Every finding on record at Momence Meadows Nursing & Rehab

Based on interview and record review the facility failed to protect a residents' right to be free from resident to resident physical abuse. This failure resulted in R4 sustaining a fracture of the right third metacarpal and R5 sustaining swelling to his face (facial trauma).This applies to 2 of 4 residents (R4, R5) reviewed for abuse in the sample of 6. Findings include:1.The face sheet showed R4 was admitted to the facility on [DATE], with diagnoses of type II diabetes, dementia, hypertension, muscle wasting atrophy, non-displaced fracture of base of third metacarpal bone, disorder of ligament, right wrist, history of falling, low back pain and hyperlipidemia.The MDS (Minimum Data Sets) dated July 20, 2026, showed R4 was cognitively intact. R4's care plan dated July 14, 2026, showed R4 has a fracture of right hand: third metacarpal and has an immobilizer related to altered weight bearing status, and impaired mobility.On August 14, 2026, at 12:15 PM, R4 stated R5 called him B---H, and he grabbed him by the collar and they started fighting. R4 stated he broke his right hand. R4 stated he went to the emergency room and they x-rayed his hand at the hospital.R4's EMR (Electronic Medical Record) showed right hand x-ray report dated July 13, 2026, the findings of the x-ray showed bones were well-mineralized. There was a nondisplaced fracture of a distal metacarpal, seen only on the lateral view, likely the third metacarpal. R4's EMR showed a physician's note dated July 14, 2026, at 8:36 AM, Follow up evaluation after return from the hospital for right third metacarpal fracture. PLAN: continue splint to right hand and maintain immobilization until orthopedic follow up.R4's EMR showed progress notes from Psychiatry dated July 16, 2026, for follow up visit after being recently hospitalized for a right-hand fracture due to a physical confrontation with another resident.2. The EMR (Electronic Medical Record) face sheet showed R5 was admitted to the facility on [DATE], with the diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, bilateral primary osteoarthritis of hip, sick sinus syndrome, atrial flutter thrombus of atrium auricular appendage, malignant neoplasm of prostate, major depressive disorder, hypertension, lack of coordination, brief psychotic disorder, tachycardia, malaise, unsteadiness on feet and weakness.The MDS (Minimum Data Sets) dated June 12, 2026, showed R5 was cognitively intact. On August 14, 2026, at 12:05 AM, R5 stated on July 13, 2026, they (R4 and R5) were both trying to pick up the same magazine, and had a little bit of scuffle. R5 stated he think he had a little bit of a black eye. R5 also stated he went to the hospital to be examined and he had some pain in his face. R5's hospital evaluation notes dated July 13, 2026, at 12:44 PM, showed R5 had a (CT/ Computed Tomography) head, CT cervical spine, and CT facial bone. Impression findings: No acute intracranial abnormalities, no acute cervical spine CT abnormalities, Age indeterminate nondisplaced right nasal bone fracture. The remaining facial bones were intact, chronic encephalomalacia in the right frontal lobe consistent with old infarct. Facial soft tissue swelling was evident. R5's physician's progress note dated July 14, 2026, showed follow up after recent assessment: emergency room evaluation and management of multiple chronic conditions: Recent facial trauma secondary to altercation with another resident, status post emergency department evaluation and treatment. Healing left eyebrow laceration, healing left skin tear, improving nasal pain following facial trauma.Plan admit to long term care service, continue supportive care following emergency department evaluation for facial trauma.On August 14, 2026, at 2:12 PM, V3 (ADON/Assistant Director of Nursing), said they heard yelling in the hallway, and R4 stated R5 was in my way he wouldn't move out of my way and he swung at him. V3 stated R5 was in the bathroom. She said R5 said R4 hit him because he was in the doorway. V3 stated she separated them and called the physician to get orders for both to be sent to the emergency room.On August 14, 2026, at 3:05 PM, V3 (ADON) provided documents titled statement for incident R4's statement I told that M-----f----r several times to move that wheelchair and turn down his (R5) TV he (R5) did not like listening, so I took care of it this time. R5's statement: I don't know what's wrong with him (R4), he's crazy a lunatic. He (R4) hit me (R5), keep him away from me. On August 17, 2026, at 11:43 AM, V20 (Physician) stated R4's hospital evaluation showed he sustained a fractured hand. V20 stated R4's fracture was the result of the altercation with R5. V20 stated the impact to R5 caused R4's fracture and he is following up with orthopedics. V20 stated R5 sustained some swelling, bruising and scratches on his face. V20 stated R5 received imaging at the hospital, and it showed no fractures. V20 stated the hospital referred him to ENT (Ear Nose and Throat), but he stated he was asymptomatic at the time, and it did not warrant it.The facility provided a document dated March 1, 2021, titled Policy and Procedure Abuse Prevention Program showed Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility.4. Physical Abuse: hitting, slapping kicking etc. It also includes controlling behavior through corporal punishment.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was maintained in a clean, comfortable, and homelike manner and kept free of odors. This failure applies to 9 of 13 residents (R3, R5, R7, R8, R9, R10, R11, R12, and R13) reviewed for environment in a sample of 13 residents.The findings include: On July 27, 2026, at 1:57 PM, a urine odor was present near the dining room. On July 29, 2026, at 10:50 AM, the floors in the dining room and hallways were extremely sticky. Several observations were made on July 27, at 11:25 AM, July 28, at 12:50 PM and 2:30 PM, July 29, at 10:55 AM, were made of foul odors present in the hallway where R9, R10, R11, R12, and R13 reside. The floors were also sticky 1. R7's medical records show she is a [AGE] year-old female who was originally admitted to the facility October 14, 2025. On July 27, 2026, at 1:45 PM, R7 said recently there has consistently been a feces odor in the hallway where R9's, R10's, R11's, R12's, and R13's rooms are located. On July 28, 2026, at 12:50 PM, V23 (Housekeeping Supervisor) said the odor smelled like sweat to her. V23 said the floors in the hallway were sticky because the chemical used to clean the floors comes out of the dispenser really thick and may need to be diluted more to prevent the floors from becoming sticky. V23 said rooms should be kept clean. V2 (Director of Nursing) said she can smell urine at the entrance the hallway and it may be coming from the resident's comforters or mattresses. There was a urine odor present in R9, R10, R11, and R12's room. V2 said she can smell an odor in their room. V2 said the nursing aides should identify the source of odors. On July 29, 2026, at 10:55 AM, there were yellowish brown stains present on R12's bed linens. There was a heavy presence of thick substances, particles, and staining on R9, R10, R11, and R12's room floor. R11 said the floors are sticky and he would like them cleaned. There was a heavy presence of red and yellow stains on R10's bed linens and pillowcase. 2. R13's medical records show she is a [AGE] year-old female who was originally admitted to the facility April 12, 2024. On July 28, 2026, at 1:11 PM, A strong odor was present in R13's room. V23 (Housekeeping Supervisor) said R13's room needs to be cleaned and has offered to deep clean R13's room. On July 29, 2026, at 11:05 AM, There was a musty odor present in R13's room and her room floor was very sticky. R13 said her room had been cleaned this morning. R13 said the floors needed to be re-waxed in order to remove the stickiness and she would like it removed. R13 said she smelled urine and fecal odors in the facility, and they needed to install some of the deodorizers that automatically spray in increments. R9's medical records show he is a [AGE] year-old male who was originally admitted to the facility May 20, 2026. R10's medical records show he is a [AGE] year-old male who was originally admitted to the facility September 19, 2025. R11's medical records show he is a [AGE] year-old male who was originally admitted to the facility July 27, 2016. R12's medical records show he is a [AGE] year-old male who was originally admitted to the facility February 04, 2026. 3. On July 28, 2026, at 9:25 AM, a strong urine odor was present on the hallway where R3 and R8's rooms were located. On July 28, 2026, at 1:25 PM There was a urine odor present at the beginning of the hallway where R3 and R8's rooms were located. V2 (Director of Nursing) said she could smell a dull urine odor in the hallway. 4. R3's medical records show he is a [AGE] year-old who was originally admitted to the facility March 31, 2009. On July 27, 2026, at 1:58 PM, R3 was in his room lying in his bed covered with a blanket and a strong urine odor present in the room. There was a large number of cobwebs present in the upper part of R3's window frame directly next to his bed. On July 28, 2026, at 10:50 AM, [NAME] and yellow stains were present on R3's bed linens and his mattress was stained and had a urine odor. At 12:50 PM, R3's mattress contained stains and a urine odor. There was a strong urine odor present on the wheelchair next to R3's bed. V23 (HousekeepingSupervisor) said she could smell urine in R3's wheelchair. At 1:40 PM, V2 (Director of Nursing) said R3's whole mattress smelled of urine and his wheelchair had a foul odor. 5. R8's medical records show he is a [AGE] year-old male who was originally admitted to the facility February 15, 2017. On July 28, 2026, at 9:27 AM, R8 was sitting in his room in his wheelchair with a strong urine odor present. At 10:50 AM, a large number of cobwebs remained present in the frame of the window in R8's room. At 12:50 PM, R8's room floor was sticky, and a urine odor was present. V23 (Housekeeping Supervisor) said she could smell the urine odor. V23 said if a urine smell remains after the room is cleaned by housekeeping, nursing may need to check the resident's incontinence briefs or their beds to determine the source of the smell and the residents, or their bed linens and mattresses may need to be cleaned. R8's bed smelled like urine and V23 said it is likely to come from his mattress. At 1:30 PM, V2 (Director of Nursing) said she could see stains on R8's bed linens and smell the urine. 6. R5's medical records show he is a [AGE] year-old male who was originally admitted to the facility September 07, 2022. On July 27, 2026, at 11:05 AM, R5 was sitting in his room in his wheelchair. R5's room floors were visibly dirty. Maintenance Work Orders show requests from June 01, 2026, to clean the hallways where R7, R9, R10, R11, R12, and R13's rooms are located; from June 10, 2026 to buff big dining room; from June 22, 2026, to scrub and buff the dining room; from June 26, 2026 to scrub the hallways where R3, R7, R8, R9, R10, R11, R12, and R13's rooms are located with the big machine; and from June 30, 2026 to scrub the hallways where R7, R9, R10, R11, R12, and R13's rooms are located.On July 29, 2026, at 2:53 PM, V16 (Maintenance Director) said the facility recently began using new floor cleaning chemicals and isn't sure if the stickiness of the facility's floors due to the mixture being too strong. V16 said some floors stickier than others and he is sure buffering the floor would make it disappear. On July 29, 2026, at 3:45 PM V2 (Director of Nursing) said the facility should be free of strong odors and agreed due to the behaviors of residents in the facility staff would need to be more diligent about keeping the facility free of odors. V2 said residents should not have stained linens and if stains are unable to be removed the linens should be discarded. V2 said linens may be stained from food or body fluids. V2 said the floors shouldn't be sticky and should be clean. The facility's Housekeeping Staff/Environmental Cleaning Practices Policy received July 29, 2026, shows: Make cleaning practices as environmentally sanitary and safe as possible to prevent infection spreading.

Based on observation, interview, and record review, the facility failed to provide effective pest control services.This failure applies to 9 of 9 residents (R3, R5, R7, R8, R9, R10, R11, R12, R13) reviewed for pests in the facility.The findings include:1. R2's medical records show he is a [AGE] year-old male who was originally admitted to the facility December 3, 2025.On July 27, 2026, at 11:05 AM, There were several flies flying around R2's room while he was lying in bed watching television.On July 28, 2026, at 10:07 AM, There were flies present in R2's room while he was lying in his bed resting. On July 28, 2026, at 2:25 PM, R2 said he sees flies sometimes and has let maintenance know. There were multiple flies present in R2's room.2. R3's medical records show he is a [AGE] year-old male with who was originally admitted to the facility March 31, 2009.R3's quarterly minimum data set assessment dated [DATE] shows he is cognitively intact.On July 27, 2026, at 1:58 PM, R3 was in his room lying in his bed covered with a blanket. R3 said he sees flies and beetles and has seen flies in his food. There were multiple gnats present in R3's room and a fly repeatedly landing on him and his blanket. There were many cobwebs present in the upper part of R3's window frame directly next to his bed. 3. R5's medical records show he is a [AGE] year-old male who was originally admitted to the facility September 7, 2022.On July 27, 2026, at 11:05 AM, R5 was sitting in his room in his wheelchair. R5 said there are always lots of flies flying around when trying to eat and the flies come out the walls. On July 28, 2026, at 2:25 PM, there were multiple flies present in R5's room and flying near and landing on R5's head. R5 said he has seen multiple flies and has reported this to the facility as recently as yesterday; the facility doesn't spray until you ask them to. 4. On July 28, 2026, at 1:09 PM, Multiple flies were present in R9, R10, R11, and R12's room V23 (Housekeeping Supervisor) said flies are normally seen in the summer due to the warm temperatures and odors.On July 28, 2026, at 2:30 PM, there were multiple flies present in R9, R10, R11, and R12's room. On July 29, 2026, at 10:55 AM, there were several gnats and flies present in R9, R10, R11, and R12's room. R12 said he sees insects and would like them removed. R11 said he sees flies and wants them removed. There were flies flying around R9 and landing on him while he was sleeping in his bed. On July 27, 2026, at 11:25 AM, gnats and a strong odor were present in the hallway where R9, R10. R11, R12, and R13's rooms were located.On July 27, 2026, at 10:40 AM, The kitchen floor was very sticky. Multiple gnats and flies were present near the food prep area, stove, and dishwashing machine. A heavy amount of limescale and food particles and dirt were present underneath the dishwashing machine. Gnats were present near four breakfast trays with leftover food sitting next to the dish washing sink area. There was no lid covering the large garbage bin sitting near the food prep area.On July 28, 2026, at 2:40 PM, there was several gnats present throughout the kitchen. There was no lid covering the large garbage bin near the food prep area.On July 29, 2026, at 9:45 AM, several gnats were flying near the food prep area. V19 (Dietary Aide) said the gnats were coming from the drain located on the floor near the food prep tables and when the pest control technician sprayed the area several of them came out of the drain. V21 (Dietary Aide) said she has seen gnats, centipedes, and other insects in the kitchen including flying ants. V19 was swatting away gnats while preparing sandwiches. There was no lid covering the large garbage bin underneath the food prep table area.On July 29, 2026, at 1:53 PM, V16 (Maintenance Director) said pest control comes monthly and as needed or requested and he does not inspect the kitchen.On July 29, 2026, at 2:12 PM, V17 (Pest Control Technician) said he had treated the kitchen drain for gnats today as part of the kitchen concerns. V17 said in some cases weekly treatments may be provided at his discretion or at the facility's request. V17 said he has also advised dietary to poor hot water and bleach down the drain twice weekly. V17 said the gel baits last approximately 3-4 days and he could apply them weekly. On July 29, 2026, at 2:58 PM, V18 (Dietary Manager) said there shouldn't be any pests in the kitchen, pest control comes out monthly or as needed, if pests are observed they report it to maintenance and they address it. V18 said he feels pest control service once per month is effective in the wintertime, but due to the facility's location during warmer months and having fields around more pest control visits may be beneficial if there is increased pest activity. V18 said keeping garbage closed, spills wiped up, and doors closed prevents attracting pests, pests want water and moisture; and gnats and flies seem to go to drains due to the water. V18 said they poor sanitizer down the drain once a week, and he doesn't have access to order bleach. V18 said bugs don't like bleach and it seems to be effective at repelling them.Pest invoices from May - July 2026 show the facility's kitchen has a history of the area underneath the dish washer being dirty, standing or pooling water providing water and breeding sites for pests, and accumulated spillage underneath equipment; and show the facility received pest services twice in one week in May, twice total in June, and once in July as of July 14, 2026.The facility's Cleaning as You Go During Meal Service and Maintaining Clean Work Areas Policy received July 29, 2026 shows:The purpose of the policy is To establish clear expectations for clean as you go practices in the healthcare kitchen. This policy protects resident safety by preventing cross-contamination, maintaining food safety standards, and supporting infection prevention in a senior living environment. A full thorough cleaning of all work areas, equipment, and floors will occur immediately after each meal service ends. General Clean as You Go Standards includes: Keep floors free of standing water, grease, or debris. Place soiled utensils/pans directly into the dish area or three compartment sink.The facility's Pest Control Policy received July 29, 2026, shows: It is the policy of the facility to ensure that an effective Pest Control Program is in place. An effective pest control program is defined as - measures to eradicate and contain common household pests. These include but are not necessarily limited to flies, gnats, and spiders. The (licensed pest control contractor) will make regularly scheduled visits with a frequency to prevent infestation of the afore mentioned pests. The maintenance staff and all other staff will be cognizant of the necessity to maintain a clean, safe, and comfortable, homelike environment that is free of pests. Pest control is part of the facility's infection prevention and control program as pests can carry/transmit disease and infection. Pests must be controlled for the purposes of cleanliness and safety in the facility's homelike environment.

