39.2 CH; this result was phoned and faxed to E12 RN at 11:04pm on 1/13. There is no notation on this report to indicate R1's physician was notified. 2/9/15 at 4:00am, R1's [MEDICATION NAME] level 25.0 CH; this result was phoned and faxed to E11 LPN at 2:20pm on 2/9. 3/16/15 at 3:50am, R1's [MEDICATION NAME] level 4.9 CL (critical low); this result was phoned and faxed to E12 RN (registered nurse) at 6:20pm on 3/16. Review of R1's progress notes dated 1/12, 2/9, and 3/16 do not indicate R1's physician was notified of the abnormal lab results until the following day. The progress notes do not indicate R1's physician was notified at all regarding the abnormal lab result on 1/13. Review of R1's POS (physician order [REDACTED]. Review of R1's MAR (medication administration record) for January 2015 notes the following: [MEDICATION NAME] capsules 300mg (milligram) oral at bedtime was not administered on 1/13/15 or 1/14/15. [MEDICATION NAME] capsules 100mg oral in the morning was not administered on 1/10/15 or 1/18/15. Review of R1's POS (physician order [REDACTED]. Review of R1's MAR for February 2015 notes the following: [MEDICATION NAME] capsules 300mg oral at bedtime was not administered on 2/10, 2/11, 2/12, or 2/13. Review of the safety event dated 2/15/15 notes R1 was found on the floor and difficult to arouse. R1's neurological assessment notes R1 was lethargic/drowsy, did not perceive the environment fully, responded to stimuli appropriately but slowly and with delay. Review of R1's POS (physician order [REDACTED]. Review of R1's right hip and femur x-rays report dated 2/15/15 notes [MEDICAL CONDITION] arthritic changes with suspicious deformity of the subcapital region of the neck of the right femur. Review of R1's progress notes dated 2/15 and 2/16 do not indicate that R1's physician was notified of R1's x-ray results. Review of R1's hospital record dated 3/4/15 notes that R1 was transferred to an acute care facility after having a [MEDICAL CONDITION]. R1's [MEDICATION NAME] level on admission was 7.0. An x-ray of R1's pelvis noted an impacted [MEDICAL CONDITION] hip. R1 required surgery on right hip on 3/5. During interview on 3/17/15 at 4;30pm, R1 stated that R1 had a [MEDICAL CONDITION] in February and fell out of bed. R1 stated that R1's right hip and right knee were injured at that time. R1 stated that R1 received medication as needed for complaints of right hip pain. R1 denied falling out of bed during recent [MEDICAL CONDITION] on 3/4. During interview on 3/18/15 at 10:45am, E4 CNA (certified nursing assistant) stated that she found R1 lying in bed having [MEDICAL CONDITION]; at no time did R1 fall out of bed. E4 stated that R1 frequently used a wheelchair after fall on 2/15. During interview on 3/18/15 at 10:51am, E5 LPN (licensed practical nurse) stated that she found R1 lying in bed having a [MEDICAL CONDITION]; at no time did R1 fall out of bed. E5 stated that R1 was observed using a wheelchair more frequently after fall on 2/15. E5 stated that R1 was receiving [MEDICATION NAME] to prevent [MEDICAL CONDITION]. During interview on 3/18/15 at 2:30pm, Z1 (attending physician) denied being notified of x-ray results dated 2/15/15 and stated this is the first time hearing that it was suspicious for right femur fracture. Z1 stated that R1 should have had further workup for this at that time. Z1 stated that R1 is receiving [MEDICATION NAME] to prevent [MEDICAL CONDITION] from occurring. Z1 stated that R1's falls on 1/25, 1/27, and 2/15 could have been due to R1 not receiving [MEDICATION NAME] as ordered resulting in [MEDICAL CONDITION]. During interviews on 3/19/15 at 12:00pm, E18 (restorative aide) and E19 (restorative aide) stated that R1 ambulated with a rolling walker since admission. After R1's fall on 2/15/15, R1 had difficulty walking, unsteady gait, used a wheelchair, and complained of rigth hip pain.. During interview on 3/19/15 at 3:50pm, E13 ADON (assistant director of nursing) stated that after R1's fall on 2/15, she often observed R1 in a wheelchair but occasionally R1 ambulated with rolling walker. E13 stated that she was not aware of R1's x-ray results dated 2/15. Review of falls care plan initiated 1/16/15 notes R1 is at increased risk for injury related to [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to secure room windows, failed to define and implement supervision and monitoring for residents at risk for elopement, failed to identify and document potentially self injurious behaviors, failed to follow elopement policy and procedure and failed to prevent one resident (R24) from falling/jumping from a third story window of three residents reviewed for elopement in the sample