Every finding on record at Marshall Rehab & Nursing

Based on observation, interview, and record review the facility failed to provide and maintain a safe, functional, sanitary and comfortable environment. This failure has the potential to affect all 53 residents residing in the facility. Findings Include: The Environmental Services Homelike Environment policy dated 12/27/23 documents the facility supports the residents to live in a homelike environment. Housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. The Resident Rights Policy and Procedure dated 2026 documents each resident has the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. On 6/12/26 at 12:05 PM, R9 stated the shower rooms are pretty bad most of the time and need cleaned and repaired. On 6/12/26 at 12:20 PM, Shower Room C/D had a black substance all over the shower tile, a rusty register, a shower head that was constantly dripping, hair clogging the shower drain, and a broken vanity cabinet with trash all under sink. Shower Room A/B had an orange substance all over the shower tile, a rusty register, a thick layer of dust covering the vanity lights, a broken toilet with plastic wrap covering toilet, and peeling black paint covering the entire shower room floor. On 6/12/26 at 1:10 PM, V13 Maintenance Man confirmed the facility has two shower rooms for the entire resident population. V13 confirmed the Shower Room on C/D had a leaking shower head. V13 also confirmed the radiators are very old and rusty. V13 confirmed there is orange and black substance appearing to be mildew on the tiles in both shower stalls. V13 confirmed the toilet in Shower Room A/B does not work and needs fixed. V13 confirmed the vanity is broken and needs replaced in Shower Room C/D. V13 stated a lot of maintenance and upgrades need to take place but the facility needs the funds to do it. On 6/12/26 at 1:16 PM, V9 Housekeeping Supervisor stated housekeeping staff are supposed to clean shower rooms daily however the facility has been short staffed, so she has had to work the floor a lot, and things are not getting done like they should. The facility's Midnight Census Reported dated 6/12/26 documents a facility census of 53 residents.

Based on observation, interview and record review the facility failed to ensure resident meals are palatable. This failure has the potential to affect all 58 residents residing in the facility.Finding include:The Facility Daily Midnight Census documents 58 residents reside in the facility.The Facility Grievance concern dated 12/1/25 documents the food was 'cold'. On 2/24/26 at 1:00 PM, Resident meal trays were sitting in the main dining room with more than half of the food left on each of twelve trays.On 2/25/26 at 12:55 PM, Resident meal trays were sitting in the main dining room with more than half of the food left on each of fifteen trays.On 2/25/26 at 1:15 PM, the facility provided a test tray. V8 Certified Dietary Manager (CDM) obtained the temperature of the beef stew at 132 degrees Fahrenheit. The beef stew and mixed vegetables did not taste warm.On 2/24/26 at 1:00 PM, R11 stated his meal was cold. R11 stated his food looked like 'slop' and would not serve it to anyone he cared about. R11 stated the food is always cold and does not taste good. R11 stated the food is frequently over cooked causing it to be burned or dried out. On 2/24/26 at 1:10 PM, R2 stated the facility food is usually served cold. R2 stated he was served cold pancakes and they were not edible. R2 stated he prefers to eat his meals in his room and states that may be part of the problem. R2 stated he has complained about this before, so the facility bought 'pucks' to heat up and place under the plates. R2 stated sometimes the pucks are not even warm and sometimes the staff forget to use the pucks altogether. On 2/25/26 at 2:00 PM, V1 Administrator stated she is aware there have been multiple complaints about the food being served cold or not tasting good. V1 Administrator stated the facility is working on this problem and hopes to have it resolved soon.

Based on observation, interview and record review the facility failed to prevent cross contamination during meal service. This failure has the potential to affect all 58 residents residing in the facility.Findings include:The Facility Daily Midnight Census documents 58 residents reside in the facility.On 2/25/26 at 11:10 AM, the facility kitchen air conditioning unit hanging on the inside of the facility kitchen was dripping water onto the dishwashing area and onto the floor splashing over three to four feet to the food service area. On 2/25/26 at 11:40 AM, V8 Certified Dietary Manager (CDM) accidentally knocked the resident paper meal tickets off of the counter during meal service. V8 used gloved hands to pick up all the food service paper tickets that had spread over a three to four foot area on the kitchen floor. V8 CDM then placed the meal tickets back on the corner of the warmer counter. V22 [NAME] was also present when this occurred and assisted in picking up the meal tickets. V22 [NAME] then took the pile of contaminated meal tickets and placed them on resident meal trays to serve to the residents. On 2/25/26 at 1:20 PM, V8 Certified Dietary Manager (CDM) stated the facility air conditioner 'broke' earlier this morning (2/25/26). V8 stated the air conditioner was dripping condensate 'all over the kitchen' but the facility has called a service worker to get the problem fixed. V8 CDM stated This doesn't look good. What a day for this to happen! V8 CDM stated V8 should have re-printed the paper meal tickets due they became contaminated when they all touched the floor. V8 CDM stated V8 and V22 both picked up the tickets and put them on the meal trays. V8 stated the tickets stay with the meal trays so there is a good chance all of the trays would have been contaminated. V8 CDM stated the facility is going to start placing the meal tickets in a small metal pan to help prevent them from being knocked off again.

Based on observation, interview and record review the facility failed to prevent cross contamination during wound care for one (R10) resident out of three residents reviewed for wounds in a sample list of 13 residents.Findings include:R10's Minimum Data Set (MDS) dated [DATE] documents R10 as moderately cognitively intact. This same MDS documents R10 requires assistance with toileting and personal hygiene.R10's Physician Order Sheet (POS) dated February 2025 documents a physician order starting 2/23/26 to apply a Hydrocolloid dressing to R10's Coccyx area every other day.R10's Wound Progress Note dated 2/23/26 documents R10's open area on R10's Coccyx as Moisture Associated Skin Dermatitis (MASD). On 2/25/26 from 9:00 AM-1:00 PM, R10 sat up in R10's wheelchair without being provided incontinence care. On 2/25/26 at 2:35 PM, V11 Licensed Practical Nurse (LPN) and V23 LPN completed wound care for R10. V11 LPN gathered the necessary supplies of gauze, dressing, scissors and wound cleanser by holding them against her jacket with her arms. V11 LPN was wearing a zip up hoodie style jacket. V11 LPN placed R10's wound supplies on her bedside table prior to ensuring R10's bedside table was disinfected. The previous dressing was a simple foam dated 2/23/26. R10's Coccyx showed an open, red wound approximately the size of a quarter size with a non-blanchable peri wound. R10 also had a separate open, red, line shaped open wound approximately an inch long. On 2/25/26 at 2:50 PM, V11 LPN stated she contaminated R10's supplies by holding them against her contaminated jacket. V11 LPN stated R10's open Coccyx wound was the size of a pencil eraser 'a few days ago'. V11 LPN stated R10 did not have any open areas on R10's Right Buttock. V11 LPN stated R10's Coccyx wound had worsened.On 2/25/26 at 3:15 PM, V16 LPN/Wound Nurse stated the staff do not lay R10 down after breakfast as they should and that is why R10 has open areas on R10's bottom. V16 stated she was not aware that R10's Coccyx wound had worsened nor that R10 had a new area on R10's Right Buttock.On 2/25/26 at 3:30 PM, V2 Director of Nurses (DON) stated staff should provide incontinence care for residents every two hours and as needed. V2 DON stated the expectation is for staff to provide preventative cares such as repositioning and toileting in order to prevent wounds from happening. V2 DON stated R10 is incontinent and requires assistance with incontinence care.

Based on observation, interview and record review the facility failed to prevent cross contamination during incontinence care for one (R6) resident out of three residents reviewed for incontinence care in a sample list of 13 residents.Findings include:R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. This same MDS documents R6 requires assistance with toileting and personal hygiene.On 2/24/26 at 1:50 PM V5 and V6 Certified Nurse Aides (CNA) completed incontinence care for R6. R6's bedside table was not disinfected prior to V5 placing clean dry washcloths on the bedside table. V5 CNA repeatedly used both gloved hands to provide front perineal care, then used both contaminated hands to obtain and wring out a washcloth that was sitting in a basin of warm water. After V5 CNA completed front incontinence care, R6 was assisted to R6's left side. R6 stated 'Oh! I am going again'. As R6 was urinating again, V5 CNA used the contaminated incontinence brief to 'catch' R6's urine. V5 CNA did not provide front perineal care after R6 urinated. V5 CNA used contaminated gloves to pull out the urine saturated incontinence brief and then placed a new brief without washing her hands, changing her gloves or using hand hygiene. V5 CNA did not apply barrier cream after completing incontinence care for R6. On 2/24/26 at 2:05 PM, V5 CNA stated V5 should have provided incontinence care after R6 urinated. V5 stated V5 should have changed V5's gloves after touching contaminated items and before placing the new incontinence brief. V5 stated V5 contaminated the clean wash water each time V5 used her contaminated gloved hands to dip into the water. On 2/24/26 at 2:15 PM, V2 Director of Nurses (DON) stated staff should remove their gloves, wash their hands and then reapply clean gloves when their gloves become contaminated. V2 DON stated staff are supposed to prevent cross contamination. V2 DON stated she will in-service staff on infection control/cross contamination.

Based on interview and record review, the facility failed to consistently provide hot meals to residents receiving room trays for five residents (R2, R4, R5, R6, and R7) of five reviewed for dietary services on a sample list of six. Findings include:The facility's Food Temperatures Policy dated 12/30/24 documents that food will be stored in accordance with local, state, and federal guidelines. The Policy Interpretation and Implementation section documents that food stored hot will be kept at 135 degrees Fahrenheit or above; food will be cooked to the appropriate internal temperature per regulations; the temperature of food items will be checked prior to service to the resident and as frequently as necessary when being stored hot for service; and hot foods being reheated will be reheated to 165 degrees Fahrenheit or above for at least 15 seconds.On 12/30/25 at 12:50 PM, a test tray was provided containing a fish fillet (with half of the breading missing on the bottom side), California blend vegetables, bow tie pasta, bread, and peach cobbler. The internal temperature of the fish fillet was measured at 130 degrees Fahrenheit and felt cold to the touch.The facility's Grievance Log dated 9/25/25 to 12/1/25 documents two grievances filed related to cold food during this period.R2's Minimum Data Set (MDS) dated [DATE] documents that R2 is cognitively intact.On 12/30/25 at 10:02 AM, R2 stated that she eats in her room and that the food is cold every time. R2 stated that the facility tries to keep the food warm by putting heaters beneath the food trays delivered to resident rooms, but that the heaters do not work.R4's MDS dated [DATE] documents that R4 is cognitively intact.On 12/30/25 at 12:09 PM, R4 stated that the facility's food is gross and often cold. R4 stated that he recently received just a hamburger, and although there were fries on the tray, they were ice cold.R5's MDS dated [DATE] documents that R5 is cognitively intact.On 12/30/25 at 11:45 AM, R5 stated that the food provided by the facility is so-so and often cold.On 12/30/25 at 12:40 PM, R6 stated that his only complaint was about the food. He stated that he eats his meals in his room and that the food is always cold.On 1/3/26 at 5:14 AM, R7 stated that he is not crazy about the food at the facility and that, more often than not, it is cold and very institutionalized.On 12/30/25 at 11:51 AM, V14 (Certified Nursing Assistant [CNA]) stated that residents who receive room trays often complain that the food is cold.On 12/30/25 at 11:52 AM, V15 (CNA) stated that residents who eat in their rooms complain that the food is cold, most likely because dietary staff are not placing heating pucks under the plates.On 12/30/25 at 11:58 AM, V16 (CNA) stated that residents who receive hall trays often complain that the food is cold.On 12/30/25 at 12:01 PM, V17 (CNA) stated that residents who do not eat in the dining room often complain that it takes a while to receive their food and that it is cold when it arrives.On 12/30/25 at 2:49 PM, V5 (Dietary Manager [DM]) stated that he was made aware of resident concerns about cold food approximately a month ago during a resident council meeting and believed the problem had been corrected. V5 stated that morning shifts were using hot pucks for breakfast and lunch but were not using them for supper. V5 admitted that there is a problem with fries served by the facility, stating that after cooking and temperature checks, the fries cool rapidly because shoestring fries do not hold heat. V5 agreed that residents deserve to receive their meals hot.

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This failure affects two residents (R1, R2) of four reviewed for abuse in the sample of four.Findings include: The facility's Resident's Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure (2025) documents residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation. The facility Final Report (undated) documents R1 and R2 were roommates and had a verbal argument on 9/19/2025 followed by R1 striking R2 in the face. On 11/25/2025 at 1:07PM, R2 reported having an argument about politics with R1 in their room on 9/19/2025. R2 reported telling R1 why don't you just hit me? and repeatedly asked R1 to hit R2. R2 reported R1 then approached R2 and began striking R2 in the jaw. On 11/25/2025 at 2:52PM, V4 (Housekeeper) reported being nearby R1 and R2's room and hearing the above altercation. V4 reported entering their room and observing R1 hitting R2 and immediately separating the residents. On 11/25/2025 at 1:43PM, V2 (Director of Nursing) reported responding to R1 and R2's altercation on 9/19/2025. V2 reported R2 told V2 at the time that R2 had been repeatedly asking R1 why don't you just come hit me?, and then leaned forward in R2's chair and stated to R1 are you going to hit me or what?

Based on interview and record review the facility failed to protect the residents right to be free from physical abuse for four (R1, R2, R3, R4) of four residents reviewed for physical abuse from a total sample list of nine residents reviewed for abuse. Findings include: The facility provided Resident Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure dated 2025 documents the facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation with the purpose to facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation. 1.) R1's undated diagnosis sheet documents diagnoses of Major Depressive Disorder, Anxiety Disorder, Alzheimer's Disease, and Dementia with Psychotic Disturbance. R1's progress notes dated [DATE] document that R1 died at the facility. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as severely cognitively impaired. R1's progress notes dated [DATE] document an altercation involving R1 and R2. R1's care plan dated [DATE] documents that R1 became combative with R2. The facility provided report to the state agency documents an altercation between R1 and R2 dated [DATE]. The Report documents On [DATE] (R1) struck (R2) with an open hand on the left cheek in front of the C/D nurses station. On [DATE] at 11:36AM, V2 Director of Nursing stated that after the altercation, R1 was placed on 1:1 observation until she went to sleep. R2's undated diagnosis sheet documents diagnoses of Traumatic Hemorrhage of the Cerebrum, Anxiety, Schizoaffective Disorders, Aphasia following Cerebral Infarction, and Dementia. R2's Minimum Data Set, dated dated dated [DATE] documents R2 as severely cognitively impaired. R2's progress notes dated [DATE] document an altercation involving R2 and R1. On [DATE] at 12:13PM, V7 Certified Nursing Assistant stated, I was there, standing in the hallway and before I could get to them, I saw and heard (R1) slap (R2) after hearing (R1) tell (R2) to move. I immediately separated (R1) and (R2) and then reported it to the nurses. (R1) was frightened because she thought that his wheel chair was too close to her wheelchair in the hallway. (R2) was really confused and upset after (R1) slapped him and (R2) just kept apologizing to (R1) even though he was the one who was hit. 2.) R3's undated diagnosis sheet documents diagnoses of Parkinson's Disease, Atherosclerosis, Prostate Cancer and Aphasia. R3's Minimum Data Set, dated dated dated [DATE] documents that R3 is cognitively intact. R3's progress notes dated [DATE] document an altercation between R3 and another resident. On [DATE] at 9:50AM, R3 stated that R4 pulled on his arm in the dining room and then he pushed her. She has touched me before but this is the first time that I ever pushed her away. She does it for attention. She touches you and if you don't give her attention, she pulls and I don't like it. On [DATE] at 9:44AM, R5 stated that he was in the dining room when R3 kicked R4. R5 stated that R3 wasn't moving R3 was out of the way but that R3 kicked her (left leg) because he hates her, lots of people do because she touches them. I used to be a Certified Nursing Assistant and I'm afraid that she is going to get hurt. She doesn't understand what she's doing. R4's undated diagnosis sheet documents diagnoses of Dementia, Psychosis and Depression. R4's Minimum Data Set, dated dated dated [DATE] documents that R4 is severely cognitively impaired. R4's progress notes dated [DATE] document an altercation between R4 and another resident. On [DATE] at 9:35AM, V3 Registered Nurse stated that R4 is alert to herself only and that she touches everyone. On [DATE] at 9:37AM, V4 Certified Nursing Assistant stated that R4 touches people on the arms. On [DATE] at 9:57AM, V5 Certified Nursing Assistant stated that R4 moves throughout the facility and touches arms but not everyone likes it. On [DATE] at 9:46AM, R6 stated, She (R4) has touched me before and I punched her. I asked her seven times to stop and she just won't stop. I don't like it and I will do it again if she touches me again. On [DATE] at 11:25AM, R8 stated that R4 used to touch him and that he didn't like it. On [DATE] at 11:28AM, R9 stated that he knew R4 and that she touches him but that there isn't anything that can be done. On [DATE] at 11:40AM, V2 Director of Nursing stated that it is not ok for resident's to touch one another without their permission. I have tried to explain to the staff that we have to keep an eye on R4 to protect her. As of today she is a 1:1 observation when out of bed. I know that some residents don't like her touching.