Based on interview and record review, failed to ensure resident lice treatments and environmental cleaning stopped lice re-infection. This applies to 5 residents (R6, R10, R4, R2, R9) reviewed for infection control practices.The findings include: On 6/24/26 at 12:19 pm, R4 said that she had head lice and she had to have her hair cut to get rid of them. R4's 4/15/26 progress note showed that lice were noted in R4's hair and a treatment was given. Two days later, R4's 4/17/26 progress notes showed that a small white substance was observed crawling on R4 again and a second dose of the treatment was ordered. R4's June 2026 eMAR (electronic Medication Administration Record) showed another round of treatment was started on 6/3/26, approximately six weeks later.On 6/23/26 at 1:02 pm, R2 said that she was itching all over her body and she was told by staff she had lice and she was treated. R2's Physician orders Summary's showed the lice treatment was applied starting 6/2/2026 and was completed. Two weeks later, R2's 6/17/26 nursing note showed the physician was notified lice was again seen and a second round of treatment was ordered. On 6/24/26 at 12:50 pm, R9 said that she was very itchy and was upset the staff found lice on her. R9's eMAR showed a 6/4/26 physician order for lice treatment. R9 said that the staff had put her clothes in a bag and she got her clothes back the next day. Approximately two weeks later, R9's 6/17/26 nursing notes showed lice were crawling on her and she again required treatment. R10's 4/13/26 progress note showed that she complained that her head was itching and upon examination, small white substances were found crawling and a lice treatment was given. R10's 4/17/26 progress note showed that another treatment was given because a small substance was seen crawling on R10 again. On 6/24/26 at 1:11 pm, R10 stated that she had head lice and she had to have her hair cut and get medication to get rid of the lice. R10's June 2026 eMAR showed lice treatment was given again on 6/2, approximately six weeks later.R6's 4/3/26 progress note showed that R6 had head lice and a 4/4/26 physician's order showed the lice treatment. R6's eMAR showed that she received the treatment again on 4/9/26. R6's 4/13/26 progress note showed that R6 was noted with a small white substance crawling on her and another treatment was given. R6's 4/15/26 progress note showed yet another treatment was given as a small white substance was observed crawling on R6. Two months later on 6/2/206, R6's eMAR showed additional body/pubic lice treatments were needed. On 6/24/26 at 12:11 pm, R6 said that she had head lice and the staff washed her hair and put her clothes in a bag to be washed and brought it back to her the next day. R6 said that the staff did not vacuum her floor. On 6/23/26 at 2:48 pm, V11 (Housekeeper), stated that staff did not vacuum the rooms of residents with lice infestations because the facility did not have a vacuum cleaner. V11 also stated that housekeeping staff did not perform any additional cleaning or disinfection measures for residents identified with lice infestations.On 6/25/26 at 11:47 am, V2 (Acting Assistant Director of Nursing [ADON]), stated that the facility follows guidance from the Centers for Disease Control and Prevention (CDC) regarding the treatment and prevention of lice. V2 provided CDC guidance titled Lice, dated November 12, 2024. The guidance directs staff to machine wash and dry clothing, bedding, and other items used by an infested individual during the two days prior to treatment using hot water of at least 130 degrees Fahrenheit and a high-heat dryer setting. Guidance showed if items cannot be washed or dry cleaned, they should be sealed in a plastic bag for two weeks. The guidance instructed staff to vacuum floors and furniture where the infested person sat or lay. V2 stated that the expectation was for all clothing and bed linens belonging to residents with lice infestations to be washed in hot water of at least 130 degrees Fahrenheit before being returned to residents or placed back into circulation. V2 further stated that none of the rooms occupied by residents with lice infestations had been vacuumed because the facility did not have a vacuum cleaner. V2 stated that failure to follow these measures would result in the continued spread of lice throughout the facility.On 6/23/26 at 2:00 p.m., V8 (Laundry Staff) stated that the facility had not had hot water available for laundering clothing since before April 2026. V8 stated that all clothing and linens, including those contaminated with lice, were washed in cold water together with other residents' clothing and linens and then returned to residents. On 6/23/26 at 2:15 pm, V13 (Maintenance Director), verified that the facility had no hot water available for the laundry machines because the hot water heater had been inoperable for several months. On 6/25/26 at 2:26 pm, V1, (Administrator) stated that the facility's hot water heater serving the laundry machines had been inoperable since at least April 2026. V1 stated that the facility had been washing residents' clothing and bed linens in cold water since that time. V1 further stated that the facility had not been following its policy or CDC guidance regarding the treatment and prevention of lice transmission. V1 acknowledged that if contaminated or infested clothing and linens were not properly cleaned and stored, lice could spread throughout the facility. The facility's Guideline for Head Lice - Body Lice - Scabies (dated 4/24), showed that the facility's policy is to ensure that head lice, body lice, or scabies are identified and managed. The guideline showed Pediculosis Prevention and Control, pediculosis is an infestation of the hairy parts of the body or clothing with eggs, larvae, or adults of lice. The crawling stages of this insect feed on human blood which can result in extreme itching. Head lice are usually located on the scalp. Crab lice are usually in the pubic area and body lice along seams of clothing. Body lice travel to the skin to feed then return back to clothing. Prevention of lice involves avoiding contact with belongings of an infested person, especially clothing, headgear, and bed linens or any cloth covered furniture. Laundering clothing and bed linens and cleaning headgear is extremely valuable in the prevention of contracting pediculosis lice. Machine wash and dry clothing, bed linens and other items that the infested person wore or used three days prior to treatment using hot water cycle and the high heat dryer setting. If some items cannot be cleaned this way, place them in tightly closed plastic bags for two weeks.

Based on observation, interview and record review, the facility failed to ensure medications were administered within acceptable time parameters. This applies to 4 of 7 residents (R1, R11, R12, R13,) reviewed for medication administration. The findings include:.1.R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including spinal stenosis, congestive heart failure, type II diabetes, cardiomyopathy, hypercholesteremia, atrial fibrillation, anxiety, hyperlipidemia, morbid obesity, functional quadriplegia, low back pain, edema, depression, restless leg syndrome, and need for assistance with personal use.R1's April 2026 medication administration record (MAR) showed R1 has an order for Acetaminophen 500 milligrams (mg): give two tablets by mouth every four hours as needed for pain, Oxycodone 5-325mg: give one tablet by mouth every six hours as needed for a pain level of 7 or above.On April 07, 2026, at 11:56 AM, R1 said that medications often come late. R1 said that when R1 asks for pain medications, R1 is given several different responses. R1 said that some nurses will tell R1 that R1 can only receive pain medications every eight hours while others will inform R1 that they have to wait twenty-four hours. R1 said that they have bad back pain that is not taken seriously. 2. R11 was admitted to the facility on [DATE]. R11 has multiple diagnoses including hemiplegia and hemiparesis, weakness, unsteadiness on feet, anemia, hypertension, psychoactive substance abuse, cerebrovascular disease, hyperlipidemia, type II diabetes, and abnormal gait and mobility.R11's April 2026 (MAR) showed an order for Novolog injection solution 100 units per milliliter (ml) with sliding scale to be given at 0600, 1100, and 1600 daily before meals.3. R12 was admitted to the facility on [DATE]. R12 has multiple diagnoses including hemiplegia, hemiparesis, absence of left leg, atrial fibrillation, type II diabetes, peripheral vascular disease, hypertension, falls, and agitation.R12's April 2026 MAR showed an order for Insulin Lispro injection Solution 100 unit/ml with sliding scale to be given at 0700, 1100, and 1600 daily before meals.4. R13 was admitted to the facility on [DATE]. R13 has multiple diagnoses including hemiplegia, hemiparesis, viral hepatitis b, difficulty walking, type II diabetes, lack of coordination, muscle wasting, chronic kidney disease, heart disease, morbid severe obesity, congestive heart failure, hypertension, and hypothyroidism.R13's April 2026 MAR showed an order for Insulin Lispro 100 unit/ml solution with a sliding scale to be administered at 0600, 1100, and 1600 daily and an order for NovoLog flex pen 100 unit/ml solution pen injector with orders to inject eight units subcutaneously three times daily at 0600, 1100, and 1600 daily before meals.On April 07, 2026, at 12:53 PM, V13 (Agency RN) was administering medications. V13's electronic medication administration record (EMAR) for the unit was open and R11, R12, and R13's EMARs were highlighted in red for the 1100 medication pass. V13 said that when the EMAR is highlighted in red it means that the medication is past due and was not given. V13 said blood glucose checks and sliding scale insulin are performed prior to meals. V13 said they believe lunch is around 12:00 PM.On April 09, 2026, at 10:20 AM, V9 (RN) was passing medications. V9's EMAR showed residents' profile highlighted in red. V9 said that a profile highlighted in red meant that medications had not been administered. V9 said the medications were administered but had not been signed out. V9 said that medication is to be signed out when administered to residents. V9 said that it is not possible to administer medications in the allotted time at the facility or to sign medications out as given because there is always a lot going on.On April 09, 2026, at 10:15 AM V23 (LPN) was standing at the medication cart passing medications. V23 said that residents who were highlighted in red had not received their medications yet and that red meant that the medications were past due.On April 10, 2023, at 1:30 PM V2 (Interim DON) said that the color code system in the EMAR tells when medications are due for administration. V2 said that a profile highlighted in green means the medications have been administered, yellow means the medication is due for administration, red means the medication is past due, and white means the medication is not due yet. V2 said medications should be signed off as administered by staff and that medications can be administered one hour before and one hour after the scheduled time for example a medication scheduled for 0800 can be given between 0700-0900. A red profile means the medications were not administered during the time frame of one hour before or one hour after administration time. The facility's Drug Administration-General Guideline Policy showed that medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. The procedure showed 8.) medications are administered within sixty minutes of scheduled time, except before and after meal orders, which are administered precisely as ordered. Unless otherwise specified by physician, routine medications are administered according to the established administration schedule for the facility.

Based on interview and record review, the facility failed to ensure a resident's choice for a representative was honored. This applies to 1 of 16 residents (R3) reviewed for residents' rights. The findings include:R3 was readmitted to facility on June 02, 2025, with multiple diagnoses including neuroleptic Parkinson's, selective mutism, major depressive disorder, need for assistance with personal care, weakness, muscle wasting, tremors, catatonic disorders and anxiety.R3's face sheet showed a general note section where it was documented that V16 (Family member) was R3's power of attorney (POA). Writer had spoken with V16, and facility was preparing to accept R3 into the facility.R3's progress notes showed the last communication with V16 was on November 21, 2025.R3' s hospital discharge instructions dated and uploaded on March 25, 2025, showed V16 is R3's legal guardian and substitute decision maker.On April 07, 2026, at 2:48PM, V16 said that they had tried consistently for months to get in touch with the facility's care team to discuss R3's condition and had not received any response. V16 said they called twice in January, three times in February, and three times in March and had finally received a return call on Monday April 06, 2026. V16 said they do not live close to the facility and relied on the care team to provide information regarding R3's care, especially since R3 is mute and unable to advocate for themself. V16 said there are court documents to show that V16 is R3's guardian and does not understand why it has taken so long for a return call. V16 said they are concerned about the lack of communication for other residents and family members.On April 08, 2026, R3's guardianship paperwork was entered into the electronic medical record (EMR) by V6 (Social Services) and V16's contact information was added under contacts on R3's face sheet.On April 08, 2026, at 11:03AM V6 reviewed R3's face sheet and said they did not enter the general note that stated V16 was R3's POA and said that perhaps nursing had entered that information.On April 10, 2026, at 1:30PM, V2 (Interim Director of Nursing) reviewed R3's chart and said that they did not write the general note on R3's face sheet that said that V16 was R3's POA. V2 said they had just learned that V16 wanted to speak with V2 on Friday April 03, 2026. V2 said they were off on Monday April 06, 2026, so they called V16 on Tuesday April 08, 2026, apologized for the communication delay and reviewed all medical diagnoses and medication regimen. V2 said that they previously only looked at the contact list in R3's EMR to determine if R3 had a POA and had not contacted V16 because R3 had not had a change in condition and there was no information listed under the contact list. V2 said they had never reviewed the general notes section on R3's face sheet and that they should have looked in other areas of the R3's EMR for additional information.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect by failing to respond timely to call lights.This applies to 3 of 15 residents (R1, R6, R8) reviewed for call light response time in the sample of 15. The findings include:1.R1 is alert and oriented and was admitted to the facility on [DATE]. R1 has multiple diagnoses including spinal stenosis, congestive heart failure, type II diabetes, cardiomyopathy, hypercholesteremia, atrial fibrillation, anxiety, hyperlipidemia, morbid obesity, functional quadriplegia, low back pain, edema, depression, restless leg syndrome, and need for assistance with personal care.On April 07, 2026, at 11:56 AM R1 said that staff are often slow to respond to call lights, and it takes them awhile to come in to see what they may need if they even come in.2. R6 is alert and oriented and was admitted to the facility on [DATE]. R6 has multiple diagnoses including cerebral palsy, paraplegia, epilepsy, asthma, morbid severe obesity, type II diabetes, schizoaffective disorder, anxiety, anemia, schizophrenia, depressive disorder, psychosis, suicidal ideations and hypertension.On April 08, 2026, at 3:05 PM, R6 said that it takes the staff a long time to respond to call lights. R6 said it can take from thirty minutes to over an hour for a response especially if the assigned certified nurse assistant (CNA) is on break. If the CNA is on a break, then the resident has to wait for the CNA to return. R6 said that another CNA or nurse should be able to respond to the call light if the assigned CNA is busy.3. R8 is alert and oriented and was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disorder, lymphedema, venous thrombosis, hypothyroidism, hypertension, and morbid obesity.On April 07, 2026, at 11:42 AM, R8 said that call light response has been a major concern. R8 said that they are bedbound and rely heavily on staff for all needs. R8 said that if the assigned CNA is busy the resident has to wait. This can be up to a little over an hour.On April 08, 2026, at 3:28 PM a call light alarmed while a nurse sat at the nurse's station unmoved. Activity aids and another nurse walked past the call light before it was answered by a CNA at 3:36 PM.On April 09, 2026, at 12:33PM two call lights were alarming at the nurses' station while two staff members were sitting at the desk. The call light was finally responded to by a CNA at 12:50 PM.On April 09, 2026, at 12:35PM a call button was alarming at the nurses' station. During this time there were several nurses at the nurses' station with V2 (Interim Director of Nursing) who provided an in-service to the nurses. During this time the CNAs were still assisting other residents in the dining hall. At 12:45 PM the call light was still alarming and had not been answered. At 12:50 PM the in-service concluded, and the DON went to their office. The call light remained unanswered. R6 exited the room with a visitor at 12:55 PM. The call light continued to alarm and staff still had not shown up to R6's room to respond. At 12:58 PM the call light had not been answered, during this time housekeeping staff walked past, and CNAs delivered food trays through the halls while nurses sat at the nurses' station. The room was checked and the call light was turned off by a CNA picking up dietary trays at 1:10 PM.On April 10, 2026, at 10:24 AM V12 (Activity Aide) said that CNAs are responsible for answering call lights and sometimes the nurses can answer.On April 10, 2026, at 10:30 AM V27 (CNA) said that everyone is responsible for responding to call lights and that they should be answered as soon as possible. On April 10, 2026, at 10:45AM V14 (LPN) said that everyone is responsible for answering call lights as soon as possible.On April 10, 2026, at 10:49 AM V15(Registered Nurse) said that all staff members are responsible for answering call lights.On April 10, 2026, at 1:30 PM, V2 said that everyone is responsible for answering call lights and that call lights should be responded to as soon as possible. V2 said that response should not be more than twenty minutes anyone can enter to see what the needs are. The facility's Call Light policy showed that it is the policy of the facility to have a system in place to allow the staff to respond promptly to a resident's call for assistance and to ensure that the call system is in proper working order. The facilities procedure showed: 1) all facility staff are to be oriented to the call light system. 2) Call lights are to be answered promptly by staff who see that the call light has been activated. 3) Even if unable to meet the needs of a resident, staff should report the need to the appropriate staff member. 4) Bedside call lights are seen and heard above the door of the residents' rooms and at the nurses' station area.