of 26 residents. This failure resulted in R24 sustaining wrist, rib, hip and foot fractures from the fall. Findings include: Physicians Order Sheet dated 5/1/14 to 5/31/14 indicates R24 is a [AGE] year old female who was admitted to the facility 4/11/14 with [DIAGNOSES REDACTED]. R24 was a resident on the third floor of the facility, the building has three resident floors. Nursing Notes dated 4/14/14 at 9:41pm indicate at 5:00pm R24 was agitated and noted to be ambulating out of her room with all her belongings. Note also indicates R24 was screaming out her window "help" but refused to state what she needed help with when asked. Psychiatric Evaluation dated 4/28/14 indicates R24 had poor impulse control and poor insight. Note also indicates R24 was delusional, denied suicidal and homicidal ideations. Social Service Notes dated 4/15/14 at 5:04pm indicates R24 was observed screaming out of the window. Social Service Note dated 4/18/14 3:07pm indicates R24 had attempted to elope twice from the facility, that R24 is ambulatory and spends the majority of her time looking out the window in her room. Note indicates R24 Brief Interview For Mental Status (BIMS) score is 13/15. Note furthers indicates Assessment: Unauthorized Departure/Elopement Risk Assessment score is (2) - Moderate risk and that the R24 has attempted to elope from the facility twice. Unauthorized Departure/Elopement Risk assessment dated [DATE] indicates that on 4/14/14 R24 tried to leave the building and was difficult to redirect and that on 4/15/14 R24 was screaming out of her bedroom window. Assessment indicates risk score of 12 and states that a score of (4) or greater indicates a reasonable departure risk potential and appropriate interdisciplinary interventions. Care Plan Problem: Behavioral Symptoms with problem start date of 4/26/14 indicates (Wandering) R24 with attempts to elope from the facility because she wanted to go wash her clothes. Approach start date of 4/26/14 indicates: Maintain safe environment (secured windows, functioning alarm device, etc.) No documentation of R24 screaming out of her window was found in R24's care plan or description of a second attempt by R24 to elope from the facility. On 5/15/14 at 2:00pm E5, Psychosocial Rehabilitation Services Coordinator (PRSC) stated that on 4/15/14 she was walking by and checking on residents when she observed R24 screaming out of her room window. E5 further stated that the window screen was slightly pushed over at that time but not pushed out. Facility Nursing and Rehabilitation Center Elopement Policy (undated) indicates: If a resident attempts to elope from the facility, resident will be put on increased supervision and monitoring in order to ensure knowledge of whereabouts. On 5/15/14 at 2:15pm E12, Psychosocial Rehabilitation Services Director (PRSD) stated that the facility doesn't have any formal supervision or monitoring for residents at risk for elopement, "We just try to eyeball them more." On 5/21/14 at 12:40pm via telephone E12 stated that there is no documentation of how staff are monitoring residents assessed to be at elopement risk. E12 further stated that the facility elopement policy is the same as elopement precautions and there is no documentation of increased monitoring or supervision by social service or nursing staff. E12 identified seven residents currently in the facility who have been identified as being on Elopement precautions. On 5/14/14 at 3:50pm R43, roommate of R24, stated that she last saw (R24) on 5/11/14 at approximately 9:45am. R43 stated "I went out of the room then to go smoke. I wasn't in the room when R24 jumped." On 5/15/14 at 10:45pm E13, Housekeeper stated that on 5/11/14 he was just coming to clean R24's room when he noticed that the window curtain was pulled back, the window was wide open and the window screen was behind the bed. E13 stated he then looked out of the window and saw R24 lying on the ground and was moving on the grass. E13 further stated that he noticed a big suitcase with belongings packed on top of the suitcase placed in front of and below the window. E13 went on to state that he had never seen the window open like that before, that usually the windows are only open about 6-8 inches. Nursing Notes dated 5/11/14 at 11:01am indicates R24 was noted on the ground below her window lying on her left side, at 10:20am emergency department called. Note further indicates R24 was alert and complained of pain to right wrist and on right side of body. Note at 12:44 indicates R24 had a laceration to her left forearm area and was transported to the hospital. Social Service Note dated 5/11/14 at 12:07pm indicates R24 jumped out of