Based on interview and record review the facility failed to provide effective dementia treatment and services for one (R4) of four residents reviewed for dementia care from a total sample list of nine residents. Findings include: R4's undated diagnosis sheet documents diagnoses of Dementia, Psychosis and Depression. R4's resident census documents admission to the facility on [DATE]. R4's Minimum Data Set, dated dated dated [DATE] documents R4 is severely cognitively impaired. R4's progress notes dated 4/17/25 document an altercation between R4 and another resident. On 5/7/25 at 9:35AM, V3 Registered Nurse stated that R4 is alert to herself only and that she touches everyone when she is out of bed. On 5/7/25 at 9:37AM, V4 Certified Nursing Assistant stated that R4 touches people on the arms. On 5/7/25 at 9:57AM, V5 Certified Nursing Assistant stated that R4 moves throughout the facility and touches arms but not everyone likes it. On 5/7/25 at 9:46AM, R6 stated, She has touched me before and I punched her. I asked her seven times to stop and she just won't stop. I don't like it and I will do it again if she touches me again. On 5/7/25 at 11:25AM, R8 stated that R4 used to touch him and that he didn't like it. R4's undated care plan does not document behaviors including touching other residents, nor interventions to address these behaviors. R4's behavior tracking for April 2025 does not document any behaviors. On 5/7/25 at V2 Director of Nursing stated that the staff did not see R4's touching other residents as a behavior. On 5/7/25 at 2:48PM, V4 and V8 Certified Nursing Assistants stated that they could not recall having dementia training at the facility. On 5/7/25 at 2:50PM, V9 Dietary Aid stated that she had never received dementia training. On 5/7/25 at 2:51PM, V5 Licensed Practical Nurse stated that she had not received dementia training at the facility. On 5/7/25 at 9:45AM, V1 Administrator and V2 Director of Nursing confirmed that the facility does not have a dementia unit, nor a dementia coordinator. On 5/7/25 at 3:37PM, V1 Administrator stated that the facility needed more dementia training including early intervention, dementia behavior management.

Based on record review and interview the facility failed to recognize and report reasonable suspicion of a crime to a law enforcement agency, related to physical abuse of R3 by R2 and R4, and failed to recognize and report suspicion of a crime to a law enforcement agency of an allegation of sexual abuse of R1 by V4, R1's Visitor. These failure affects four (R1,R2,R3,R4) of five residents reviewed for abuse on the sample list of eight. Findings include: The facility facsimile Incident Report Form - IDPH ( Illinois Department of Public Health) Notification) dated 2/23/25 signed by V1, Administrator/Abuse Prevention Coordinator documents: The facility received an allegation of physical abuse that R2 struck R3. The same form documents the police were not notified. As part of this investigation V6, Licensed Practical Nurse witness statement documents V6 observed R2 hit R3 in the face leaving a red mark on R3's cheek. The facility facsimile Incident Report Form - IDPH ( Illinois Department of Public Health) Notification) dated 2/24/25 signed by V1, Administrator/Abuse Prevention Coordinator documents: The facility received an allegation of physical abuse that R4 struck R3. The same form documents the police were not notified. As part of the same investigation, R5's witness statement documents R5 observed R4 hit R3 on the upper arm, and R5 heard a pop. The facility facsimile Incident Report Form - IDPH (Illinois Department of Public Health) Notification) initial report dated 3/25/25 signed by V1, Administrator/Abuse Prevention Coordinator documents: The facility received an allegation of sexual assault that (R1) was sexually assaulted on 3/17/2025 by an employee (with the same first name as a family friend of R1's). The same form documents the police were not notified. On 3/27/25 at 9:40 am V1, Administrator / Abuse Prevention Coordinator stated I did not call the police on any of the three allegation (V4 to R1, R2 to R3 and R4 to R3). I did not know I was supposed to. I thought I just reported to IDPH right away, and then I finished my investigation within five days. It makes sense to report all three, since one was a sexual abuse (R1) allegation and two (R3 by R2, and R3 by R4) could be considered allegations of battery. The facility Resident Right To Freedom From Abuse, Neglect, And Exploitation Policy And Procedure dated 2025 documents: The facility will ensure compliance with the Elder Justice Act pursuant to the Facility's Elder Justice Act Policy and Procedure. The facility The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure protocol dated 2025 documents: PURPOSE; To facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation.: The same policy documents: Reasonable suspicion of a crime must be reported to the State Survey Agency and at least one local law enforcement agency. Procedure: I. Definitions A. Alleged violation is defined as a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. a. An alleged violation can be observed or reported by staff, resident, relative, visitor, another health care provider, or others. b. An individual (e.g., a resident, visitor, facility staff) who reports an alleged violation to the Facility staff does not have to explicitly characterize the situation as abuse, neglect, mistreatment, or exploitation in order to trigger reporting requirements. Rather, if the Facility staff could reasonably conclude that the potential exists for noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property, then it would be considered reportable. The same policy documents: C.Abuse a. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. b. The deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. c. Instances of abuse of all residents, irrespective of any mental or physical condition, that cause physical harm, pain or mental anguish. This includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. i. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. ii. Sexual abuse is non-consensual sexual contact of any type with a resident. e. Abuse includes resident to resident altercations, including, but not limited to any willful action that results in physical injury, mental anguish, or pain. f. Willful actions include, but are not limited to the following: i. Hitting; ii. Slapping; iii. Punching; iv. Choking; v. Pinching; vi. Biting; vii. Kicking; vii. Throwing objects; ix. Grabbing; x. Shoving.

Based on observation, interview and record review the facility failed to remove R2, the perpetrator of physical abuse, from direct access with R2's vulnerable, dependent, non-verbal roommate R6. This failure affects two (R2,R6) of five residents reviewed for abuse on the sample list of eight. Findings include: R2's Brief Interview of Mental Status (BIMS) assessment dated [DATE] documents R2 has a score of 15 out of a possible 15, which indicates no cognitive impairment. R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status (BIMS) score of two out of a possible 15 indicating, severe cognitive impairment R6, MDS dated [DATE] documents R6 has severe cognitive impairment and is totally dependent of staff for all activities of daily living and does not ambulate R6's Diagnoses List last updated 01/16/25 documents the following: Cerebral Palsy, Quadriplegia, Unspecified, Metabolic Encephalopathy, Adjustment Disorder With Anxiety, Major Depressive Disorder Recurrent, Unspecified, and Adjustment Insomnia R2's Nursing Progress Note dated 02/23/2025 at 12:30 pm, and signed by V6, Licensed Practical Nurse (LPN), documents the following: Note Text : Resident has been up to the nursing desk several times calling his (V20, Family Member) and his son. No one answered the phone, Resident (R2) is becoming angry. Another resident sitting buy (by) the assignment board (R3) and he (R2) became physically aggressive with her. Separated the two (R2 and R3). Assessed resident (R3) for any injuries she has a red mark on her right upper cheek. Took v/s (vital signs) and assisted her to bed to relax. The DON (Director of Nursing) and the Administrator (V1, Abuse Prevention Coordinator) was (were) notified. On 3/26/25 at 12:48 pm , R6, (R2's roommate) was in a reclined geriatric type wheeled chair parked next to R6's bed. R6's gestured with spastic movements and made inaudible sounds. R6 did attempt to converse and shook his head back and forth, yes, he feels safe and no one has hurt him. R2 then closed his eyes as if to sleep. On 3/26/25 at 12:50 pm, R2 wheeled his wheel chair into his room and transferred himself to bed. R2 confirmed he was anger and hit R3 in the eye on 2/23/25. On 3/26/25 at 1:34 pm V6, Licensed Practical Nurse (LPN) stated V6 LPN witnessed R2 hit R3 on the right cheeks leaving a red mark. V6 also stated she had talked to V1, Administrator/ Abuse Prevention Coordinator and wanted to move R2 to a different room, because R6, R2's roommate was still in their shared room. V1, Administrator /Abuse Prevention Coordinator told V6, LPN that if (R2) had any more aggressive behaviors, staff could send him to the hospital. On 3/26/25 at 2:05 pm V10, Certified Nursing Assistant stated I worried about (R6), (R2's) roommate. (R6) couldn't defend himself. He is totally dependent on staff for everything. (V1, Administrator/Abuse Prevention Coordinator) gave the direction for us not to move them to a different rooms. (V6, LPN) the nurse and I would really worried. Actually everybody here was really worried. I have never seen (R2) do anything to another resident. He has been mad and yelling at staff. We had just witnessed the outburst with (R3), and felt he needed to be moved to a different room, away from (R6) . He (R2) stayed in his room the rest of the shift watching tv (television). He did come out for supper, but we watched him extra close. When he went back to his room, I looked in there several times just to make sure he wasn't doing anything toward (R6) He didn't. He knew he had to have staff with him to come out of his room. On 3/27/25 at 9:40 am V1, Administrator / Abuse Prevention Coordinator confirmed R6, R2's roommate remained in their shared room overnight, on the night R2 hit R3 on 2/23/25. The facility (facility name) RESIDENTS RIGHT TO FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION POLICY AND PROCEDURE policy dated 2025, documents the following: : B. IV. When the Facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: A. Taking steps to prevent further potential abuse .

Based on observation, interview and record review, the facility failed to protect residents' right to be free from physical abuse of R3 by R2 and R4. This failure affects three (R2,R3,R4) of five residents reviewed for abuse on the sample list of eight. Findings include: 1.) R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status (BIMS) score of two out of a possible 15 indicating, severe cognitive impairment R2's Brief Interview of Mental Status (BIMS) assessment dated [DATE] documents R2 has a score of 15 out of a possible 15, which indicates no cognitive impairment. The facility Illinois Department of Public Health (IDPH) Final Report Incident Date: 2/23/2025 signed by V1, Administrator/Abuse Prevention Coordinator, documents the following: Summary; Received report that (R2) resident, struck (R3) resident. They were immediately separated without any apparent injuries (right cheek injury documented below) . R2's Nursing Progress Note dated 02/23/2025 at 12:30 pm, and signed by V6, Licensed Practical Nurse (LPN), documents the following: Note Text : Resident has been up to the nursing desk several times calling (V20, Family Member) and (V22, Family Member). No one answered the phone. Resident (R2) is becoming angry. Another resident sitting buy (by) the assignment board (R3), and he (R2) became physically aggressive with her (R3). Separated the two (R2 and R3). Assessed resident (R3) for any injuries, she has a red mark on her right upper cheek. Took v/s (vital signs) and assisted her to bed to relax. The DON (Director of Nursing) and the Administrator (V1, Abuse Prevention Coordinator) was (were) notified. R3's Nursing Progress Note dated 02/23/2025 at 5:24 pm documents: Note Text: Resident remains resting in bed. Awakens easily. Right upper cheek remains red. Denies any tenderness to the area at this time (four hours and 54 minutes after the above physical abuse was documented). On 3/26/25 at 12:50 pm , R2 propelled his wheelchair into his room, over to the side of his bed, and transferred himself. R2 laid semi-Fowler back onto his bed. R2 stated I sure can tell you what the hell went on. (R3) was touching my arm in the dining room earlier that day. I was in a pissed off mood after getting off the phone. I saw her sitting across from the nurse's station. I remembered earlier in the dining room she was tapping on my arm. I went over to her. I (R2) hauled off and busted her (R3) in the eye, just like this (R2 raised his elbow up to his shoulder level, tightened his fist, and punched into the air). It is the law. If someone hits you first, you can hit them back. She (R3) tapped my arm several times earlier in the day. I (expletive, f***ing) hit her (R3), once with my fist. Staff took her away somewhere and that ended that. R2 then stated She (R3) wanders in the dining room and does the same thing, to other residents too. She (R3) is tapping peoples arms all the time. I was sick of it, she is annoying. That one punch is how I let her know. I have had no problems with her since. On 3/26/25 at 1:34 pm V6, LPN stated I witnessed (R2) getting mad. He wants to go home. He had been asking to use the portable phone repeatedly that day. His family (unidentified) will not answer the phone. He was getting frustrated, that escalated to real angry because he couldn't reach his family. Then everybody (residents and staff) went to the dining room, residents to eat lunch and staff to serve it. I was passing medication on halls A and B (unit's divided by a nurses station). I had just finished med pass (medication administration) and he (R2) came up to use the phone again. His family still did not answer. He was really upset again. Very angry. (R3) was seated in her wheelchair across from the nurse's station, 12 to 15 feet away from (R2). (R2) wheeled his wheelchair over to (R3's) wheelchair. His room is right down B hall. I thought he (R2) was just going to pass in front of her (R3). (R3) had her hands in her lap. I was looking right over at them, He raised his arm, to his shoulder level. His hand was fisted. He hit her on her upper right cheek. Her whole cheek was red. It happened really fast. He (R2) knew what he was doing, and (R3) was not doing anything. Me (V6, LPN) and (V10, Certified Nursing Assistant) (sic) separated them. She took him (R2) to his room and educated him, that he could not hit anyone. That is abuse. We took (R3's) vital signs. She was upset. She is not a talker but put both her hands on her face. I did a skin assessment and laid her in bed. I checked on her again and again. I gave her roommate (R8) medication and checked on (R3) again then too. (R3) was sleeping by then, about a half hour later. (R3's) right upper cheek was still red. On 3/26/25 at 2:05 pm V10, CNA stated It was a rough day. I was here. He (R2) was having a bad day trying to call his family. He called repeatedly. Then ate a meal. He tried again to reach his family. (V6, LPN) helped him with the phone down there (points to the opposite end of the nurses station). (R3) was seated in her wheelchair across from the nurses station right here (V10, points approximately 12 feet away from where she said R2 had used the phone). (R3) had her hands in her lap. She (R3) was looking around and I was standing up here (three feet away) talking to her. He (R2) was really upset not reaching his family on the phone. I could hear his (R2) raised voice but could not make out what he said. He (R2) wheeled his wheelchair in the direction of his room. I thought he was going to pass (R3) up. He (R2) suddenly drew up his fist and hit (R3) in the right check. When I realized what had happened, I took him immediately away to his room, and (V6, LPN) was taking care of (R3). I saw (R3) put her hands up over her face and made a loud sound. She (R3) then said 'he (R2) hit me'. When (V6, LPN) and I (V10, CNA) put her to bed, She was scared. I sat with her in her room for a while. I (V10) kept telling her (R3) I would keep her safe. She was clingy and very nervous. It just broke my heart. (V6, LPN) reported to the (V1, Abuse Prevention Coordinator)Administrator. The DON (V2, Director of Nursing) and (V13, CNA) were here and notified (V1) too, as soon as we made sure the resident was safe. On 3/28/25 at 12:00 pm V13, CNA stated confirmed she was present when R2 hit R3 in the eye. V13 stated the physical abuse of R3 by R2 happened on a Sunday 2/23/25, V13 did not work on Monday 2/24/25. V13, CNA also stated I worked Tuesday (2/25/25) or Wednesday (2/26/25) after that happened. (R3's) eye and cheek were still dark red with a purple tint. (two and three days after R2 hit R3). 2.) R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status (BIMS) score of two out of a possible 15 indicating, severe cognitive impairment. R4's MDS dated [DATE] documents R4's BIMS score of 15 out of a possible 15, indicating no cognitive impairment. R5's MDS dated ,d+[DATE] documents R5's BIMS score of 14 out of a possible 15, indicating no cognitive impairment. The facility Illinois Department of Public Health (IDPH) Final Report Incident Date: 2/24/2025 signed by V1, Administrator/Abuse Prevention Coordinator, documents the following: On February 24th, 2025, it was reported by resident (R5) that resident (R4) struck resident (R3) on the arm. The residents were in the dining room for dinner when (R3) approached (R4) multiple times. (R3) enjoys greeting all of the residents. patting them on the hand, leg and arm as if to greet them. (R4) had eventually gently steered (R3) wheelchair away from him. (R3) did not make any indications at the time of experiencing any pain. The same report documents: There were not any employees present at the time of this interaction. On 3/26/25 at 12:20 pm, R4 stated (R3) when she comes into the dining room, she comes and reaches for other people's food. When I interrupt her, I started batting at her. I don't think I made contact with her, though. If I did hit her, it didn't hurt her. I had to push her wheelchair away from me twice, before she would stay away from me. That is all I did on that day you're referring to (2/24/25). R4 also stated I am not the only one that has a problem with her. We (unidentified) even ask her is a nice way. I'd just try to turn around and go on with what I'm doing. Sometimes I have to swat at her to get her to leave me alone. I can't think of any of the other resident name, off the top of my head, but there are several she gets on their nerves too. I don't remember names very well, but others can tell you the same thing about her (R3). Yes, I (R4) have raised my voice telling her to get the hell away from me. If staff are around, they take her (R3) to the far table, and lock her wheelchair brakes. There are times she still scoots her wheelchair over to people. Even with the brakes locked. There are staff around that see it all the time. There are other times when there aren't any staff in the dining room at all, until it's time to serve food. They come in and out bringing people in the dining room for meals. There have been many times going down the hall she (R3) starts slapping at me. Staff see it, I tell them too. They (unidentified staff) say she doesn't know what she is doing ( R3 has severe cognitive impairment). They say just ignore her. I don't feel I have ever been abusive to her. She (R3) is just annoying to have to deal with this every day. On 3/27/25 at 10:25 am V2, Director of Nursing (DON) stated V1 Administrator / Abuse Prevention Coordinator told V2, DON about the allegation that R4 hit R3, but she was not working the day it happened. V2, DON then stated R4 'is educated constantly' that R3 has Dementia and does not know what she is doing. He is alert and oriented, he needs to leave the situation and find a staff member. On 3/28/25 at 1:00 R5 stated I witnessed (R4) getting mad at (R3), raising his (R4) fist up and acting like he was going to follow threw and hit (R3) in the head. She (R3) was about two feet from him (R4). That (hit her in the head) didn't happen. He (R4) hadn't hit her (R3) yet. (R3) wheeled her wheelchair up closer to where (R4) was sitting. (R4) turned around and pushed (R3's) wheelchair backwards. He pushed it hard. He is a lot bigger than she is. I bet she doesn't weigh one hundred pounds. He is a bigger guy, even when seated in a wheelchair. She (R3) flew in her wheelchair backwards, about eight feet. There were no staff anywhere around. I looked (for staff) for a minute or two. Then, I watched (R4) as (R3) approached (R4) table. (R3) gave him (R4) a little pat on the arm to get his attention. She (R3) barely touched him (R4). (R3) was not being aggressive in any way. She is very sweet and was being kind to him. (R4) purposely struck (R3) on the upper arm. I (R5) saw it all. You could hear he (R4), slapped her (R3) hard. He then, forcefully pushed R3's wheelchair again, but not as far (eight feet prior in this interview) as he had. He (R4) yelled 'get the hell out of here'. (R3) looked stunned as she propelled herself away to the other end of the dining room. It was definitely, abuse. There is no way around that. I went immediately out to find a staff member (unidentified). I can't remember who it was I told. Several staff came into the dining room right away. The staff are few and far between at mealtimes. They are all getting people out of their rooms, and bringing them to the dining room. I was eating about eight feet away from (R4), facing him (R4). I saw every bit. He (R4) hates her with a passion, and I don't know why. Her little hand, was a tender tap. She is very loving. Nothing he (R4) should be so upset about. He knows exactly what he is doing. She has Dementia, and doesn't understand what she is doing. The facility (facility name) RESIDENTS RIGHT TO FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION POLICY AND PROCEDURE policy dated 2025, documents the following: PURPOSE To ensure that all of (Facility name) residents are free from abuse, neglect, misappropriation of their property, and exploitation. POLICY The facility's residents have the right to be free from abuse, neglect, misappropriation of their property and exploitation as defined in this policy. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the residents medical symptoms. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the Facility (''Associates). PROCEDURE III. The Facility shall review altercations from resident to resident as a potential situation of abuse. A. Staff shall monitor for any behavior that may provoke a reaction by residents or others, which include, but are not limited to: a. Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; b. Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects.