Based on observation and interview, the facility failed to perform hand hygiene before and after providing incontinence care. This applies to 1 (R5) of 4 residents reviewed for infection control. The findings include: R5 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, metabolic encephalopathy, cognitive social or emotional deficit, cerebral infarction, epilepsy, chronic kidney disease, bipolar disease, hypertension and bradycardia.R5's minimum data set (MDS) dated [DATE], showed that R5 required maximal assistance from staff for all activities of daily living (ADL) including toileting. On April 10, 2026, at 11:18 AM, R5 was sitting in a wheelchair near the nurses' station. V26, certified nurse assistant (CNA), wheeled R5 into the bedroom to perform incontinence care. V26 applied gloves without performing hand hygiene. V25 (CNA) entered R5's room donning gloves to assist with care. R5 was placed on the bed and R5's clothing was removed. R5's adult brief had a moderate amount of soft feces. V26 cleansed the area and removed R5's soiled brief. V26 removed soiled brief, removed soiled gloves and sanitized hands before donning new gloves. V25 assisted V26 with applying a new brief, pulling up trousers and placing R5 back into the wheelchair. V25 removed and emptied trash while V26 removed gloves and escorted R5 back to the nurse's station. V25 placed trash and soiled gloves into a larger receptacle. V25 and V26 did not perform hand hygiene after removing gloves, following incontinence care.On April 10, 2026, V2 (Interim Director of Nursing) said that staff should always perform hand hygiene before care, in between patients, and after care. Hand hygiene should also be performed during dining services. V2 said that staff should be sure to wash hands prior to the start of care and before leaving the residents' room.The facility's Handwashing/Hand Hygiene Policy showed the facility considers hand hygiene the primary means to prevent the spread of infection. 7. Use of alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a.) before and after direct contact with residents e.) before donning sterile gloves l.) after removing gloves. 9. The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for residents who require assistance with care.This applies to 2 of 10 residents (R1, R6,) reviewed for ADLs.The findings include:1. R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including spinal stenosis, congestive heart failure, type II diabetes, cardiomyopathy, hypercholesteremia, atrial fibrillation, anxiety, hyperlipidemia, morbid obesity, functional quadriplegia, low back pain, edema, depression, restless leg syndrome, and need for assistance with personal use.R1's minimum data set (MDS) dated [DATE], showed R1 is cognitively intact and requires a wheelchair for mobility. R1 requires maximal assistance from staff with toileting, showers, dressing, transfers, standing and personal hygiene.R1's current physician's orders showed an order for oxygen at bedtime related to acute embolism and thrombosis.R1's current care plan showed that R1 is incontinent of bladder and that staff should check and change R1 according to facility protocol and administer appropriate cleansing and peri-care after each incontinent episode. Staff should provide R1 with opportunities to go to the toilet before and after meals, activities, laying down for naps and at bedtime.On April 07, 2026, at 11:56 AM, R1 was observed in their room sitting in a wheelchair. R1's hair was greasy, and shirt was soiled. R1 stated that R1 was in the same clothes that they went to bed in. R1 said the staff did not assist them in getting dressed for bed the night before. R1 said that the staff does not place the adult brief on correctly or use the correct size which causes them to soil clothing and bed linen often. R1 said that there are times when staff will not change the adult brief and R1 then has to struggle to change the brief alone. R1 said that they do not like to do this for fear that they may fall but the alternative would be that they remained lying in urine for endless amounts of time. R1 said that overnight CNAs (Certified Nurses Assistants) had not provided them with a new adult brief the night before and they went to bed with just clothes on from earlier in the day and no brief. R1 said they went all night long with wet sheets that had not been changed and that it took staff a long time to empty urinals as well. R1 said staff do not help push residents in wheelchairs, R1 said they have to wheel from their room all the way down to the therapy gym on the other side of the building alone. R1 said that by the time they get to the gym, they are already tired from the long haul down. When they are too tired, they may refuse therapy or care, and it is counted against them. R1 said that when they asked for assistance, staff said that R1 was supposed to wheel the chair on their own. R1 said that they have only received a shower once since entering the facility. R1 requested a bed bath on one occasion and staff handed R1 a bucket with water and a towel and told them that they had to do the bed bath themself. R1 said that staff do not like to assist with showers, so they say that R1 has refused. R1 said that they have not refused showers because R1 does not like to feel dirty and knows that the help is needed. R1 said that it is not easy for R1 to reach certain areas due to size and back pain and R1 therefore requires assistance. R1 said that they often attempt to put themselves into bed because some of the staff do not help.On April 08, 2026, at 2:47 PM, R1 was sitting on the edge of the bed in R1's room. R1 said that R1 transferred to the bed alone because staff would not assist. On April 09, 2026, at 1:19 PM, R1 was wheeling themselves from their room to go out for a smoke break. R1 was visibly tired and moving about slowly. R1's room is not far from the exit door to the smoking area. A resident walking behind R1 on the way to the smoking area asked V5 (Activities Director) to assist R1 due to R1 struggling to get down the hall. V5 was near the door leading to the smoke break area when they reluctantly walked towards R1 to help. V5 said to R1 You know we encourage you all to do these things on your own. On April 10, 2026, at 9:34 AM V11 (Physical Therapy Assistant) said that they are familiar with R1 and work with R1 for physical therapy. V11 said that R1 is required to wheel down alone to the therapy gym as a part of R1's therapy, however if R1 is tired and short of breath then staff should assist. V11 said that they have not checked R1's oxygen saturation when R1 enters the gym and was unaware that R1 utilizes oxygen therapy at bedtime. V11 said that R1 should be transferred using a mechanical lift and should not be encouraged to transfer alone.On April 09, 2026, at 12:05 PM V10 (CNA) said that R1 will sometimes refuse care if R1 is in a bad mood but will often apologize and cooperate once given time to settle down.On April 10, 2026, at 10:00AM V2 (Interim DON) asked R1 if they had received a bed bath the evening before. R1 said that they had not received a bed bath and were unsure of what happened the evening before. 2. R6 was admitted to the facility on [DATE]. R6 has multiple diagnoses including cerebral palsy, paraplegia, epilepsy, asthma, morbid severe obesity, type II diabetes, schizoaffective disorder, anxiety, anemia, schizophrenia, depressive disorder, psychosis, suicidal ideations and hypertension.R6's MDS dated [DATE], showed R6 is cognitively intact and requires a wheelchair for mobility. R6 requires touching assistance for eating, is dependent on staff for toileting, transfers, showers, and dressing and requires maximal assistance for personal hygiene.R6's current care plan showed R6 is incontinent with bladder and staff should administer appropriate cleansing and perineal care after each incontinent episode. Staff should provide R6 with the opportunity to use the toilet before and after meals, activities, and laying down for naps and bedtime. Staff should provide physical assistance with toileting needs and staff should remind R6 to use the toilet every two hours.On April 08, 2026, at 3:05 PM, R6 was leaning towards the right side of the wheelchair. R6 said that they were not comfortable in the way in which they were situated in the chair but said the staff did not help to straighten them out. R6 said that on the evening shift prior, they had to wait for the adult brief to be changed from 8:30 PM until 9:15 PM because R6's assigned CNA was on break and they were told that they had to wait until the CNA returned to be assisted. R6 said that they are on a list for the overnight CNAs to get them up and ready for the day. R6 said that a lot of the staff do not like to do this and often tell R6 that they are short staffed to avoid getting them up for the day. R6 is then left alone to attempt to do things by themself or wait for the next shift. R6 said that R1 was their previous roommate. R6 had recently moved to a different room because they were not getting along. R6 said that they watched staff treat R1 terribly. R6 said that R1 fell from the bed twice and staff told R1 that R1 was falling to get a new bed. R6 said that they also heard staff tell R1 that R1 needed to get in the wheelchair on their own and that R6 did not need a mechanical lift to do so.On April 09, 2026, R6 was pushed in the wheelchair by another resident at 12:30 PM, 1:19 PM, and 2:30 PM. R6 was slumped over to the right side of the wheelchair as several staff members walked by.On April 10, 2026, R6 was pushed in the wheelchair by another resident at 10:00 AM and 1:30 PM. R6 was slumped over to the right side of the wheelchair.On April 10, 2026, at 1:30PM V2 said that showers are given twice a week and as needed. V2 said that garbage should be emptied frequently throughout the shift and immediately when soiled items are placed in the receptacle. V2 said urinals should not be left at the resident's bedside and should be emptied when filled or as soon as possible. Urinals should not be left for hours at the bedside. V2 said that staff should assist residents in need regardless of level of dependance. Staff are to assess resident needs day by day, and shift by shift to determine the level of assistance needed at that time. V2 said that residents are to be checked and changed promptly.The facilities Activities of Daily Living policy showed: Residents are given routine care and night care by a CNA or a nurse to promote hygiene, provide comfort, and provide a homelike environment. ADL care is provided throughout the day, evening, and night as care planned and/ or as needed. ADL care is coordinated between the resident and the care givers with emphasis on resident preference as much as possible. ADL care of the resident includes assisting in personal care such as bathing, showering, dressing, eating, hair care, nail care, oral care, appropriate skin care as well as encouraging participation in physical, social and recreational activities, and assisting with movement and ambulation and range of motion as indicated and care planned.

Based on interview and record review, the facility failed to protect a resident's rights to be free of sexual abuse. This applies to 2 of 2 residents (R3 and R4) reviewed for sexual abuse. The findings include:The facility's 03/01/26 Initial Report to IDPH (Illinois Department of Public Health) showed CNA (Certified Nursing Assistant) stated R1 [R3] attempted to make contact with R2 [R4]. R3 and R4 separated. 1:1 placed with R3. Head to toe assessments of R3 and R4 were conducted with no new findings and no complaints of pain. Telehealth evaluations conducted. MD (Medical Doctor), family, and police were notified. Well-being checks initiated. Investigation initiated.The facility's 03/06/26 Final Report to IDPH showed, Conclusion: After investigation and interviews, no evidence of abuse was found. R3 admitted to facility on 02/15/25 and [had moderately impaired cognition]. R4 admitted to the facility on [DATE] and [had moderately impaired cognition]. Per interviews, staff member noticed R3 in wheelchair sitting next to R4's bed. Staff member removed R4 from room and 1:1 put in place. Both R3 and R4 interviews revealed no contact was made with one another. Due to proximity of room location, R3 has been moved to another room. There have been no further instances involving R3 and R4. Care plans have been reviewed and updated. Wellbeing checks confirm residents' moods are stable.On 03/26/26 at 11:40 AM, V5 (Laundry Aide) stated she was delivering clothes to the residents. V5 stated as she was walking down towards the nurses station, she saw R3 sitting in R4's room next to the bed facing the window. V5 stated she found that strange since R4 was sleeping. V5 stated she informed V6 (CNA/Certified Nursing Assistant) that R3 was in R4's room. V5 stated she left the unit after informing V6. V5 stated she did not go in R4's room because R3 is known to be violent with people and she is not a CNA.On 03/26/26 at 3:15 PM, V6 stated on 3/01/26 during the evening shift, V5 informed her that R3 was in R4's room. V6 stated when she walked in R4's room, R3 was standing up from his wheelchair, and standing next to R4. V6 stated R3 had R4's shirt lifted up, and R4's breast was exposed. V6 stated R3's hand was on R4's chest area. V6 stated she removed R3 from R4's room and reported what she witnessed to the nurse and the administrator. On 04/01/26 at 11:00 AM, V1 (Administrator) stated he was not working at the facility when the incident occurred. V1 stated it is expected that all residents in the facility are safe. V1 stated all residents should be free from abuse and neglect.R3 was admitted to the facility on [DATE] with multiple diagnoses which included hepatic encephalopathy, chronic obstructive pulmonary disease, epilepsy, major depressive disorder, lack of coordination, and cirrhosis of liver per the Face Sheet. R3's MDS (Minimum Data Set) dated 02/05/26 showed R3 had moderate cognitive impairment. R4 was admitted to the facility on [DATE] with multiple diagnoses which included hyperlipidemia, diabetes, major depressive disorder, schizoaffective disorder, neoplasm of brain, and panic disorder per the Face Sheet. R4's MDS dated [DATE] showed R4 had moderate cognitive impairment. The Facility's Investigative folder from the incident was reviewed. The folder contained a typed statement from V6. The statement dated 03/01/26 showed, I was walking to the nursing station. I saw the laundry girl there. She said- R3 is in R4's room. I said ok and I headed down there. When I walked in the room, R3 was standing up over R4's bed. He had his arms extended and they were on her chest area. It happened so fast. I said, R3 are you supposed to be in here and he sat down in his chair. He left the room. R4 was ok- she wasn't upset or crying. I informed the nurse and we had someone stay with R3. The facility's Abuse Prevention Program revised 03/01/21, showed, Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. If you suspect abuse, separate the alleged perpetrator and assure all residents safety.

Based on observation, interview, and record review, the facility failed to ensure a resident with a gastrostomy tube feeding received care and services to maintain his weight. This failure resulted in a resident experiencing significant weight loss of 13.49% in less than 39 days. This applies to 1 of 2 residents (R12) reviewed for gastrostomy tube use.The findings include:R12 is a [AGE] year-old male admitted to the facility on [DATE]th, 2022, with diagnoses including brain damage from a lightning strike, functional quadriplegia, dysphagia, cognitive communication deficit, and gastrostomy status for tube feeding. R12's December Physician Orders show he takes no food orally and receives nutrition from a gastrostomy tube feeding only. On 12/26/25 at 12:17 PM, R12 was in a wheelchair in his room. R12 appeared very thin and frail. R12 was alert and oriented and communicated using a communication board. R12 communicated that he frequently does not get fed and frequently does not get his medications. R12 communicated that when he does get fed, it is often late. R12 communicated that he is always depressed because of the care he is receiving at the facility. On 12/24/25 at 11:10 AM, V3 CNA (Certified Nurse's Assistant) said that R12 has told her that he is hungry. V3 said that she tells R12's nurse and they will tell her that they will get to it or that it is next on their list. V3 said that R12 has lost a lot of weight. V3 said that the nurses tell R12's family that R12 was fed when he has not been fed. V3 said that she works 6:00 AM to 2:00 PM and she had never seen R12 get a 6:00 AM feeding until the family started complaining about it. On 12/26/25 at 10:20 AM, V15 (CNA) said that R12 has told her that he was hungry. V15 said He has lost tons of weight and looks like a skeleton. He cannot get out of bed and relies on staff to feed him. He should not look like a skeleton.On 12/24/25 at 11:10 AM, V5 (CNA/Restorative Aide) also said that R12 has communicated to her that he is hungry, and she has let the nurse know. On 12/27/25 at 2:30 PM, V4 (CNA) said that she works the 10:00 PM to 6:00 AM shift. V4 said that she noticed R12 has been losing weight and she has never seen him be fed on the night shift. V4 said that sometimes on the night shift the residents don't get fed or don't get their medications because there is only one nurse in the facility. R12's electronic health records showed his weight was 114.2 pounds on 11/19/25. On 12/26/25 at 12:35 PM, R12 was weighed at the facility again and his weight was 98.8 pounds, a 13.49% weight loss in 38 days. R12's December 24, 2025, hospital Discharge Summary listed a diagnosis of severe protein calorie malnutrition, and comments under the physical exam described his appearance as cachectic (extremely thin and frail due to severe unintentional weight loss, primarily from muscle and fat). R12's Summary further showed Weight: 30% weight loss in less than one year. Muscle mass severe loss to clavicular and temporalis muscle areas. Malnutrition: severe.R12's December 2025 Medication Administration Record (MAR) showed R12's order as Enteral Feed Order every 6 hours for Diet- Jevity 1.2, 300 [milliliters] every 6 hours. R12's MAR had the feedings scheduled four times daily at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Up to December 20, 2025, R12's December 2025 MAR had every box checked as though the tube feeding was administered as scheduled except four times, which are 12/1 at 6:00 AM and 6:00 PM, on 12/16 at 6:00 AM, and 12/19 at 6:00 PM, and those were left blank. On 12/23/25 at 4:13 PM, V2 (Director of Nursing) said that if there is nothing documented in the EMAR, the medications or feedings were not given.R12's December 2025 Medication Administration Audit Report showed the times when the remaining entries were actually signed off as administered:On 12/2/2025, R12's 12:00 AM and 6:00 AM feedings were both signed off as given at 6:55 AM.On 12/5/2025, R12's 12:00 AM and 6:00 AM feedings were both signed off by V2 (Director of Nursing), two days later, on 12/8/2025 at 2:26 PM.On 12/6/2025, R12's 12:00 AM and 6:00 AM feedings were both signed off at 7:16 AM.On 12/8/2025, R12's 6:00 AM feeding was signed off by V2 at 8:52 PM.On 12/14/2025, R12's 12:00 AM feeding was signed off at 5:27 AM, and his 6:00 AM feeding was signed off at 5:19 PM. R12's 12:00 PM and 6:00 PM feedings were both signed off as given at 6:04 PM. On 12/15/2025, R12's 12:00 AM feeding was signed off at 8:44 AM, his 6:00 AM was signed off at 8:45 AM, and his 12:00 PM was signed off at 5:28 PM.On 12/17/2025, R12's 12:00 AM feeding was somehow signed off at 12:30 AM the day before, and his 12/17 6:00 AM was also signed off the day before at 5:56 AM. R12's 6:00 PM feeding was signed off at 10:49 PM.On 12/18/2025, R12's 12:00 AM feeding was signed off at 4:54 AM, his 6:00 AM was signed at 6:04 AM, and his 6:00 PM was signed at 8:54 PM.On 12/19.2025, R12's 12:00 AM and 6:00 AM were both signed off as administered at 6:16 AM, and his 12:00 PM was signed off as administered at 4:51 PM.In addition to what is already outlined, R12's Audit Report for 12/1-12/20 also showed ten times where his feeding administration times were signed off as administered more than three hours later than scheduled: on 12/1 for the 12:00 AM feeding, 12/6 for the 12:00 PM, 12/7 for the 12:00 AM, 12/9 for the 12:00 AM and the 12:00 PM, 12/10 for the 12:00 AM, 6:00 AM, and 12:00 PM, and 12/13 for the 12:00 AM and 6:00 AM feedings. Additionally, there are three times where R12's scheduled feedings were signed off more than four hours past their scheduled administration times: on 12/4 for the 12:00 AM feeding, on 12/8 for the 12:00 PM feeding, and 12/12 for the 12:00 AM feeding.On 12/30/25 at 10:29 AM, V7 (R12's Primary Care Physician) said that he was not made aware of R12's weight loss or that he was not getting his feedings as ordered. V7 said that he was also unaware of R12 asking for food. V7 said that he had just examined R12 and there was nothing wrong with R12 medically that would cause him to lose weight. V7 said that if R12 is losing weight, it would only be from him not being fed. On 12/30/25 at 11:09 AM, V16 (R12's Registered Dietician) said that if R12 was getting his feedings as ordered, he would not have lost any weight because his feedings were exceeding his needs. V16 said the only reason for R12's weight loss is that he is not getting enough feedings. On 1/2/26 at 5:50 PM, V1 (Administrator) said that it is her expectation that the residents get their tube feeding as ordered. V1 said that she does not expect R12 to be losing weight because he is to be feed as ordered. V1 said that she is aware of R12 not being fed and that he is malnourished, and it is not acceptable.