the window of her room. Social Service Note dated 5/11/14 at 12:35pm indicates R24 presented with self-injurious behavior as evidenced by jumping out of the window. Hospital Emergency Department/Trauma History and Physical Addendum dated 5/12/14 indicates: R24 was found on the ground outside of an open third story window, purportedly jumped. Left hip fracture, mildly displaced fracture of right fourth and right 5th rib; displaced right 9th and 10th rib fractures, small right hydropneumothorax; right wrist fracture; left 2nd and 3rd toe fractures. On 5/15/14 at 10:55am E14, Maintenance Director stated "Approximately two weeks ago we put two screws in (R24's) window track to keep the window from sliding more than 6 inches because (R24) was sticking her head out the window and screaming." E14 further stated that all windows are checked visually on Mondays but documented only monthly. On 5/15/14 at 11:10am during inspection of third floor windows, it was observed that windows can be lifted entirely out of the frame. E13 acknowledged that he was aware that the sliding window could be entirely removed from the frame which would allow window opening greater than 6 inches. One standard type screw was observed placed into the window track in windows on the second floor to prevent the windows from opening more than six inches, E13 acknowledged that was how the window was in R24's room on the third floor previous to her jumping from the window. On 5/23/14 at 3:15pm E8, Maintenance Supervisor stated that the type of windows used throughout the facility in resident rooms is a thermal pane window with a steel frame. The windows measure 71.5 inches wide and 58.5 inches tall with the opening of the window 35.25 inches if fully opened. On 5/15/14 at 12:00pm E8, Maintenance Supervisor stated that on 5/6/14 he was told by social service staff that R24 was sticking her head out her window and screaming and at times would push the screen aside and throw things from the window. E8 went on to state that he went to R24's room and added an additional screw into the window track next to the original screw to prevent the window from sliding all the way open. E8 further stated that he notified his supervisor E14 after placing the second screw on 5/6/14. E8 stated that he did not follow up to check if the screws were intact after adding the screw on 5/6/14. E8 went on to state that on 5/11/14 after R24 went out the window, that one screw was taken out from R24's window track and one screw was snapped in half. E8 stated that he could not recall who the social service staff were that notified him on 5/6/14. No documentation was found or presented regarding R24 sticking her head out of the window on 5/6/14. On 5/23/14 at 3:15pnm E8 stated that he believed R24's window was a safety issue and that he is supposed to report safety issues to the mainteance supervisor. On 5/16/14 at 9:30am R24 was interviewed at the hospital where she was recovering from her injuries sustained in the fall. At that time R24 stated that she was just looking over and out the window ledge when she fell out of the window. R24 went on to state that she had pushed the window "up and over" because it wouldn't freely go by itself. R24 went on to state that "normally there is a stopping point when sliding the window so you can't stick your head out - that's when I lifted the window up and over which broke the screws." R24 admitted to taking the screen out and placing it inside by the bed. R24 stated that she did not recall maintenance ever coming in prior to the accident to fix or secure the windows. Monthly Maintenance Inspection Log dated April and May 2014 indicate on 4/18/14 and 5/6/2014 Item: Windows (be sure they cannot be opened more than 6 to 10 inches). Item is marked "No" for good working order with "replaced screws as needed" as the action to correct the issue. Log does not indicate what room or rooms had screws replaced. Monthly Maintenance Inspection Log Policy and Procedure (undated) indicates: 2. Immediately repair any item that poses a hazard to residents or employees. On 5/16/14 at 4:15pm via telephone E1, Administrator stated that he was aware that all building windows were initially using the one screw method of stopping windows from sliding all the way open. E1 also stated he was aware that R24 had been screaming out of her window, however was not aware that R24 had been sticking her head out of the window or that E8 placed an additional screw in R24's window on 5/6/14 after R24 was observed sticking her head out of the window and screaming. E1 went on to state that he should've been notified about the incident on 5/6/14 and maintenance's response.