Based on interview and record review the facility failed to maintain complete and accurate medical records for two (R3,R4) of five residents reviewed for abuse on the sample list of eight. Findings include: 1.) R2's Nursing Progress Note dated 02/23/2025 at 12:30 pm, and signed by V6, Licensed Practical Nurse (LPN), documents the following: Note Text : Resident has been up to the nursing desk several times calling (V20, Family Member) and (V22, Family Member). No one answered the phone. Resident (R2) is becoming angry. Another resident sitting buy (by) the assignment board (R3), and he (R2) became physically aggressive with her (R3). Separated the two (R2 and R3). Assessed resident (R3) for any injuries, she has a red mark on her right upper cheek. Took v/s (vital signs) and assisted her to bed to relax. The DON (Director of Nursing) and the Administrator (V1, Abuse Prevention Coordinator) was (were) notified. R3's Nursing Progress Note dated 02/23/2025 at 5:24 pm is the only documentation in R3's chart that refers to R3's reddened facial area and does not mention the physical abuse noted above. R3's Progress note documents: Note Text : Resident remains resting in bed. Awakens easily. Right upper cheek remains red. Denies any tenderness to the area at this time (four hours and 54 minutes after the above physical abuse was documented). R3's complete electronic medical records does not documents the above physical abuse occurred, measurements of the red mark on R3's face, family or physician notification, and there is no ongoing assessments alert charting' or monitoring of R3 response to the physical abuse by R2. On 3/26/25 at 1:34 pm V6, Licensed practical Nurse (LPN) confirmed she did not measure R3's reddened face, therefor did not document the skin impairment measurement, when R3 was hit in the face by R2. V6 also confirmed she did not document the physical abuse by R2 in R3's chart. V6 also confirmed she did not document that V1, Administrator/Abuse Prevention Coordinator was notifying the physician and families V6, LPN also acknowledged V6, LPN should have initiated 72 hour assessments post the abuse on 2/23/25. On 3/28/25 at 1:50 pm V3, Assistant Director of Nursing/Wound Nurse stated I complete assessments and document the measurement on a spread sheet and on the resident assessment in pcc (electronic medical record) in resident chart. (R3) has had bruises in the past. I did not know she had a red area on her face that needed measured. I did not look at her skin the day of the incident with (R2), but I don't remember seeing anything the next day, so I did not document an assessment, because I saw nothing. Our floor nurses are supposed to initiate 72 hour documentation after skin issues. I don't see that happened. 2). The facility Illinois Department of Public Health (IDPH) Final Report Incident Date: 2/24/2025 signed by V1, Administrator/Abuse Prevention Coordinator, documents the following: On February 24th, 2025, it was reported by resident (R5) that resident (R4) struck resident (R3) on the arm. The residents were in the dining room for dinner when (R3) approached (R4) multiple times. (R3) enjoys greeting all of the residents, patting them on the hand, leg and arm, as if to greet them. (R4) had eventually gently steered (R3) wheelchair away from him. (R3) did not make any indications at the time of experiencing any pain. R3's complete electronic medical records does not documents the above physical abuse by R4, family or physician notification, and there is no ongoing assessments alert charting' or monitoring of R3 response to the physical abuse by R4. R4's complete electronic medical records does not documents the above physical abuse of R3, family or physician notification, and there is no ongoing assessments alert charting' or monitoring of R4. On 4/1/25 at 1:00 pm V2, Director of Nursing stated When you (surveyor) entered the building to investigate the allegations of abuse (R2 hit R3 and R4 hit R3), I reviewed their charts. I talk to (V6, Licensed Practical Nurse) and asked her why she did not document (R3) was hit by (R2), in (R3's) chart. She acknowledged she should have documented in both charts. I also saw (R4) had nothing in his chart about the incident between him and (R3), nor did (R3). Documentation is expected to be complete including notifications of family and physician. Though both situations were reported to the (V1, Administrator/Abuse Prevention Coordinator) and she called the families and physician, the nurse should have documented that (V1) was doing the notifications. Ongoing behavior tracking was completed for (R2 and R4's) behaviors. On (R3) there needed to be follow-up for signs and symptoms of fearfulness and her red bruise measurements and tracking. I saw one follow up note with (R3) redness documented, the next day I believe. There should have been 72 hour follow-up charting as I mentions to you before. Documentation is not a new issue but will still be addressed in the next staff meeting. The facility policy Policy and Procedure, Charting and Documentation dated 11/05/2019 documents the following: Purpose To maintain a medical record to serve a legal document that details the services provided to the resident, or any changes in the resident's medical or mental condition, through charting and documentation. Each resident will have an active medical record that contains accurately documented information, systematically organized and readily accessible to authorized persons. The same policy documents: 10. Documentation will include information on assessment, notifications, interventions and evaluation including but not limited to: a. Incidents/Accidents per facility policy b. Change in condition per facility policy c. Physician notification d. DPOA/Responsible Party notification e. Refusal of medications/treatment or recommendations The same policy documents: 11. Additional documentation requirements will be followed: d. Alert Charting - documentation on incident/accident or change in condition for 72 hours or until stable.

Based on interview and record review, facility staff failed to immediately report an allegation of staff to resident physical and verbal abuse to the facility administrator. This failure affects one resident (R1) of four reviewed for abuse in the sample of four. Findings include: The facility abuse prevention policy (2022) documents the facility will report all allegations of abuse within required timeframes pursuant to Federal and State statutes. The Code of Federal Regulations (S483.12, 10/1/2023) documents: (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility incident report submitted to the State Survey Agency and subsequent abuse investigation (both dated 8/8/2024) document V4 (Cook) allegedly observed V3 (Cook) physically and verbally abuse R1 on the evening of 8/7/2024. The same record does not document the date, time, or the person who first reported the allegation to V1 (Administrator). On 8/20/2024 at 1:07PM, V1 reported receiving the above allegation on the morning of 8/8/2024. V1 reported V4 (Cook) first reported the allegation to V4's manager, V6 (Dietary Manager), during suppertime on 8/7/2024 but V6 did not report the allegation to V1 until the morning of 8/8/2024. On 8/20/2024 at 1:37PM, V4 (Cook) reported telling V6 about the abuse allegation sometime between 6-6:30PM on 8/7/2024 and requesting V6 inform V1 (Administrator) about the allegation. V4 reported V6 stated, V6 was leaving work for the day. On 8/20/2024 at 1:44PM, V5 (Cook) reported observing V4 report the abuse allegation to V6 on 8/7/2024 and hearing V6 state V6 would contact V1 as soon as possible. On 8/21/2024 at 1:07PM, V6 (Dietary Manager) reported V4 came to V6's office on the evening of 8/7/2024 to report an allegation of alleged abuse. V6 denied informing V1 of the allegation until the next day on 8/8/2024 and denied making any observations or inquiries of either the alleged perpetrator (V3) or the alleged victim (R1) after receiving the above abuse allegation from V4.

Based on interview and record review the facility failed to identify the root cause of pain for one resident (R1) of three residents reviewed for pain in a sample of three residents. This failure resulted in (R1) experiencing continued pain requiring narcotic pain medications. Findings Include: R1's Care Plan updated 3/13/24 includes the following diagnoses: Fractured Neck of Right Femur with open Reduction and Internal Fixation, Right Hip Pain, Dementia, Osteoarthritis, Contusion of the Wall of the Thorax, Weakness, Insomnia, and Depression. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired. This MDS documents R1's indicators of Pain/Possible Pain per staff interview include Nonverbal Sounds, Vocal Complaints of Pain, Facial Expressions, and Protective body movements and postures. These indicators are documented as being present three to four out of five days. R1's progress note dated 03/12/2024 at 6:25PM documents (R1) arrived via facility van at 3:15 PM from (Local Hospital). Alert, oriented to self. Very confused per baseline. fell at home and broke Right hip. Open Reduction Internal Fixation done on the 8th. (R1) is Weight Bearing as Tolerated and transfers with two person assist. Complains of severe pain to hip. New Order received from (Medical Director) for Tylenol as needed as (R1) did not come with any pain medication orders. Vital Signs: Temperature 97.8, Heart Rate 90 beats per minute, Respirations 18, Blood Pressure 150/80, Oxygen concentration 97% on room air. Call light in reach but not able to use due to dementia. (R1's) Room right next to nurses station and (R1) has been yelling out when she needs help. R1's Pain level tracking documents R1's pain rating on a scale of one through ten. The following entries are documented: 3/12/24 at 8:18PM 3/10 and 3/13/24 at 12:04AM 0/10. R1's Progress Note dated 03/13/2024 at 4:23AM documents This nurse heard a loud noise from (R1's) room and (R1) yelled 'help!' (R1) was sitting on floor beside bed on buttocks, legs out in front. No rotation or shortening of Bilateral Lower Extremities noted. (R1) stated (R1) 'was trying to get out of bed and I just slid out.' No injuries noted. Vital Signs Temperature 97.3, Pulse 78, Respirations 16, blood pressure 124/72. Wearing non skid socks. Bed in lowest position. Alert to self only, normal for (R1). (R1) complained of buttock pain, same intensity and anatomical area as prior to sliding out of bed. Denied striking head. After assessment, resident assisted to feet per two staff and transferred back to bed. Bore weight well, Moves all Extremities well. Hand grips strong and equal. Reminded (R1) to ask for help, reoriented to call light, and 15 min checks begun. Neurochecks initiated, Within Normal Limits. R1's Occupational Therapy notes for 3/13/24 document Underlying impairments/Skills analysis impaction functional performance: Balance deficit, Decreased Safety Awareness, Cognitive Decline/Cognitive Loss, Pain and Strength Impairments. R1's Progress Note dated 03/13/2024 at 7:13PM documents Tylenol Extra Strength Oral Tablet 500 MG Give 1 tablet by mouth every 6 hours as needed for as needed for pain. Administration was: Ineffective. Follow-up Pain Scale was: 8. On 3/14/24 at 1:00AM a new order per progress note is documented for Hydrocodone-Acetaminophen Tablet (narcotic pain reliever) 5-325 MG Give 1 tablet by mouth every 12 hours as needed for pain until 05/13/2024 Maximum Acetaminophen 4 GM / 24 hours right leg pain The narcotic pain reliever is documented as given at least daily until R1's discharge on 4/1/24. There is no documentation the facility assessed root cause of increasing pain following R1's fall 3/13/24 or attempted other interventions to identify cause of pain. On 4/29/24 at 8:04AM V10, R1's family member stated (R1) didn't do well in therapy and was in a lot of pain the whole 20 days (R1) was at the (Facility). I brought (R1) home on 4/1/24. The first thing I noticed was a large bump on (R1's) right hip. I contacted (V4) the orthopedic Surgeon and we brought (R1) to the hospital. (R1) had broken the entire head off (R1's) femur bone. (R1) has since gone through a total hip replacement. On 4/30/24 at 9:00AM V4, Medical Doctor Orthopedic Surgeon stated I can't say for certain (R1) fractured the hip during a fall at the facility or elsewhere and it just could have been something serendipitous. Who knows? I can say experiencing increased pain or even sustained severe pain following a recent hip repair is not the expected outcome and the cause of the pain should be investigated with a follow-up at our office or the emergency room or elsewhere where something can be done to diagnose the cause of the pain. On 4/30/24 at 10:00AM V2, Director of Nursing stated We did get a pain medication order for hydrocodone for (R1) when we noted the extra strength Tylenol was not working. On 4/30/24 at 12:00PM V9, Physical Therapy Assistant (PTA) stated, I did not see (R1) until she had fallen the night she got to the facility. I can say (R1) had a lot of pain when we moved her. It interfered with (R1's) ability to take part in therapy. Most residents don't continue to have severe pain following therapy, but (R1) did. It was hard because (R1) had dementia and she couldn't tell you she was in pain, but (R1) cried out and resisted when (R1) was moved. The facility's policy Pain Management and Assessment revised 11/22/21 states Policy Statement: To provide a broad spectrum of treatments for pain management as they apply specifically to older people and with specific recommendations to aid in decision making about pain management. To develop clinical practice guidelines for the management of acute and chronic pain. Evaluation and assessment: A comprehensive pain assessment will be completed upon admission, transfer, or onset of new pain which includes: 1. Quality of Pain (e.g.,Aching, Numbness) 2. Pain intensity (numeric visual analog scale, or nonverbal behavior changes in functional observation). 3. Changes in mood state (e.g. Depression Anxiety) 4. Location and/or radiation of pain. 5. Factors that palliate or provoke pain. 6. Characteristics of pain (i.e., Stable, progressive, crescendo). 7. Duration of Pain.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 53 in the facility. Findings include: On 4/9/2024 at 10:58AM, V8 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V8 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V8 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V8 reported the facility dietician does not work full-time in the facility. V8 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. On 4/9/2024, the facility dietary staff failed to prevent direct cross-contamination of food and failed to maintain sanitary food storage areas. On 4/12/2024 at 11:50AM, V8 reported the food prepared in the facility kitchen is available for all residents to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (3/9/2024) documents 53 residents reside in the facility.