Based on observation, interview, and record review, the facility failed to ensure a resident remained free from abuse. The facility also failed to keep a resident free from physical abuse, resulting in one resident striking another in the head with his cane and that resident requiring sutures.This applies to 1 out of 6 residents (R29) reviewed for neglect and abuse.The findings include: On 12/31/25 at 12:26 pm, R29 was observed with a bruise to his upper right cheek below the eye, and three sutures on the right eye lid. R29's 12/26/25 6:45 am progress notes showed that R29 was observed with bleeding from below his right eye. The progress note showed that it was reported that another resident hit R29. R29's 12/26/25 hospital report showed that R29 sustained a head injury and a laceration requiring three sutures. The facility's 12/26/25 incident report to Illinois Department of Public Health showed that on 12/26/25, R2 and R29 engaged in inappropriate physical contact. On 1/2/26 at 5:50 pm, V1 Administrator said that it was reported to her that R2 hit R29 in the head with his cane. V1 said that R29 was sent to the hospital and received sutures. R29's 12/24/25 care plan shows a focus for a history of suspected abuse with interventions including assure R29 is in a safe environment.R2's 10/16/25 care plan showed a focus on inappropriate sexual behavior, but did not identify an assessment for the potential for physical abuse against others.The facility's Abuse Prevention Program policy (revised 01/2019) defined physical abuse as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. The Policy also showed It is the policy of this facility to prohibit and prevent resident abuse, neglect against a resident in the facility .

Based on observation, interview, and record review, the facility failed to have enough licensed nursing staff to pass medications in a timely manner and to consistently provide a resident's gastrostomy tube feeding as ordered.This applies to 15 residents (R1, R10, R12, R18-R29) reviewed for licensed nurse staffing. The findings include:On December 31, 2025, at 11:00 AM, R19 was still in bed and was restless. R19 asked for his medications and stated he did not get his morning medications. R19 stated he goes a lot of nights without getting his 9:00 PM medications until around midnight, adding he also goes a lot of days without getting his morning meds until around 11 or 12:00 PM, too. R19 stated I need them- I am very sick and me not getting my medications on time is making me sicker. R19's October 10, 2025, MDS (Minimum Data Set) showed R19 is cognitively intact.On December 31, 2025, at 11:05 AM, V20 LPN (Licensed Practical Nurse) was at his medication cart, passing medications using the facility's EMR (Electronic Medical Record). The computer screen showed the eMAR (electronic Medication Administration Record) in pink for residents whose medications had not been passed. V20 verified that the pink color for the residents showing meant that there were overdue medications and that there were 14 total residents on the hall who had overdue medications, including R1, R10, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, and R29. V20 stated there was only one nurse down here on this side and there are supposed to be two. V20 stated he did not know if someone had called off or why there was only one nurse. V20 stated nurses work 12-hour shifts and he had worked the overnight shift as well. On December 31, 2025, at 12:00 PM, V26 RN (Registered Nurse) prepared R20's late 9:00 AM medications. V26 stated she just started passing medications around 11:00 AM because she had been working on the other side with another nurse because she's new. V26 stated she had been at the facility since the previous evening at 11:00 PM. V26 stated she was about to take R20's blood pressure. The Medication Administration Audit Report for December 31, 2025, showed R20's two 9:00 AM hypertension medications with blood pressure parameters for dosing were administered late on December 31, 2025, at 12:09 and 12:11 PM. R12's Face Sheet showed he was admitted to the facility on [DATE]th, 2022, with diagnoses including functional quadriplegia, dysphagia, and gastrostomy status for tube feeding. R12's December Physician Orders show he takes no food orally and receives nutrition from a gastrostomy tube feeding only. R12's electronic health records showed his weight was 114.2 pounds on 11/19/25. On 12/26/25 at 12:35 PM, R12 was weighed at the facility again and his weight was 98.8 pounds. On 12/30/25 at 10:29 AM, V7 (R12's Primary Care Physician) stated that he had just examined R12 and there was nothing wrong with R12 medically that would cause him to lose weight. V7 said that if R12 is losing weight, it would only be from him not being fed.On 1/2/25 at 3:51pm, V9 ADON (Assistant Director of Nursing) said that the facility's minimum for nurses is 3 on day shift and 2 on night shift. The shifts are twelve-hour shifts scheduled from 7am to 7pm, and 7pm to 7am. V9 was reviewed the facility's November 2025 and December 2025 daily floor assignment sheets, the daily staffing sheets, and the staff time sheets. V9 confirmed the following information to be true:On Nov. 17th, 2025, there was only 1 nurse on from 7pm to 7am.On 11/22/25 there was 1 nurse on from 7pm - 7am. On 11/29/25 there were 2 nurses 2 on from 7am - 7pm. On 12/3/25 there was 1 nurse from 9pm - 7am. On 12/13/25 there were 2 nurses from 7am - 7pm and only 1 nurse from 12am to 7am. On 2/14/25 there was 1 nurse from 7am - 4:30pm, and only 2 nurses from 4:30pm to 7pm.On 12/17/25 there were 2 nurses from 7am - 815am.On 12/18/25 there were 2 nurses from 2pm until 7pm, and only 1 nurse from 11pm - 7am. On 12/19/25 there were 2 nurses from 7am - 1045 am and only 1 nurse from 8:45 pm to 7am. On 12/22/25 there were 2 nurses from 7am - 845 am. On 12/23/25 there was 1 nurse from 7am - 745 am.On 12/25/25 there were 2 nurses from 7am - 730am, and only 1 nurse from 830pm - 7am. On 12/30/25 there were only 2 nurses from 7am - 7 pm.On 12/31/25 there were 2 nurses from 7am - 7pm, and only 1 nurse from 10pm to 7am. V9 (ADON) continued and said that her expectations for staffing are for the facility to meet the minimum requirements. V9 said, if not, it affects the care that should be provided, such as passing medications and tube feedings given on time.On 12/31/2025 at 2:55 PM, V20 (LPN) stated he thought the facility was short on nurses.On 12/26/25 at 2:34 pm, R3, who was alert and oriented, said there is not enough staff at the facility. R3 said that some nights there is no nurse on duty, and he does not get his medications. R3 said that he has had to yell for his medications and threaten to call 911. R3 said that sometimes he is unable to sleep because he hasn't gotten his pain medications that night. On 12/26/25 at 2:48 pm, R15, who was alert and oriented said that some nights there are no nurses on the floor, and she does not get her pain medications. R15 said that she has threatened to call the state about it. On 12/26/25 at 2:45 pm, R16 who was alert and oriented, said that sometimes he is unable to sleep at night because he has not gotten his medications to help him sleep. On 12/26/25 at 2:55pm, R17, who was alert and oriented, said that he does not get his medications at night, including his medications to help him sleep. On 1/2/26 at 5:50 pm, V1 (Administrator) said that her expectations are that the minimum number of staff work to provide care. V1 said that it is not acceptable to have just one nurse on the floor. V1 acknowledged that it is not safe for only one nurse to have the whole facility, and it happens. On 12/23/25 at 4:13 pm, V2 DON (Director of Nursing) said that the minimum of nurses on at night shift is 2. V2 said that on 12/14/25 at 1:17 am, she was aware that there was only 1 nurse working in the facility. On 12/24/25 at 11:10 am V3 CNA (Certified Nurses Assistant) said that there are not enough nurses. V3 said that some residents don't get their medications and their G-tube feedings, and some residents must wait to get their medications. On 12/27/25 at 2:30 pm, V4 CNA said that there are times that there is only 1 nurse working on the floor and she has made V2 aware of it. V4 said that she has seen residents begging for their medications and threatening to call 911 to get their medications. On 12/26/25 at 10:20 am, V15 CNA said that on 12/14/25 at 9:18 am, V15 sent a text to V1 and V2 telling them that there was only 1 nurse on the floor and there were residents waiting on medications. V15 said the text also informed V1 and V2 that there were resident behaviors happening. V15 said that neither V1 nor V2 replied to her text. The facility's Strategies to Mitigate Staffing Shortages policy dated 5/1/2020 showed that Maintaining staffing is essential to provide a safe work environment for healthcare professionals and safe patient care.The facility Assessment Tool dated 11/17/2025 showed the Staffing Plan with the total number of licensed nurses providing direct care needs to be 3 on days and 2 on nights. The Staffing Plan also showed that the facility had zero for average number of residents for the category, behavioral symptoms and cognitive performance.

Based on observation, interview, and record review, the facility failed to ensure significant medications were administered as ordered.This applies to 6 residents (R10, R12, R18, R19, R20, R28) reviewed for medications.The findings include:1.On December 31, 2025, at 11:00 AM, R19 was still in bed and was restless. R19 asked for his medications and stated he did not get his morning medications. R19 stated he goes a lot of nights without getting his 9:00 PM medications until around midnight, adding he also goes a lot of days without getting his morning meds until around 11 or 12:00 PM, too. R19 stated I need them- I am very sick and me not getting my medications on time is making me sicker. R19's October 10, 2025, MDS (Minimum Data Set) showed R19 is cognitively intact.R19's Face Sheet showed he his diagnoses include malignant lung neoplasm, absence of his right and left legs above the knee, and hydradentis suppurativa (a chronic and painful skin condition that causes recurrent abscess-like lumps). R19's December 31, 2025, Order Summary Report showed Physician Orders for baclofen three times daily for muscle spasms and gabapentin three times daily for muscle spasms. R19's December 2025 MAR (Medication Administration Record) showed the two medications were scheduled to be administered daily at 9:00 AM, 5:00 PM, and 9:00 PM. The Medication Administration Audit Report for December 31, 2025, showed he received his first doses of both medications at 11:24 AM, his 5:00 PM doses at 4:35 PM (five hours later), and his 9:00 PM doses at 8:10 PM (under four hours after that). On December 31, 2025, at 11:05 AM, V20 LPN (Licensed Practical Nurse) was at his medication cart, passing medications using the facility's EMR (Electronic Medical Record). The computer screen showed the eMAR (electronic Medication Administration Record) in pink for residents whose medications had not been passed. V20 verified that the pink color for the residents showing meant that there were overdue medications and that there were 14 total residents on the hall who had overdue medications, including R19, R28, R10, R20, and R18.2. On December 31, 2025, at 11:05 AM, R28's MAR was pink. R28's Face Sheet showed his diagnoses include diabetes with hyperglycemia. R28's December 31, 2025, Order Summary Report showed Physician Orders for 6 units of short-acting insulin injected three times daily for diabetes, and 25 units of long-acting insulin injected once daily. R28's December 2025 MAR showed his short-acting insulin was scheduled for administration before meals at 7:00 AM, 11:00 AM, and 4:00 PM. The same MAR showed his daily dose of long-acting insulin was scheduled for administration at 8:00 PM. The MAR showed the 7:00 AM and 11:00 AM doses of R28's short-acting insulin were administered on December 31, 2025, and the MAR showed both doses were signed off at 11:35 AM, as does R28's Medication Administration Audit Report for December 31, 2025. R28's MAR showed his once daily long-acting insulin scheduled for 8:00 PM was signed off as administered on 12/25, 12/26, 12/27, refused on 12/28, and signed off again on 12/29. R28's December 2025 Medication Administration Audit Report showed the 8:00 PM dose on 12/25 was administered at 6:21 AM on 12/26, his 8:00 PM dose on 12/26 was administered at 5:57 AM on 12/27, his 12/27 8:00 dose was administered 12/28 at 7:08 AM, his 12/28 refused dose at 8:00 PM was administered 12/29 at 6:48 AM. The Audit Report showed his actual 12/29 8:00 PM dose was administered 14 hours later at 8:34 PM.3. On December 31, 2025, at 11:05 AM, R10's MAR was pink. R10's Face Sheet showed her diagnoses include the bi-polar type of schizoaffective disorder, and recurrent major depressive disorder. R10's December 31, 2025, Order Summary Report showed Physician Orders for benztropine mesylate two times daily for Parkinson's, and clozapine every twelve hours and lithium carbonate three times daily, both related to bipolar-type schizoaffective disorder. R10's MAR showed the benztropine and clozapine were both scheduled for administration at 9:00 AM and 9:00 PM, and lithium was scheduled for 9:00 AM, 1:00 PM, and 9:00 PM. The Medication Administration Audit Report for December 31, 2025, showed all three 9:00 AM scheduled doses were signed off as administered at 12:58 PM, with the second 1:00 PM scheduled dose of lithium signed off as administered at 12:59 PM. The same Audit Report showed on 12/30/25, R10's 9:00 AM doses of clozapine, lithium, and benztropine were signed off as administered at 2:58 PM, and her 1:00 PM scheduled dose of lithium signed off as administered at 2:20 PM. 4. On December 31, 2025, at 11:05 AM, R20's MAR was pink. R20's Face Sheet showed his diagnoses include diabetes with hyperglycemia and foot ulcer, combined heart failure, and hypertension. R20's December 31, 2025, Order Summary Report showed Physician Orders for amlodipine and lisinopril daily for hypertension with parameters to hold the medications for a systolic blood pressure value under 110, orders for 45 units of long-acting insulin injected at bedtime, and orders for short-acting insulin injected three times daily with a sliding scale.R20's MAR showed to administer the amlodipine and lisinopril at 9:00 AM. On December 31, 2025, at 12:00 PM, V26 RN (Registered Nurse) prepared R20's medications. V26 stated she just began passing medications around 11:00 AM because she had been working on the other side. V26 stated she was about to take R20's blood pressure and it was last taken the day before at 3:03 PM. The Medication Administration Audit Report for December 31, 2025, showed R20's hypertension medications were administered on December 31, 2025, at 12:09 and 12:11 PM. The Medication Administration Audit Report showed for the previous day on December 30, 2025, that R20's 9:00 AM scheduled hypertension medications were administered at 3:00 PM.R20's MAR showed to check his blood glucose and inject short-acting insulin as needed per sliding scale before meals at 6:00 AM, 11:00 AM, and 4:00 PM. R20's MAR showed the 11:00 AM insulin dose on 12/28 was administered at 6:20 PM and the 11:00 AM dose on 12/30 was administered at 2:23 PM. R20's Medication Administration Audit Report for his bedtime dose of long-acting insulin (scheduled for 9:00 PM) showed his 12/26 dose was administered at 6:05 AM on 12/27, his 12/27 dose was administered on 12/28 at 7:11 AM, his 12/28 dose was administered on 12/29 at 6:43 AM, and his 12/29 dose was administered at 8:47 PM, approximately 14 hours later.5. On December 31, 2025, at 11:05 AM, R18's MAR was pink. R18's Face Sheet showed her diagnoses include malignant neoplasm of brain and epileptic seizures. R18's December 31, 2025, Order Summary Report showed Physician Orders for levetiracetam and lacosamide twice daily for seizures. R18's MAR showed both seizure medications were to be administered twelve hours apart at 9:00 AM and 9:00 PM. R18's December Medication Administration Audit Report showed the two 9:00 AM seizure medications were administered on 12/26 at 10:41 and 10:44 AM and the 9:00 PM dose was administered on the next day on 12/27 at 6:03 and 6:04 AM; her 12/27 9:00 AM doses were administered seven hours later at 1:06 PM and her 12/27 9:00 PM doses were administered on 12/28 at 6:52 AM; her 12/28 9:00 AM doses were administered at 6:24 PM and her 9:00 PM doses were administered on 12/29 at 6:30 AM; her 12/29 9:00 AM doses were administered just over seven hours later at 1:45 PM, her 12/29 9:00 PM seizure medications were administered at 8:52 PM, just over seven hours after that, making that a third dose within 15 hours. The Audit Report showed her 12/30 9:00 AM doses were administered at 2:58 PM, with the 12/30 9:00 PM doses not being signed off as administered at all. The same Audit Report showed the 12/31 9:00 AM doses were administered at 1:00 PM, 22 hours later.6. R12's Face Sheet showed his diagnoses include functional quadriplegia, dysphagia, and history of acute respiratory failure and pneumonia. R12's December 24, 2025, hospital Discharge Summary showed Weaned off oxygen successfully. [Intravenous] Zosyn (antibiotic) transitioned to [oral] antibiotic. R12's Transition of care section showed 1. Medication changes: start levofloxacin (antibiotic) 750 mg (milligrams) daily for five days.R12's Order Summary Report had the order transcribed to give levofloxacin 750 mg two times a day via his gastrostomy tube every five days. R12's MAR showed 9:00 AM and 5:00 PM doses were signed off as administered on 12/25 and 12/30, instead of once daily for five straight days. Further, R12's Medication Administration Audit Report showed his 9:00 AM dose on 12/30 was administered at 5:19 PM, and his 5:00 PM dose was administered at 7:13 PM, less than two hours later. R12's Advanced Practice Nurse progress note late entry from date of service of 12/29 also showed [History of Present Illness]: .started on a five-day course of levofloxacin 750 mg one tab via [gastrostomy tube] two times a day for infection prophylaxis following [Emergency Department] visit.started 12/25 with no end date.R12's December 25, 2025, pharmacy Physician's Order Note from 7:38 AM showed This order is outside the recommended dose or frequency. levofloxacin Oral Tablet 750 MG (Levofloxacin) Give 1 tablet via G-tube two times a day every 5 days for prophylaxis- The frequency of 2 times per 5 days is below the usual frequency of every 2 days to daily.The facility's undated Policy and Procedure- Medication Administration Errors showed Procedure: A medication error is any preventable event that may cause or lead to inappropriate medication use. Such events may be related to professional practice. administration. The Medication Administration Error Policy listed Medication not administered within the allowed time frame which is greater than one hour from its scheduled administration time or exceeds the time in relation to meals, and missed medication as administration-based errors.