Based on record review and interview the facility failed to follow their policy for transferring one resident (R1) out of five residents reviewed for falls in a sample of seven. This failure resulted in one resident (R1) sustaining a fracture of the right leg. Record review of facility's final incident report dated 2-18-12 denotes E7(certified nurse assistant - CNA) in room with resident preparing to transfer resident into wheelchair and resident slid off the side of bed landing on her right side. Resident complained of pain to right leg. Medical doctor was notified and gave order to send resident to emergency room . In an interview, E1 (Director of Nursing) on 3-16-12 at 9:50 AM stated that E7 was terminated because of the fall incident. E7 did not wait for help before transferring R1. The facility's safe lifting and movement of residents policy denotes "Mechanical lifting devices shall be used for any resident needing a two person assist." R1's Minimum (MDS) data set [DATE] denotes under section G: Transfer- how resident moves between surfaces including to or from bed,chair, wheelchair; (4) total dependence, (3) two+ persons physical assist. The facility's written statement of witness dated 2-18-12 denotes, "was in the process of transferring R1 to chair and I sat her up on the side of the bed and turn around to put the sit to stand belt on R1 and she moved and started to slide so to prevent her fall I slid her to the floor by her bed. In the process of sliding her left leg was bend while trying sit to the floor. She complained of pain and I reported to 11-7 nurse and 7-3 nurse." On 3-27-12 at 10:05 AM E6, (CNA) stated she was showering another resident when E7 came in shower room and asked her to help get R1 off the floor. E6 states after she put her resident in the chair and came out of the shower room the nurse told her that they had already gotten R1 off the floor and put him in the bed. R1's nurse's notes dated 2-18-12 denotes "informed per 11-7- CNA that resident (R1) slid off bed landing on her buttock and right leg. R1 started crying that her right leg hurt. Doctor paged orders to send R1 to hospital." R1's hospital record dated 2-18-12 denotes X-ray of right knee showed comminuted fracture involving distal right femur with posterior medial displacement. R1's hospital consultation report dated 2-25-12 indicates that R1 underwent ORIF (open reduction internal fixation) on 2-24-12.

