Every finding on record at Park Ridge Healthcare Center

Based on interview and record review, the facility failed to follow their dining room standards in assigning a staff member to monitor and supervise residents in the dining room after mealtime. This failure resulted in one (R2) of four residents reviewed for residents' safety in the dining room. Findings include: R2 is a [AGE] year-old male admitted to the facility on [DATE] with a brief interview of mental status score of 99 upon admission. Review of R2 nurses note indicated that V5 (RN) witnessed R1 leaning forward in his BRODA (Geriatric/positioning) wheelchair and to his right side and fell off the wheelchair and onto the floor on 7/18/2026 at 1:35 PM. Review of R1's fall risk analysis indicated that behavior symptoms such as jumpy and a history of seizure might have contributed to R1's fall. The analysis also indicates that the facility intervention is to provide behavior monitoring to address R1's behavior symptoms. Based on staff interviews, no staff member was monitoring R1 at the time of his fall.On 8/4/2026 at 11:54 AM, V4 (Restorative CNA) that he has taken care of R2 before. V4 said , R2 is non-verbal. V4 said , R2 fell on her day off. V4 said he worked the following day. V4 said, the report was that R2 fell out of his BRODA (Geriatric/positioning) wheelchair. V4 said, R2 has a behavior of moving around in the wheelchair, side to side and forward that might cause him to slide/fell off from the wheelchair. V4 said, the staff are doing close monitoring of R2 while sitting in his wheelchair. V4 said , a staff member should have been in the dining room to monitor the residents.On 8/4/2026 at 12:27 PM, V5 (LPN) said, she was assigned to R2 on July 18th, the day she fell out of his BRODA ( Geriatric/positioning ) wheelchair. V5 said, she was at the nurse's station when observed R2 sitting in the dining room leaning forward and to his right side, then fell out of his wheelchair. V5 said, she ran towards R2. She said ,the 2nd nurse came after her, then the CNAs came to assist R2. V5 said, the CNAs transferred R2 back to his wheelchair after he was assessed to rule out injury. V5 said, R2 was then taken back to his room and transferred to bed for a comprehensive assessment. V5 said, R2 sustained some redness to his scalp with some swelling but no open areas. V5 said, R2 was properly seated in his wheelchair with the footrest in place. V5 said, R2 has a behavior of being restless and moving while in the wheelchair. V5 said ,she believes that all safety measures were in place. V5 said, the residents were supposed to be monitored by a staff member while they were in the dining room after meals. V5 said, when R2 fell, no staff member was in the dining room to monitor the residents.On 8/4/2026 at 2:14 PM, V6 (CNA) said that he was the CNA assigned to R2 on July 18th when R2 fell out of his BRODA ( Geriatric/positioning) wheelchair . V6 said, R2 was placed in his wheelchair, properly seated with the footrest up. V6 said, R2 restlessness might have contributed to the fall. V6 said that the last time he monitored R2 was at lunch time when he fed R2. V6 said, he was not in the dining room when R2 fell. V6 said, when staff observe that R2 is restless while sitting in his wheelchair, R2 is normally put in bed. V6 said, there should be a staff member always monitoring the residents in the dining room.On 8/5/2026 at 11:18 AM, V10 (CNA) said that he worked on July 18th, the day R2 had a fall in the dining room. V10 said, R2 was not assigned to him that day. V10 said, he heard a sound coming from the dining room and went to observed R2 on the floor with the nurse by his side. V10 said, there was supposed to be a staff member watching the resident in the dining room. V10 said, there was no staff member monitoring the dining when R2 fell and he does not know why.On 8/5/2026 at 12:40 PM, V3 (Social Worker/Activity Director) said that the activity aide assigned to monitor the dining room while the residents are there on July 18th called in sick. V3 said, the CNAs were supposed to rotate in monitoring the residentsOn 8/5/2026 at 4:09 PM, V2 (Director of Nursing) said that the facility dining policy stated that there should be a staff member monitoring the residents when residents are in the dining room. V2 said, on July 18th about 1:35 PM, V5 (LPN) observed R1 from the nurse's station leaning forward and falling out from his BRODA ( Geriatric/positioning) wheelchair. V2 said that no staff member was in the dining room at the time of the fall. V2 said that there should have been a staff member in the dining area even if it was just one resident room. Dining Room StandardsGuideline: The community will ensure that an attractive, cheerful dining room is maintained with comfortable sound, lighting, furnishings, temperature and adequate space.Procedure: 17. A staff member will be assigned at each meal to oversee the dining Experience.

Based on observation, interview, and record review, the facility failed to follow their facility assessment and ensure adequate nursing staffing. This failure affects all 43 residents residing in the facility.Findings include:During the course of this survey 1/20/2026, it is to be noted that three CNA's (Certified Nurses Assistants) were assigned to the floor while one CNA was conducting a 1:1 supervision assignment.On 1/20/2026 at 10:10AM, V5 (Licensed Practical Nurse) said the morning shift, there should be two nurses however sometimes there is only one. It is definitely better when there are two nurses on duty. Normally there are three CNA's assigned on first shift but sometimes there is four and sometimes there is only two. It can be a struggle with only two CNA's.R3 was observed lying horizontal on his bed. His upper torso was observed to be hanging off the bed with his head touching the floor mat.At 10:55AM, R3 was still observed in this position. This surveyor asked V6 (Certified Nursing Assistant) to come look at R3 and said he should not be like this and finally repositioned him.At 11:20AM, V2 (Director of Nursing) said staffing has been a concern recently due to staff being sick, etc. Our facility is small so we do not have a long list of staff that we can call to help cover when there are call-offs. We have not used agency staff for many years.At 11:50AM, V2 said typically we should be staffing two nurses and four CNA's for day shift. Recently this has been a struggle because we have one resident, R2, who needs to be on 1:1 supervision, which pulls one of our CNA's from the floor. Sometimes we only have one nurse during the day also.Facility Assessment states in part but not limited to the following: Direct Care Staffing: Day shift: 2 nurses, 4 CNA's; Evening shift: 2 nurses, 4 CNA's; Night shift: 1 nurse, 2 CNA's.Facility Assignment Sheets/Actual Working Schedules were reviewed from 12/20/2025-1/19/2026. It is to be noted that out of 31 days reviewed, there were only 2 days that were staffed according to the facility assessment requirements.