Based on interview and record review, the facility failed to report allegations of staff to resident abuse and an allegation of resident-to-resident abuse to the Illinois Department of Public Health within the required timeframes. This applies to 3 of 3 residents (R1, R5, R9) reviewed for abuse reporting.The findings include:1.On 1/2/25 at 9:57 am, R5, who was alert and oriented, said that on 12/7/25 she told the staff that R1 had a knife and held it to her neck and threatened her. R5 stated she was scared in the moment. On 12/27/25 at 2:30pm, V4 CNA (Certified Nurse's Assistant) said that 12/7/25 she worked the night of 12/7/25 and she heard R1 threatening R5 with a knife and R1 was standing over R5. V4 said that night, the staff found a knifes, a drill, a hammer, and lighters in R5's room. On 12/31/25 at 11:09 am, V3 CNA said the next day on 12/8/25, V2 DON (Director of Nursing) instructed her to search R1's room after it was reported that R1 had threatened R5. On 12/24/25 at 11:10am, V3 said while searching R1's room, she found a taser and a pocketknife under R1's bed. On 12/17/25 at 9:30 am, a pink and black electric drill, a pink and black hammer, scissors, razor blades, and lighters were present in the medication room. At 3:16 pm V2 DON (Director of Nursing) removed the items and brought them to V1's (Administrator) office. The knife in V1's desk was metal and was like a folding boxcutter or utility knife. Unfolded, it was about 6 inches long, with the top half holding an angled blade.On 1/2/26 at 5:50 pm, V1 Administrator verified the objects found belonged to R1. V1 stated they were confiscated the night R1 went to the hospital and other potentially dangerous items were found and taken the next day. V1 said that she did not report R5's allegation of 12/7/25 to the Illinois Department of Public Health.2. On 12/19/25 at 2:32 pm, R9, who was alert and oriented, said that on 12/14/25 staff ripped his shirt and had their knee on his neck during a verbal altercation between himself and the staff. R9 said that he told the CNA (Certified Nurse's Assistant) that night that they ripped his shirt, and he told the nurse that the CNAs had their knees on his neck. On 12/14/25 at 11:10 am, V5 CNA verified that R9 did tell her and show her that his shirt was ripped during the altercation. V5 said that R9 was sent to the hospital that night for his behaviors and she reported the allegation to the Administrator and the DON. On 1/2/26 at 5:50 pm, V1 said that R9 did report that the staff ripped his shirt and staff was being physically aggressive to him. V1 said that the incident happened on 12/14/25. The facility Initial Report dated 12/23/24 at 8:10 pm (nine days after the incident) to the Illinois Department of Public Health showed that on 12/14/25, at 1:30 PM, R9 alleged that staff engaged in physical contact with him. The incident report did not include the alleged report of staff ripping R9's shirt. 3. On 12/23/25 at 1:59 pm, R5, who was alert and oriented, said that once she was choking and a CNA helped her, but V17 CNA told her that he would have let her choke. R5 said that she reported it to V1 (Administrator). On 12/24/25 at 3pm, V1 said that R5 did report the incident to her but R5 said that it happened right before V1 had started at the facility, so she did not report it to IDPH. The facility's Abuse Prevention Program policy (revised 01/2019) showed that the staff are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of residence property, mistreatment or a crime against a resident they observe, her about, or suspect to the Administrator.Complete an incident report immediately. Fax report to IDPH (Illinois Department of Public Health) immediately. The Administrator or the absence of the administrator the DON is then responsible for forwarding a final written report of the results of the investigation and any corrective actions taken to the Department of Public health within 5 working days of the reported incident.

Based on interview and record review, the facility failed to investigate reported allegations of resident abuse, and subsequently failed to ensure residents were protected while the reported allegations were investigated. This applies to 3 of 3 residents (R1, R5, R9) reviewed for abuse. The findings include:1. On 12/19/25 at 2:32 pm, R9, who was alert and oriented, said that on 12/14/25, staff ripped his shirt and had their knee on his neck during a verbal altercation between R9 and the staff. R9 said that he told the CNA (Certified Nurse's Assistant) that night that they ripped his shirt, and he told the nurse that the CNAs had their knees on his neck. On 12/14/25 at 11:10 am, V5 CNA verified that R9 did tell her and show her that his shirt was ripped during the altercation. V5 said that R9 was sent to the hospital that night for his behaviors and she reported the incident to the Administrator and the DON. On 1/2/26 at 5:50 pm, V1 (Administrator) said that R9 did report that the staff ripped his shirt and the staff was being physically aggressive to him. V1 said that the incident happened on 12/14/25 and she investigated it on 12/23/25. V1 said that she did not investigate the allegation until after R9 reported it to IDPH (Illinois Department of Public Health). The facility Initial Report dated 12/23/24 at 8:10 pm to the Illinois Department of Public Health showed that on 12/14/25, at 1:30 PM, R9 alleged that staff engaged in physical contact with R9. The facility reported the incident 9 days after the incident. The incident report did not include the alleged report of staff ripping R9's shirt. 2. On 1/2/25 at 9:57 am, R5, who was alert and oriented, said that on 12/7/25 she told the staff that R1 held a knife to her neck and threatened her. R5 stated she was scared in the moment. On 12/27/25 at 2:30pm, V4 CNA (Certified Nurse's Assistant) said that on 12/7/25 she worked that night, and she heard R1 threatening R5 with a knife and R1 was standing over R5. V4 said that night, the staff found a knifes, a drill, a hammer, and lighters in R5's room. On 12/31/25 at 11:09 am, V3 CNA said the next day on 12/8/25, V2 DON (Director of Nursing) instructed her to search R1's room after it was reported that R1 had threatened R5. On 12/24/25 at 11:10am, V3 said while searching R1's room, she found a taser and a pocketknife under R1's bed. On 1/2/25 at 10:48 am, V5 CNA said that on 12/8/25 the following day, R5 reported to her that R1 had a knife in her room and held it to her neck and she was scared. V5 said that the facility found the knife, a hammer and drill. On 1/2/26 at 5:50 pm, V1 Administrator verified the objects found belonged to R1. V1 stated they were confiscated the night R1 went to the hospital and other potentially dangerous items were found and taken the next day. V1 said that she did not investigate R5's abuse allegation of 12/7/25 or report it to the Illinois Department of Public Health (IDPH).3. On 12/23/25 at 1:59 pm, R5, who was alert and oriented, said that once she was choking and a CNA helped her, but V17 CNA told her that he would have let her choke. R5 said that she reported it to V1. On 12/24/25 at 3pm, V1 Administrator said that R5 did report the incident to her but R5 said that it happened right before V1 had started at the facility, so she did not investigate the incident, nor did she report the incident to the Illinois Department of Public Health. The facility's Abuse Prevention Program policy (revised 01/2019) showed .After notification of alleged abuse.the Administrator.shall immediately commence an investigation of the incident reported.If you suspect abuse- separate the alleged perpetrator and assure all residents safety.complete an Incident Report immediately. Under Investigation, the policy showed any incident or allegation involving abuse. against a resident will result in an abuse investigation.

Based on observation, interview, and record review, the facility failed to maintain a safe resident environment after a resident was able to obtain objects that could be used to threaten others. This applies to 2 residents (R1, R5) reviewed for safe environment. The findings include:On 1/2/25 at 9:57 am, R5, who was alert and oriented, said that on 12/7/25 she told the staff that R1 had a knife and held it to her neck and threatened her. R5 stated she was scared in the moment. On 12/27/25 at 2:30pm, V4 CNA (Certified Nurse's Assistant) said that 12/7/25 she worked the night of 12/7/25 and she heard R1 threatening R5 with a knife and R1 was standing over R5. V4 said that night, the staff found a knifes, a drill, a hammer, and lighters in R5's room. V4 said R1 also threatened to burn down the facility before she was discharged to the hospital that night. V4 said that the facility was trying to send her to jail, but she went to the hospital instead. On 12/31/25 at 11:09 am, V3 CNA said the next day on 12/8/25, V2 DON (Director of Nursing) instructed her to search R1's room after it was reported that R1 had threatened R5. On 12/24/25 at 11:10am, V3 said while searching R1's room, she found a taser and a pocketknife under R1's bed. V3 said that she was instructed by V2 to put the items in the medication room. V3 said the night before after R1 was sent to the hospital, a hammer and drill were also found in R1's room. V3 said that the reason R1 was sent to the hospital on [DATE] was because R1 threatened R5, and after the police arrived, R1 threatened to burn down the facility. On 12/24/25 at 4:51 pm, R1, who was alert and oriented, said that she had kept a hammer, a drill and a pocketknife in her room for her protection.On 12/17/25 at 9:30 am, a pink and black electric drill, a pink and black hammer, scissors, razor blades, and lighters were present in the medication room. At 3:16 pm V2 DON (Director of Nursing) removed the items and brought them to V1's (Administrator) office. The knife in V1's desk was metal and was like a folding boxcutter or utility knife. Unfolded, it was about 6 inches long, with the top half holding an angled blade.On 1/2/26 at 5:50 pm, V1 Administrator verified the objects found belonged to R1. V1 stated they were confiscated the night R1 went to the hospital and other potentially dangerous items were found and taken the next day. V1 said when residents have these types of items in the facility it makes the facility unsafe. R1's 12/7/25 11:55 pm nurses note showed that R1 threatened to burn the facility down and was transferred to the local community hospital for evaluation. R1's 11/13/25 care plan showed that R1 displays maladaptive behaviors that may detrimentally affect others. R1's care plan did not show a focus on any aggressive behaviors or previous possession of objects that could be used as weapons. R5's electronic health records showed on 10/8/25 that her cognition is intact and her 7/31/2025 care plan shows a risk for alteration in mood and psychosocial well-being, with an intervention to provide a calm and positive environment. The facility's 6/20/2023 Guidelines for Homelike Environment policy showed that the facility will ensure that the environment is safe. The policy showed that the furnishings should be safe, clean, and comfortable .

Based on observation, interview and record review the facility failed to provide care to a resident dependent on staff for ADL (activities of daily living). This applies to 1 of 3 (R5) residents reviewed for ADL care.The findings include:According to the Electronic Medical Record (EMR), R5 was admitted to the facility on [DATE], with multiple diagnoses including acquired absence of left leg above knee, cellulitis of groin, hidradenitis suppurativa, and pressure ulcer of sacral region, stage 3. R5's MDS (Minimum Data Set) dated June 5, 2025, showed R5 had mild cognitive impairment and required maximum assist with toileting hygiene, shower, and bathing. R5's Care Plan dated April 13, 2025, showed R5 has an ADL (Activity of Daily Living) self-care deficit and required staff assistance and showed that R5 is incontinent of bladder and bowel. Interventions include the CNA (Certified Nurse Aide) should check and change R5 every 2 hours and as needed.On August 25, 2025, at 12:40 PM, R5 was in bed with an empty urinal on his bedside dresser table. R5 stated that he uses the urinals and was incontinent of bowel. R5 also stated that he calls the CNA (Certified Nursing Assistant) when he needs to be cleaned up after a bowel movement and has had to wait up to 30 minutes sometimes. R5 also added that he has had chronic ulcers for about 20 years and developed a sore on his buttock at the facility about 3 months ago.On August 26, 2025, R5 was awake in bed with his urinal almost about half full of urine. R5's room was noted with a strong urine odor, and the bed linens and padding were stained and heavily soiled with urine. On August 26, 2025, at 9:33 AM V6 (Certified Nursing Assistant) and V7 (Certified Nursing Assistant) stated they are scheduled from 6 AM to 2 :00 PM and are both assigned to R5's room. V6 and V7 stated they were working in other rooms and giving bed baths. V6 and V7 stated they were getting ready to check in on R5. When V6 and V7 attempted to provide care to R5, a large area of R5's beddings, disposable pad and blanket were soiled with urine. On August 26, 2025, at 9:49 AM, V6 (Certified Nursing Assistant) and V7 (Certified Nursing Assistant) stated they typically complete their morning rounds during their shift around 10:30 AM. On August 26/2025 at 12:09 PM, V2 (Director of Nursing / DON) stated that CNAs (Certified Nursing Assistant) work from 6:00 AM to 2:00 PM and should complete their morning rounds which includes, checking on their residents, attending to their needs, and checking with the nurses to determine any specific needs for the resident such as an appointment or anything else. V2 also stated that the CNAs should prioritize attending to the residents who needs incontinence care right away unless another resident was experiencing an emergency. V2 added that CNAs are expected to complete incontinence care for all residents within the first 2 hours of their shift.R5's nurse practitioner progress note created by V4 dated August 22, 2025 documents R5 has a sacral wound, and a history of (IAD) incontinence associated dermatitis. On August 25, 2025, at 3:52 PM, V4 (Nurse Practitioner) stated she determined R5's skin irritation to be incontinence associated because R5 wears incontinence briefs, and it gets really moist from his incontinence episodes and also has leakage from having HS.The facility's Guidelines for A.M. Care policy dated March 21, 2023, stated, Policy: It is the policy of the facility to see that residents receive A.M. care in preparation for the activities of the day.The facility's Guidelines for Incontinence Care dated September 21, 2025, stated, Policy: It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with daily care. Frequency depends on bladder diary results and/or routine minimal q [every] 2 hour checks as well as care planning.