Based on observation and interview, the facility failed to prevent direct cross-contamination of stored food and failed to maintain sanitary food storage areas. This failure has the potential to affect all 53 residents residing in the facility. Findings include: 1. On 4/9/2024 at 11:05AM, three wire shelving sections located in the kitchen walk-in cooler were partially covered with a gray-colored, fuzzy biological growth resembling mold. Boxes of food items, pans of prepared food, and jugs of milk were stored directly on these shelving racks. 2. On 4/9/2024 at 11:21AM, the facility walk-in freezer evaporator/condenser supply lines were leaking accumulated condensation onto boxes of food stored below on shelving. The leak had dripped directly into a fully open box of frozen green beans, partially covering the product. At this time, V8 (Dietary Manager) was present and observed the box of green beans. When asked if the ice on the green beans was condensation that had leaked from the above evaporator/condenser supply lines, V8 replied yes. On 4/12/2024 at 11:50AM, V8 reported food in kitchen is available for all residents to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (4/9/2024) documents 53 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to ensure residents' rights to dignified activities of daily living. This failure affects six residents (R11, R14, R15, R16, R31, and R48) of six reviewed for dignity on the sample list of 35. Findings include: 1.) On 4/09/2024 at 12:30PM, five tables were pushed together in a row, at the center of the facility dining room with residents seated around the perimeter of the tables. Facility staff began serving lunch meals to the residents seated at the tables at 12:30PM, with residents seated at the same table receiving lunch meals within five minutes of each other. R11, R14, and R48 were all seated at the center table waiting for lunch to arrive while watching other residents eat lunch. R11, R14, and R48 did not receive a meal until 1:20PM, fifty minutes after the first meal was served to the adjoined tables. V10 (Activities Aide) was present and reported residents are supposed to eat lunch at 12:30PM. On 4/10/2024 at 12:45PM, no residents seated in the facility dining room had received a meal. On 4/11/2024 at 12:55PM, no residents seated in the facility dining room had received a meal. On 4/11/2024 at 1:20PM, R48 stated meals are late all the time. On 4/12/2024 at 11:46AM, R11 reported meals are late almost every day and usually don't arrive until 1-1:30PM. Resident Council meeting minutes (3/26/2024) document council members reported breakfast, lunch, and dinner meals are often served late. 31642 2.) R15's Minimum Data Set (MDS) dated [DATE] documents R15's Brief Interview of Mental Status (BIMs)score as 12 out of a possible 15, indicating moderate cognitive impairment, on the day of assessment. (interviews of staff documented below indicate R15 is cognitively intact and reliable). The same MDS documents R15 has limited range of motion of bilateral upper and lower extremities, and is occasionally incontinent of bowel and bladder. R15's Care Plan dated 04/09/24 documents the following: R15 currently has an alteration to her ability to care for herself and need assistance due to Activity intolerance, Pain, Weakness.The same care plan documents: R15 requires extensive assistance of two staff for toileting, and peri-care will be completed anytime R15 is toileted and as needed. On 4/10/24, during resident council group, between 10:00 am -10:55 am, R31 (R15's roommate) stated (R15) puts her call light on to be transferred to the bedside commode. It takes two people. Often it will take an hour to an hour and a half. I have heard in the hall, staff (unidentified) say '(R15's) on the call light again'. Then, I hear the response, 'that is just (R15)'. This woman (R15) has had to wait so long she goes (incontinence) in her pants. The other day she (R15) asked me (R31) to help. I can't help her get up on the toilet. (R15) would never complain. I think staff know this, and don't get into a hurry for (to help) her. R31's MDS dated [DATE] documents R31's BIMS score as 15 out of a possible 15, indicating R31 has no cognitive impairment. On 4/11/24 at 9:20 am R15 confirmed she turns on her call light and has to wait long period of time for staff to respond. R15 also stated I don't want to get anyone in trouble. I can't say I have waited a full hour or more. It may just seem like it to me, because I can't hold my bladder and bowel. When I need to go (void bowel or bladder), I need to go sooner then the staff can get (help) to me at times. I have a diaper (incontinence brief) on, and have learned to accept the fact that I may not make it to the commode. I don't like it, but I have accepted it. I know staff are busy. They provide good skin care, when they get to me. There are a lot of people here for them to care for. R15 also stated,I can't get up on my own to sit on the commode. If I could, I would not ever be sitting in my own (slang for urine and feces). On 4/12/24 at 10:25 am V16, CNA stated Yes, there have been times when I found (R15) really wet, and redness on her peri-area (Moisture Associated Skin Damage/MASD). V16 stated, There have been times where she says she had her call lights on for a long time. There are times where the call light isn't on and she thinks it was. I always check to make sure the call light is working. On 4/12/24 at 10:52 V12, Registered Nurse (RN) confirmed R15 has a history of UTI's and Moisture Associated Skin Damage (MASD). V12 RN also stated R15 is alert and oriented and if R15 said she had her call light on, V12, RN would say R15 knows what she is talking about. On 4/12/24 at 11:20 am V3, Assistant Director of Nursing/ Registered Nurse acknowledged It is a dignity issue for any resident to have to wait long periods of time to be toileted. V3 stated R15 's does have a history of MASD, V3 also stated I do expect call lights to be answered within five minutes, and bathroom call lights within a minute.' On 4/12/24 at 12:12 pm V11, Licensed Practical Nurse (LPN) stated R15 and R15's roommate R31 are both alert and oriented. V11, LPN stated if R15 and R31 said the call light was on for a long time and it caused R15 to void incontinent, 'it must have happened. The facility pamphlet titled 'The Illinois Long Term Care Ombudsman Program Residents' Rights for People in Long Term Care Facilities' revised 11/18 documents the facility must treat residents with dignity and respect and must care for you in a manner that promotes your quality of life. 41970 3.) R16's undated Face Sheet documents medical diagnoses of Traumatic Brain Injury, Dysphagia, Hallucinations, Alzheimer's Disease, Need for Assistance with Personal Care, and Cognitive Communication Deficit. R16's Minimum Data Set (MDS) dated [DATE] documents R16 is severely cognitively impaired. This same MDS documents R16 requires maximum assistance for dressing, bathing, toileting and personal hygiene. R16's Care Plan intervention dated 3/8/24 documents R16 is independent with eating. On 4/9/24 at 11:20 AM R16 was seated in a wheelchair, in the hallway. R16 was wearing a grey t-shirt with dried liquid spots down the front, and wet spot that extended from the left midsection of R16's shirt, to side of R16 wheelchair. R16 had fruit loops sitting beside him, on the seat of wheelchair that were touching R16's pants. On 4/9/24 at 2:45 PM R16 was seated in a wheelchair with same soiled clothing, with the same food debris and liquid spots on front of his shirt, as identified earlier in the day as documented above. On 4/10/24 at 10:15 AM R16 was seated in a wheelchair in hallway. R16 was wearing dark blue sweatpants, that had food debris and other circular spots of liquid spilled on R16's pants. On 4/10/24 at 1:30 PM R16 was seated in a wheelchair in hallway with the same clothing on soiled with food debris as observed earlier in day and documented above. On 4/9/24 at 3:00 PM V18, (R16's) Power of Attorney (POA) stated (R16) is partially blind and can't see if his clothes or clean or not. (R16) has Dementia and was never real picky about his clothes. I don't think he would care if (R16) was wearing matching clothes or not, but I know he would not want to wear dirty clothes. They (staff) should change that. On 4/11/24 at 9:15 AM V2 Director of Nurses (DON) stated the facility offers clothing protectors for residents during meal times. V2 DON stated if the resident declines to wear a clothing protector and spills food on themselves, then the staff should offer to assist that resident with changing clothes and 'getting cleaned up'. V2 DON stated Sometimes the resident refuses to change their clothes but the staff should reattempts to help provide hygiene cares. V2 DON confirmed the staff should ensure that dignity of all residents is maintained. The facility pamphlet titled 'The Illinois Long Term Care Ombudsman Program Residents' Rights for People in Long Term Care Facilities' revised 11/18 documents the facility must treat residents with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on observation, interview and record review the facility failed repeatedly to adequately supervise a resident (R40) at risk for self harm, and failed to document a resident (R159) fall into the facility's risk management system, initiate neurological checks, conduct a fall investigation, determine a root cause, and implement a specific fall intervention to aid in future fall prevention. These failures affect two of five residents (R40, and R159) reviewed for accidents/supervision on the sample list of 35. Findings include: 1.) R40's Current (multiple dates) Diagnoses Sheet documents the following diagnoses: Unspecified Dementia , Unspecified Severity With Psychotic Disturbance, and Unspecified Dementia, Moderate With Anxiety R40's Minimum Data Set, dated dated dated [DATE] documents R40 has severe cognitive impairment and uses a wheelchair for mobility. R40's Care Plan dated 04/04/24 documents the following: I currently have an alteration in my behavior status r/t (related to) Anxiety, Depression, Res (resident) preference to not follow medical recommendations '(noncompliance)', Aggressive Behavior '(Physical or Verbal)', Agitation, Crying/Tearful, Restlessness, (and) Yelling out. Interventions include: Intervene as necessary to protect rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. I currently have an alteration to my Mood status d/t (due to) Restlessness, anxiousness, and exit seeking. Cognition wise, I am not able to understand some commands or questions. I am known for coming out of my room looking for food therefore, I take any food I find, even if it's others and I take objects that aren't food and put in my mouth to try and eat. I am known for verbal aggression and repetitive statements. R40's same Care Plan documents: Behavior- Agitation/ Restlessness/ Anxious. Behavior- eating/ licking inappropriate items. Behavior- taking items that are not mine.' My current risk for Wandering / Elopement is High Risk 7 ( score of seven) or higher and my safety will be monitored every shift by all staff. R40's Behavior Note dated 3/3/2024 at 2:10 pm documents the following: Note Text: Resident was in the front lobby and grabbed a bottle of lotion off of the desk it was taken from the resident as he wouldn't give it back he then picked up a wooden out going mail box and threw it across the floor towards the copy room and was cursing at staff. Resident removed from front lobby and taken to his room. R40's Nursing Progress Note dated 03/06/2024 at 12:15 pm documents the following: Note Text: CNA came to this nurse with the fact that resident had put some calazime cream in his mouth called poison control spoke with (proper first name only) to see what we needed to do since it was a keep out of reach of children warning label was told to give him a drink of water milk or juice, water was given and he drank without issues V/S T 97.9 P 76 R 18 B/P 116/56 O2 sat at 98% on room air. He might experience some GI upset vomiting or diarrhea if excessive call back but to just watch resident. R40's Behavior Note dated 03/10/2024 at 3:12 pm documents the following:Note Text: Resident had been in and out of his room numerous times, attempting to take stuff off the carts, trash bags and going to the dinning room to eat off other residents used trays, then going to the nurses carts shaking the drawers to attempt to get in them, resident has been redirected several times given snacks, talking with him ,watching his tv (television). Continues to come behind the nurses desk looking for food. Has took (taken)decorations from the desk and then he places them under his blanket to hide them. Goes to the dinning room and gets into the condiments and licks the packages. Became verbally aggressive with the cna (unidentified, Certified Nursing Assistant) when the cna asked for the trash bags back give those back u (you) son of a (expletive). R40's Nursing Progress dated 3/11/2024 at 2:10 pm documents the following: Note Text: Reported to ( proper first name only) at ( V25, Physician) office about resident attempting to eat things that are non edible, items such as kleenex, oxygen tubing, lancets, paper clips and getting into staffs purses and bags behind the nurses station. Not currently on anything for anxiety. R40's Behavior Note dated 3/17/2024 at 10:43 am documents the following: Note Text: Resident grabbed a bottle on hand sanitizer and took the lid off and this nurse took bottle from resident and he took the top of the bottle and threw it at the wall behind B hall med cart. Screaming at this nurse to go to my room. Attempts to redirect resident met with resistance. R40's Behavior Note dated 3/17/2024 at 11:25 am (37 minutes after the last incident documented above) documents the following: Note Text: Resident was in the front lobby and picked up a small bottle of hand sanitizer and took a drink and stated 'that killed me honey it burns it burns' (.) Called poison control and was asked by (proper first name only) what the ingredients were and told her ethyl alcohol 80% she told this nurse to give him something to eat to help absorb the alcohol it was like drinking a shot of scotch he didn't need to go to the hospital. R40's Behavior Note dated 3/20/2024 at 10:11am documents the following: Note Text: Resident has been very agitated this AM taking Easter decorations off the table and trying to eat the Styrofoam egg had 2 (two) eggs in his mouth and staff had to place fingers on his cheeks to get the eggs from resident's mouth to prevent him from sucking the eggs down his throat (,) he was then taken to his room and given a snack and some water (.) he then went across the hall and opened a bottle of lotion and tried to drink it, staff removed the lotion and he threw the lid across the room and cursed at staff, before breakfast trays were picked up he was eating off multiple trays this nurse removed him from the dining room and was cursed at he also drew back his fist as if to hit this nurse. R40's Nursing Progress Note dated 3/20/2024 at 3:12 pm documents the following: Note Text: Called and spoke with (proper first name only) (V25's) nurse about aggressive behavior on resident toward staff ordered CBC (Complete Blood Count) and Ferritin level continue same meds if continues to be aggressive needs sent to psych (Psychiatry). R40's Behavior Note dated 4/3/2024 at 10:25 am documents the following: Note Text: Resident was waiting outside the shower room when he went into a female residents room and got in her bedside table and was trying to eat lotion before staff took the lotion and removed resident from the females room and was taken to the dining room until time for his shower. On 4/10/24 at 10:00 am, during a resident group meeting R31 stated R31 saw R40 in the dining room doorway. R40 had approached an unlocked medication cart, while V11, Licensed Practical Nurse (LPN) was passing medications. V11's back was turned. When V11 turned back around she saw R40 had removed a large bag from the drawer of the medication cart. 'The bag was full of something, I think it was medication and blood test vials.' R31 also stated V11 knew if R40 got away with those medications it could really hurt him. R40 started swinging at V11. R40 was arguing with V11. (V11) and (R40) were in a tug of war for a minute. V11 got the bag away from R40. R40 was taken back to his table to eat. During the same group meeting R18 stated he saw the same event occur between R40 and V11, exactly as R31 had described. R18's Minimum Data Set (MDS) dated [DATE] documents R18's Brief Interview of Mental Status (BIMS) score as 15 out of a possible 15, indicating no cognitive impairment. R31's MDS dated [DATE] documents R31's BIMS score of 15 out of a possible 15, indicating no cognitive impairment. On 4/11/24 at 11:55 am R40 was seated in a recliner in his room. R40 had a throw blanket over his head and hummed loudly when surveyor knocked on R40's door. R40 removed the blanket from his head and said over and over I love you. When asked any question, R40 hummed or would say I love you. R40 was unable to answer any questions. R40 had three empty plastic glasses and an empty snack bowl on his bedside table. On 4/11/24 at 12:05 pm V15, Certified Nursing Assistant stated she works with R40 all the time. V15, CNA stated He (R40) is always into to something. We try to watch him close. I was off the day he got stuff out of the medicine cart and hit (V11, Licensed Practical Nurse). I heard about it the next day. That was a couple weeks ago. I was not surprised. He can be easily re-directed but is consistently taking stuff off the medicine carts. Staff intervene daily. We all know to watch him every minute. He has dementia and doesn't know better. It is up to us to give him something to do. He is a good eater. We give him snacks a lot. He will try to eat other things he should not be eating. He just doesn't understand. He can get agitated with us. He has never been agitated with another resident, that I know about. On 4/12/24 at 10:10 am V16, CNA stated R40 grabbed a potted plant on the nurses station and another time he had taken another residents a gift set of shampoo, body wash and lotion set. V16 said she assumed he was going to eat it and got V26, LPN. V16, CNA also stated R40 has taken the water pitcher off of the med cart and V16 has seen him shake the drawers of the med cart. V16 also stated an unidentified CNA saw R40 drink pericare liquid wash. On 4/12/24 at 12:12 pm V11, LPN confirmed she provided care to R40 (3/17/24) when R40 consumed a good size swallow of hand sanitizer in the lobby, and had tried earlier the same day to drink the hand sanitizer at the nurses station. V11 had to call poison control and was directed by V25, Physician to follow poison control recommendations. V11 also stated she was R40's nurse when he had gotten medicated Calazime cream in his mouth (3/6/24). V11 stated R40 had gone into the shower room that day and had already got the medicated cream when an unidentified CNA saw R40 and reported. V11 stated she had to call V25, Physician and Poison Control. V11 stated R40 needs constant supervision sometimes because he puts thing in his mouth that are not food. V11 also stated On the weekend we do not have ancillary staff. Those days are very hard to keep constant eye on him (R40) if he is having one of those days where he is busy and trying to put stuff in his mouth. We intervene a lot those days. When ancillary staff are here, they see him and redirect too. Those extra eyes make a difference when he is really active. On 4/12/24 at 12:35 pm V25, Physician stated she has observed staff fail to supervise R40 as closely as they should, on the weekend. V25 also stated it is expected, knowing R40 history, that staff stay diligent in supervising him. 32172 2.) The facility Fall Reduction Policy dated 6/17/22 documents all falls should be documented in the residents electronic medical record and the risk management report and fall risk assessment should be completed after each fall. If the fall is not witnessed neurological checks should be initiated. Nursing staff should update the 24 hour report. The resident's care plan should be reviewed after every fall and updated with a new intervention. R159's Medical Diagnoses List dated April 2024 documents R159 is diagnosed with Repeated Falls, Psychotic Disorder, Mild Cognitive Impairment, Dementia, Motor and Sensory Neuropathy, and Muscle Weakness. R159's Minimum Data Set, dated dated dated [DATE] documents R159 is severely cognitively impaired, uses a wheelchair, and requires substantial assistance for chair/bed transfer and toilet transfers. R159's Fall Risk assessment dated [DATE] documents R159 is high risk for falls due to dementia diagnoses, he has three or more falls in past three months, he is ambulatory and incontinent, has balance problems while standing and walking, requires assistive devices, and has at risk medications and at risk diagnoses. R159's Nurses Progress Note dated 4/3/24 documents R159 continues to be on fall follow-up protocol (from a fall on 3/31/24) and had another fall at 10:00 PM (on 4/2/24) when he was attempting to self-transfer to his wheelchair to use the bathroom. There is no other documentation concerning this fall on 4/2/24. Neurological checks were not initiated. A fall investigation was not completed. A root cause was not determined and a new, root cause specific intervention was not implemented. R159 fell again on 4/9/24. On 4/12/24 at 11:15 AM V2 Director of Nurses confirmed R159 had an unwitnessed fall on 4/2/24 at approximately 10:00 PM which was not entered into the risk management system, neurological checks were not initiated, a fall investigation and root cause was not determined, and no new fall interventions were implemented to aid in future fall prevention.