Based on observation, interview, and record review, the facility failed to put into place interventions to prevent 1 resident ( R3) from falling repeatedly out of a recliner chair, in the sample of 18. R3 sustained a laceration at the frontal area of the head requiring sutures. Findings include : R3 has [DIAGNOSES REDACTED]. During 3/4/11 observation at 11 AM, R3 was observed in a recliner chair, calm and not restless, and is unable to get out of the recliner. Per incident report log, R3 had the following fall incidents : a) 5/6/10 - fell in the room during morning shift, sustaining hematoma of the head and ear. b) 7/2/10 11:48 AM - fell from the recliner chair in the dayroom during morning shift, sustained no injury. Per facility investigation, R3 attempted to reposition self without staff assistance, and that R3 tries to move around constantly. c) 12/3/10 3:20 PM - Observed in the 2nd floor dayroom, R3 on her right side with small amount of blood on the lower lip. R3 was up in the recliner chair prior to being found on the floor. R3 was assisted back to chair. d) 1/11/11 5:15 PM - R3 was seen jump out of the recliner to the floor. Prior to incident, R3 was seen sitting on her recliner chair. During 3/4/11 interview at 2 PM with E4 (social service staff ), E4 said that on 1/11/11, she was on the 2nd floor nurses station and R3 was in her recliner in the hallway, directly in E4's view. E4 said that 20 minutes before that, she also saw R3 in the same spot squirming. E4 added that R3 normally would slide down from her recliner chair but would sit back up, if told. E4 continued that she just heard a thump, and saw R3 lying on the floor in front of the recliner. When E3 (Rehab Nurse) was interviewed on 3/4/11 at 2:45 PM, E3 said that she just started in her position around November 2010. E3 said that regarding the 1/11/11 fall, she does not know how R3 could jump out of the recliner because R3 cannot do anything. E3 said that R3 has hand splints so R3 cannot grab the recliner arm rests. Although R3's nurses notes on 1/11/11 indicated that the nurse charted that R3 jumped out of the recliner, E3 said that she did not talk with that particular nurse. Review of the facility's investigation indicated that no one actually saw how R3 fell on [DATE]. E3's fall assessments done for the 12/3/10 and 1/11/11 fall did not actually indicate what caused R3 to fall from the recliner, despite R3's needing total assistance with transfers. Review of R3's post fall assessment showed that for the above 3 falls in 2010, the facility's post fall assessments were all done late. Although R3 fell on [DATE], her post fall assessment was done on 5/26/10. Post fall assessment for 7/2/10 was done on 7/12/10 and the one for the 12/3/10 fall, was done by E3 on 12/7/2010. Furthermore, R3's care plan indicated no interventions to prevent R3 from falling out of the recliner chair. Care plan review with E3 of R3's 12/3/10 and 1/11/11 care plan, showed no change in facility's interventions to prevent R3 from falling off the recliner. E3 verified that R3 never had a chair alarm while up on her recliner, and that her entry on 12/22/10 care plan was a typo error which she corrected on the 1/12/11 care plan. Although R3's 5/7/10 care plan indicated chair alarm, safety belt, and anti-tipper are in place when R3 is up on her chair, E6 (7-3 nurse) said during 3/4/11 interview at 11 AM, that she does not remember any device used for R3 while in her recliner. Added to this, R3's 5/7/10 care plan also indicated use of gait observation and evaluate R3's footwear needs despite R3's non-ambulatory status. Similarly, review of R3's 7/2/10 care plan showed no intervention to prevent R3 from falling from her recliner chair. Per R3's incident report dated 1/11/11, R3 sustained a laceration to the left frontal area of the head and was sent to the hospital and came back with 3 sutures to the left eye area.

Based on interviews and record reviews, the facility failed to consistently utilize an assistive device, mechanical lift, in transporting of one sampled residents, R1. Facility staff failed to follow it's policy for transfers. This deficient practice has the potential of affecting all 7 residents on the unit who require total assist with transfer. Findings include: R1's closed record review shows that she has very limited mobility due to a [DIAGNOSES REDACTED]. R1 is totally dependent on staff for transfers and requires the use two person assist with a mechanical lift. R1 sustained a fracture of unknown origin to her left arm on 10/6/10. E5, Certified Nurses Aide (CNA) was responsible for R1's care at the time the injury was first observed. E5 told surveyor during a phone interview on 11/9/10 that he did not use the mechanical lift to transfer R1 from bed to recliner chair. E5 stated that, with two persons assist, he used the bed sheet to transfer R1. E4, CNA, also told surveyor during a separate interview, that when she transferred R1 back to bed having observed grossly swollen left arm, she used the "two-man lift". E16, CNA, told surveyor during an interview on 11/10/10 that at least two of five days the mechanical lift does not work and she, E16, uses two-person manual lift for residents who require total assist. E16 stated that the mechanical lift batteries are not consistently re-charged and the lift cannot be used. E15, CNA, also confirmed during an interview that the mechanical lift does not always work because the battery is not always charged. Review of the facility's in-service training report dated 6/6/10 and 10/11/10 shows CNA's being inserviced on the use of the mechanical for namely R1, R3, R7. R9 was not named as requiring mechanical lift on those reports.