Based on interviews and record review the facility failed to protect a resident's right to be free from physical abuse from another resident for one (R1) of four residents reviewed for abuse in a sample of four.This failure resulted in R1 feeling unsafe, anxious, and threatened to be battered by R2. Findings include:R1 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Acute on Chronic Diastolic (Congestive) Heart Failure; Alzheimer's Disease; Type 2 Diabetes Mellitus without Complications; Cognitive Communication Deficit; Dementia; Chronic Kidney Disease, Stage 3; Mild Intellectual Disabilities; Anxiety Disorder; and Major Depressive Disorder.According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 12 indicating moderate cognitive impairment.Absent is any documentation of R1's abuse care plan prior to the current survey, 12/8/2025.R2 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Ileus; Other Disorders of Psychological Development; Rectal Prolapse; Retention of Urine; Other Postprocedural Complications and Disorders of Digestive System; Encounter for Fitting and Adjustment of Urinary Device; Colostomy Status; Unspecified Hearing Loss; Deaf Nonspeaking; Anxiety; and Unspecified Psychosis.According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section C, R2 has BIMS (Brief Interview of Mental Status) score of 7 indicating severe cognitive impairment.R2's behavioral care plan initiated 10/8/2025 reads in part, Focus: I am/have the potential to be physically aggressive r/t (related to) Anger, Depression, History of harm to others, Poor impulse control and not being able to express (R2's) needs through sign language to staff. Interventions: Assess and address for contributing sensory deficits; Monitor/document/report PRN any s/sx (signs and symptoms) of resident posing danger to self and others; When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.On 12/8/2025 at 1:21 PM R2 observed propelling down the hallway. Surveyor attempted to interview R2, R2's deaf, uses sign language, also communicates via writing. R2 refused to be interviewed.On 12/8/2025 at 1:42 PM Surveyor observed R1 sitting in the day room. R1 clean and dressed appropriately. No visible injuries noticed on R1's face upon observation. R1 said, I'm scared of this boy, he's in his room. I don't know his name. He punched me. I don't remember when it happened. He also hit one of the nurses on the back. R1 unable to provide further details due to forgetfulness.On 12/8/2025 at 1:50 PM V1 (Administrator/Abuse Prevention Coordinator) said, R1 was not hit yesterday (12/7/2025). The most recent incident was on 11/2/2025. R2 was agitated and during his outburst, R2 hit R1. R2 was then sent out to the hospital for a behavioral assessment. R1 had developed redness to her face. No one saw the incident, there was no staff in the day room. Since then, R2 was put on behavioral plan with short-term and long-term goals. R2 has a behavioral chart with reward system to motivate him to have appropriate behavior. R2 has cognition issues and communication deficit. We do additional supervision and frequently check on R1 to assure her safety and make sure R2 is not around her. We make sure R1 and R2 reside on opposite sides of the building, eat in different dining rooms, etc. On 12/8/2025 at 2:11 PM V4 (Restorative Aid/CAN-Certified Nurse Assistant) said, on 11/2/2025, after lunch, R2 was in his wheelchair in the hallway holding a bottle of soda. R2 then stood up and was trying to grab somebody else's soda from the therapy room. When I addressed it, R2 got agitated, sat back down in his wheelchair, and propelled himself out of the therapy room. I didn't see R2 hit R1 that day. I don't know what happened, I just know R2 was agitated. After the incident on 11/2/2025, we provide additional supervision to R2 to make sure R1 is safe. We make sure R2 stays on the other side of the building. R1 remains afraid of R2.On 12/9/2025 at 10:10 AM V5 (CNA) said, I worked on 11/2/2025 from 7:00 AM to 3:00 PM. I only remember that R2 went to the therapy room to get treats. I didn't see R2 upset nor attack anyone, including R1. R2 was assigned to me that day (11/2/2025), it was just a regular day, I didn't have any problems. R2 generally does not cause any problems. We keep R2 in his wing to prevent him from approaching R1.On 12/9/2025 at 10:26 AM V6 (Licensed Practical Nurse) said, R2 has tendency to be aggressive towards females, whether they are staff or residents. I worked on 11/2/2025 and 12/7/2025. On 11/2/2025, R2 was agitated, restless, and hyperactive. I was at the nursing station and all of the sudden, I hear residents screaming in the dining room. I didn't see what happened, but I immediately went in there. I separated R2 and R1. R1 went into her room and R2 went into his room. R2 was spitting on me. R2 also touched his anal area and attempted to touch me, his behavior was continually inappropriate, I called local police. The incident happened between change of shift. I had V7 (Certified Nurse Assistant) stay with R1. I didn't see anybody else in the building. Right after that, I called V8 (Psychiatric Mental Health Nurse Practitioner) to get an order to send R2 to the hospital for psychiatric assessment. On 12/7/2025, I heard screaming in the dining room. Me and V9 (Activity Aid) went in there immediately, and noticed R2 approaching R1, so right away, V9 grabbed R2's wheelchair, turned him around, and as I was watching, R2 was trying to elbow V9. I attempted to deescalate the situation, R2 slapped the left side of my face. Right after that R2 went into his room. I once again let V8 know, notified V1 (Administrator), and I was done for the day. Some of the preventative interventions for R2 are to keep him occupied and give him extra snacks and treats. R1 is very mellow and never displays any behaviors to provoke R2. R1 often says she's scared of R2. Every morning R1 asks me to keep R2 away and appears to tear up while saying that. Whenever R1 sees R2 she says, Don't let the boy near me!On 12/9/2025 at 10:51 AM V9 (Activity Aid) said, I worked on Sunday 12/7/2025. I was documenting in the hallway when I heard R1 screening as R2 was approaching the dining room. I immediately grabbed his wheelchair to redirect him. As V6 (Licensed Practical Nurse) was deescalating R2's behavior, R2 slapped her in the face. R2's behavior varies but when he gets angry, he tries to hit whoever approaches him. R1 is very scared of R2. R2 can be all the way down the hallway and R1 gets scared that R2 will come and hit her again; R1 says, He's coming in here, he's coming this way!. R1 also is afraid to do therapy because she may approach R2 while she walks in the hallway, R1 needs to be reassured multiple times that she will be safe during the therapy.On 12/9/2025 at 11:06 AM V7 (Certified Nurse Assistant) said, I worked on 11/2/2025 and 12/7/2025. On 11/2/2025, I didn't see what happened between R1 and R2, but I responded to residents screaming in the dining room. There was no staff in the dining room at the time of the incident. Usually, activity aids watch residents. If activity aids are not available, then nurses watch residents. On 12/7/2025, R1 started screaming when she saw R2, then V9 (Activity Aid) grabbed R2's wheelchair to prevent him from approaching R1. R2 got angry and hit the nurse. R1 is very afraid of R2, R1 screams every time she sees him, even when R2 is a distance away from her. R1 also covers her face when she sees R2, tries to avoid him by all means.On 12/9/2025 at 12:37 PM V8 (Psychiatric Mental Health Nurse Practitioner) said, R2 is developmentally delayed. It is very hard to do an accurate assessment because he is in nonverbal state. I go off staff's reports. Every time I see him, R2 is pleasant, he's smiling, doesn't try to hit me or anything. Aggression towards residents and staff has been an ongoing issue with R2. We are trying to adjust his medications almost on a weekly basis. I diagnosed R2 with adjustment disorder and unspecified psychosis. I am aware of incidents on 11/2/2025 and 12/7/2025. On 11/2/2025 R2 was sent out to the hospital and the following day he had additional behaviors. I saw R2 on 12/5/2025 and started R2 on additional psychotropic medication. On 12/7/2025 the nurse notified me that R2 hit her in the face and asked for additional medication. Other than trying to engage R2 in activities that he enjoys, staff keeps close supervision and prevents interaction between R2 and R1. R2 is not appropriate for this facility but I understand it is a challenge to find another facility for him. Controlling R2's behaviors is a working progress. On 12/5/2025, I talked to R1 as well. R1 told me that she wants to stay away from R2. R1 appears to be R2's target. Covering face, tearing up, or screaming while seeing someone are signs of fear. R1's constant fear may lead to on anti-anxiety medications dependence.On 12/9/2025 at 1:44 PM V3 (Social Service Director) said, on 11/2/2025, there was no activity aid coverage in the dining room, but normally the dining/day room is constantly monitored by activity aids, CNAs, and nurses. It is the activity aids main responsibility. R2 uses sign language to communicate. We have sign language cards to help communicate but it is challenging. R2's cognitive capacity is limited too. R2 also writes but it is choppy and hard to understand. R2's behavior ranges. R2 will often watch his cartoons; however, he had two tablets that he destroyed. R2 is very impulsive, we are not sure what triggers him. We have R2 on an award plan, he gets rewarded for good behaviors with things he likes. R2 is more aggressive towards females. R2 never had an incident with male staff. R1 has been in the facility for about 6 years. R1 is a favorite of staff. R1 is a little anxious, always worried about things. R1 has her routines. R1 gets along with everybody, she is our resident council president. I did notice that R1 is afraid of R2 after he hit her. It seems like R2 is fixated on R1. R1 is having a difficult time with therapy and showers because those are located where R2 resides.On 12/9/2025 at 2:53 PM V1 (Administrator) said in a follow up interview, anytime abuse occurs in the facility, we separate the residents, do assessments, make sure there are no injuries, we do psychosocial assessments, and we continue to monitor. Depending on the situation, we may notify police and send residents to the hospital, it is all based on severity of an incident. We follow up on involved residents, we meet with the instigator and try to find the root cause of the incident. With the incident that occurred on 11/2/2025 between R1 and R2, I found out, through an investigation, that R2 was trying to look for some snacks. V4 (Certified Nurse Assistant) closed and locked the door to prevent R2 from getting other residents' snacks, and that's what caused R2's agitation. If staff sees any type of abuse, they should let me know right away. I was notified by the nurse what occurred on 11/2/2025 and 12/7/2025 right away. The initial report was completed and submitted on the same day (11/2/2025). Staff abuse training is provided upon hire, annually, and as needed. Most recent abuse training was in April and August of 2025Per record review, progress note dated 11/2/2025 written by V6 (Licensed Practical Nurse) reads in part, 14:35 (2:35 pm) - Resident (R2) is agitated, restless, and aggressive. (R2) does not listen to redirection and will hit staff during care. (R2) was kept in room [ROOM NUMBER]:1 with this nurse for safety precautions. Resident (R2) is physically aggressive and threw items and bedside tables across the room. He opened bottles containing liquids (water/juice) and spilled them on the floor. Resident stood up and grabbed items off the medication cart (applesauce, medication tray, laptop mouse, mousepad) and threw it at this nurse. He attempted to throw the silent knight medication crusher and a full pitcher of water at this nurse. Since he was unable to successfully throw those heavy items, he proceeded to continuously kick the medication cart at full force. He stood up and banged the medication cart, door, walls, and furniture around the room with his fists. Resident would continuously point, show his fists, and tried multiple times to grab and hit this nurse. (R2) picked on his nostrils and rubbed his hands on his groin/anal area and attempted to touch this nurse after failing to land a hit. The resident continuously spat on this nurse multiple times in the face while smiling and giggling. Monitored frequently for safety. Call light placed within easy reach. 14:45 (2:45 pm)- (V8 Psychiatric Mental Health Nurse Practitioner) contacted and given an update regarding (R2's) behaviors. Per V8, send out to (local hospital) for a psych evaluation. 15:07 (3:07 pm)- (local emergency response services) contacted for ambulance transfer to (local hospital). Per telephone operator, (local police) will be on the scene due to resident behaviors. V1 (Administrator), V2 (Director of Nursing), and Medical Director contacted and given update.Absent is any documentation of physical altercation between R1 and R2.R1's Skin assessment dated [DATE] reads in part, Left side of face (cheek, temple, and forehead area) red, discoloration and swelling. Skin intact. Ice to the affected area; PRN (as needed) pain medication administered.Per record review, progress note dated 12/7/2025 written by V6 (Licensed Practical Nurse) reads in part, 1330 (1:30 pm): Staff intervened to redirect (R2) from approaching female resident (R1) in the large dining room. Activity aid (V9) redirected (R2) away from the dining room towards the hallway. While (R2) was being redirected, he was attempting to hit activity aid (V9) with his elbow. When the writer (nurse) attempted to diffuse the situation, he hit the writer (nurse) on the left side of her face using the back of his hand. Social Services (V3) in the building, aware of the situation. Medical Director, (V8 Psychiatric Mental Health Nurse Practitioner), and V1 (Administrator) notified.R2's most recent psychiatric assessment dated [DATE] written by V8 (Psychiatric Mental Health Nurse Practitioner) reads in part, History of Present Illness: (R2) continues with aggressive behaviors towards staff and other patients. (R2) hit another female patient this am; appears he has been targeting one particular female patient. Patient seen in his w/c (wheelchair) in no acute distress. He is calm on approach. Patient's mood is up and down, improved by nursing care, his (tablet), and medication. This has been going on multiple days. Assessment: This patient has multiple medical comorbidities that puts him at risk of psychiatric issues; he would benefit from continued monitoring of mood and behavior. Will titrate medications based on current symptom progression.R2's hospital record dated 11/2/2025 reads in part, Today's visit: Diagnoses: Aggressive Behavior, Encounter for Medical Screening Evaluation. R2's police report requested on 12/9/2025; however, not received during course of the survey. The facility Abuse Prevention and Reporting - Illinois policy last reviewed 10/24/22 reads in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Definition: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.