Based on interviews and record review, the facility failed to prevent resident to resident abuse. This applies to 2 of 5 residents (R2 and R3) reviewed for abuse in the sample of 10. The findings include: 1. FRI (Facility Reported Incident) report documents an incident of April 14, 2025, alleging that R1 made inappropriate contact with R2. The report indicates that immediate action taken: Residents were immediately separated. Body and pain assessments completed on R1 and R2. Police was notified. R1 was placed on 1:1 monitoring until sent out to the hospital for further evaluation. After interviewing staff and residents, it was discovered that R1 and R2 were waiting in the hallway to go out for smoke break but staff did not witness the incident. R2's EMR included diagnoses of End Stage Renal Disease; Chronic Obstructive Pulmonary Disease; Major Depressive Disorder, Recurrent; Unspecified Bipolar Disorder, Schizoaffective Disorder unspecified R2's Admission MDS dated [DATE], showed that R2 was cognitively intact. R1's EMR (electronic medical records) included diagnoses of other Lack of Coordination; Hypothyroidism, Unspecified; Dementia In Other Diseases Classified Elsewhere, Moderate, With Other Behavioral Disturbance; Weakness; Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris. R1's quarterly MDS (minimum data set) dated April 14, 2025 showed that R1 was moderately impaired cognition. On May 1, 2025 at 10:20 AM, R2 stated that she doesn't remember the date or time of the incident. R2 continued We were lining up for smoke break. He (R1) came out of his room and came by me and said Hi and I said Hi. I have always said Hi (previously). This time he decided to touch me on my breast. He was just rubbing across. Then he decided that he was going to move his hand down below on my vagina through my clothes and I smacked is hand and said 'No.' He didn't stop. That was the end of it as they (staff) were to open the door, and he stopped as he didn't want to get caught. I went to V7 (Activity Aide), who opened the door and came to hand out the cigarettes. But she didn't see it. She told somebody who was over her about it and I guess they send him to the hospital for a while . On May 1, 2025 at 10:39 AM, V4 CNA (Certified Nursing Assistant) was seen seated outside R1's door and stated that R1 is on 1:1 monitoring since he got back from the hospital on April 19, 2025. V4 continued He has had two or three incidents of inappropriate touching of other residents. It was R5 and another resident who is no longer here. That resident did not report it until she was getting to leave at the door. I don't know if those incidents happened. He (R1) has been on 1:1 monitoring after each incident On May 1, 2025 at 11:36 AM, V1 stated that during investigation, R2 stated that while she was in line to go for cigarette break, R1 touched her breasts and tried to touch her vagina area and that she pushed his hand away. V1 stated that there were no more witnesses of the incident so it was not substantiated. V1 continued that R1 had had another allegation against him on November 15, 2024 alleging that he was touching another resident on the breasts which was witnessed by a Dietary staff. V1 added that this was investigated by IDPH and cited for the same. V1 stated that as a precautionary measure, R1 is placed on 1:1 monitoring until facility finds an alternate placement for him. 2. FRI (Facility Reported Incident) report included that R4 made physical contact with R3 on April 24, 2025. The facility concluded afrer interviewing staff and residents, that R3 wandered into R4's room and tried to remove some items from his table and R4 tried to stop her. The staff came into the room and removed R3 from the room. R3 and R4 were assessed and noted without pain or serious injury. R3 was noted to have a small skin alteration to her left eyebrow. R3's EMR included diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Generalized Anxiety Disorder. R3's quarterly MDS, dated [DATE], showed that R3 was severely impaired in cognition. R4's EMR included diagnoses of Hypothyroidism, Unspecified; essential (Primary) Hypertension; hyperlipidemia, Unspecified; weakness; dementia in Other Diseases Classified Elsewhere, Mild, With Mood Disturbance; and Anxiety Disorder, Unspecified. R4's quarterly MDS, dated [DATE], showed that R4 was severely impaired in cognition. On May 1, 2025 at 10:20 AM and 10:56 AM, R3 was seen wandering from hallway to hallway. R3 was also seen walking about during activities eating pudding from a disposable container and going from table trying to feed it to other residents or touching them and those residents appeared annoyed. V7 and V8 (both activity aides) stated that R3 is a wanderer. V7 and stated that R3 just walks around and tries to touch people. V8 stated that R3 touches people and some residents say, get away.' On May 1, 2015, at 11:04 AM, R4 was resting in bed and when asked, stated that no residents bothered him. V10 (LPN-Nurse) who was in the vicinity, stated that R4 is confused and not aware of any incidents with other residents. On May 1, 2025 at 12:45 PM, R10 stated that R4 is his roommate. [R4] and the other person [R3] who was a female were fighting. I was sleeping and woke up and he was hitting her. They were both down on the floor and were wrestling. He said that she took something of his, and he was trying to get it back. He hit her right by the eye. I went to get V4 (CNA) who was standing by the front desk as I did not want to get involved and everything. On May 1, 2025 at 11:46 AM, V1 stated that R3 had wandered into R4's room and was trying to get something from his over the bed table and he was trying to stop her from getting into his stuff. V1 stated that R4's roommate R10 woke up and ran to get help. V1 continued V4 (CNA) came in there and called for more help and another V5 (CNA) came and got V6 (Licensed Practical Nurse) for more help. V6 took R3 out of the room and assessed her. V4 did not take her out of the room earlier as she was on the floor and she did not want to move her. V6 did a head to toe assessment and R3 had a small scratch over her left eyebrow. R3 has severe Dementia and wanders a lot and means no harm and tends to tap people as she is walking On May 5, 2025, at 3:35 PM, V6 confirmed the above and stated that when she entered the room, R3 was sitting on the floor and R4 was on his bed. V6 stated that when she assessed R3 and observed a scratch on her eyebrow that was bleeding a little bit Facility provided other reportable's for R3 which showed R3's history of wandering and altercations. November 25, 2024: R3 wandered into the dining room and tried to touch things on R9's table and R10 tried to push her away. November 5, 2024 : R3 wandered into R8's room and touched her. September 30, 2024: R3 wandered in the hallway and touched R7. September 24, 2024: R3 wandered into R6's room and touched her. Facility policy and procedure titled Abuse Prevention Program (last revised January 1, 2019) included as follows: Policy: It is the policy of this facility to prohibit and prevent resident abuse. Abuse prevention program: As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches regularly .

Based on observation, interview, and record review, the facility failed to ensure that a resident was free from abuse for one of three residents (R3) reviewed for abuse in a sample of 3. This failure resulted in R3 being physically slapped by a staff member which caused R3 to experience emotional distress and led to R3 displaying increased agitation, aggression, and combative behavior. Findings include: R3's face sheet indicated that resident admitted to the facility on [DATE] and has a past medical history not limited to: cerebral infarction due to thrombosis, metabolic encephalopathy, bipolar disorder, personal history of physical injury and trauma, and tension-type headaches. R3's screening assessment for indicators of aggressive and/or harmful behavior dated 09/16/2024 revealed that R3 is at minimal risk for aggression with dementia, related interventions of re-orientation, re-assurance, emphasis on safety/security, and severe mental illness interventions of stress management/relief and harm reduction. Review of R3's active physician's orders summary on 01/21/2025 showed the following: divalproex sodium delayed release 125 milligram (mg), give 2 capsules by mouth three times a day for manic depression with start date of 10/11/2024; topiramate 50 mg tablet, give 1 tablet by mouth two times a day for bipolar disorder with start date of 10/24/2024; trazodone hcl 50 mg, give 1 tablet by mouth at bedtime for depression, insomnia. The facility's final report with incident date of 10/22/2025 indicated that the facility had conducted an investigation of physical contact made to R3 by staff member V3 (Certified Nursing Assistant). The facility substantiated the alleged act based on witness reports that revealed V3 (CNA) was observed striking R3 on the hand when R3 attempted to grab at V3's laptop. R3 responded by hitting V3 (CNA). Review of R3's Minimum Data Set (MDS) Section C - Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) score of 08/15 dated 12/11/2024 that indicated moderate cognitive impairment. On 01/21/2025 at 10:30 AM, R3 was observed in his wheelchair across from the 200 unit nurse's station. R3 appeared to be in a calm and pleasant mood and did not recall the physical abuse incident. On 01/21/2025 at 10:35 AM, V4 (Certified Nursing Assistant) said R3 can get agitated at times due to loudness or if someone bumps into him for example. V4 added that she has never seen R3 be aggressive with staff because his arms can be stiff, almost contracted at times. On 01/21/2025 at 12:06 PM, V1 (Administrator) said on the date of incident, V3was assigned to R3 for 1:1 monitoring and was told to take R3 into the dining room. While in the dining room, R3 was attempting to reach for V3's personal laptop that she should not have had with her at work. V3 was observed by staff members V5 (Restorative Nurse) and V7 (Activity Aide) slap R3's hand away then R3 punched V3 in the face. V1 (Administrator) then said that V3 was immediately removed from the dining room and suspended pending the outcome of her investigation. V1 added that she always tells staff they cannot hit a resident under any circumstances and that V3 should have called for assistance, attempted to redirect R3, and/or should have removed her laptop from R3's immediate area. V1 (Administrator) then said that V3 was terminated because the abuse allegation was substantiated. V1 added that R3 was not sent out to be evaluated. On 01/21/2025 during interview from 12: 28 PM to 12:40 PM, V5 said she was standing in the doorway of the main dining room and facing inside the room where she observed R3 sitting in the dining room at a table seated next to V3. V5 then said that she saw R3 was grabbing at V3's laptop then V3 had pushed R3's hand away, but R3 kept grabbing for the laptop. V5 then saw V3 slap R3's left hand with her right hand, and R3 immediately punched V3 in the face. V5 approached the table and informed V3 that V10 (Registered Nurse) would stay with R3. V5 then said that she escorted V3 to V2's (Director of Nursing) office and informed V2 of the incident. V5 added that R3 has a known behavior to get nervous and react when people don't explain things to him, approach him with a loud tone, or if they rush R3 to do tasks. V5 then said that V3's behavior was not appropriate because staff should not use physical methods to redirect a resident. V5 added that V3's slap triggered R3's aggression towards her. On 01/21/2025 at 12: 44 PM, V6 (Assistant Director of Nursing) said around 02:30 PM on day of incident, she was standing in the doorway of the dining room but was facing towards the hallway. V5was standing next to her facing inside the dining room when she heard a slap sound. V6 added that V5 then turned to her (V6) and said, did you see that, she just slapped him on the hand like he was a kindergartener. V6 then said after she heard the slap sound, she turned around and saw R3 hit V3 in the face. V6 approached V3 and told her to go to her office, then briefly assessed R3 for any apparent injuries before reporting the incident to V1 (Administrator). V6 added that if staff interact with R3 in an aggressive manner, he will become aggressive. Staff must talk to him in calm manner, then said R3's voice became louder after V3 slapped him. V6 also said that staff who are familiar with R3 are knowledgeable of this calm approach, and that V3 normally worked with him and knew about his temperament. On 01/21/2025 during interview from 1:01PM to 01:10 PM, V10 (Registered Nurse) said V3 was in the dining room with R3 on day of incident and he was R3's nurse. V10 said as he approached the dining room to relieve V3 for a meeting, he saw V5 and V6 standing in the doorway and heard V5 saying that V3 had hit R3. V10 then said he observed R3 beginning to calm down as V3 was being removed from the dining room. V10 added that R3 is much calmer now and has had no further issues since the incident. On 01/21/2025 at 01:25 PM, V3 said she was assigned to R3 for 1:1 monitoring. V3 said she took him into the dining room, put him up to a table, and had put the wheel locks on to the wheelchair, V3 then sat down next to him, but he kept trying to unlock the wheelchair and slapped at her hand when she tried to cover the wheelchair lock with her own hand. V3 then said R3 started digging his nails into her wrist, forearm, and right hand and then began digging harder so she slapped her own forearm to get R3 to understand that he was hurting her. V3 said R3 then punched her in the face with a closed fist. V3 added that R3 can have aggressive behaviors but she did not call out for assistance and knows that hitting residents isn't allowed. V3 then indicated that V13 and V7 were both present in the dining room and had both observed the incident then indicated that V13 no longer is employed at the facility. V3 then said she was told by V6 that there was an allegation of abuse by V3 towards R3, so she was walked out of the facility and then terminated on 10/29/2024 because the abuse allegation was substantiated. Review of V3's employee disciplinary action form dated 10/29/2024 revealed that V3 was terminated due to an allegation of physical abuse of physical abuse towards a resident was substantiated. Review of V13's (Certified Nursing Assistant) signed confidential witness statement dated 10/28/2024 revealed that V13 did not personally observe the incident between R3 and V3 (CNA). On 01/21/2025 at 2:09 PM, V7 said at about 03:00 PM on day of the incident, V3 was in the dining room with R3 and that he (V7) was nearby them and could see that V3 was trying to prevent R3 from standing up from his wheelchair. V7 then said after a few minutes, R3 was getting agitated, and it looked like he was scratching at V3's (CNA) arm when he then saw V3 slap R3's hand then R3 punched V3 in the face immediately afterwards. V7 added that after V3 was removed from the area, R3 then began to calm down. Review of undated employee roster on 01/21/2025 showed that V3 and V13 are not currently employed at the facility. Review of Abuse Prevention Program policy on 01/21/2025 that was last revised 01/2019 reads in part: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against in the facility. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party. Protection of Residents: the facility will take steps to prevent mistreatment while the investigation is underway. Residents and visitors are protected from any retaliation or possible harm. Staff members who are suspected of abuse or misconduct shall immediately (regardless of time left on shift) be barred from any further contact with residents of the facility and suspended from duty, pending the outcome of the investigation, prosecution or disciplinary action against the employee. Prevention: The facility desires to prevent abuse, neglect, misappropriation, and a crime against a resident by establishing a resident-sensitive and resident-secure environment. This will be accomplished by a comprehensive Quality Assurance Performance Improvement approach. Abuse and Crime Reporting: this facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends or other individuals. For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. 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. Physical Abuse: hitting slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. After notification of alleged abuse, neglect or a suspected crime against a resident, the administrator or DON in the administrator's absence shall immediately commence an investigation of the incident reported. The findings of such investigation will be provided to the administrator within 5 working days of the occurrence of such incidents. The administrator shall either rule-out or substantiate the allegation of abuse. The administrator or DON shall review the findings of the investigation and determine if further training or other corrective action is needed to prevent future occurrences.

Based on observation, interview, and record review, the facility failed to ensure a resident's Cosentyx was available for administration. This failure resulted in a resident experiencing a psoriasis flare-up. This applies to 1 of 4 residents (R1) reviewed for medications in a sample of 7. The findings include: R1's Face Sheet showed his diagnoses include psoriatic arthritis mutilans, generalized pustular psoriasis, and other psoriasis. On December 14, 2023 at 11:50 AM, R1 stated he had psoriasis and starting having skin issues when he was around [AGE] years old. R1 said he has been waiting on the pharmacy to receive his Cosentyx injections, stating he has not gotten it. R1 stated it works great when he received the starter doses. R1 stated if he does not get it, he turns out like I am now .with scales, itchy, and painful. R1 rated his pain at a 7 and stated he takes oxycodone for his pain. R1 denied he had any open skin areas and again described his skin as scaly, itchy, and painful. The skin on R1's face and hands was clear. R1's September 28, 2023 Minimum Data Set showed he is cognitively intact. On December 14, 2023 at 1:45 PM, V8 LPN (Licensed Practical Nurse- Wound Nurse) went with Surveyors to R1's room to visualize the skin on more areas of R1's body. R1 was in bed lying on his left side and he was under the covers. R1 wore a long-sleeved shirt and sweat pants. R1 lifted up his right sleeve, and the skin to R1's forearm was dry, thicker, cracked, scaly, and dusty white and it was dotted with tiny scabs. While still on his left side, R1 raised up his shirt; the skin on his back, sides, abdomen, and chest were 100% covered with either scaly skin, scabs, cracked skin, or superficial/raw open areas. The largest of the open areas was to R1's mid-back, which appeared to be approximately five inches long and around an inch wide. Two other open areas were present on his ride side, one approximately two inches long and the other around three inches long. R1 rolled over in the bed and an open area around three inches long was noted on his left side. R1's Active Physician Orders as of June 1, 2023 showed a Cosentyx loading dose order of 300 mg (milligrams) to be injected subcutaneously every Tuesday until June 13, 2023, and then a monthly dose of 300 mg injected monthly on the 13th every month thereafter. R1's Medication Administration Records (MAR) from June, July, August, September, October, November and December of 2023 showed to inject 300mg of Cosentyx on the 13th of each month. Instead of a check mark on the 13th for all seven months (indicating the medication was administered), 9 was written. The legend for Chart Codes on the MAR showed 9 means Other/See Nurse Notes. Nursing notes from June 13, 2023 showed a note written by V13 (LPN) at 5:51 PM given this AM [first name] LPN; from July 13, V12 RN (Registered Nurse) wrote medication on order; from August 13, V11 (LPN) wrote N/A, reordered. Notes were not present in R1's medical record regarding the lack of R1's Cosentyx administration for September 13 or October 13, 2023. For November 13, V10 (RN) wrote Med not available. Needs prior [authorization]. The December 13, 2023 nursing note regarding R1's Cosentyx medication on that day showed not available. On December 14, 2023 at 3:15 PM, V2 (Director of Nursing) stated R1's Primary Care Physician was not who prescribed R1's Cosentyx and it has to come from a specialty pharmacy. V2 stated it is R1's Dermatologist that prescribed Cosentyx and there needs to be a verification in place so R1's insurance would cover the medication so the specialty pharmacy will send it. On December 19, 2023 at 10:00 AM, V2 stated when she called the specialty pharmacy on December 18, 2023 (during the survey), she was told the pharmacy had been emailing with R1's Mother, so she called her. V2 stated she was hoping the facility could take over handling the Cosentyx verifications, and added if there was no break in medication administration, another verification would not be needed for a year. On December 14, 2023 at V16 (Pharmacy Technician at specialty pharmacy that dispenses Cosentyx) stated their records showed that four of the five weekly loading doses of R1's Cosentyx were dispensed on March 22, 2023. V16 stated their system can tell that additional Cosentyx doses were not ordered from anywhere else. R1's MDS history showed he was out of the facility two different times when his monthly April and May doses were due. On December 14, 2023 at 3:05 PM, V17 (Pharmacist at specialty pharmacy) stated generally it is best that a patient is adherent [to the dosing schedule] so there is no relapse. V17 added she could not say how soon symptoms would return if a dose was missed, and usually the prescribing physician will assess for the medication efficacy at three months. On December 19, 2023 at 12:20 PM, V20 (Assistant Director of Nursing) stated if a medication is not available, pharmacy and the physician should be notified. V20 stated nurses can find out of there is an alternative medication if a medication is not available. V20 stated if there is an issue with insurance, call the pharmacy and call the insurance and see what needs to be sent over. V20 stated this process should happen immediately and a progress note should be made. On December 19, 2023 at 10:25 AM, V9 (R1's Primary Physician) stated psoriasis must be controlled with medication, otherwise, it will flare up. V9 stated he has no control over insurance, but he expects the facility to follow up and try to get the medication. R1's psoriasis exacerbation care plan (revised 8/25/22) showed R1 has lesions to his entire body related to psoriasis exacerbation with a goal for psoriasis lesions to be healed by review date (target date of) 12/27/23. Interventions include Administer medication as ordered The facility's undated 5.2 Medication Administration policy showed Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. The facility's undated 2.6 Ordering Medications policy showed Policy: Medications and related products are ordered from (pharmacy name) on a timely basis .