Based on observation, interview, and record review, the facility failed to put in place interventions to prevent 1 resident ( R3) from falling repeatedly out of a recliner chair, in the sample of 18. R3 sustained a laceration at the frontal area of the head requiring sutures. Findings include : R3 has [DIAGNOSES REDACTED]. During 3/4/11 observation at 11 AM, R3 was observed in a recliner chair, calm and not restless, and is unable to get out of the recliner. Per incident report log, R3 had the following fall incidents : a) 5/6/10 - fell in the room during morning shift, sustaining hematoma of the head and ear. b) 7/2/10 11:48 AM - fell from the recliner chair in the dayroom during morning shift, sustained no injury. Per facility investigation, R3 attempted to reposition self without staff assistance, and that R3 tries to move around constantly. c) 12/3/10 3:20 PM - Observed in the 2nd floor dayroom, R3 on her right side with small amount of blood on the lower lip. R3 was up in the recliner chair prior to being found on the floor. R3 was assisted back to chair. d) 1/11/11 5:15 PM - R3 was seen jump out of the recliner to the floor. Prior to incident, R3 was seen sitting on her recliner chair. During 3/4/11 interview at 2 PM with E4 ( social service staff ), E4 said that on 1/11/11, she was on the 2nd floor nurses station and R3 was sitting on her recliner in the hallway, directly on E4's view. E4 said that 20 minutes before that, she also saw R3 in the same spot squirming. E4 added that R3 normally would slide down from her recliner chair but would sit back up, if told. E4 continued that she just heard a thump, and saw R3 lying on the floor in front of the recliner. When E3 ( Rehab Nurse ) was interviewed on 3/4/11 at 2:45 PM, E3 said that she just started in her position around November 2010. E3 said that regarding the 1/11/11 fall, she doesn't know how R3 could jump out of the recliner because R3 cannot do anything. E3 said that R3 has hand splints so R3 can't grab the recliner arm rests. Although R3's nurses notes on 1/11/11 indicated that the nurse charted that R3 jumped out of the recliner, E3 said that she did not talk with that particular nurse. Review of the facility's investigation indicated that no one actually saw how R3 fell on [DATE]. E3's fall assessments done for the 12/3/10 and 1/11/11 fall did not actually indicate what caused R3 to fall from the recliner, despite of R3's needing total assistance with transfers. Review of R3's post fall assessment, showed that for the above 3 falls in 2010, the facility's post fall assessment were all done late. Although R3 fell on [DATE], her post fall assessment was done on 5/26/10. Post fall assessment for 7/2/10 was done on 7/12/10 and the one for the 12/3/10 fall, was done by E3 on 12/7/2010. Furthermore, R3's care plan indicated no interventions to prevent R3 from falling out of the recliner chair. Care plan review with E3 of R3's 12/3/10 and 1/11/11 care plan, showed no change in facility's interventions to prevent R3 from falling off the recliner. E3 verified that R3 never had a chair alarm while up on her recliner, and that her entry on 12/22/10 care plan was a typo error which she corrected on the 1/12/11 care plan. Although 5/7/10 care plan indicated chair alarm, safety belt, and anti-tipper are in place when R3 is up on her chair, E6 ( 7-3 nurse ) said during 3/4/11 conversation at 11 AM, that she does not remember any device used for R3 while on her recliner. Added to this, R3's 5/7/10 care plan also indicated use of gait observation and evaluate R3's footwear needs despite R3's non-ambulatory status. Similarly, review of R3's 7/2/10 care plan showed no intervention to prevent R3 from falling from her recliner chair. Per R3's incident report dated 1/11/11, R3 sustained a laceration to the left frontal area of the head and was sent to the hospital and came back with 3 sutures to the left eye area.