Based on interviews and record review, the facility failed to provide sufficient fluid intake to maintain proper hydration for one of four (R1) residents reviewed for therapeutic diets in the sample of four. Findings include: R1 was admitted to the facility with diagnoses including but not limited to Anemia; Hyperkalemia; Pressure Ulcer of Sacral Region, stage 4; Personal History of Immunosuppression Therapy; Other Reduction Deformities of Brain; Kidney Transplant Status; Gastrostomy Status; Severe Intellectual Disabilities; Hyperosmolality and Hypernatremia; Unspecified Severe Protein-Calorie Malnutrition; and Chronic Kidney Disease, stage 3a. On 2/10/2025 at 10:02 AM, R1 was sitting in the specialty chair in her room. R1 had a calm disposition, was clean, appropriately dressed, and well-groomed. Non-interviewable. R1 does not appear neglected. R1 appears thin. R1 observed wearing a left leg stabilizing boot. No tube feeding set up observed at this time. R1's gastrostomy tube site clean, dressing changed with date 02/10/2025. On 2/10/2025 at 11:21 AM V4 (Family Member) said, From what I heard, it seemed like after one of R1's hospitalization s, the tube feed water flush order was entered wrong. I brought it up to the nurse's attention, don't remember the name, during one of the feedings, and the facility took care of it. On 2/10/2025 at 11:43 AM V2 (Director of Nursing) said, R1 was hospitalized on [DATE] for anemia and discharged the next day (12/31/2024). First page of the hospital record (provided to the surveyor by V2) is a form that the facility nurse uses to take verbal hand-of-report, before resident is readmitted to the facility. V5 (Licensed Practical Nurse/LPN) wrote on R1's hand-off-report form that R1 should receive 200 ml (milliliters) water flush QID (four times a day). V5 (LPN) did not include that water flushes are to be done four times a day before and after each meal. The report is verbal, not always detailed, and not final. The actual discharge hospital record was supposed to be reviewed thoroughly after R1 was readmitted to the facility. R1's discharge hospital record showed that R1 is to receive increased free water flush to 200 ml QID before and after meals. The nurse on duty transcribes all new orders to electronic medical record upon residents' return to the facility. V6 (LPN) was the one who put in all new orders upon R1's readmission on 12/31/2024. V6 (LPN) transcribed inaccurate order. V6 (LPN) put it in an order as: water flush 200 ml/four times a day instead of 200 ml four times a day before and after meal. Nurses' assumption was to flush feeding tube with 100 ml of water before and 100 ml of water after each of R1's four meals. When in fact, it was supposed to be 200 ml water flush before and after meals four times a day. R1 was hospitalized again on 1/2/2025, and that's when the hospital called me and asked how many flushes R1 is getting. We told the hospital staff the mistake was on our part. On 2/10/2025 at 12:27 PM V7 (Medical Director) said, R1 has a history of kidney transplant from 2010. Nephrology manages R1 for the most part, but dialysis is no longer an option. R1 has not been able to manage electrolyte balance since she was admitted to the facility (11/27/2024). It seems like R1's kidney started to fail before she was admitted to the facility; however, we were not aware of that. There was no long term negative outcome from the inaccuracy of the water flush order. On 2/10/2025 at 9:33 PM V6 (LPN) said, I readmitted R1 on 12/31/2024. I entered water flush order as 200 ml (milliliters) QID (four times a day) based on what V5 (LPN) told me, but I might have not caught it correctly. I misinterpreted it. I don't remember now what the correct order was. It's important to transcribe physician orders accurately to ensure the order corresponds with physician's ordered treatment for residents' ongoing condition. R1's physician order dated 12/31/2024 11:07 PM reads in part, Enteral Feed Order four times a day Enteral - Flush Tubing with 200 ml water QID. Discontinued on 01/04/2025 at 12:13 AM. R1's January 2025 Medication Administration Record shows that R1 received two 200 ml and one 150 ml water flushes on 01/01/2025, two 200 ml water flushes on 01/02/2025, and one 200 ml water flush on 01/03/2025. R1 was hospitalized from 01/02/2025 05:20 PM to 01/03/2025 10:00 PM. Hospital record 12/31/2024 reads in part, Discharge Instructions: increase FWF (free water flushes) to 200 ml (milliliters) before and after meals. Hospital record 01/03/2025 reads in part, Admitting diagnosis: Hypernatremia. Hospital course: It was discovered that (R1) was only receiving 200 ml (milliliters) FWF (free water flush) with meals (not BOTH before & after meals). Absent are any care plans related to R1's fluid imbalance dated prior to 01/04/2025. The facility Enteral Nutrition policy (no date) reads in part, Enteral feedings provide nutrients and fluids using the gastrointestinal tract. The choice of enteral feeding depends on the medical and nutritional needs of the individual as assessed by the Registered Dietitian and physician. Enteral Nutrition Feeding Orders should include: [a., b., c., d., e.] f. The amount of water flushes per 24 hours. The facility Admission of Resident policy (no date) reads in part, Purpose: To facilitate smooth transition into a health care environment. To gather comprehensive information as a basis for planning individualized therapeutic care. [ .] Complete and submit diet orders.

Based on interview and record review, the facility failed to ensure that dietary staff are properly certified for food handling. This failure has the potential to affect all 37 residents who receive food by mouth from the kitchen. Facility census provided by V1 (Administrator) upon entrance is 38 minus 1 resident that gets nothing by mouth (NPO). Findings include: On [DATE] at 11:30AM, conducted a second visit in the kitchen and requested the certification for all dietary staff from V5 (Dietary manager). V5 presented 3 food handing certificates for the dietary aides. Review of facility employee list showed 6 dietary aides currently work at the facility. V5 stated, three dietary staff that are missing the food handling certificate are working at another place and are going to send V5 their certificates. V5 later presented certificates for 2 additional staff, stating the remaining staff (V9) is still looking for his own and will send it over. On [DATE] at 1:177PM, V5 stated, he did not receive the food handling certificate. The staff could not find it and is taking the test right now and he will send over the certificate after completion. V5 added, V9 has worked at the facility for months now, he had a certificate in another place before he started working at the facility but could not find. On [DATE] at 3:00PM, V1 (Administrator) said, V9 has worked at the facility for about one year. V1 was told that V9 had a certificate that expired and is now taking the test again. V1 stated, V9 works part time for a couple of hours a week but should still have a current food handling certificate on file. Surveyor requested the expired copy of V9's license. V1 stated that they could not find it, and the facility does not have any policy regarding required qualifications for dietary staff. Illinois Food Handling Regulation Enforcement Act (410 ILCS 625) amended by SB1495, (in part) requires all food handlers in Illinois to receive training in basic food safety concepts from an ANAB-Accredited provider. Food Handlers must complete a food safety training within 30 days of beginning of employment.