Based on interview and record review, the facility failed to provide residents food at an appetizing temperature for four of four resident ( R11, R12, R18, and R31) reviewed for palatable meals on the sample list of 35. Finding include: R11, R12, R18 and R31's Current, Minimum Data Sets document R11, R12 R18 and R31 all have Brief Interview of Mental Status scores of 15 out of a possible 15, indicating they have no cognitive impairment. On 4/10/24 at 10:00 am during a resident group meeting, R11, R12, R18 and R31 their meals were often served late, up to one and a half hours past the scheduled meal time, resulting in hot food being served cold. All residents stated there has not been cold food served since state surveyors arrived in the building 4/9/24. On 4/10/24 at 11:30 am V8, Dietary Manager (DM) stated V8 DM Inherited a lot of kitchen problems when he started as DM two weeks ago. V8, DM stated All the hall trays are delivered to the halls first. We use a disc at the bottom and a cover over the top of the plate to keep the food hot. There have been a lot of complaints. The food comes out of the kitchen at safe hot temperatures, then they set on the hall for 30 to 45 minutes before the aides (Certified Nursing Assistants) get the trays delivered to the resident. I have discussed this with nursing staff. What I hear is, they are busy getting people up and out to the dining room, so they can't deliver the trays yet. The problem happens in the dining room as well. The food is at a safe temperature and brought out to the dining room. I watched a cart, with food set for 30 minutes with the dining room full of residents waiting to eat. There is no problem with the kitchen re-heating the food to a safe temperature. The CNA's just need to let us know. I said something to nursing when I saw the cart of food had not been delivered. That is when the Aides got the trays out to the residents in the dining room. There were a couple residents that asked for their food to be reheated that day. I think it was Monday. The facility Resident Council (meeting notes) Tuesday, January 30, 2024 documents Old Business-Last Month. Some members had several dietary concerns. Food Temps (Temperatures) are documented as one of the concerns Resident Council follow-up. document. The facility Resident Council (meeting notes) Tuesday, February 27, 2024 documents December and January (unidentified council) Members expressed some meals are not warm enough when received. The facility Resident Council (meeting notes) Tuesday, March 26, 2024 document council members reported breakfast, lunch, and dinner meals are often served late, lately.

Based on observation, interview and record review the facility failed to properly restrain (R1) during a transport in the facility van. This failure caused (R1) to be thrown from the chair and sustain a compression fracture of the first lumbar vertebrae. R1 is one of three residents reviewed for injuries in a sample list of six. Findings Include: R1's Diagnoses report dated 9/29/21 includes the diagnoses: Difficulty Walking and Acquired absence of Right Leg below the knee. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R1's progress note dated 8/9/21at 5:30PM by V7, Certified Nurse's Aide (CNA) transport aide documents We (R1 and V7) hit the bump pretty hard and (R1) came out of the chair and back down in her chair again. R1's progress note dated 8/11/21 at 9:51AM documents Text to Doctor: (R1) went to [NAME] for an appointment and during transfer in van back to facility they hit a large bump. (R1) states it 'jarred her back'. (R1) has been taking PRN (as needed) [MEDICATION(S)] (Pain medication) every six hours. (R1) requesting an X-Ray for lower back pain. Do you want to see (R1) or order an X-Ray? Please advise. R1's progress note dated 8/12/21 at 7:13AM documents (R1) stated that she was in pain from her back and went on to explain the details of what happened again. It was explained to (R1) that we are awaiting orders from PCP (primary care physician) at this time. (R1) has been a two assist transfer and has been incontinent all this shift. PRN (as needed) [MEDICATION(S)] given to relieve pain. R1's progress note dated 8/26/21 at 12:37PM by V4, Medical Doctor documents Back Pain after hitting large bump in transport van. Better with pain medication. X-Ray showed compression fracture. R1's Magnetic Resonance Imaging (MRI) report dated 9/15/21 documents Impression: Acute Compression Fracture L1 (Lumbar Vertebrae #1) level. R1's Progress note dated 9/17/21 at 3:12PM documents (R1) notified of MRI results from 9/15/21. Results note an acute compression fracture of the lumbar region. (R1) already has PRN pain medication. New order received from Dr for LSO brace X 6 weeks. On 9/29/21 at 11:36AM R1 stated Early in August I think it was the nineth we were coming back from [NAME] in the van. There was a lot of construction and we hit a big bump really hard. I bounced up out of the wheelchair and came down really hard. I felt a pop in my back. I didn't go anywhere for a couple of weeks after that. I was in so much pain. Back pain is one of the worst pain you can have. I kept telling the CNA's and nurses I was hurt, but they didn't listen to me. I was taking [MEDICATION(S)] as often as I could. It was so bad sometimes I took so much I would sleep all day. I did not have the belt on that goes through the wheel chair arm rests like I should have. Every time I have gone anywhere since that they always use that belt but they never did before I got hurt. The back brace they got for me helps and I am getting therapy now and that helps too. It has gotten some better over time. On 9/29/21 at 11:52 AM V5, Licensed Practical Nurse (LPN) stated (R1) has always complained of pain at times, but I would say it got a lot more frequent and worse after the day they hit the bump in the van. She used her [MEDICATION(S)] pretty much every time she could after that. On 9/29/21 at 12:00PM V6, Certified Nurse's Aide (CNA) stated (R1) complaint of a lot of pain almost all the time after the time she came out of the chair on the van. (R1) never really complained of pain to me before that. On 9/29/21at 12:30PM V7, Certified Nurse's Aide (CNA) transportation Aide stated On 8/9/21 I was driving (R1) back to the facility after an appointment in [NAME]. They had been working on the road. There was a huge bump where there had not been before. I tried to slow down, but we hit it hard. (R1) bounced up and came down hard. (R1) said her back kind of hurt. The lap belt probably should have been on, but it wasn't. I had never been trained that it should be. I [NAME] use the lap belt now that I know it is needed. On 9/29/21 at 12:40PM V7 (CNA) demonstrated the restraint procedure in the facility van. After the wheelchair is rolled into the van two hooks are attached to the frame of the wheel chair to secure the wheels. A belt is secured between the resident's legs to keep the resident from sliding forward out of the chair. Then a belt is place over the resident's shoulder and through the arms of the wheelchair and secured to the van to keep the resident in the wheelchair. V7 verbalized the shoulder belt was the belt not in use when R1 bounced up. On 9/29/21 at 1:00PM V4, Medical Doctor stated I would say (R1) is a good historian and is capable of telling us how she was injured. I can say that the incident on the van would have created an impact that is consistent with a compression fracture such as the one (R1) has. The facility's policy Accident Incident Investigation revised 11/5/19 states Purpose: To ensure all accidents, incidents and allegations of abuse involving residents, visitors, or employees are investigated and reported to the facility administration. Procedure: 1. All accidents, incidents, and allegations of abuse (see Abuse and Neglect Prevention Policy) including injuries of unknown source, shall be reported to the department supervision as soon as it is discovered or when information of occurrence is learned. The policy also states 5. Reporting of incident, accidents and abuse to state and federal agencies shall be in compliance in accordance with agency guidelines.states.

Based on interview and record review, the facility failed to develop, implement, and provide timely interventions resulting in repeat falls for a resident. This failure affects one resident (R13) of five residents reviewed for falls in the sample list of 29. R13 fell , requiring medical intervention resulting in a scalp laceration with 8 sutures. Findings include: R13's undated Face Sheet documents R13's diagnoses as: Difficulty in Walking, History of Falling, Repeated Falls, Age Related Physical Debility, Shortness of Breath. R13's Minimum Data Set (MDS) dated [DATE], documents R13 requires extensive assistance with transferring and toileting, can only stabilize self with staff assistance when moving, walking, turning around, moving on and off toilet, and surface to surface transfers. This same MDS documents R13 uses a wheelchair and walker for mobility. The facility's Rehabilitation and Nursing Incident by Incident Type Report, documents R13 having 15 falls on the following dates: 10/4/20, 11/9/20, 11/23/20, 11/25/20, 11/29/20, 12/2/20, 1/1/21, 1/4/21, 1/18/21, 1/30/21, 2/19/21, 2/23/21, 4/13/21, 4/20/21, and 5/2/21. R13's falls documented on 11/23/20 - educate resident R13 to ask for assistance with tasks; 12/2/20 - remind resident (R13) not to get up; 1/1/21 - remind resident (R13) to call for help; and 1/4/21 - move resident's (R13) rooms closer to nurse's station, all which proved to be ineffective for R13's falls. R13's fall dated 5/2/21, documents resident (R13) took off alarm and clipped it to the wheelchair. The intervention documented is to try a floor mat alarm which the DON stated on 5/13/21 at 3:30 PM, the new alarm had to be ordered because the facility doesn't have one. The facility's Purchase Order dated 5/7/21, document a 90-day Floor Mat Sensor Pad 24 inches by 48 inches was ordered. This same Purchase Order documents a delivery date of 5/17/21, which shows the floor mat sensor pad intervention was ordered 5 days after the fall and to be delivered 15 days after R13's fall on 5/2/21. The facility's Incident Audit Report dated 2/23/21, documents R13's alarm was sounding, R13 had a fall noting R13 seated, on buttocks,on the floor near the bathroom, bleeding profusely from R13's head, a half-dollar sized laceration noted front of scalp, bleeding from left side of head, and dark bruising noted on left hand along fingers. This same report documents the following factors for R13's fall - fall alarm, confused, gait imbalance, impaired memory, incontinence, weakness, and ambulating without assistance. The discharge instructions from the emergency room visit on 2/23/21, document R13's diagnoses from this visit as: fall, scalp laceration, fracture of cervical vertebra. There was no documentation specific to after care treatment of fracture. R13's Nursing Notes dated 2/23/21, document resident (R13) arrived back by ambulance with 8 stitches to left forehead and hematoma to left forehead. R13's fall on 1/30/21, documents an intervention to assist R13 to the bathroom every two hours and as needed. On 5/14/21, at 12:04 PM, V4, Assistant Director of Nursing (ADON) stated there is no documentation of when R13 was toileted prior to the fall on 2/23/21. On 5/13/21, at 1:20 PM V4 ADON confirmed R13 has had multiple falls and the interventions prior to 2/23/21 were not adequate and did not prevent R13 from falling and sustaining injuries. The facility's Policy and Procedure Fall/Accident/Incident Protocol dated 11/1/2015, documents the policy of this facility is to provide guidelines for the appropriate handling of a resident fall, accident, or incident.

Based on interview and record review, the facility failed to administer pain medication as ordered by the physician for two residents (R1 and R18) of five reviewed for pain medication administration in the sample of 15. This failure resulted in R1 being admitted to the hospital and being diagnosed with [REDACTED]. Findings include: 1. R1's Physician order [REDACTED]. The facility Resident Transfer Form documents on 6/18/2016 R1 was transferred to the hospital due to slurring of speech and lethargy (drowsiness). The hospital History and Physical Report (6/19/2016) documents R1 was brought to the hospital due to being drowsy and unresponsive. The same report documents R1 had altered mental status and There were two [MEDICATION NAME]es on the patient. The hospital Discharge Summary (6/19/2016) documents R1 had two [MEDICATION NAME]es on which were removed. The same report documents R1's discharge [DIAGNOSES REDACTED]. Altered mental status likely secondary to opioid overdose from the [MEDICATION NAME]. The hospital Inter-Agency Discharge (6/21/2016) documents for R1: Primary [DIAGNOSES REDACTED]. Z4 (R1's attending physician) documented on 6/29/2016 that R1 was in hospital last week for confusion, appeared to be from having 2 [MEDICATION NAME] ([MEDICATION NAME]) patches on at one time . On 8/26/2016 at 9:50AM, Z2 (R1's physician at the hospital) acknowledged R1 had two [MEDICATION NAME]es on when R1 arrived at the hospital. On 8/26/2016 at 1:54 PM, Z3 (Z2's Nurse representative relaying a statement for Z2) confirmed R1 did have two pain patches on when R1 arrived at the hospital, there was no possibility the hospital administered a second pain patch at the hospital as none were ordered for R1 at the hospital, and R1 was harmed by having two pain patches on at the same time because of low blood pressure and acute mental status changes that caused R1 to be admitted to the intensive care unit. 2. R18's Physician order [REDACTED]. The facility Medication Error Report (7/30/2016) documents R18 was due to receive a pain patch on 7/25/2016 and 7/28/2016. The facility Medication Error Report (7/30/2016) documents Patch dated 7/25/2016 on back R (right) Patch dated 7/27/2016 on front left in place at same time .check for patch placement each shift confirm existing patch d/c'd (discontinued) before replacing with new patch.

Based on interviews and record review the facility staff failed to ensure that R1 and R2 were not mistreated in accordance with facility policy. Witnessed mistreatment of [REDACTED]. Witnessed mistreatment of [REDACTED]. This resulted in R2 becoming very upset, flinging her arms and screaming at the nurse and other attending staff. Neither incident was recognized as mistreatment by the facility's Abuse Prevention Coordinator, the Administrator. R1and R2 are two residents reviewed for abuse in a sample of three. These failures have the potential to affect all 71 residents. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/6/13 the facility remains out of compliance at a severity level two. The facility is in the process of implementing a new Abuse Prevention and Prohibition policy, revised and implemented the Medication Administration policy and the Feeding Residents/Assisting Resident policy. The facility also appointed a new Abuse and Prevention Coordinator E2, ADON (Assistant Director of Nurses) who is monitoring the effectiveness of staff retraining directed toward the new polices on abuse prevention, feeding and administering medications. Findings include: 1. The physician's orders [REDACTED]. The Minimum Data Sheet ((MDS) dated [DATE] states R2 is severely cognitively impaired, has unclear speech and only responds adequately to simple, direct communication. R2 requires extensive assistance with two staff for bed mobility, transfers and toileting. R2 was not able to be interviewed due to her cognitive impairment. On 2/21/13 at 12:06 PM E14, Activity Aide stated to IDPH (Illinois Department of Public Health) Surveyor that she had reported an allegation of mistreatment of [REDACTED]. E15 stated on 2/21/13 at 12:38 PM she reported this allegation of mistreatment of [REDACTED]. E14 stated that she witnessed E16, RN (Registered Nurse) come into the D Wing without announcing herself and went behind R2's wheelchair and wrapped her arm around R2's chest. E16 grabbed R2's chin tilted R2's head back, held R2's head, and told R2 she had to take her medicine and poured the medicine into R2's mouth. E14 stated that E17, CNA also witnessed E16 doing this to R2 and reported this to E15. E14 stated that E16 was rough with R2 during this incident. On 2/27/13 at 12:55 PM E17, CNA (Certified Nurse Assistant) stated, "I was in the day room passing trays when (E16) came down to D wing. (E16) just came through to the front of the dayroom area, went up to (R2) and stated 'I have your medicine.' then put a hand to the side of her face and was trying to force the spoon into (R2's) mouth. (R2) had her mouth clamped. (E16) was holding (R2's) head still and (R2) finally did get the spoon of medication into her mouth. (R2) was very angry and was making noises, (R2) started flinging her arms at (E16), when (E16) walked away from (R2) myself and another CNA (E18) tried calming (R2) down. (R2) was having no part of that and R2 was still angry and making noises at us. (E17 and E18). ( E16) the nurse just walked out of D wing, did not check on (R2) at all. I reported this to the nurse (E15) right after the incident happened. I seen this as abuse to (R2)." E18, CNA stated on 2/27/13 at 12:19 PM "It was me and (E17) working that day, ...(E16) made (R2) drink the shake she had her medications in. (E16) was a little rough to (R2) trying to make (R2) drink and held her head. (E16) held( R2's) head back to put the drink into (R2's) mouth. I don't think this was appropriate, (E16) could of asked one of us how (R2) takes her medications but( E16) did not ask. (R2) threw a fit at first , flinging her arms about and screaming. I did not report this to the nurse because (E17) reported it to (E15). R2's Care Plan dated 2/7/13 states under "Problems" " I (R2) have a hearing deficit and do not always speak clearly. I(R2) also have dementia which can make my communication ability impaired." The Intervention section states "....... I (R2) did live on a small special dementia unit with consistent caregivers. They are able to understand me(R2) better because of the familiarity. If you have trouble understanding me, ask them for assistance." 2. The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states R1 to be moderately impaired in making decisions regarding tasks of daily life, R1's decisions are poor and requires cues and supervision by staff. R1 has difficulty focusing attention and was not able to be interviewed due to being cognitively impaired. R1 requires extensive assistance of two staff for toileting and ambulation. R1 also requires setup help only for meals and is able to feed self without assistance of staff. R1's Nurses Notes dated 1/21/13 at 3 PM documents that R1 returned from the doctor's office with an order to be placed on [MEDICATION NAME] and respiratory isolation for five days. Temperature 100 degrees. R1's Nurses Notes dated 1/21/13 to 1/27/13 describes R1 as being weak, not willing to get out of bed, having a non productive cough, refusing to eat or drink and unable to perform activities of daily living with assistance from the staff. Nurses Notes on 1/28/13 at 12:30 PM states " Updated physician on patient's condition. No temperature, still coughing , refusing to eat." E10, CNA (Certified Nurses Assistant) documented on an untitled sheet of paper given by E1, that she witnessed E3, LPN (Licensed Practical Nurse) on 1/28/13 at R1's bed jerking R1 up by the neck from a lying position. The document stated that E3 was trying to force R1 to eat and was yelling at her that R1 had to eat. R1 was repeatedly stating to E3 that she did not want to eat. On 2/13/13 at 10:59 AM E10 confirmed that she did document the incident and placed it in E1's mailbox. E10 stated on 2/13/13 at 10:59 AM she had witnessed E3 on 1/28/13 jerking R1 up by the neck and was forcing R1 to eat. E10 stated E3 was trying to put food into R1's mouth and R1 kept moving her head and stating she did not want to eat. E10 stated E3 was yelling at her to eat. E10 stated that she did not report the incident until 1/30/13 because bed alarms were going off and she had no help or time. On 2/27/13 at 2:30 PM E1 stated "I did not see this incident as abuse". The facility's undated Abuse, Prevention and Prohibition policy states "Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including , but not limited to facility staff, other residents....or other individuals. The policy continues to state: "The facility prohibits mistreatment, neglect or abuse of residents.. This also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being...." The Abuse Policy states under section II "Training": "Facility staff shall be trained on the abuse prohibition program during orientation and ongoing during educational sessions..." The facility's form titled "Abuse Policy Acknowledgement" was signed by E16, on 11/13/12 and E3 signed the form on 4/19/12. The form has an acknowledgment at the bottom stating "This will certify that a copy of facility Abuse Policy was given to the person who signed the above receipt and that training was provided to the contents. It is confirmed that this person understands the policy." An additional inservice on Abuse Prohibition was held on 12/18/12 at 1:30 PM. There is no documented evidence that either employee, E16 or E3 attended this inservice training, their signatures are not on the sign in sheet. E1 stated on 2/28/13 at 10:55 AM that both employees E3 and E16 had continued access to all 71 residents in the building. The Illinois Department of Public Health form titled "Facility Data Sheet" lists the facility census at 71 residents residing in the facility. On 2/28/13 at 11:10 AM an Immediate Jeopardy was identified to have begun on 12/28/12 when E1, Administrator/Abuse Prohibition Coordinator failed to recognize an allegation of abuse when reported . E1 was notified of the Immediate Jeopardy on 2/28/13 at 11:10 AM. The surveyor confirmed through record reviews and interviews that the facility took the following actions to remove the Immediate Jeopardy: 1. On 2/11/13 at 3 PM E1, Administrator terminated E3's, LPN employment due to abuse findings. 2. On 2/28/13 at 11AM E2, APC (Abuse Prevention Coordinator) terminated E16's, RN employment due to abuse findings. 3. On 2/28/13 E1 appointed E2, ADON as the new Abuse Prevention Coordinator. 4. On 2/28/13 the Abuse Prevention and Prohibition policy was revised by E2. 5. On 3/6/13 at 12:30 PM E1 and E2 verbalized an understanding of and demonstrated competency with regard to Abuse Prevention regulations and facility operating policies. 6. On 3/6/13 at 1:30 PM all staff were trained on the new Abuse Prevention and Prohibition policy, the revision in the "Feeding Residents" policy and the revisions to the "Administering Medications" to residents policy. This was completed by E2. 7. Quality Assurance (QA) Committee will monitor and oversee the abuse allegations and investigation. The QA committee will review all allegations of abuse at the quarterly meeting for proper implementation, recognition of abuse and management of the investigation. Designated member of the Board of Directors will oversee the Abuse QA by receiving a report of the discussion at the quarterly meeting. The Designated member of the Board of Directors will also review each allegation of abuse, received monthly for proper implementation.