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from neglect when a resident did not receive his psoriasis medication to prevent a psoriasis flare-up, and when the resident did not have weekly skin assessments to monitor his flare-up. These failures resulted in R1 experiencing a psoriasis flare-up, and then subsequently his skin lesions were not monitored. This applies to 1 of 7 residents reviewed for neglect in the the sample of 7. The findings include: 1. R1's Face Sheet showed his diagnoses include generalized pustular psoriasis, psoriatic arthritis mutilans, and unspecified psoriasis. On December 14, 2023 at 11:50 AM, R1 stated he had psoriasis and starting having skin issues when he was around [AGE] years old. R1 said he has been waiting on the pharmacy to receive his Cosentyx injections, stating he has not gotten it. R1 stated it works great. R1 stated if he does not get it, he turns out like I am now .with scales, itchy, and painful. R1 rated his pain at a 7 and stated he takes oxycodone for his pain. R1 denied he had any open skin areas and described his skin as scaly, itchy, and painful. The skin on R1's face and hands was clear. R1's September 28, 2023 Minimum Data Set showed he is cognitively intact. On December 14, 2023 at 1:45 PM, V8 LPN (Licensed Practical Nurse- Wound Nurse) went with Surveyors to R1's room to visualize the skin on more areas of R1's body. R1 was in bed lying on his left side and he was under the covers. R1 wore a long-sleeved shirt and sweatpants. R1 pulled up his right sleeve, and the skin to R1's forearm was dry, thicker, cracked, scaly, and dusty white, and it was dotted with tiny scabs. While still on his left side, R1 raised up his shirt; the skin on his back, sides, abdomen, and chest were 100% covered with either scaly skin, scabs, cracked skin, or superficial/raw open areas. The largest of the open areas was to R1's mid-back, which appeared to be approximately five inches long and around an inch wide. Two other open areas were present on his ride side, one approximately two inches long and the other around three inches long. R1 rolled over in the bed and an open area around three inches long was noted on his left side. R1's Active Physician Orders as of June 1, 2023 showed a Cosentyx injection was to be administered on the 13th of every month after the starter doses. R1's Medication Administration Records for June through December 2023 show that no Cosentyx was administered because it was not available. On December 19, 2023 at 10:25 AM, V9 (R1's Primary Physician) stated psoriasis must be controlled with medication, otherwise, it will flare up. V9 stated he has no control over insurance, but he expects the facility to follow up and try to get the medication. The facility's undated 5.2 Medication Administration policy showed Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. The facility's undated 2.6 Ordering Medications policy showed Policy: Medications and related products are ordered from (pharmacy name) on a timely basis . 2. On December 14, 2023 at 1:05 PM, the last weekly skin check noted in R1's Electronic Medical Record (EMR) was dated and signed September 14, 2023, which showed R1 had loss of skin integrity that was not new. Under Ulcers, Wounds, and Skin Problems on R1's September 28, 2023 Minimum Data Set (two weeks later), it showed None of the above were present. R1's November 2, 2023 Physician Progress Note showed R1 had a rash under his Review of Systems and Physical Exam. The Assessment area in the Note showed extensive psoriasis improving psoriatic erythroderma . The same language was used in R1's December 7, 2023 Physician Progress note. R1's October 19, 2023 Weekly Wound Evaluation showed R1 has chronic psoriasis, and showed an unhealed wound was identified on August 22, 2022. Regarding the peri-wound, the Evaluation showed wound margins are defined, the surrounding tissue texture is dry and scaly, with dry, cracked, and fissured skin. The October 19, 2023 note was signed on December 15, 2023 (during the survey). On December 19, 2023 at 2:15 PM, V2 DON (Director of Nursing) stated floor nurses or the wound nurse complete the skin assessments. V2 stated the assessment pops in the computer for the nurse to complete and then they can fill the form. On December 14, 2023 at 12:50 PM, V8 LPN (Licensed Practical Nurse- Wound Nurse) stated she only treats actual wounds and the floor nurses are supposed to do the ointments and powders. At 1:55 PM, V8 LPN stated she has not done any skin assessments and does wounds. V8 was asked for a copy of R1's last skin assessment, which was completed on September 14, 2023. On December 19, 2023 at 10:30 AM, R1's EMR was reviewed again for assessments. Weekly Skin Assessments were present for September 21st and 28th, 2023; October 5th, 12th, 19th, and 26th, 2023; November 9th, 16th, 23rd, 30th, 2023; and December 7th, and 14th, 2023. All said R1 did not have a loss of skin integrity-including the one dated as completed on December 14, 2023- and all assessments were signed between 1:50 PM and 2:20 PM on December 15, 2023. The Purpose of the facility's undated Skin Integrity Guideline showed To provide a comprehensive approach for monitoring skin conditions, and To promote healing of wounds of any etiology . Objectives include Provide a guideline for optimal care to promote healing to patients/residents with all identified alterations in skin integrity (i.e. surgical incisions, skin tears, bruising, etc.) . The General Guidelines section showed .develops a routine schedule to review patients/residents with wounds or at risk on a weekly basis and will document findings .Wound status is monitored on a weekly basis . Under Documentation and Care Interventions for Skin Integrity it showed Patients/Residents will be observed by CNA daily for reddened/open areas .Changes will be reported to the licensed nurse and documented . The Documentation of Weekly Skin Evaluation/Observations section showed Licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly Skin Review ., and Licensed nurse to document weekly on identified wounds using the 'Wound Evaluation Flow Sheet' . The facility's Abuse Prevention Program (revised 01/2019) showed Policy- It is the policy of this facility to prohibit and prevent resident neglect . The Program continued to show definitions, as 8. Neglect/Mistreatment: means the failure to provide .adequate medical care .that is necessary to avoid physical harm, mental anguish .

Based on interview, and record review, the facility failed to monitor physician ordered [MEDICATION NAME] levels after every third dose and then failed to hold [MEDICATION NAME] doses after levels were elevated. This failure resulted in R1 being hospitalized with Acute Kidney Injury secondary to [MEDICATION NAME] toxicity and requiring [MEDICAL TREATMENT]. This applies to 1 of 3 residents (R1) reviewed for antibiotic use in a sample of 9. Findings include: R1's Physician Wound Note dated 9/6/19 documents R1 with [MEDICAL CONDITION] with severe debility and multiple ulcers with [MEDICAL CONDITION] to the left buttock and hip. This same note documents to start intravenous (IV) [MEDICATION NAME] 1 Gram (gm) every 8 hours. R1's Order Recap Report dated 9/6/19 through 10/1/19 documents an order on 9/6/19 to complete a [MEDICATION NAME] levels every third dose. This order also documents to hold [MEDICATION NAME] from 9/12/19 at 6:22 AM through 9/13/19 at 6:21 AM. In addition, further orders document to hold [MEDICATION NAME] 9/13/19 beginning at 2:35 PM through 9/18/19. R1's (MONTH) 2019 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. R1 then received [MEDICATION NAME] again 9/12/19 at 2 PM, 10 PM and 9/13/19 at 6 AM. All other doses of R1's [MEDICATION NAME] are documented as held beginning 9/13/19 at 10 PM. R1's first Laboratory Report documents a [MEDICATION NAME] level completed on 9/11/19 (resulted) at 7:55 PM at which time the level is documented as critically high at 65.6 (normal range 10-20). R1's Laboratory Report documents a [MEDICATION NAME] level completed on 9/13/19 at which time the level is documented as critically high at 64.5 (normal 10-20). In addition, R1's Blood Urea Nitrogen (BUN) is documented as 184 (normal range 5-28) and creatinine is 9.7 (normal 0.6-1.2). On 10/2/19 at 2:23 PM V3 (Assistant Director of Nursing) confirmed the first [MEDICATION NAME] level was completed late on 9/11/19. V3 stated the [MEDICATION NAME] level was to be completed every 3rd dose throughout receipt of [MEDICATION NAME]. V3 stated R1 was sent to the hospital on [DATE] due to abnormal lab values including the elevated [MEDICATION NAME] level. On 10/2/19 at 1:40 PM V9 (Pharmacist) stated [MEDICATION NAME] is metabolized by the kidneys and monitoring of [MEDICATION NAME] includes [MEDICATION NAME] levels and BUN and creatinine levels per physician discretion. V9 stated elevated [MEDICATION NAME] levels can cause kidney damage. V9 stated on 9/12/19 the Pharmacy seen R1's elevated [MEDICATION NAME] level from 9/11/19 and contacted V4 (Medical Director) who ordered to hold the [MEDICATION NAME] and repeat a [MEDICATION NAME] level on 9/13/19 at 1 PM. On 10/3/19 at 12:50 PM V6 stated he was unaware of R1's critically high [MEDICATION NAME] levels and the protocol for elevated levels is to hold the [MEDICATION NAME]. V6 stated he expected the [MEDICATION NAME] level to be kept in therapeutic ranges. V5's (Nephrologist) hospital Nephrology Progress Note dated 9/19/19 documents R1 with Acute Kidney Injury with [MEDICAL CONDITION]ly secondary to [MEDICATION NAME] toxicity. On 10/3/19 at 9:30 AM, V5 confirmed R1 was hospitalized with Acute Kidney Injury secondary to [MEDICATION NAME] toxicity. V5 stated if a [MEDICATION NAME] level is 20-25 it should be held until it comes down to normal range and then re-dose it. V5 stated R1 already had [MEDICAL CONDITION] stage 3 prior to receipt of [MEDICATION NAME]. V5 stated as a result of the toxic [MEDICATION NAME] level she was hospitalized and is now receiving [MEDICAL TREATMENT], at least temporarily, due to the kidney injury. V5 stated he is not sure if the damage to her kidneys is permanent. V5 further stated, he is 100% positive if R1's [MEDICATION NAME] was monitored and dosed correctly R1 would not have needed [MEDICAL TREATMENT].

Based on interview, and record review, the facility failed to make timely notifications to the physician of critical lab values which delayed hospitalization . This failure resulted in R1 being hospitalized with Acute Kidney Injury secondary to [MEDICATION NAME] toxicity and requiring [MEDICAL TREATMENT]. This applies to 1 of 3 residents (R1) reviewed for change in condition notifications in a sample of 9. Findings include: R1 's Physician Wound Note, completed by V6 (Wound Physician), dated 9/6/19 documents R1 with [MEDICAL CONDITION] with severe debility and multiple ulcers with [MEDICAL CONDITION] to the left buttock and hip. This same note documents to start intravenous (IV) [MEDICATION NAME] 1 Gram (gm) every 8 hours. R1's Order Recap Report dated 9/6/19 through 10/1/19 documents an order on 9/6/19 to complete a [MEDICATION NAME] levels every third dose. R1 's Laboratory Report documents a [MEDICATION NAME] level completed on 9/11/19 as critically high at 65.6 (normal range 10-20). This same report also documents this high level was called to the facility to V14 (Nurse) on 9/11/19 at 23:57 PM. R 1 's Laboratory Report dated 9/13/19 documents critically high values as follows; [MEDICATION NAME] level of 64.5 (normal 10-20), a Blood Urea Nitrogen (BUN) of 184 (normal range 5-28), and creatinine of 9.7 (normal 0.6-1.2). This same report also documents these high levels were called to the facility to V15 (Nurse) on 9/14/19 at 2:50 AM. On 10/2/19 at 2:23 PM V3 (Assistant Director of Nursing) stated once the facility became aware of the critically high lab values the physician should have been notified. V3 confirmed the facility did not notify the physician timely. V3 stated R1 was sent to the hospital on [DATE] due to abnormal lab values from 9/13/19 when V3 contacted V16 (Physician). On 10/3/19 at 12:50 PM V6 stated he was unaware of R1's critically high lab values from 9/13/19 and if he was notified R 1 would have been sent to the hospital for evaluation. V6 stated lack of notification delayed hospitalization and treatment for [REDACTED]. V5's (Nephrologisl) hospital Nephrology Progress Note dated 9/19/19 documents R1 with Acute Kidney Injury with [MEDICAL CONDITION]ly secondary to [MEDICATION NAME] toxicity. On 10/3/19 at 9:30 AM, V5 confirmed R1 was hospitalized with Acute Kidney Injury secondary to [MEDICATION NAME] toxicity. V5 stated if a [MEDICATION NAME] level is 20-25 it should be held until it comes down to normal range and then re-dose it. V5 stated R1 already had [MEDICAL CONDITION] stage 3 prior to receipt of [MEDICATION NAME]. V5 stated as a result of the toxic [MEDICATION NAME] level she was hospitalized and is now receiving [MEDICAL TREATMENT] due to the kidney injury. V5 stated he is not sure if the damage to her kidneys is permanent. VS further stated, he is 100% positive if R1's [MEDICATION NAME] was monitored and dosed correctly R1 would not have needed [MEDICAL TREATMENT].

Based on interview and record review the facility failed to make timely notifications to the physician of critical lab values. This failure resulted in R1 being hospitalized with Acute Kidney Injury secondary to [MEDICATION NAME] toxicity and requiring [MEDICAL TREATMENT]. This applies to 1 of 3 residents (R1) reviewed for change in condition notifications in a sample of 9. Findings include: R1's Physician Wound Note, completed by V6 (Wound Physician), dated 9/6/19 documents R1 with [MEDICAL CONDITION] with severe debility and multiple ulcers with [MEDICAL CONDITION] to the left buttock and hip. This same note documents to start intravenous (IV) [MEDICATION NAME] 1 Gram (gm) every 8 hours. R1's Order Recap Report dated 9/6/19 through 10/1/19 documents an order on 9/6/19 to complete a [MEDICATION NAME] levels every third dose. R1's Laboratory Report documents a [MEDICATION NAME] level completed on 9/11/19 as critically high at 65.6 (normal range 10-20). This same report also documents this high level was called to the facility to V14 (Nurse) on 9/11/19 at 23:57 PM. R1's Laboratory Report dated 9/13/19 documents critically high values as follows; [MEDICATION NAME] level of 64.5 (normal 10-20), a Blood Urea Nitrogen (BUN) of 184 (normal range 5-28), and creatinine of 9.7 (normal 0.6-1.2). This same report also documents these high levels were called to the facility to V15 (Nurse) on 9/14/19 at 2:50 AM. On 10/2/19 at 2:23 PM V3 (Assistant Director of Nursing) stated once the facility became aware of the critically high lab values the physician should have been notified. V3 confirmed the facility did not notify the physician timely and there is no evidence any physician was contacted by V14 or V15. V3 stated R1 was sent to the hospital on [DATE] due to abnormal lab values from 9/13/19 when V3 contacted V16 (Physician). On 10/3/19 at 12:50 PM V6 stated he was unaware of R1's critically high lab values from 9/13/19 and if he was notified R1 would have been sent to the hospital for evaluation. V6 stated lack of notification delayed hospitalization and treatment for [REDACTED]. V5's (Nephrologist) hospital Nephrology Progress Note dated 9/19/19 documents R1 with Acute Kidney Injury with [MEDICAL CONDITION]ly secondary to [MEDICATION NAME] toxicity. On 10/3/19 at 9:30 AM, V5 confirmed R1 was hospitalized with Acute Kidney Injury secondary to [MEDICATION NAME] toxicity. V5 stated if a [MEDICATION NAME] level is 20-25 it should be held until it comes down to normal range and then re-dose it. V5 stated R1 already had [MEDICAL CONDITION] stage 3 prior to receipt of [MEDICATION NAME]. V5 stated as a result of the toxic [MEDICATION NAME] level she was hospitalized and is now receiving [MEDICAL TREATMENT] due to the kidney injury. V5 stated he is not sure if the damage to her kidneys is permanent. V5 further stated, he is 100% positive if R1's [MEDICATION NAME] was monitored and dosed correctly R1 would not have needed [MEDICAL TREATMENT].