Based on interview and record review, the facility failed to have measures in place to minimize the risk of Legionella and other opportunistic pathogens in building water systems and failed to have corrective actions for temperature variances outside control limits. This failure has the potential to affect all 38 residents residing at the facility. Findings include: Facility census provided by administrator upon entrance was 38. On 4/16/2024 at 2:32PM, V2 (DON) said he is the infection prevention nurse and has worked at the facility for about [AGE] years. V2 stated she does not know anything about facility water management or Legionella prevention, the administrator and maintenance director takes care of that. On 04/16/24 at 3:02PM. V1 (administrator) stated, the facility does not do any testing for Legionella disease. If they did any testing it was in the past. V1 has been at the facility for 5 years and they have not done any testing. The facility only takes temperatures and do routine flushing. V1 stated the only time they will do any testing is if there is an indication of legionella or during construction, otherwise they are not required to test. On 04/17/24 at 10:13 AM, V1 presented documentation for the facility's Legionella prevention temperature log from July 2023 to April 2024. Documents show the temperature in the water heater storage tank and the circulating water exiting the mixing valve does not meet the temperature parameters. The section of the documents for corrective action taken for variance outside parameters were left blank. V1 was presented with this observation and V1 stated, We don't have any corrective action, we do not take any measures unless there is an indication of a problem. On 04/17/24 at 10:13 AM, V7 (Maintenance Director) who was present during the interview stated, he just started at the facility about 6 months ago and has never done any testing at the facility or in his previous job. V7 just checks the temperatures and does not do anything additional for temperatures that do not meet stated range. On 04/17/24 at 11:30 AM, V1 stated, she told the maintenance director to change the temperature setting in the water heater to match the parameter. V1 stated, V7 was supposed to do the testing today and the reading from today is okay. Water management policy revised 12/28/2017 stated its purpose as to identify and reduce the risk of Legionella growth and spread. Under guidelines, the policy states that preventive maintenance will be performed ss applicable, including, but not limited to hot water temperatures to be obtained at the domestic hot water boiler and at the mixing valve at least 5 times a week. Environmental services will monitor the identified areas of risk per guidelines above and implement corrective action as indicated. Additional monitoring or actions may need to be implemented for the following: Data shows control measures are persistently outside of control limits.

Based on observation, interview and record review, the facility failed to ensure six (R5, R13, R23, R26, R32 R37) residents rights were maintained. This failure affected six (R5, R13, R23, R26, R32 and R37) of six residents reviewed for resident rights out of a total sample of 22. Finding include: R23 is a [AGE] year-old resident most recent admission to the facility on [DATE] with diagnoses of but not limited to severe intellectual disabilities, down syndrome, and Alzheimer's dementia. On 04/15/24 at 10:03AM, during random observation, R23 was in TV area with activity staff. R23 was observed sleeping in geriatric chair with mechanical lift sling visible underneath resident. On 04/15/24 at 10:34 AM R23 was observed in room sleeping in geriatric chair and mechanical lift sling visible underneath resident. R5 is a [AGE] year-old resident admitted to facility on 09/16/20 with diagnoses of but not limited to Alzheimer's disease, dementia and down syndrome. On 04/15/24 at 10:06 AM, R5 was observed in geriatric chair in TV area with activity staff V3. R5 was observed sleeping in geriatric chair with mechanical lift sling visible underneath resident. On 04/15/24 at 10:24 AM, R5 was observed awake in TV area watching television with mechanical lift sling visible underneath resident. R32 is a [AGE] year-old resident readmitted to facility on 04/14/2023 with diagnoses including but not limited to profound intellectual disability, Alzheimer's disease, autism, dementia, and down syndrome. R13 is a [AGE] year-old resident admitted to facility on 07/15/2022 with diagnoses including but not limited to Alzheimer's disease and down syndrome. R26 is a [AGE] year-old resident admitted to facility on 06/07/2022 with diagnoses including but not limited to down syndrome and Alzheimer's disease. R37 is a [AGE] year-old resident admitted to facility on 09/13/2023 with diagnoses including but not limited to bipolar disorder, down syndrome, profound intellectual disability, and Alzheimer's disease. On 04/17/24 at 09:27 AM R5, R13, R23, R26, R32, and R37 identified by V3 (Social Services) were all observed in small activity room. R5, R13, R23, R26, R32, and R37 were sitting in geriatric chairs with mechanical lift slings visible beneath them in the chair. On 04/17/24 at 11:34 AM, V2 (Director of nursing) stated, mechanical lift slings being left in geriatric chair underneath residents is typical practice here. The reason is because it would be hard to lift them and replace the sling and cause friction and shearing to residents. V2 agreed mechanical lift slings being left under residents and visible could be a dignity issue as well. Anyone who walks through this facility can see the resident is transferred using a mechanical lift by seeing the sling. On 04/17/24 at 1:37 PM, V4 (Licensed Practical Nurse) stated, mechanical lift slings being left under patients is typical practice here. Our patients have osteoporosis, weakness and are cognitively impaired residents so I feel this is a safer practice. We leave the mechanical lift slings underneath residents for ease of staff to transfer our residents. Resident rights policy dated 08/23/2017 states: Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to: Privacy and confidentiality Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules as long as those rules do not violate a regulatory requirement.