Based on record review and interview the facility failed to recognize two incidents as allegations of abuse, failed to protect residents from alleged perpetrators, failed to investigate and failed to report allegations of abuse involving R1and R2 immediately to the Administrator. The facility also failed to report the allegations of mistreatment to the state survey and certification agency for R1and R2. R1 and R2 are two of three residents reviewed for abuse in a sample of three. These failures have the potential to affect all 71 residents. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/6/13 the facility remains out of compliance at a severity level two. The facility is in the process of implementing a new Abuse Prevention and Prohibition policy, revised and implemented the Medication Administration policy and the Feeding Residents/Assisting Resident policy. The facility also appointed a new Abuse and Prevention Coordinator E2, ADON (Assistant Director of Nurses) who is monitoring the effectiveness of staff retraining directed toward the new polices on abuse prevention, feeding and administering medications. Findings include: 1. The physician's orders [REDACTED]. The Minimum Data Sheet ((MDS) dated [DATE] states R2 is severely cognitively impaired, has unclear speech and only responds adequately to simple, direct communication. R2 requires extensive assistance with two staff for bed mobility, transfers and toileting. R2 was not able to be interviewed due to her cognitive impairment. On 2/21/13 at 12:02 PM E14, Activity Aide stated that she had reported an allegation of mistreatment of [REDACTED]. E14 stated that she witnessed E16, RN (Registered Nurse) come into the D Wing without announcing herself and went behind R2's wheelchair and wrapped her arm around R2's chest. E16 grabbed R2's chin, tilted R2's head back, held R2's head, told R2 she had to take her medicine and poured the medicine into R2's mouth. E14 stated that E17, CNA also witnessed E16 doing this to R2 and E17 also reported this to E15, LPN. E14 stated that E16 was rough with R2 during this incident. On 2/27/13 at 12:55 PM E17, CNA (Certified Nurse Assistant) stated, "I was in the day room passing trays when (E16) came down to D wing. (E16) just came through to the front of the dayroom area, went up to (R2) and stated 'I have your medicine' then put a hand to the side of her face and was trying to force the spoon into (R2's) mouth. (R2) had her mouth clamped. (E16) was holding (R2's) head still and (R2) finally did get the spoon of medication into her mouth. (R2) was very angry and was making noises, (R2) started flinging her arms at (E16). When (E16) walked away from (R2) myself and another CNA (E18) tried calming (R2) down. (R2) was having no part of that and (R2) was still angry and making noises at us (E17 and E18). ( E16) the nurse just walked out of D wing, did not check on (R2) at all. I reported this to the nurse (E15) right after the incident happened. I seen this as abuse to (R2)." E18, CNA stated on 2/27/13 at 12:19 PM "It was me and (E17) working that day, ...(E16) made (R2) drink the shake she had her medications in. (E16) was a little rough to (R2) trying to make (R2) drink and held her head. (E16) held( R2's) head back to put the drink into (R2's) mouth. I don't think this was appropriate, (E16) could of asked one of us how (R2) takes her medications but( E16) did not ask. (R2) threw a fit at first , flinging her arms about and screaming. I did not report this to the nurse because (E17) reported it to (E15). E15 stated on 2/21/13 at 12:38 PM that E14 and E17 did report the allegation of R2 being mistreated by R16 to her. E15 stated the two CNAs were upset and stated E16 was very rough with R2 when giving R2 her medication. E15 stated she reported the allegation to E1 right after the two CNAs reported this information to her. E15 stated she told E1 how upset E14 and E17 were about the mistreatment of [REDACTED]. E16 was never removed from direct resident care following receipt of the alleged mistreatment of [REDACTED]. The facility's daily and monthly time schedules document that E16 was scheduled and worked her designated dates as a Registered Nurse from 12/28/12 to 2/21/13. E16 had access to all the residents within the facility. On 2/28/13 at 10:55 AM E1 confirmed that E16 had access to all residents and continued to work in the facility as a Registered Nurse from 12/28/12 to 2/21/13. 2. The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states R1 to be moderately impaired in making decisions regarding tasks of daily life, R1's decisions are poor and requires cues and supervision by staff. R1 has difficulty focusing attention and was not able to be interviewed due to being cognitively impaired. R1 requires extensive assistance of two staff for toileting and ambulation. R1 also requires setup help only for meals and is able to feed self without assistance of staff. E10, CNA documented on an untitled sheet of paper given to E1,Administrator/Abuse Coordinator on 1/30/13 that she witnessed E3, LPN on 1/28/13 at R1's bed jerking R1 up by the neck from a lying position. The document stated that E3 was trying to force R1 to eat and was yelling at her that R1 had to eat. R1 was repeatedly stating to E3 that she did not want to eat. On 2/13/13 at 10:59 AM E10 confirmed that she did document the incident and placed it in E1's mailbox. E1 confirmed on 2/21/13 at 10:48 a.m. that E10 did document the incident on paper and placed it in E1's mailbox and E1 did not retrieve the paper from her mailbox until the following week. E1 stated in the same interview that she could not give an answer as to why she did not do anything about the incident when she finally found the document that E10 had written. E10 stated on 2/13/13 at 10:59 AM that she had witnessed E3 on 1/28/13 jerking R1 up by the neck and forcing R1 to eat. E10 stated E3 was trying to put food into R1's mouth and R1 kept moving her head and stating she did not want to eat. E10 stated E3 was yelling at R1 to eat. E10 stated that she did not report the incident until 1/30/13 because bed alarms were going off and she had no help or time. E10 stated on 2/13/13 at 10:59 AM that E10 first reported the incident to E12, CNA Supervisor on 1/30/13 and E12 stated "I don't believe (E3) would do anything like that. She is not that type of nurse." E12 failed to report the incident to E1. On 2/21/13 at 11:04 E12 stated she did not remember E10 reporting anything to her about the incident with E3 and R1. E12 stated she was off the next two days after E10 stated she reported the allegation to her. E12 stated she was not saying that E10 didn't report to her but E12 stated she could not remember. E10 stated that E12 did not report the allegation to E1, so E10 reported the incident to E11, RN and E13, LPN. E10 continued to state that E11 called E1 and reported the allegation to E1. E10 stated E11 gave her the phone and E10 also gave all the details to E1 about the allegation of mistreatment of [REDACTED]. On 2/21/13 at 9:51 AM, E11 confirmed that E10 reported to her the allegation of mistreatment of [REDACTED]. E11 confirmed she called E1 and reported the allegation to E1. E11 stated she witnessed E10 write the incident on a piece of paper and placed it in E1's mailbox on 1/30/13. On 2/21/13 at 10:11 AM E13, LPN confirmed she was present when E11 called E1 and reported the allegation of mistreatment to E1. On 2/21/13 at 10:48 AM E1, confirmed that on 1/30/13 she received a phone call from E11 stating E10 saw E3 jerk R1 up by the neck and tried to force R1 to eat. E1 also confirmed that she spoke with E10 and asked her to write the incident up and place into her mailbox. E1 stated that she did not do anything about the incident until IDPH (Illinois Department of Public Health) Surveyor entered the building on 2/6/13. E1 stated "I can't give you an answer why I did not do anything about the allegation." E1 confirmed she failed to report this allegation of alleged abuse to IDPH until 2/6/13. E3's time cards document that E3 continued to have unrestricted access and worked as a Licensed Practical Nurse for the facility on 1/28/13, 2/1/13, 2/4/13 and 2/6/13. E3's employment was terminated by E1 on 2/6/13 for the mistreatment of [REDACTED]. The facility's undated Abuse, Prevention and Prohibition policy states under section "VI Protection Employee Allegations: "When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension..." The facility's Abuse Policy states under section VII "Reporting/Response" The facility employee or agent who becomes aware of abuse or neglect, ......shall immediately report the matter to the facility Administrator and Director of Nursing." The policy continues to state "The facility Administrator, employee, or agent shall immediately report all alleged abuse and substantiated abuse cases or cause a report to be made to the mandated state agency per reporting criteria or in person...." E1 confirmed on 2/21/13 at 1:30 PM that E14 and E15 reported the incident to her about E16 giving medications to R2 . E1 stated in that same interview that E1 did not investigate the incident as mistreatment of [REDACTED]. E1 stated that "she did not believe it was abuse, just inappropriate way of giving medications." E1 stated that R16 had been a hospital nurse for years and they did things differently in the hospital. E1 explained that E16 did not have the knowledge in giving R2 her medications properly because R2 is a difficult resident to give medications to and R2's medication had to be placed in her milk for R2 to drink. E1 stated on 2/28/13 at 10:55 AM that both employees E3 and E16 had continued access to all 71 residents in the building. E1 stated she discharged E3 from the facility's payroll on 2/6/13 and E16 still worked in the building. The Illinois Department of Public Health form titled "Facility Data Sheet" list the facility census at 71 residents residing in the facility. On 2/28/13 at 11:10 AM an Immediate Jeopardy was identified to have begun on 12/28/12 when E1, Administrator/Abuse Prohibition Coordinator failed to recognize an allegation of abuse when reported . E1 was notified of the Immediate Jeopardy on 2/28/13 at 11:10 AM. The surveyor confirmed through record reviews and interviews that the facility took the following actions to remove the Immediate Jeopardy: 1. On 2/11/13 at 3 PM E1, Administrator terminated E3's, LPN employment due to abuse findings. 2. On 2/28/13 at 11AM E2, APC (Abuse Prevention Coordinator) terminated E16's, RN employment due to abuse findings. 3. On 2/28/13 E1 appointed E2, ADON as the new Abuse Prevention Coordinator. 4. On 2/28/13 the Abuse Prevention and Prohibition policy was revised by E2. 5. On 3/6/13 at 12:30 PM E1 and E2 verbalized an understanding of and demonstrated competency with regard to Abuse Prevention regulations and facility operating policies. 6. On 3/6/13 at 1:30 PM all staff were trained on the new Abuse Prevention and Prohibition policy, the revision in the "Feeding Residents" policy and the revisions to the "Administering Medications" to residents policy. This was completed by E2. 7. Quality Assurance (QA) Committee will monitor and oversee the abuse allegations and investigation. The QA committee will review all allegations of abuse at the quarterly meeting for proper implementation, recognition of abuse and management of the investigation. Designated member of the Board of Directors will oversee the Abuse QA by receiving a report of the discussion at the quarterly meeting. The Designated member of the Board of Directors will also review each allegation of abuse, received monthly for proper implementation.