Based on interview, and record review, the facility failed to follow the physician's orders and hold an intravenous (IV)[MEDICATION NAME] when blood levels were elevated resulting in a significant medication error. This failure resulted in R1 being hospitalized with Acute Kidney Injury secondary to [MEDICATION NAME] toxicity and requiring [MEDICAL TREATMENT]. This applies to 1 of 3 residents (R1) reviewed for antibiotic use in a sample of 9. Findings include: R1's Physician Wound Note completed by V6 (Wound Physician), dated 9/6/19, documents R1 with [MEDICAL CONDITION] stage 3 with severe debility and multiple ulcers with [MEDICAL CONDITION] left buttock and hip. This note documents to start intravenous (IV) [MEDICATION NAME] 1 Gram (gm) every 8 hours. R1's (MONTH) 2019 Medication Administration Record [REDACTED]. This same MAR indicated [REDACTED]. R1 then received [MEDICATION NAME] again 9/12/19 at 2 PM, 10 PM and 9/13/19 at 6 AM. All other doses of R1's [MEDICATION NAME] are documented as held beginning 9/13/19 at 10 PM. R1's Order Recap Report documents to hold R1's [MEDICATION NAME] from 9/12/19 at 6:22 AM through 9/13/19 at 6:21 AM. In addition, further orders document to hold [MEDICATION NAME] 9/13/19 beginning at 2:35 PM through 9/18/19. R1's Laboratory Report dated 9/11/19 documents a [MEDICATION NAME] level as critically high at 65.6 (normal range 10-20). R1's Laboratory Report dated 9/13/19 documents a [MEDICATION NAME] level as critically high at 64.5 (normal 10-20). On 10/2/19 at 1:40 PM V9 (Pharmacist) stated on 9/12/19 the Pharmacy seen R1's elevated [MEDICATION NAME] trough level from 9/11/19 and contacted V4 (Medical Director) who ordered to hold R1's [MEDICATION NAME]. On 10/2/19 at 2:23 PM V3 (Assistant Director of Nursing) stated R1 was sent to the hospital on [DATE] due to abnormal lab values including the elevated [MEDICATION NAME] trough level. On 10/3/19 at 12:50 PM V6 (Wound Physician) stated he was unaware of R1's critically high [MEDICATION NAME] levels and the protocol for elevated levels is to hold the [MEDICATION NAME]. V6 stated he expected the [MEDICATION NAME] level to be kept in therapeutic ranges. V5's (Nephrologist) hospital Nephrology Progress Note dated 9/19/19 documents R1 with Acute Kidney Injury with [MEDICAL CONDITION]ly secondary to [MEDICATION NAME] toxicity. On 10/3/19 at 9:30 AM, V5 confirmed R1 was hospitalized with Acute Kidney Injury secondary to [MEDICATION NAME] toxicity. V5 stated if a [MEDICATION NAME] level is elevated it should be held until it comes down to normal range and then re-dose it. V5 stated R1 already had [MEDICAL CONDITION] state 3 prior to receipt of [MEDICATION NAME]. V5 stated as a result of the toxic [MEDICATION NAME] level she was hospitalized and is now receiving [MEDICAL TREATMENT], at least temporarily, due to the kidney injury. V5 stated he is not sure if the damage to her kidneys is permanent. V5 further stated, he is 100% positive if R1's [MEDICATION NAME] was monitored and dosed correctly R1 would not have needed [MEDICAL TREATMENT].

Based on interview and record review the facility failed to ensure the safe transfer of a resident (R1) from his bed to the wheelchair resulting in a laceration to the forehead requiring 2 sutures. This applies to one of three residents (R1)reviewed for fall precautions/transfers in the sample of three. The findings include: According to the POS (physician's orders [REDACTED]. According to the Quarterly Restorative Nursing Review in the record dated 05/02/14 R1 requires extensive assistance (2+ persons physical assist) to transfer. R1's care plan updated quarterly including the dates of 05/05/14 and 07/23/14 notes R1 was assessed for his transfer needs and continues to require the following support: total dependence (full staff support). R1's care plan also denotes the requirement of a Mechanical Lift. According to an incident report of 07/16/14 while being transferred by E2, CNA (Certified Nurses Aide) R1 hit his head sustaining a laceration. R1 was transferred to the local hospital where he received 2 sutures to the forehead. On 11/06/14 E2 stated she was getting R1 up from the bed to the wheelchair for breakfast on 07/16/14. They are supposed to use the full mechanical lift but the batteries needed charging. They are supposed to have 2 people to transfer him so she went to find another CNA in the hallway, but no one was out there. She went and got the sit to stand lift because he was agitated and trying to stand up. The PT person who was working with R1's roommate came and helped. R1 leaned forward and hit his head on the lift before they got him seated. She said she should have waited until she had another person to help before she tried to transfer him. She was suspended for 2 days after this happened and was re-inserviced afterwards. E3, PT (Physical Therapy) stated during interview on 11/06/14 she was working with R1's roommate on 07/16/14. E3 said, she saw the CNA was working with R1 and he was very anxious, and thought she would help the CNA, R1 kept struggling, he was wearing a strap for the sit to stand lift but no gait belt. She has had him for therapy in the past. They are supposed to use a full mechanical lift. He is heavy and leans forward. She don't know exactly how he hit his head. She just saw the blood.

Based on interview and record review the facility failed to keep resident bathrooms free of personal care equipment when not in use, as a result one resident, R2 tripped over a toilet seat riser, fell and sustained a fracture. This applies to one resident (R2) out of four sampled residents reviewed for fall incidents. The findings include: R2 was admitted to the facility 5/3/13. The admitting [DIAGNOSES REDACTED]. R1 was to receive rehabilitation to strengthen her ability to ambulate and return home. On 10/15/14 at 10:00am R2 was sitting in a wheelchair in her room. R2 had a black immobilizer boot device applied to the left leg. " I broke my leg. I am doing much better now after three surgeries. Looks like I will get to go home soon " . R2 explained that when she first came here she was in a different wing of the facility. R2 explained that she had a roommate R1 who needed a " riser " (a device that increases the height of the toilet) on the toilet. R2 said that she is only four feet 10 inches tall. R2 explained that she asked E3 (Registered Nurse) to have the device removed as she could not get it off the toilet and it was too high for her to get on without falling. R2 said that E3 was not able to get the device off either and would let maintenance know that it needed to come off. R2 said that no one ever came to take it off. R2 stated that a few days later, " I tripped over the legs of the riser and fell all the way down on the floor with my walker. I broke my ankle and needed to have surgery. They had to put hardware in my ankle. The wound from the hardware got infected and I had to have surgery two more times after that. I was on intravenous antibiotics for at least eight weeks. Sometimes I felt sick and warm. I told the nurses but no one ever even took my temperature " . R2 ' s clinical record showed that on 4/5/14 R2 fell in the bathroom. The incident report for 4/5/14 at 10:15 am showed that R1 was found on the floor of the bathroom and that the left ankle was abnormally positioned and protruding sideways. The Initial Fall Investigation for this fall showed that R2 stated that she tripped over the commode on the toilet with her walker. On 10/1614 at 11:10am E3 via telephone said that she had no recall of whose toilet riser it was and if R2 needed to have it. E3 could only recall that R2 ' s ankle was visibly deformed and needed immediate medical attention. Documents from the community hospital dated 4/5/14 showed that R2 had a left trimalleolar fracture requiring surgical intervention. On 10/15/14 E6 Registered Nurse presented a written statement showing that she was the manager on duty when R2 fell . E6 stated that R2 was observed on the floor outside the bathroom door. R2 told E6 that she had to move the raised toilet seat to use the toilet. After R2 was done she went to move the seat back and got the device caught on her foot causing her to fall.

Based on observation, interview, review of the facility's policy and record review the facility failed to follow it's policy use of mechanical lifts and failed to follow it's care plan for the safe transfer of residents. This applies to 2 of 5 residents (R1 and R2) reviewed for fall precautions in the sample of 9. Findings include: On 12/10/14 during the facility tour, R1 and R2 were observed during staff use of mechanical lifts. 1). R1 was observed 12/10/14 at 11:30 AM as E3 and E4 (CNA) used a mechanical lift to raise the resident from a sitting position to a standing position out of the wheelchair. E3 and E4 failed to lock the wheels of the wheelchair prior to lifting the resident up from the wheelchair. While being lifted, R 1 stated "Ow that hurt". Neither E3 nor E4 stopped the transfer to determine the cause of the resident's pain. In the bathroom E3 and E4 were observed to have difficulty maneuvering the legs of the mechanical machine to the toilet for placement of R1 onto the toilet. Staff did not remove the wastebasket in the corner which would have allowed more room to move the lift. During the positioning of R1 over the toilet, the resident repeatedly said "Ow" and said that his left leg hurt. His left leg was between the toilet and the wall. Staff continued to try to place the resident onto the toilet. After being placed onto the toilet, E3 and E4 left the transfer sling which was bunched up around the upper back on R1. R1 was observed leaning to his right with his head leaning against the paper towel holder. R1 also repeatedly stated "Ow my left arm" without staff intervening; his left arm was hanging down over the sling. While R1 was on the toilet, staff left him in the bathroom alone, with the door closed without supervision or visual control. After cleaning the resident E3 and E4 took him out of bathroom into his room used the mechanical standing lift to take R1 into his room. When E3 saw that additional cleaning was needed, E4 left E3 alone in the room with R1 positioned "standing" in the machine. E3 then wheeled R1 back into the bathroom alone and in the process hit the resident's left elbow against the door jamb causing him to say "Ow you hit my arm". When asked, R1 stated that he could only use his left side and arm "a little bit". Review of R1's record showed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. His current Minimum Data Set (MDS), dated [DATE] showed that he requires extensive assistance of two or more persons with transfers, dressing, and hygiene. The resident was also assessed as only able to stabilize himself with staff assistance when moving on/off toilets, in surface to surface transfers. R1's Transfer and Bed Mobility/ Limited Lift Review, dated 12/3/14 assessed the resident as totally dependent on transfers with a poor ability to sit up unassisted and with a poor ability to maintain sitting and standing balance and maintaining standing balance and unable to bear weight on his left and right lower extremities. Section E of the same form documented R1 had a CVA with a history of left [DIAGNOSES REDACTED] with some loss of sensation to his left extremities. R1's current care plan addressed his poor trunk balance, poor weight bearing and his tendency to lean to the side increasing his risk for falls. Staff approaches included instructions to use "sit to stand" with assist of two with all transfers for safety and to apply brakes on the wheel chair prior to all transfers in and out of chair. 2). R2 was observed at 11:45 AM as he laid on a full body sling while partially reclined in an adult mobile reclining chair. During interview R2 was observed with his upper body leaning to the left and his head leaning to the far left; the resident stated that he was uncomfortable and would like to be repositioned. E5 and E6 (Certified Nursing Assistants/CNAs) approached with a mechanical lift which they used to reposition the resident. E5 and E6 failed to lock the wheels of R2's reclining chair before using the mechanical lift to reposition the resident. Additionally, E3 (CNA) who was present, informed E5 and E6 that they had not applied the loops of the harness slings properly to the hooks of the lift and showed them how they should have been placed. Review of the facility's Sit to Stand Lift policy instructs staff to make sure to apply the brakes on the mobile chair before lifting or lowering residents. On 12/11/14 at 12:30 PM E2 (Director of Nurses/DON) stated that the Limited Lift policy covers both mechanical lifts and those that position residents from sitting to standing. E2 also stated that there are to be 2 staff present when using the lifts ,that slings should be removed during care and that residents should never be left alone when the lifts are being used.

Based on record review and interview the facility failed to: - Manage a resident (R1) with gastrostomy tube (GT) to prevent complications from dislodgement of GT. - Develop and implement GT care and interventions individualized and specific to R1's functional status. - Have effective policy and procedure for the management of GT. As a result: R1's GT came out three times ([DATE], [DATE] and [DATE]). On [DATE] the facility sent R1 to Hospital for elevation in temperature 102.2 degrees Farenheit. On [DATE] R1 expired in the Hospital due to Septic Shock, Peritonitis and Fever. This is for one of three residents (R1) in the sample of 13 residents in the facility with GT. Findings include: R1's admission record indicated he had multiple [DIAGNOSES REDACTED]. The following entries were made in R1's Nurses Notes: On [DATE] R1 had a new GT put in due to Failure to Thrive, Severe Anorexia, Dementia with behaviors and status [REDACTED]. On [DATE] GT came out, E5, a Licensed Practical Nurse (LPN) sent R1 to Hospital for GT re-insertion per physician order. There was no documentation between [DATE] and [DATE] to reflect the patency of the GT. On [DATE] GT came out, E5, LPN re-inserted GT per physician's (Z1) order but, unable to hear air rush after she re-inserted the GT. E5 sent R1 to Hospital per Z1's order. Again there was no documentation to reflect the patency of R1's GT between [DATE] and [DATE]. On [DATE] GT came out during care. E8, night shift LPN re-inserted a 16 FR urinary catheter and endorsed to the day shift nurse, but reported wrong residents's name. The facility discharged E8 for sleeping on the job and poor quality of work. E9 the day shift LPN found R1 had urinary catheter in place of GT when she went to administer medications. E9 then removed the urinary catheter and inserted a GT. At 10:30 pm R1 developed heavy breathing, no blood pressure felt, temperature 102.2 degrees Farenheit. The facility sent R1 to Hospital emergency room , admitted to Intensive Care Unit. At the hospital R1's abdomen CT Scan noted the GT was positioned in extra [MEDICAL CONDITION] space. There was free air and fluid noted in his abdomen. On [DATE] at 6:55 am R1 expired due to septic shock, peritonitis and fever. All three times when R1's GT came out, there was no documentation to indicate what time and why the GT tube came out, how long it took for its re-insertion, what time R1 went to the hospital, what time R1 returned to the facility or whether any one checked for its placement after R1 returned to the facility. On [DATE] reviewed facility policy and procedure for GT insertion. The policy and procedure prior to [DATE] noted if a similar GT does not slide easily into the tract or can not be located a 16 FR urinary catheter may be used to maintain the sinus tract until a more permanent tube can be inserted. On [DATE] the facility revised the policy and procedure not to use urinary catheter. The policy and procedure also does not have guidelines: (1)When to replace or change GT; (2) How and when to examine GT; (3) Instances when a GT can be replaced within the facility and by whom; (4) When GT be replaced in another setting. On [DATE] at 3:40 pm E5 stated on [DATE] there was a different physician. He always sends residents for re-inserting the GT when it comes out. On [DATE] it was different physician (Z1). He orders the nurses to re-insert the GT. On [DATE] when she re-inserted the GT for R1 she could not hear air rush. Z1 then ordered to send R1 to hospital. On [DATE] when R1 returned from the hospital, E5 stated did not hear air rush which was verified by another LPN. E5 then contacted the hospital again, but the hospital told E5 R1's GT was in place and E5 did a good job re-inserting the GT. There was no documentation to reflect the hospital staff phone interview, or E5 not being able to hear air flush when R1 returned from the Hospital. E5 stated she did not document or informed any of her supervisors. When the facility sent R1 to the hospital on [DATE], GT proper placement was not confirmed with [MEDICATION NAME] of stomach to ensure good infusion. The facility obtained this information from the hospital on [DATE] when the surveyor questioned E2. On [DATE] at 12:50 pm E9, LPN stated on [DATE] morning shift she got report from the night LPN (E8) stating she put in a 16 FR urinary catheter for R4 and she did not mention any thing to E9 about R1's GT. E9 when caring for R1, E9 found out R1 had a 16 FR urinary catheter and not R4. E9 then called R1's doctor (Z1) and re-inserted a GT per Z1's order. E9 did not find any notation in R1's chart indicating E8 notified Z1 of inserting a 16 FR urinary catheter. E9 continued to say on [DATE] at 11:00 am she checked R1's GT placement by pushing air, turned on tube feeing at 2:00 pm. E9 also stated she understood from the evening nurse R1 developed a temperature of 102.2 degrees Farenheit, no blood pressure and had abdominal breathing. E9 stated she became aware when R1 went to the hospital the GT was not in place and R1 expired from septic shock. E9 concluded if she was to go back to the situation she would send R1 to hospital and not re-insert the GT her self. On [DATE] at 2:55 pm E4, a Certified Nurse Aide (CNA) stated she was involved with two incidents ([DATE] and [DATE]) with R1. E4 stated both times R1 was restless and had shakes in his arms. When the staff goes to him to change, he wiggles his hands. The tubing got wrapped around his fingers and hands. When turned over he held on to the tube and tube got out. E4 stated she has been CNA in the facility close to an year, but has been CNA for seven year. E4 also stated she only got three days of orientation when the facility hired her and does not remember what she had during that time. E4 also stated she should have been more care full with R1, knowing he has contractures and wiggles. The facility documented all the three incidents of dislodgement of R1's GT. All three occasions the GT came out when CNAs providing care. R1 had a care plan for the maintenance of nutritional approaches for GT which he had for significant weight loss, poor appetite and failure to thrive. This care plan was developed on [DATE] and revised on [DATE]. The care plan interventions are the same for both care plans. The care plan do not address (1) when to replace or change GT; (2) how and when to examine GT; (3) instances when a GT can be replaced within the facility and by whom; (4) when GT be replaced in another setting. The interventions also did not include approaches to deal with his contractures, and wiggling of his fingers and hands. When the facility sent R1 to the hospital on [DATE] the hospital discharge instructions noted under tips: 'be sure to kink the tubing before removing the cap or disconnecting a syringe to prevent back flow. If a balloon catheter type tube, check for level of tube placement every day. If the length of the tube seems less than normal, call care giver." These tips / instructions were not included in the GT plan of care for R1. On [DATE] E2, the Director of Nurses confirmed the care plan interventions are not specific and did not include tips from the [DATE] hospital discharge instructions. E2 was not aware there were tips noted in the discharge instructions. On [DATE] at 12:35 pm Z1 stated on [DATE] night he did not get a call from the nurse or inserting a 16 FR urinary catheter in place of R1's GT, he only came when the day shift nurse called him. Z1 stated when the nurses call him, he question them if they are proficient to re-insert the GT. If the nurse says they are proficient in re-inserting the GT, he would authorize them to re-insert, if not he sends resident to hospital for re-insertion. In case of R1, he authorized to re-insert GT when she stated she is proficient in re-inserting the GT and expected to be 100% correct. Z1 stated he could not explain why R1's GT was in extra [MEDICAL CONDITION] space, having peritonitis or going into Septic Shock and dying.