Based on interview and record review the facility failed to protect the resident right to be free from use of physical restraints for 1 of 3 residents (R1), a resident with diagnosis of down syndrome, anxiety and major depression. On 10.27.23 R1 observed by hospice aide to be wrapped inside a bed sheet and the sheet was tied around R1 legs restricting free movement of R1. Findings include: R1 face sheet R1 has diagnosis of down syndrome, major depressive disorder, and anxiety. Facility investigation dated 10.27.23 denotes in-part on 10.27.23, RN case manager told DON (director of nursing) and Administrator the CNA ( certified nursing aide) had found the sheets of R1 positioned around her legs in a way R1 would not be able to move them. V4 stated she was taking care of R1 morning and R1's sheets kept falling off her so she wrapped the sheets around R1 so they would not slide off and her legs would stay covered. On 11.18.23 at 8:45 am R1 observed sleeping in bed. At 9:28am V7 (CNA- Certified Nursing Aide) and V8 (CNA- Certified Nursing Aide) observed to provide care to R1. V8 said she often works with R1 and R1 likes to put her legs out of the bed. V8 said R1 moves around in the bed a lot. V8 said R1 is a fall risk. R1's bed observed in the high position. R1's top bed rails observed in the up position bilaterally. R1's air mattress observed to have 4 boasters, 2 at the upper and 2 at the lower part of the bed. V8 turned R1, R1 did not participate in holding the bed rails during care. R1 did not communicate with the staff during care. R1 did not follow directives. On 11.18.23 at 11:59am V4 (CNA- Certified Nursing Aide) said she wrapped R1 in a sheet when she worked on 10.27.23 because R1 put her hand inside her adult brief. V4 explained she wrapped R1 like you wrap the babies, cradle wrapping the sheet around the body. V4 said the facility gave her an in-service and told her she cannot wrap R1 up like, it's a restraint. V4 said R1 could not remove the sheet she wrapped R1 up inside. On 11.18.23 at 1:46pm V2 (Director of Nursing) said the facility does not use restraints. V2 said she was made aware of 10.27.23 incident when V1 (case manager of hospice company) arrived at the facility and informed her and V3 (Administrator). V6 observed R1 legs tied in a sheet. V2 said she did not see the picture presented by V1 but V3 (Administrator) saw the picture. V2 said she immediately went to assess R1. R1 noted with no injuries. V2 said V3 initiated an investigation. V2 said she interviewed V4 (CNA-certified nursing aide) and V4 informed her V4 wrapped a sheet around R1 so R1 was comfortable because R1 kicks off her sheet at night. V2 said R1 has behaviors of touching her face, messing wither adult brief, putting her legs out of the bed, and fidgeting. V2 said she asked V4 to demonstrate how she wrapped the sheet around R1. V2 demonstrated for surveyor. V2 put the sheet around her upper body/waist, tied the sheet at the upper body area, leaving the lower part of the sheet to be open freely. V2 was shown the picture presented to surveyor. V2 said R1 should not be wrapped in the sheets like that, it a was a restraint. V2 said the sheet should not be tied around R1 legs. V2 said R1 has a right to move freely. V2 explained the facility has removed the rails off their beds because they don't use restraints. V2 described when the bed rails are in the up position it's considered a restraint (if the resident is not assessed for bed rails use and approved). V2 was made aware surveyor observed bed rails in the up position on R1 bed. V2 said R1 should not have the bed rails in the up position. V2 explained R1's bed was provided by the hospice company but staff knows how to put the bed rails in the down position and they should put the bed rails in the down position. V2 said R1 has down syndrome and has dementia. V2 explained R1 is a fall risk, R1 has boosters on her mattress for fall prevention intervention and R1 bed should be in a low position. V2 made aware R1 bed was not in the low position when observed by the surveyor at 8:45am. On 10.18.23 at 10:49am V6 (Hospice Aide) said she is the hospice aide was assigned to R1 care on 10.27.23. V6 said she visited R1 on 10.27.23 and observed R1 to be cradled in a bedsheet from upper body down to legs and at the legs the sheet was tied. R1 did not appear to be in distress at time. V6 said she had to literally unwrap R1 body from the sheets. V6 said she called her supervisor at the hospice company to inform them. V6 said she did not mention this to facility because she didn't know how to manage the situation with the facility. V6 said she took picture to show her supervisor. V6 said she untied R1 and provided care to R1. V6 said she did not see any bruises on R1. V6 said the facility has asked her not to return because she expressed concerns about the clients she was assigned to at the facility. On 11.18.23 at 10:49am V1 (case manager hospice company) said it was reported to her by V6 that V6 observed R1's legs tied up in a sheet on 10.27.23. V1 said the hospice company had a previous episode with R1 being restrained at the facility in April 2023. V1 said she asked V6 not to talk to the facility and she would inform the facility. V1 said she informed V3 on 10.27.23 of the issue and she showed V3 the photo image also. On 11.18.23 at 11:18am V3 (Administrator) V3 said it was reported to her on 10.27.23 by V1 that R1 was observed with the bed sheet tied around her legs. V3 said V1 showed V3 the picture of R1 but V3 couldn't recall what V3 observed in the picture because the angle was not clear. V3 said she interviewed staff and V4 reported that V4 wrapped R1 up in a sheet. At 2:15pm V3 was showed the photo of R1 wrapped in a bed sheet and the sheet was tied around R1 legs. V3 said the sheet should not be tied around R1 legs. V3 said the facility does not use restraints. Review of the photo presented by V1 shows a resident observed, resident has a ring on (R1 observed wearing ring on 11.18.23), the white bed sheet is around the resident body tightly, the sheet comes down to the legs and at the legs the sheet is tied. Facility concern form dated 10.27.23 denotes in-part, R1 name, report taken by V3, concern- hospice CNA stating resident's sheet is wrapped too tightly around her legs. Summary of pertinent findings- not substantiated, staff positioned sheet around legs so they would stay on comfortable. V4 notice of corrective action form dated 10.27.23 denotes in-part on 10.27.23, the employee stated during an investigation she wrapped a blanket around a resident in order to keep the blanket on. Those could be considered a restraint and all restraints must be approved by the IDT (interdisciplinary team). Using a restraint without approval is against the policy of the facility. Facility records of in-service dated 5/18-5/23/23, topic- restraint free facility, side rails, summary of the presentation denotes: no side rails without orders, anything is attached to resident body and prevents them from free movement is a restraint. V4 name is noted on in-service report. R1 physician order sheet for the month of October 2023, does not reflect any order for use of restraints. Review of R1 care plan presented by V3 as the most recent plan, target date of 02.24.23, 20 pages, there is not a plan of care denoting the use of restraints for R1, there is not plan of care denoting to tie bed sheets around R1 legs, there is no care plan denoting to cradle R1 inside a bed sheet because she touches her adult brief. Facility policy titled restraints with revision date on 4.24.18 denotes in part to ensure each resident is to attain and maintain his/her practicable well-being in an environment prohibits the use of restraints for discipline or convivence and limits restraint use to circumstance in which the resident has medical symptom warrant the use of restraints. Definitions: physical restraints are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident body the individual cannot remove easily which restricts freedom of movement to normal access to one body. Physical restraints may include but are not limited to leg restraints, arm restraints, hand mitts, soft ties or vest, lap cushions, and lap trays the resident cannot remove easily. The resident right for the people living in long term care denotes your facility must treat you with dignity and respect and must care for you in a manner promotes your quality of life. You have a right to be free from physical or chemical restraints.

Based on interview and record review the facility failed to follow their abuse prevention policy and report and allegation of abuse of using a physical restraint to the department for 1 of 1 resident (R1) for 22 days. Findings include: R1 face sheet R1 has diagnosis of down syndrome, major depressive disorder, and anxiety. On 11.18.23 at 11:18am V3 (Administrator) said V3 did not report the allegation of the sheets being tied around R1's legs to the department because V1 (case manager of hospice company) said she did not think it was done with ill intent. V3 said it was reported to V3 on 10.27.23 by V1 that R1 was observed with the bed sheet tied around her legs. V3 said V1 showed V3 the picture of R1 but V3 couldn't recall what V3 observed in the picture because the angle was not clear. V3 said she interviewed staff and V4 reported that V4 wrapped R1 up in a sheet. At 2:15pm V3 was showed the photo of R1 wrapped in a bed sheet and the sheet was tied around R1 legs. V3 said the sheet should not be tied around R1 legs. V3 said the facility does not use restraints. V3 presented initial report to department on 11.18.23 for physical abuse, denoting in-part it was reported to her (V3) that R1's blanket was secured around her (R1) legs. Facility policy tiled abuse prevention and reporting with last revision date 10.24.22 denotes in-part, external reporting, when allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident representative and department of public health regional office shall be informed by telephone or fax. Public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated. If there is reasonable suspicion that a crime has been committed that is not listed above and does not involve serious bodily injury, then a report to local law enforcement and department of public health as soon as possible but within 24 hours of when the suspicion was formed.

Based on interview and record review, the facility failed to follow their policy and update resident's fall care plan with new interventions to prevent one resident (R6) who was a risk for falls, from falling and hitting her head on 1/23/23. This failure effects 1 resident of 3 residents reviewed for falls in a sample of 12. Findings include: R6 post fall occurrence forms document three falls 11/21/22, 12/8/22, and 1/23/23. R6's fall-initial occurrence report for 11/21/2022 documents R6 tried to get up but slid off the bed. R6 was found sitting on the floor with legs outstretched on the side of her bed. R6's fall-initial occurrence report for 12/8/2022 documents R6 was found face down on the floor, resident stated she lost her balance and fell , and precipitating factors: resident needed to void and forgets to use the call light and is on an anticoagulant. R6's Fall initial occurrence report for 1/23/23 documents R6 was found on the floor in her room lying on her back and head on the floor. R6 stated she was trying to go to the restroom. R6's Progress note dated 12/8/2022 documented a bruise to the forehead and was sent to the hospital. R6's hospital records dated 12/8/2022 document diagnosis as fall and traumatic hemorrhage of cerebrum. Resident was readmitted to the facility on [DATE]. There are no new interventions documented on the fall risk care plan after 7/13/22 until 1/23/23. Therefore, no new interventions after the 11/21/22 fall or the 12/8/22 fall with injury. 6/07/23 01:22 PM V2 (DON) stated after resident's fall, the facility came up with interventions and updated the resident's care plan with new interventions. The facility's Comprehensive Care Plan policy dated 11/17/17 documents the following: to develop a comprehensive care plan that directs the care team and incorporates the resident's highest practicable physical, mental, and psychosocial well-being. The facilities fall prevention program policy documents the care plan interventions are changed with each fall, as appropriate.

Based on observation, interview and record review, the facility failed to provide treatment and care for a resident with seizures for one (R14) of four residents reviewed for seizures in a sample of 12. Findings include: On 06/06/23 at 10:06 AM during observation, R14 was observed sitting on a Geri-chair in the dining room when she started presenting with jerking body movements, eyelids fluttering, and eyes rolling back. V6 (Certified Nursing Assistant) noticed R14, checked her, and informed V3 (Licensed Practical Nurse). V3 checked R14 and stayed with her. R14's jerking movements stopped after approximately 15 seconds, but eyelids and eyes remained the same. After approximately another 10 seconds, R14's eyelids and eyes started to relax. V3 was observed taking R14 to her room. On 06/07/23 at 10:48 AM, V3 said she brought R14 to room to decrease stimuli and make her comfortable. V3 stated she didn't think that when R14 had the jerking movements and eyes rolling backwards she was having a seizure. V3 said she did not check R14's vital signs or call the doctor. On 06/07/23 at 10:52 AM, V2 (Director of Nursing) stated that R14 has diagnosis of seizure disorder and she might've been having seizures at that time. V2 added that R14 is on seizure medication but cannot locate any laboratory results for R14 to check therapeutic levels. On 06/08/2023 at 1:12PM, V2 said if a resident had a seizure, she expects the nurses to assess the resident including the vital signs, provide care as needed, and then notify the doctor and/or family. On 06/07/23 at 11:00 AM, V6 said he saw R14 having jerking body movements, so he checked on R14 and informed V3. R14's order summary report dated 6/7/23 indicated admitted [DATE], diagnoses including other seizures and other sequelae of cerebral infarction, and order for Levetiracetam 250 milligrams (mg) by mouth in the morning and 500mg by mouth in the evening with start date of 7/12/2022. Care plan revised 7/22/2022 indicated R14 is at risk for seizures, Levetiracetam with interventions including monitor lab values for therapeutic levels of anticonvulsant medications and report to MD (Doctor of Medicine). Review of physician orders from 7/12/2022 to 06/06/2023 did not show any current or previous laboratory order to check therapeutic levels of Levetiracetam. Facility unable to provide policy on change in condition.