Based on interview and record review the facility's Administrator , designated as facility Abuse Prohibition Coordinator failed to operationalize all components of the facility's abuse policy by not recognizing two witness accounts of alleged abuse for R1 and R2, failing to report the two allegations of abuse to the State Survey and Certification Agency, failing to protect R1 and R2 from the alleged perpetrators and failing to investigate the two witnessed accounts of alleged abuse for R1 and R2. The Administrator failed to ensure the safety and well being of all residents. Staff delayed 3 days before reporting a witnessed allegation of abuse involving R1 to the Administrator. R1and R2 are two residents reviewed for abuse in a sample of three. These failures have the potential to affect all 71 residents. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/6/13 the facility remains out of compliance at a severity level two. The facility is in the process of implementing a new Abuse Prevention and Prohibition policy, revised and implemented the Medication Administration policy and the Feeding Residents/Assisting Resident policy. The facility also appointed a new Abuse and Prevention Coordinator E2, ADON (Assistant Director of Nurses) who is monitoring the effectiveness of staff retraining directed toward the new polices on abuse prevention, feeding and administering medications Findings include: 1. On 12/28/12 an allegation of witnessed abuse by two staff members, E14, Activity Aide and E17 CNA (Certified Nursing Assistant) was reported to E1, Administrator, Abuse Prohibition Coordinator. E1 failed to recognize this allegation of abuse and failed to suspend the alleged perpetrator E16, RN (Registered Nurse) and protect R2 from further possible abuse. E1 also failed to investigate the witnessed abuse and failed to report the allegation of abuse to the state survey and certification agency. On 2/21/13 at 12:02 PM E14, Activity Aide stated that she had reported an allegation of mistreatment of [REDACTED]. E14 stated that she witnessed E16, RN (Registered Nurse) come into the D Wing without announcing herself and went behind R2's wheelchair and wrapped her arm around R2's chest. E16 grabbed R2's chin, tilted R2's head back, held R2's head, told R2 she had to take her medicine and poured the medicine into R2's mouth. E14 stated that E17, CNA also witnessed E16 doing this to R2 and E17 also reported this to E15, LPN. E14 stated that E16 was rough with R2 during this incident. On 2/27/13 at 12:55 PM E17 stated, "I was in the day room passing trays when (E16) came down to D wing. (E16) just came through to the front of the dayroom area, went up to (R2) and stated 'I have your medicine' then put a hand to the side of her face and was trying to force the spoon into (R2's) mouth. (R2) had her mouth clamped. (E16) was holding (R2's) head still and (R2) finally did get the spoon of medication into her mouth. (R2) was very angry and was making noises, (R2) started flinging her arms at (E16). When (E16) walked away from (R2), myself and another CNA (E18) tried calming (R2) down. (R2) was having no part of that and (R2) was still angry and making noises at us (E17 and E18). (E16) the nurse just walked out of D wing, did not check on (R2) at all. I reported this to the nurse (E15) right after the incident happened. I seen this as abuse to (R2)." E1 confirmed on 2/21/13 at 1:30 PM that E14 and E15 reported the incident to her about E16 giving medications to R2 . E1 stated in that same interview that E1 did not investigate the incident as mistreatment of [REDACTED]. E1 stated that "she did not believe it was abuse, just inappropriate way of giving medications." 2. E10 stated on 2/13/13 at 10:59 AM that she had witnessed E3 on 1/28/13 jerking R1 up by the neck and forcing R1 to eat. E10 stated E3 was trying to put food into R1's mouth and R1 kept moving her head and stating she did not want to eat. E10 stated E3 was yelling at R1 to eat. E10 stated that she did not report the incident until 1/30/13 because bed alarms were going off and she had no help or time. E10 continued to state that E10 first reported the incident to E12, CNA Supervisor on 1/30/13 and E12 stated "I don't believe (E3) would do anything like that. She is not that type of nurse." E12 failed to report the incident to E1. E10 stated that E12 did not report the allegation to E1, so E10 reported the incident to E11, RN and E13, LPN. E10 continued to state that E11 called E1 and reported the allegation to E1. E10 stated E11 gave her the phone and E10 also gave all the details to E1 about the allegation of mistreatment of [REDACTED]. On 2/21/13 at 10:48 AM E1, confirmed that on 1/30/13 she received a phone call from E11 stating E10 saw E3 jerk R1 up by the neck and tried to force R1 to eat. E1 also confirmed that she spoke with E10 and asked her to write the incident up and place into her mailbox. E1 stated that she did not do anything about the incident until IDPH (Illinois Department of Public Health) Surveyor entered the building on 2/6/13. E1 stated "I can't give you an answer why I did not do anything about the allegation. I don't know why." E1 confirmed she failed to report this allegation of alleged abuse to IDPH until 2/6/13. The facility's undated policy titled "ABUSE, PREVENTION AND PROHIBITION" states under the section titled "Policy" reads "This facility prohibits mistreatment, neglect or abuse of patients.....The residents must not be subjected to abuse by anyone. The facility will notify all employees upon hire of the definitions of abuse and neglect." The facility's policy under the section titled "III Prevention" reads "The resident has the right to be free from verbal, mental, sexual or physical abuse, corporal punishment and involuntary seclusion...." Section V titled "Procedure" states "Complete a thorough investigation. Two management staff will conduct interviews with completion of abuse questionnaires..... Implement steps to prevent further potential abuse..." Section "VI Protection" states under "Employee Allegations" "When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension,..." Section "VII Reporting/Response" states "The facility employee or agent who becomes aware of abuse or neglect, including injuries of unknown source....shall immediately report the matter to the facility Administrator and Director of nursing. The facility Administrator , employee, or agent shall immediately report all alleged abuse and substantiated abuse cases or cause a report to be made to the mandated state agency per reporting criteria or in person...." E1 confirmed on 2/27/13 at 2:30 PM that E1 did not report either incident of abuse for R1 and R2 to the state survey agency, did not investigate or suspend alleged perpetrators E3 or E16 when the allegations of abuse were reported to her. E1 stated on 2/28/13 at 10:55 AM that both employees E3 and E16 had continued access to all 71 residents in the building. The Illinois Department of Public Health form titled "Facility Data Sheet" list the facility census at 71 residents residing in the facility. On 2/28/13 at 11:10 AM an Immediate Jeopardy was identified to have begun on 12/28/12 when E1, Administrator/Abuse Prohibition Coordinator failed to recognize an allegation of abuse when reported. E1 was notified of the Immediate Jeopardy on 2/28/13 at 11:10 AM. The surveyor confirmed through record reviews and interviews that the facility took the following actions to remove the Immediate Jeopardy: 1. On 2/11/13 at 3 PM E1, Administrator terminated E3's, LPN employment due to abuse findings. 2. On 2/28/13 at 11AM E2, APC (Abuse Prevention Coordinator) terminated E16's, RN employment due to abuse findings. 3. On 2/28/13 E1 appointed E2, ADON as the new Abuse Prevention Coordinator. 4. On 2/28/13 the Abuse Prevention and Prohibition policy was revised by E2. 5. On 3/6/13 at 12:30 PM E1 and E2 verbalized an understanding of and demonstrated competency with regard to Abuse Prevention regulations and facility operating policies. 6. On 3/6/13 at 1:30 PM all staff were trained on the new Abuse Prevention and Prohibition policy, the revision in the "Feeding Residents" policy and the revisions to the "Administering Medications" to residents policy. This was completed by E2. 7. Quality Assurance (QA) Committee will monitor and oversee the abuse allegations and investigation. The QA committee will review all allegations of abuse at the quarterly meeting for proper implementation, recognition of abuse and management of the investigation. Designated member of the Board of Directors will oversee the Abuse QA by receiving a report of the discussion at the quarterly meeting. The Designated member of the Board of Directors will also review each allegation of abuse, received monthly for proper implementation.

Based on interviews and record review the facility Administrator, designated as facility Abuse Prohibition Coordinator, failed to recognize two separate witnessed accounts of alleged physical, verbal and mental mistreatment as possible abuse. The Administrator failed to act on these reported incidents so as to protect residents of the facility. The Administrator demonstrated poor working knowledge of the facility's abuse prevention policies, regulations related to abuse prevention, and the necessity to remove alleged perpetrators pending an investigation. The Administrator demonstrated poor judgement and questionable ability with regard to performing an investigation of reported witnessed mistreatment. Failure of the Administrator to operationalize all components of the facility abuse prevention policy placed all 71 residents at risk for potential further abuse. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/6/13 the facility remains out of compliance at a severity level two. The facility is in the process of implementing a new Abuse Prevention and Prohibition policy, revised and implemented the Medication Administration policy and the Feeding Residents/Assisting Resident policy. The facility also appointed a new Abuse Prevention Coordinator E2, ADON (Assistant Director of Nurses) who is monitoring the effectiveness of staff retraining directed toward the new polices on abuse prevention, feeding and administering medications. Findings include: 1. An allegation of abuse was reported to E1, Administrator/Abuse Prohibition Coordinator on 12/28/13 by E14, Activity Aide and E17, CNA (Certified Nurse Assistant) regarding R2. On 2/21/13 at 12:02 PM E14, Activity Aide stated that she had reported an allegation of mistreatment of [REDACTED]. E14 stated that she witnessed E16, RN (Registered Nurse) come into the D Wing without announcing herself and went behind R2's wheelchair and wrapped her arm around R2's chest. E16 grabbed R2's chin, tilted R2's head back, held R2's head, told R2 she had to take her medicine and poured the medicine into R2's mouth. E14 stated that E17, CNA also witnessed E16 doing this to R2 . E14 stated that E16 was rough with R2 during this incident. On 2/27/13 at 12:55 PM E17 stated, "I was in the day room passing trays when (E16) came down to D wing. (E16) just came through to the front of the dayroom area, went up to (R2) and stated 'I have your medicine' then put a hand to the side of her face and was trying to force the spoon into (R2's) mouth. (R2) had her mouth clamped. (E16) was holding (R2's) head still and (R2) finally did get the spoon of medication into her mouth. (R2) was very angry and was making noises, (R2) started flinging her arms at (E16). When (E16) walked away from (R2), myself and another CNA (E18) tried calming (R2) down. (R2) was having no part of that and (R2) was still angry and making noises at us (E17 and E18). (E16) the nurse just walked out of D wing, did not check on (R2) at all. I reported this to the nurse (E15) right after the incident happened. I seen this as abuse to (R2)." E1 confirmed on 2/21/13 at 1:30 PM that E14 and E15 reported the incident to her about E16 giving medications to R2 . E1 stated in that same interview that E1 did not investigate the incident as mistreatment of [REDACTED]. E1 stated that " E1did not believe it was abuse, just inappropriate way of giving medications." E1stated on 2/27/13 at 2:30 PM "(E16) came from the hospital and (E1) worked at the hospital so (E1) know things are different there the way they handle things....The other nurses and I know (R2's) personality and behaviors as well as how (R2) will take her medicine best." E1 confirmed on 2/28/13 at 10:55 AM that E1 did not suspend E16 when she received the allegation of abuse. E1 stated E16 was still employed and working as a RN at the facility as of 2/28/13 and had continued access to all 71 residents in the building. 2. E10 stated on 2/13/13 at 10:59 AM that she had witnessed E3 on 1/28/13 jerking R1 up by the neck and forcing R1 to eat. E10 stated E3 was trying to put food into R1's mouth and R1 kept moving her head and stating she did not want to eat. E10 stated E3 was yelling at R1 to eat. E10 stated that she did not report the incident until 1/30/13 because bed alarms were going off and she had no help or time. E10 continued to state that E10 first reported the incident to E12, CNA Supervisor on 1/30/13 and E12 stated "I don't believe (E3) would do anything like that. She is not that type of nurse." E10 stated that E12 did not report the allegation to E1, so E10 reported the incident to E11, RN and E13, LPN. E10 continued to stated that E11 called E1 and reported the allegation to E1. E10 stated E11 gave her the phone and E10 also gave all the details to E1 about the allegation of mistreatment of [REDACTED]. On 2/21/13 at 10:48 AM E1, confirmed on 1/30/13 she received a phone call from E11 stating E10 saw E3 jerk R1 up by the neck and tried to force R1 to eat. E1 also confirmed that she spoke with E10 and asked her to write the incident up and place into her mailbox. E1 stated that she did not do anything about the incident until IDPH (Illinois Department of Public Health) Surveyor entered the building on 2/6/13. E1 stated "I can't give you an answer why I did not do anything about the allegation. I don't know why." E1 confirmed she failed to report this allegation of alleged abuse to IDPH until 2/6/13. E1 stated on 2/27/13 at 2:30 PM E1 did not report or investigate either incident involving R1 and R2. I did not suspend either nurse, E3 or E16 until receiving the complaint on 2/6/13. Both E2 and E16 continued to work the facility having continued access to all residents. E3 was discharged from employment on 2/6/13 and E16 continued to work as a RN in the building as of 2/28/13 having continued access to all 71 residents in the building. E1 stated on 2/21/13 at 1:30 PM "I did not terminate E16 because I did not see it as abuse just inappropriate way of giving medications." E1 stated on 2/28/13 at 10:55 AM that both employees E3 and E16 had continued access to all 71 residents in the building. The Illinois Department of Public Health form titled "Facility Data Sheet" list the facility census at 71 residents residing in the facility. The facility's undated policy titled "ABUSE, PREVENTION AND PROHIBITION" states under the section titled "Policy" reads "This facility prohibits mistreatment, neglect or abuse of patients.....The residents must not be subjected to abuse by anyone. The facility will notify all employees upon hire of the definitions of abuse and neglect." The Abuse Policy states under section II "Training": "Facility staff shall be trained on the abuse prohibition program during orientation and ongoing during educational sessions..." The facility's policy under the section titled "III Prevention" reads "The resident has the right to be free from verbal, mental, sexual or physical abuse, corporal punishment and involuntary seclusion...." Section V titled "Procedure" states "Complete a thorough investigation. Two management staff will conduct interviews with completion of abuse questionnaires..... Implement steps to prevent further potential abuse..." Section "VI Protection" states under "Employee Allegations" "When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension,..." Section "VII Reporting/Response" states "The facility employee or agent who becomes aware of abuse or neglect, including injuries of unknown source....shall immediately report the matter to the facility Administrator and Director of nursing. The facility Administrator , employee, or agent shall immediately report all alleged abuse and substantiated abuse cases or cause a report to be made to the mandated state agency per reporting criteria or in person...." On 2/28/13 at 11:10 AM an Immediate Jeopardy was identified to have begun on 12/28/12 when E1, Admnistrator/Abuse Prohibition Coordinator failed to recognize an allegation of abuse when reported . E1 was notified of the Immediate Jeopardy on 2/28/13 at 11:10 AM. The surveyor confirmed through record reviews and interviews that the facility took the following actions to remove the Immediate Jeopardy: 1. On 2/11/13 at 3 PM E1, Administrator terminated E3's, LPN employment due to abuse findings. 2. On 2/28/13 at 11AM E2, APC (Abuse Prevention Coordinator) terminated E16's, RN employment due to abuse findings. 3. On 2/28/13 E1 appointed E2, ADON as the new Abuse Prevention Coordinator. 4. On 2/28/13 the Abuse Prevention and Prohibition policy was revised by E2. 5. On 3/6/13 at 12:30 PM E1 and E2 verbalized an understanding of and demonstrated competency with regard to Abuse Prevention regulations and facility operating policies. 6. On 3/6/13 at 1:30 PM all staff were trained on the new Abuse Prevention and Prohibition policy, the revision in the "Feeding Residents" policy and the revisions to the "Administering Medications" to residents policy. This was completed by E2. 7. Quality Assurance (QA) Committee will monitor and oversee the abuse allegations and investigation. The QA committee will review all allegations of abuse at the quarterly meeting for proper implementation, recognition of abuse and management of the investigation. Designated member of the Board of Directors will oversee the Abuse QA by receiving a report of the discussion at the quarterly meeting. The Designated member of the Board of Directors will also review each allegation of abuse, received monthly for proper implementation.

Based on record review and interview the facility failed to provide appropriate post fall interventions for R14. The facility failed to properly assess and notify the physician of R14's condition relating to behaviors and altered mental status relating to a fall R14 had on [DATE]. Failure to notify the Physician on R14's behaviors and altered mental status resulted in R14's treatment to be delayed for a time period of eight hours. R14 was subsequently diagnosed with [REDACTED]. R14 is one of five residents reviewed for falls in the sample of 15. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE] the facility remains out of compliance at a Severity Level 2 as the facility is in the process of implementing a new policy for Physician notification, post fall assessment and treatment for [REDACTED]. Findings include: R14's physician's orders [REDACTED]. R14's Minimum Data Set ((MDS) dated [DATE] documents that R14 is severely cognitively impaired and requires one person physical assist for transfers, toileting and is unable to balance without staff assistance . R14's Fall Risk assessment dated [DATE], [DATE], [DATE] and [DATE] documents that R14 was at high risk for falls. The Facility's Occurrence Report dated [DATE] documents that on [DATE] at 1:15 AM "( R14) climbed out of bed and the bed alarm did not sound, this nurse (E8) LPN (Licensed Practical Nurse) coming down the hall and found (R14) on the floor laying on his back scooting around on the floor. Raised bump noted to crown of head with raised area to back of head and scalp region...." The same Occurrence report documents that the Physician was faxed the information regarding the fall with injury to his office at 2 AM on [DATE]. R14's Nurses Notes dated [DATE] at 4:15 AM documents ".....(R14) continues to be very restless and fidgets almost constantly. Will continue to monitor." R14's Nurses Notes dated [DATE] at 5:30 AM documents " (R14) on toilet and pointed penis at CNA (Certified Nursing Assistant) and attempted to urinate on CNA, then had toilet tissue in hands as if holding a gun and told staff (R14) will shoot them and then (R14) threw tissue at staff. (R14) in hallway with staff monitoring one to one and (R14) raised right leg and kicked this nurse (E8) in stomach. Will continue to monitor." R14's Nurses Notes dated [DATE] at 6:20 AM documents "(R14) complaints of buttocks hurting PRN (whenever necessary) Tylenol given with difficulty. (R14) would not swallow pills and had difficulty getting (R14) to open his mouth. C/D Wing nurse sat with (R14) and reports (R14) attempting to pull out his tongue. Staff sits with (R14) one to one at nurses station." R14's Nurses Notes shows no documented evidence of attempts to notify or consult with R14's Physician regarding the behavioral changes in R14 that occurred on [DATE] after R14's fall with a known head injury. The only notification of R14's Physician regarding the fall on [DATE] is the facility's Occurrence Report dated [DATE] that documents that R14's Physician was faxed the information regarding the fall with injury to his office at 2 AM on [DATE]. On [DATE] at 10:30 AM E2, DON (Director of Nurses) stated she had no additional information regarding R14's Physician being personally contacted except what was already written in R14's Nurses Notes. R14's Nurses Notes dated [DATE] at 8:40 AM documents R14's Physician was contacted and an order was received to send R14 to the emergency room . R14 Nurses Notes at 9:15 AM documents an Ambulance was here to transport to emergency room . R14's hospital Radiology Report dated [DATE] documents: "Acute subdural hematoma with extension into the anterior falx and a component of subarachnoid hemorrhage all described. There is cerebral [MEDICAL CONDITION] in the right hemisphere and cerebral atrophy is noted. Linear skull fracture is an equivocal finding in this case." R14's Nurses Notes dated [DATE] at 9:30 PM documents "Daughters came to report that their father (R14) died at 8:15 PM.......they said there was so much brain damage that a conscious life could not be sustained....." Z4, Physician for R14 stated on [DATE] at 11:40 AM, " I was on call for that week.....I did not receive any phone call related to (R14) having a fall. The facility always calls me off hours and they should of called me about this fall. If I was notified of the fall I would of sent (R14) to emergency room to be evaluated and treated. They should of not faxed the office because no one would see the fax until Monday Morning. .... I read the emergency room report for (R14). The report stated (R14) had a acute subdural hematoma, subarachnoid hemorrhage and skull fracture. I can say the subdural hematoma and skull fracture was the result of trauma from the fall. This was part of the reason for his death, I can not say it was the only reason for death. The trauma from the fall resulted in (R14's) skull fracture and subdural hematoma." On [DATE] at 12:30 PM an Immediate Jeopardy was identified to have begun on [DATE] at 4:15 AM when facility staff failed to notify R14's Physician with a condition report of R14's change in mental status with R14 being very restless and constant fidgeting. E1 was notified of the Immediate Jeopardy on [DATE] at 12:30 PM. The surveyor confirmed through record reviews and interviews that the facility took the following actions to remove the Immediate Jeopardy: 1. On [DATE] at 10:30 AM E1, Administrator and E2, DON developed and implemented a new facility policy titled "Post-Occurrence Notifications and Treatment" which directs staff how to respond to various events and falls, and specifies procedures to assess and notifications to be made for appropriate prompt medical intervention. 2. On [DATE] at 11 AM E1 and E2 stated the Post-Occurrence Notification and Treatment policy specifies different levels of events and falls and to notify the physician by telephone immediately. If the physician cannot be contacted and licensed staff are seeing symptoms not generally associated with the residents (behavior, confusion) the policy will be to send the resident to the emergency room for evaluation. 3. On [DATE] E1 and E2 provided and completed inservice re-education of all licensed staff with the new policy for post-occurrence notifications and treatment.