Based on interview and record review the facility failed to follow its policy for using restraints and failed to prevent a physical restraint from being used for staff convenience for one resident (R1) in a sample of five residents reviewed for restraints. Findings include: On 5-6-2023 at 3:10pm V8 (R1's Family member) said, on 4-23-2023 I came at 11:00am to see my family member (R1), she was in bed with a facility gown that was tied to the bed side rail and holding both legs next to each other, unable to move her legs freely. R1 was restrained. On 5-6-2023 at 11:00am V5 (Certified Nurse Assistant) said, on Sunday 4-23-2023 I was working here, I went to R1's room about 10:00 am and I provided morning care and since she likes to play with her feces, I folded the gown under her knees to avoid for her to reach her incontinence under garment. I should have never done that because it can be consider a restraint On 5-6-2023 at 1:25pm V2 (Director of Nursing) said, tied a gown under the knees is consider a restraint because R1's will not be able to move her legs freely. We consider that as a restraint. 3:30p V1 (Administrator) said, a gown tied at the knee level is consider a restraint, we are not supposed to restraint any residents. V1 presented: Restraints policy dated: 11-28-2012. Reads: The use of side rails as restraints is prohibited.

Based on interview and record review, the facility failed to keep a resident free from physical abuse from another resident. This failure applied to two of two (R3, R4) residents reviewed for abuse. Findings include: R3 is a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses that include: Down Syndrome, Alzheimer's disease with early onset, bipolar disorder, weakness, and need for assistance with personal care. R3's care plan focus dated 12/10/22 reads that R3 has the potential to be physically aggressive related to diagnosis of bipolar. Interventions include: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; modify environment: reduce noise, dim lights, place familiar objects in room, keep door closed, etc.; remove resident from crowded situation; observe resident when in company of peers (initiated on 9/9/22). R4 is a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses that include: Down Syndrome, Alzheimer's disease, dementia, muscle weakness, and anxiety disorder. R4's care plan focus dated 8/18/22 reads that R4 can be non-compliant/resistive to care with screaming/yelling/pushing staff away. I don't like to hear noise; I get agitated and will start to scream. Focus area dated 9/9/22 reads that R4 has impaired communication: expressive problems, receptive problems, speech problems, specify: mumbling to non-verbal related to: dementia, expressive aphasia. Interventions include: Leave resident alone and re-approach later as needed (initiated on 8/21/22); Be conscious of resident position when in groups, activities, dining room to promote proper communication with others (initiated on 9/9/22). Facility provided incident report describing incident on 4/6/23 between R3 and R4. Report reads: The CNA stated that he was bringing a resident into the dining room when he observed R3 hit R4. He immediately removed R4 from the area and then alerted the nurse. The nurse, while not witnessing this incident herself, she immediately assessed both R4 and R3 for any signs of injuries and/or pain. There was some discoloration on R4's left lower face as well as an open area on her lip . Summary of investigators findings: After a review of the staff and resident interviews as well as medical record review, it was determined that R3 hit R4. R3 and R4 were seated next to each other. R3 became agitated due to noises in the dining room and this is what likely caused him to react in such a way. Nurse progress note dated 4/6/202316:18, written by V3 (LPN) reads: Narrative: V4 (CNA) witnessed (R3) using his right closed fist to punch (R4) on her face. CNA immediately interfered and separated both residents. Writer heard the commotion and assisted CNA to separate both residents. (Facility Medical Director) here, seen resident with order to send resident to ER via 911.Local Authorities notified and arranged for 911 transport. ( Correction on the time above of People/Agencies notified. Incident happened at 15:00.MD notified at 15:10 DON notified at 15:01Administrator notified at 15:12. Interview with V3 (LPN) on 5/6/23 at 1:22PM, V3 stated that she was at the nurses station right across from the small dining room (during 4/6/23 incident) so she heard the commotion. V3 stated, I don't think there was any staff in there at the time, but I am right here (nurses station is approximately less than 15 feet from the dining room) and V4 (CNA) separated them quickly. R4 is very confused and disoriented. R3 is usually redirectable and calm throughout the day. On 5/6/23 at 4:02PM, V3 confirmed that V4 (CNA) reported the incident to her, just as she had charted and that R3 has a history of aggressive behaviors with loud environments. During interview with V4 (CNA) on 5/6/23 at 12:24PM, V4 stated that he was bringing a resident (on 4/6/23) into the dining room when he saw the incident. R4 likes to yell and R3 doesn't like loud noises. R4's lip was open a little at the bottom. At the time (of incident) we were in the middle of shift change and sometimes they might be alone momentarily. 5/6/23 at 1:36PM V2 (DON) was interviewed about the incident between R3 and R4 and stated that there should be staff in the dining room (with residents) and confirmed that R4 is confused and can get agitated which is not new for R4. V2 stated, staff try to keep R4 away from loud noises and if R4 is loud, they keep R4 away too and try to keep R4 in a calm environment. V2 added that she (V2) did not consider this incident abuse based on the residents' impaired cognition and intellectual disability and added that she did not think that R3 intended to harm R4. They both have Alzheimer's. 5/6/23 at 3:19PM, V1 (Administrator) was interviewed about the incident between R3 and R4 and stated that they (R3 and R4) were sitting in the dining room together and R3 hit R4. When R3 went to the hospital (after incident), they determined R3 had a UTI (urinary tract infection), and was treated with antibiotics. V1 stated. He's (R3) not normally aggressive. With his cognition, I don't believe that (R4) really knows because if you go back and ask him, he doesn't recall what happened. V1 confirmed that she did not substantiate abuse for this incident. Facility provided document titled, Abuse Prevention and Reporting- Illinois (last revised 10-24-22), which includes: .Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR Interpretive Guidelines). The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. (42 CF R 483.5). An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines) . Resident-to-Resident Abuse (any type): A resident-to-resident altercation should be reviewed as a potential situation of abuse.

Based on observation, interview, and record review, the facility failed to apply hand splints on 1 resident (R16) out of 3 residents observed for hand splints in the sample of 15. Findings Include: On 8/31/2022 at 3:40 PM, R16 was observed with V2 (Director of Nursing) lying in bed without bilateral hand splints on. The DON said the bilateral splints should have been applied to R16 and the nurse was supposed to put them on. On 8/31/2022 at 3:42 PM, R16 was observed with V6 (Licensed Practical Nurse) lying in bed without bilateral hand splints on. V6 said that the splints should have been applied at the beginning of the evening shift. R16 has an initial admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A clinical physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify of any skin breakdown to nurse. Directions: Every evening shift at 3:00 PM. Focused care plan with initiated date of 7/5/2022 indicates that R16 requires the use of splint. Interventions/Tasks: Establish wearing schedule: On for 5 hours a day for 6 days a week. Facility Policy: Restorative Nursing Program Effective Date: 11-28-12 Department: Nursing; Restorative Reviewed/Approved by: IDT 01.2022 Review/Revisions: 11-17-17 1-4-19 Purpose: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Includes, but is not limited to programs in walking/mobility, dressing and grooming, eating and swallowing, transferring, bed mobility, communication, splint or brace assistance, amputation care and continence program.