Based on interview and record review the facility failed to maintain the most effective assessed intervention of one to one direct supervision for R14 to minimize the risks of recurring falls and serious injury. R14 fell twice within a six hour time period . The second fall incident failed to activate the pressure alarm when R14 climbed out of the bed. This resulted in a fall where R14 sustained a Subdural Hematoma, Subarachnoid Hemorrhage and Skull Fracture. R14 is one of five residents reviewed for falls in the sample of 15. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE] the facility remains out of compliance at a Severity Level 2 as the facility is in the process of implementing a new policy for falls and monitoring the effectiveness of staff retraining directed towards new interventions for falls. Findings include: R14's physician's orders [REDACTED]. R14's Minimum Data Set ((MDS) dated [DATE] documents that R14 is severely cognitively impaired and requires one person physical assist for transfers, toileting and is unable to balance without staff assistance . R14's Fall Risk assessment dated [DATE], [DATE], [DATE] and [DATE] documents that R14 was at high risk for falls. R14's Nurses Notes dated [DATE] at 1:30 PM on the date of admission to the facility documents " (R14) Has personal alarm due to history of six falls at home in the past week. (R14) has multiple scrapes /bruising from falls. (R14) has stitches above left eye that needs removed and awaiting orders to remove." The Facility's Occurrence Report dated [DATE] documents that on [DATE] at 6:45 PM "(R14) was sitting in the wheelchair (w/c) at the nursing station holding cane in hands, (R14) went to stand up and staff member went to assist (R14) and (R14 ) swung cane hitting staff member and fell to the floor landing on right side, staff member braced (R14) during fall, no injuries noted." R14's Nurses Notes dated [DATE] at 10 PM documents "Staff sits with (R14) 1:1 (one to one) will continue to monitor." Nurses Notes dated [DATE] at 10:30 (late entry) documents "( R14) assisted to bed around 10:15 PM and staff heard bed alarm sounding. (R14) up walking in room with belt in hand. (R14) in the doorway with belt, staff quickly ran to (R14) and removed belt from situation and assisted (R14) to wheelchair and (R14) brought to nurses station to monitor". Nurses Notes dated [DATE] at 12:12 AM documents "PRN (whenever necessary) Tylenol given at 11 PM for restlessness. (R14) sat in w/c at nurses station and was becoming sleepy, staff assisted (R14) to bed at this time. Bed alarm on, will continue to monitor, call light in reach." The Facility's Occurrence Report dated [DATE] documents that on [DATE] at 1:15 AM "( R14) climbed out of bed and the bed alarm did not sound, this nurse (E8) LPN (Licensed Practical Nurse) coming down the hall and found (R14) on the floor laying on his back scooting around on the floor. Raised bump noted to crown of head with raised area to back of head and scalp region...." The same Occurrence report documents that the Physician was faxed the information regarding the fall with injury to his office at 2AM on [DATE]. R14's Nurses Notes dated [DATE] at 4:15 AM, 5:30 AM and 6:20 AM documents R14 was displaying bizarre behaviors / altered mental status. R14's Nurses Notes shows no documented evidence of attempts to notify/consult with R14's Physician regarding these behaviors at any of the times. R14's Nurses Notes at 8:40 AM documents that R14's Physician gave order to send to emergency room for evaluation. Nurses Notes on [DATE] at 9:15 AM documents the Ambulance transported R14 to the hospital. R14's hospital Radiology Report dated [DATE] documents: "Acute subdural hematoma with extension into the anterior falx and a component of subarachnoid hemorrhage all described. There is cerebral edema in the right hemisphere and cerebral atrophy is noted. Linear skull fracture is an equivocal finding in this case." R14's Nurses Notes dated [DATE] at 9:30 PM documents "Daughters came to report that their father (R14) died at 8:15 PM.......they said there was so much brain damage that a conscious life could not be sustained....." Z4, Physician for R14 stated on [DATE] at 11:40 AM, " .... I read the emergency room report for (R14). The report stated (R14) had a acute subdural hematoma, subarachnoid hemmorage and skull fracture. I can say the subdural hematoma and skull fracture was the result of trama from the fall. This was part of the reason for his death, I can not say it was the only reason for death. The trauma from the fall resulted in (R14's) skull fracture and subdural hematoma." E1, Administrator stated on [DATE] at 11:15 AM "....the staff put (R14) to bed they stopped the one to one on him because he was supposed to be in the bed sleeping. I don't know why the pressure alarm did not sound, they just malfunction at times. .... There is no policy to my knowledge explaining the procedures and time limits for one to one with residents. They usually stop one to one when the resident goes to sleep." E2 DON (Director of Nurses) was present during this interview with E1 and confirmed the facility had no specific policy for one to one with the residents. On [DATE] at 12:15 PM E2, stated the facility did not have any fall policies for residents who are considered high risks. On [DATE] at 12:30 PM an Immediate Jeopardy was identified to have begun on [DATE] at 11 PM when facility staff failed to continue with the one to one intervention with R14. Facility staff placed R14 in the bed and left R14 unattended in the bed, at 1:15 AM R14 climbed out of bed, the pressure alarm did not sound. E1 was notified of the Immediate Jeopardy on [DATE] at 12:30 PM. The surveyor confirmed through record reviews and interviews that the facility took the following actions to remove the Immediate Jeopardy: 1. On [DATE] at 10:30 AM E1, Administrator and E2, DON developed and implemented a new facility policy titled "Fall Risk Policy" 2. On [DATE] at 11 AM E1 and E2 stated the Fall Risk Policy specifies use of one to one staff supervision for high fall risk residents to include time period for the one to one supervision. The policy further requires an evaluation of the use of one to one staff upon completion of the time period by the Director of Nurses or the Assistant Director of Nurses. 3. On [DATE] E1 and E2 provided and completed inservice re-education of licensed staff while on duty with the new fall policy.

Based on observation, interview and record review the facility failed to monitor anticoagulant therapy for one of 10 residents (R6) from the sample of 15 and (R16) from the supplemental sample, all reviewed for medication monitoring. The facility failed to monitor R6's anticoagulant medication blood levels for 5 consecutive months putting him at high risk for an adverse health event. The facility also failed to monitor R16's anticoagulant medication therapy. Both residents are assessed by the facility as being at high risk for falls and subsequent injury/adverse health events. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7/24/12 the facility remained out of compliance at a Severity Level 2, until needed system wide changes could be put in place and staff trained. Findings include: 1) According to the July 2012 Physician order [REDACTED]. On 7/17/12 at 12:30 PM, R6 was assisted in the bathroom by E5 Certified Nurses Aide (CNA) and E6 CNA. R6 was unable to move or use his left arm or leg at all. R6 required the extensive assistance of two CNA's, and use of a safety grab bar on the right side to stand, in order to use the urinal. R6 was very unsteady and several times yelled out that his leg needed to be moved or his arm was stuck. According to R6's weight records R6's weight as of 6/12 was 246 pounds. At this time E6 stated that "this was the way that R6 was assisted to use the bathroom on a regular basis, although he required the use of a mechanical full body lift to get out of bed into his wheelchair. The Minimum (MDS) data set [DATE] documents that R6 is non-ambulatory, and requires extensive assistance with all activities of daily living. A facility fall risk assessment last done on 6/11/12 documents that R6 is a high fall risk. The facility Plan of Care last updated on 6/14/12 documents that R6 is a high fall risk and lists interventions that include the need for two person assist to use the bathroom and a full mechanical lift into and out of bed. The physician's orders [REDACTED]. Past Physician Orders written 12/13/11 through 7/12 , document that R6 has been on [MEDICATION NAME] since his last admission to the facility dating back to 12/13/11. The laboratory section of the medical record documents the last [MEDICATION NAME] Time (PT) and International Normalized Ratio results (INR) (both are blood tests utilized in monitoring anticoagulant therapy) was 2/9/12. A Physicians telephone order dated 3/8/12 documents that the same dose of medication is to be continued and a recheck of blood levels was to be done on 4/5/12. The Physician orders [REDACTED]. There is no documentation that the recheck of blood levels after February 2012 was ever done. On 7/18/12 at 2:30 PM E7 Unit Secretary and E11Licensed Practical Nurse (LPN) were questioned regarding R6's anticoagulant medication monitoring, E7 stated, "I don't have him on my current list of regular blood tests. He is nowhere, it must not have been done since March." E11 stated, "when we take off an order we usually write it on the desk calendar. I looked back on the date it was supposed to be drawn and it was not written down so it looks like we didn't do it. We also don't have the results from that last PT/INR drawn on 3/8/12 so we don't know what those were. I will call for those results now. I'll also call the doctor and ask him to order a STAT (to be done immediately) blood level, since we don't have any idea what his level might be." E2, Registered Nurse, Director of Nurses (RN/DON) on 7/18/12 at 2:45 PM stated, "no we do not have a policy for tracking or monitoring anticoagulant therapy. Our regular staff doctors generally check them monthly, more often if needed. The cardiology doctors do their own ordering. It is always different each time. We call with results and they give us the dose and next order for a recheck. We don't always get orders for the lab to draw a PT/INR, when we have a new admission. The orders we get from the hospital don't always include the last lab result or when the next one is due to be drawn. Sometimes the Unit Secretaries have a separate list if the dates don't get written on the calendar, but not always. We must have just missed it." Z6, Registered Nurse and Office Practice Manager for Z5 Medical Doctor on 7/20/12 at 10:00 AM stated, "this lapse in monitoring (R6's) bleeding times is very critical, I will speak to the doctor about this information." At 10:30 AM Z6 stated, " I spoke with (Z5). He reviewed the information and he said I could quote him, "This is a very severe, even critical infraction considering this patients medical history. He has had a stroke, a blood clot, an irregular heart beat and he has a pacemaker. This could have resulted in a critical situation for him, even death." 2) According to the admissions face sheet R16 was admitted to the facility on [DATE] after a Right Total Hip Arthroplasty. Other pertinent [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documents that R16 is non-ambulatory and requires extensive assistance with transfers, bed mobility and most activities of daily living. The facility Fall Risk Assessment tool dated 5/26/12 documents that R16 is a high fall risk. The facility's Plan of Care, last updated on 6/15/12 documents falls as a problem, with Non-weight bearing status on the right side. Nurses Notes dated 5/29/12 document that lab test results were faxed to Z5 Medical Doctor, (MD). On 5/31/12 nurses notes document that Z5 wants INR results faxed to him (from lab done 5/29/12). No further documentation involving the results of the 5/29/12 PT/INR is noted in the nurses notes until 6/4/12 at 2:50 PM. The 5-29-12 Nurses Notes state, " Resident has been getting 5 MG of [MEDICATION NAME] daily since 5/26/12. (Z5) had left message for 1.25 MG to alternate with 2.5 MG, order received to draw STAT PT/INR today." Nurses notes dated 6/5/12 document that Z5 gave orders to hold [MEDICATION NAME] and re-check level in two days. Laboratory results for PT/INR dated 5/29/12 document that R16's INR was at the high end of the intensive therapy acceptable range. Results of the PT/INR done on 6/4/12 document that R16's bleeding time was above intensive therapeutic range and was a "Panic Value." As a result, the medication was held through 6/7/12. On 7/19/12 at 2:45 PM E10 Registered Nurse stated, " we only heard about the orders when (R16's) Son-in-Law came in to visit. He mentioned to the nurses that (Z5)had called (R16's) answering machine at home and left the orders to change the dose and re-check the levels. We wouldn't have known otherwise. No one here followed up after the results were faxed over on 5/30." R16 was again hospitalized for [REDACTED]. The Hospital, "Inter Agency Transfer Form"dated 7/12/12, documents that R16 was discharged on [MEDICATION NAME] 5 MG daily. There is nothing documented under the area of Follow-up Labs. E9, Unit Secretary, on 7/20 at 2:20 PM stated, "After this second hip revision I happened to be looking through the hospital transcripts and on page 17, I saw when the last PT/INR had been done in the hospital. No follow up had been ordered, and they usually say to re-check in one week, so I scheduled one to be done on 7/18/12, otherwise it wouldn't have happened. The nurse who took off the admission orders [REDACTED]." The Immediate Jeopardy situation was identified on 7/18/12, when a record review documented no laboratory monitoring for anticoagulants on R6 since 2/9/12, and a delay in following up on monitoring results on R16 from 5/29/12 through 6/4/12 was confirmed. E1, Administrator was informed of the Immediate Jeopardy on 7/20/12 at 12:30 PM. The immediacy was removed on 7/24/12 with development of a facility anticoagulant policy and tracking system and the completion of staff training on these procedures. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1) E8 Licensed Practical Nurse had an immediate anticoagulant blood level drawn on R6. The resulting blood levels were shared with the Physician on 7/19/12, and new orders received. 2) A chart review was conducted by E2 RN/DON, on all 10 residents in the facility on 7/19/12, who were currently on anticoagulant therapy. Orders were obtained for blood levels and results called to the Physician where needed. 3) A facility Policy was developed and implemented by E1 Administrator and E2 RN/DON, for Monitoring anticoagulants 7/20/12. 4) Training was initiated by E2, Director of Nurses, with staff on 7/20/12 with re-training completed on 7/24/12 after an addendum was made to the facility policy.

Based on record review and interview the facility failed to maintain visual control and provide stand by assistance during care for one of four residents (R8) reviewed for falls in a sample of ten. R8 fell from the wheelchair and sustained a five centimeter laceration to the forehead. Findings include: The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states R8 is severely impaired in daily decision making skills and requires extensive assistance for transfers and toilet use. Care Area Assessment Falls Worksheet dated 8/8/11 state R8 has difficulty maintaining sitting balance, impaired balance during transitions, is non ambulatory and requires mechanical lift for all transfers. The facility's report titled "Occurrence Report" dated 9/8/11 in the section titled "Nurse Statement of Other Contributing Factors" reads R8's lap belt was released.... Section on the form titled "Witness Statement" reads E8, CNA (Certified Nurse Assistant) was in room with resident. Another resident from across the hall came into R8's room the CNA turned to assist him to leave the room and R8 fell forward onto the floor. R8's Nurses Notes dated 9/8/11 at 6:45 PM states when nurse enters room R8 is positioned on her right side on the floor with blood on the floor and on R8's face. Same nurses notes states R8 had a laceration in the middle of her forehead. E2, DON (Director of Nurses) on 10/14/11 at 11 AM confirmed that E8, CNA had released the seat belt to provide care. When another resident came into the room, E8 turned away from R8 and R8 fell out of her wheelchair. Hospital medical records for R8 dated 9/8/11 under the section titled "Final Diagnosis" reads "5 cm forehead laceration - repaired" Same report section titled "Medical Instruction" reads " Laceration, sutures - Suture removal in 7 days."

Based on interview and record review the facility failed to ensure that supervision devices, personal motion alarm and floor mat motion alarm were, in functioning condition for one of six residents reviewed for falls (R5) in a total sample of 18. R5 fell and sustained a left hip fracture. Findings include: The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states R5 is severely impaired in daily decision making skills and requires extensive assistance for transfers and toilet use. Fall Assessments dated 1/5/11 and 3/28/11 document that R5 is at high risk for falls. The facility's report titled "Occurrence Report" dated 4/30/11 in the section titled "Nurse Statement and Other Contributing Factors" reads R5 had a fall and the alarms did not sound. The report states that R5 was found sitting on buttocks next to the bed. The facility's report titled "Root Cause Analysis" dated 4/30/11 under the section titled "Was equipment (or the use or lack of use of equipment) involved in this event in any way?" reads "Yes, Personal Alarm was found to be non-functional and batteries in floor - mat alarm were dead." The same report under the section titled "Contributing Factors" reads "Unsafe behavior, impaired physical function, medications, barefooted, alarms were not operational." Hospital report titled "X-ray Report" dated 4/30/11 states under the section titled "Impression;" "....small cortical fracture in the greater trochanteric portion of left proximal femur ...." E1, Administrator, on 8/25/11 at 3:30 p.m. confirmed that the facility's Occurrence Report and Root Cause Analysis report were correct, that the motion alarms use to alert staff when R5 is getting up without assistance, did not function properly.