Based on observation, interview and record review the facility failed to ensure incontinence care was provided promptly for 2 of 3 residents (R26 and R183) reviewed for Bowel and Bladder in a sample of 15. Findings include: On 8/30/2022 at 10:27am R26 was observed in bed with three bed pads under and an adult disposable brief applied. On 8/30/2022 at 10:30am V8 (Certified Nursing Assistant-CNA) observed with surveyor R26 had three bed pads and an adult disposable brief applied. V8 said I did not do my morning rounds we are short of staff, I do not know why she has on three bed pads, I'll remove them now. On 8/30/2022 at 10:33am V4 (Licensed Practical Nurse-LPN) observed with surveyor and V8 three bed pads and an adult disposable brief applied. V4 said R26 should only have one bed pad, and one adult disposable brief applied, and assisted V8 with removing the bed pads. On 8/30/22 at 10:40am R183 was observed in bed with three bed pads and one adult disposable brief applied. On 8/30/22 at 10:42am V4 observed with surveyor that R183 had three bed pads and an adult disposable brief applied. V4 indicated the yellow line indicates that the brief is soiled. V4 said I don't know why she has three bed pads, and an adult disposable brief applied the C.N.A, should do rounds every two hours and as needed. On 8/30/2022 V8 observed with surveyor and V4 that R183 had three bed pads and a soiled adult disposable brief applied. V4 said I did not get a chance to change her. On 9/2/2022 at 10:30am V2 (Director of Nursing-DON) said I expect the nursing staff and certified nursing assistants to do rounds every two hours and as needed, and only apply one bed pad and one adult disposable brief. On 9/2/2022 R26 face sheet indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated 7/15/2022 indicates R26 has a focus of potential for skin impairment integrity related to incontinence. R183 face-sheet indicates a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated 8/18/2022 that indicates a potential for skin impairment. Facility Policy: Bowel and Bladder Assessment and Toileting Programs. Revisions: 1/16/2018, 12/3/2018 Purpose: Based on the resident's comprehensive assessment the facility will ensure that each resident with bowel or bladder incontinence will receive appropriate treatment and services to restore as much normal bowel or bladder functioning as possible. Guidelines: If the resident is identified as being incontinent: 4. The resident plan of care will be developed to address the issue(s), goals, and appropriate interventions for elimination program, using an interdisciplinary team approach. Types of Incontinent programs include: 3. Check and Change - Using the information obtained from the voiding pattern data, the decision may be made to not place the resident on a scheduled toileting program. Instead, the facility implements a care plan whereby the resident is checked frequently and cleaned as necessary. The facility may use supplies such as adult disposable briefs. Incontinence Care: Revisions 1/16/2018, 4/20/2021 Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital cate after each episode. Procedure: 10. Apply clean incontinence brief or incontinence pad.

Based on observation, interview and record review the facility failed to implement standard disinfection of medical equipment (portable Blood Pressure wrist manometer) between each resident use. This deficiency affects all three (R9, R19 and R182) residents in the sample of 15 reviewed for Infection Control when taking blood pressure during Medication Administration. Findings include: On 8/30/22 at 12:15pm V4 LPN (Licensed Practical Nurse) took R182's Blood pressure (BP) on his left wrist. At 12:27pm, after giving medication, V4 returned the BP wrist manometer inside the medication cart's lower drawer without disinfecting it. On 8/30/22 at 12:38pm, V4 LPN took BP wrist manometer from the medication cart drawer without disinfecting it. V4 took BP of R19's on her right wrist. V4 placed the BP manometer back to medication cart's lower drawer without disinfecting it. On 8/30/22 at 12:49pm, V4 LPN took BP wrist manometer from the medication cart drawer without disinfecting it. V4 took BP of R9's on his left wrist. V4 placed the BP manometer back to medication cart's lower drawer without disinfecting it. On 8/30/22 at 1:14pm, V4 LPN said she forgot to disinfect the BP wrist manometer after each use, in between resident usage with disinfecting wipes. On 8/30/22 at 4:37pm, Informed V2 DON (Director of Nursing) of above observation, V2 said that the nurse should disinfect the BP wrist manometer after each use and in between resident use. Facility's policy on Cleaning &Sanitizing-Wheelchairs and other Medical Equipment: Purpose: to assure that devices are cleaned and sanitized on regular or as needed basis. Guidelines: Medical equipment/devices will be cleaned and sanitized weekly or more often if needed, when used by the same resident. Equipment/devices used by more than one resident will be cleaned and sanitized between each use. 5. Devices/equipment used for more than one resident shall be cleaned between each resident.

Based on observation, interview and record review the facility failed to follow its policy on reporting a resident with injury of unknown origin to IDPH (Illinois Department of Public Health). This deficiency affects one (R8) of three residents in the sample of 15 reviewed for Abuse Prevention and reporting program. Findings include: On 8/30/22 at 10:15am, Observed R8 in the dining room, up in high back wheelchair with mechanical lift sling underneath his seat. He is sleepy, alert and oriented x 1 and confused. Observed yellowish green discoloration on right above the right eyebrow with swelling. R8 unable to respond when asked what has happened to his head. Informed V2 DON (Director of Nursing) and V4 LPN (Licensed Practical Nurse) of observation. Both stated that he does not have any records of recent falls, or any incidents related to his right eyebrow discoloration. Showed to V4 LPN R8's discoloration above right eyebrow. V4 said that this is new and she did not notice it. V4 added that she is his regular nurse. V4 said that V8 CNA (Certified Nurse Assistant) is the CNA assigned to him. Showed to V8 CNA discoloration on R8 above the right eyebrow. V8 said that he is the regular CNA for R8, but he did not notice the discoloration. V8 denied any recent falls, or any incidents related to his discoloration. On 8/31/22 at 10:26am, follow up with V2 DON of R8's incident report of unknown injury and report to IDPH. V2 said that V4 LPN did the incident report and V3 Social Service Director (SSD) did the report to IDPH and initiated the investigation. Review R8's injury of unknown incident report completed by V4 LPN dated 8/30/22 indicated R8 noted to have quarter size yellow discoloration to the right side of the forehead. No report written and submitted to IDPH for R8 injury of unknown origin. On 8/31/22 at 10:45am, V3 SSD said any incident of injury of unknown origin will be reported to IDPH within 24 hours and we will initiate an investigation. The investigation needs to be completed within 5 days and final report need to be sent to IDPH. V3 said that he is responsible for reporting abuse incident allegations to IDPH. V3 said that he did not write the report and submit the initial investigation report of R8's injury of unknown origin to IDPH. V3 said that he was notified by V2 DON late in the afternoon yesterday (8/30/22) at around 5:30pm. Informed V3 that that the observation unknown injury (fading yellowish greenish discoloration on right upper eyebrow) was relayed both V2 and V4 at 10:15am yesterday (8/30/22). R8 is readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Most recent abuse assessment done on 6/30/22 indicated moderate risk for abuse. No care plan for risk for abuse. Facility's policy on Abuse Prevention and reporting indicates: Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. External Reporting: Initial reporting of allegations: When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and Department of Public Health's regional office shall be informed by telephone or fax. Public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported and is being investigated. The report shall include the following information, if known at the time of the report: 1. Name , age, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Type of abuse reported ( physical, sexual, neglect, verbal or mental abuse, misappropriation of resident property) 3. Date, time, location and circumstances of the alleged incident 4. Any obvious injuries or complaints of injury 5. Steps the facility has taken to protect the resident All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials ( including to the State Survey Agency and adult protective services where state las provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures.

Based on observation, interview and record review the facility failed to monitor, record and maintain the appropriate temperature of the medication refrigerator to ensure medication safety for R6 and R11. This deficiency affects 2 (R11 and R6) of 2 residents reviewed for Medication Storage of their medication. Findings include: On 8/30/22 at 9:39am, Checked medication room with V4 LPN (Licensed Practical Nurse). Observed refrigerator temp control log was not done at 3am as scheduled. V4 said that the night shift is the one monitoring the medication refrigerator temperature. V4 read the thermometer inside the refrigerator at 50F. V4 said that normal refrigerator temperature should be at 40F to 45F. V4 said that medications inside the refrigerator are the following: R6's [MEDICATION(S)] eye drops, Facility's TB test vial, R11's [MEDICATION(S)] 70/30, 2 sealed house stock insulin med boxes and 2 boxes of [MEDICATION(S)] medication kit. On 8/30/22 at 9:42am, Informed V2 DON (Director of Nursing) of above observation. V2 said that the night shift nurse is the one responsible for monitoring and recording the medication refrigerator temperature in the medication room. The normal refrigerator temperature is written in the temperature control log as 36F to 46F. Facility's policy on Medication Storage indicates: to ensure proper storage, labeling and expiration of medications, biological, syringes and needles. Guidelines: General Storage Procedures: 11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. 11.2 Refrigeration: 36F to 46F

Based on observation, interview and record review the facility failed to count and sign the shift change accountability record for the controlled substances. The facility also failed to keep the [MEDICATION(S)] medication (controlled substance scheduled IV medication) inside the double locked compartment for the controlled substance in the medication cart. This deficiency affects one (1) of one (1) medication cart reviewed for Controlled substances storage and handling. Findings include: On 8/30/22 at 9:26am, Checked medication cart with V4 LPN (Licensed Practical Nurse). Reviewed Narcotic/controlled binder. Observed shift change accountability record for controlled substances not signed for 1st shift (7-3 shift). V4 said that she did not count the narcotic medications with the night shift this morning. V4 said she forgot to count. V4 said that incoming and outgoing shift has to count the narcotic medication after they give endorsement. Observed several shifts for this month of August 2022 were not signed namely: 8/13, 8/28-1st and 2nd shift. When counting for controlled/narcotic medications with V4, observed R29's [MEDICATION(S)] 0.5mg medication card is not in the locked drawer for controlled medication storage. V4 said that controlled medication should be placed in the double locked medication drawer. V4 said she does not know why it was not in the locked drawer. On 8/30/22 at 9:42am, Informed V2 DON of above observation. V2 said that they only place controlled II substance medication in the narcotic/controlled locked medication drawer. V2 said that [MEDICATION(S)] is a controlled I substance and not placed in locked drawer. Informed V2 that other [MEDICATION(S)] medications for the other residents are placed in the locked controlled substance drawer. V2 did not responed. V2 said that outgoing and incoming nurses should count the narcotic/controlled medications before the start of shift each shift and signed the shift change accountability record. Facility's policy on Storage of controlled substances from Pharmacy vendor indicates: Medication classified by the Drug enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures: 2. Scheduled II through V medications and other medications subject to abuse or diversion ate stored in either a permanently affixed, double locked compartment separates from all other medications or in accordance with the state regulations. The access system to controlled medications is not the same as access system for other medications (e.g., the key that opens the compartment is different from the key that opens the medication cart). If a key system is used, the medication nurse on duty maintains possessions of the key to controlled substance storage areas. Back-up keys to all medication storage areas including those for controlled substances are kept by the DON of designee. 5. Unless otherwise indicated in a facility policy and or as required by the state regulations, the following will be performed: a. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by 2 licensed personnel and is documented. Facility's policy on Controlled Substances storage and handling indicates: Controlled substances (medications in schedule II, III, IV, V) have high abuse potential and may be subject to special handling, storage and record keeping. Procedure: 6. While the drug is in use at the facility, the nursing staff will maintain the count sheet and medication as follows: b. All controlled substances will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses. 4. The 2 nurses will sign the shift/shift-controlled substances count sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented.

Based on observation, interview and record review facility failed to ensure that bed rails are not used to restrain 4 out of 4 (R5, R10, R27 and R40) reviewed for restraints in a total sample of 12 residents. Findings Include: On 3/15/20 at 9:45 am, observed R10 in bed, asleep with left full side rail up (in use) and right side of bed against the wall. On 3/15/20 at 9:47 am, observed R40 in bed, asleep with bilateral upper and lower side rails up (in use) and bed in low position. On 3/15/20 at 9:50 am, observed R5 in bed with head of bed elevated, asleep with bilateral full side rails up (in use). On 3/15/20 at 9:55 am, observed R27 in bed with head of bed slightly elevated, asleep with bilateral full side rails up (in use). On 3/15/20 at 10:00 am, verified with V5 CNA (Certified Nursing Assistant) that R27 bilateral full side rails up. V5 stated We pull the side rails up to prevent R27 from falling off the bed. We pull the side rails up on both side when R27 is in bed because R27 is at risk for fall. On 3/15/20 at 10:15am, V4 (Nurse) stated R5, R10 and R40 are at risk for fall due to their mentation, we use their side rails to prevent them from falling. Side rails up during nights and the CNAs probably did not get a chance to lower the side rails down earlier because they are providing care to other residents. On 3/16/20 at 11:00am, V2 DON (Director of Nursing) stated We are restraint free facility. We do not have any residents on restraint. We don't have any residents with order to have and use bilateral side rails while in bed. Side rails are use during repositioning of the patient, but after providing care, side rails should be lowered down. Bilateral use of side rails is a form of restraint. Residents can hurt themselves more if side rails are use while in bed. If we really feel the resident would benefit after assessment, then we will call the doctor to get an order and get consent from the resident's family. I already talked to V4 and in-serviced her about restraint and side rail use. To only to use side rails when doing patient care and lower the side rail back down after care. Record reviewed. R5's Bed Rail/Assist Evaluation (dated 3/2/20) reads in part: Evaluation Factors #6: Has the resident requested that the side rails not be lowered during the night? Answer is NO. Interventions: Side rail DO NOT appear to be indicated at this time, answer is YES. Recommendations: NONE (no side rails). R10's Bed Rail/Assist Evaluation (dated 1/2/20) reads in part: Evaluation Factors #6: Has the resident requested that the side rails not be lowered during night? Answer is NO. Interventions: Side rail DO NOT appear to be indicated at this time, answer is YES. Recommendations: NONE (no side rails). R27's Bed Rail/Assist Evaluation (dated 2/12/20) reads in part: Evaluation Factors #6: Has the resident requested that the side rails not be lowered during night? Answer is NO. Interventions: Side rail DO NOT appear to be indicated at this time, answer is YES. Recommendations: NONE (no side rails). R40's Bed Rail/Assist Evaluation (dated 1/20/20) reads in part: Evaluation Factors #6: Has the resident requested that the side rails not be lowered during night? Answer is NO. Interventions: Side rail DO NOT appear to be indicated at this time, answer is YES. Recommendations: NONE (no side rails). Current orders in Physician order [REDACTED]. R5, R10, R27 and R40's charts were reviewed and there is no noted CONSENT for any type of restraints. Side rail Policy (no date) reads: It is the policy of this facility to identify, assess and develop strategies to control the risk of resident falling and causing harm to themselves. The facility will accomplish this goal through assessing the resident. Side rail assessment is done upon admission, readmission, quarterly and as needed. Physical Restraint Policy (no date) reads in part: Physical restraints cannot be used without informed consent. There must be documented comprehensive assessment in the residents' clinical record for the need of physical restraint.

Based on interviews and record reviews, the facility failed to provide increased supervision and assistance to an agitated resident during incontinence care. This was for 1 of 3 residents (R1) reviewed for incontinence care in a sample of 11. This failure resulted in R1, who was identified as requiring assistance of two staff when agitated, receiving care by only one staff person, which resulted in R1 suffering a distal right humeral fracture. Findings Include: The Facility's Resident Admission Information Sheet documents that R1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Facility's Preliminary Incident Investigation Report documents that on 3/2/13 at 11:20am E3, Certified Nursing Assistant (CNA) was turning R1 to the right side while changing resident in bed and heard a "pop." E2, Director of Nursing (DON) was called to the room for an assessment of the resident ' s status. E2 determined that R1 sustained an injury to the right arm and R1 was sent out to the hospital for further evaluation and treatment. The Emergency Department Documentation dated 3/2/13 at 12:44pm documents that R1 presented with a right arm deformity and the x-ray results at 3:52pm documents the injury as a severely angulated fracture of the distal right humeral shaft. The Facility's Final Incident Investigation Report documents that R1 has behaviors of constant movement, flapping or thrusting arms, bobbing head, and grabbing people or items, and R1 gets overly excited when people are in close proximity. The Facility's interview with E3, CNA on 3/3/13 documents that R1 was excited, moving around, and using arms grabbing and flapping, and E3 proceeded with bed mobility and incontinence care without assistance. During an interview on 3/8/13 at 10:30am, E3 (CNA) stated "(R1) was swinging her arms and grabbing at me. (R1) is usually a one person assist but requires two people when there are behaviors. We are taught to use our judgment when there are behaviors and to get assistance when needed." E3 did not ask for assistance with R1 and continued with the care. During an interview on 3/7/13 at 12:10pm, E2 (Director of Nursing) stated R1's mood can be unpredictable. R1 is a 1 to 2 person assist depending on R1's mood, E3 was told to call for help if needed but E3 did not, and the CNA's decide if they need assistance based on R1's behavior, if R1 was fidgeting and antsy E3 should have called for assistance. During an interview on 3/8/13 at 11:05am Z1 (physician) stated " the fracture was an angulated fracture, it was a 90 degree angle where the bone was broken and turned as well. The arm presented with some bruising and it was swollen. This could have happened if maybe R1's arm got stuck in the side rails while being turned. There needs to be a better way of turning R1 and maybe from this point the facility should be looking at a two person assist with repositioning. " The Minimal Data Set ((MDS) dated [DATE] indicates that R1 is a two person assist with personal hygiene care. The Facility's Restorative Rehab Progress Notes dated 2/1/13 documents that the quarterly assessment was completed and R1 requires total assistance of one to two people depending on her mood with her dressing/grooming and transfers due to her behavioral issues such as grabbing/hitting staff during care. The Facility's care plan was not individualized with interventions to address R1's impulsive behaviors. During an interview on 3/27/13 at 10:05am E2 stated " There was not care a plan in place to address R1's behaviors and need for assistance with care, I have since formulated a care plan for all of my residents and CNA's to follow. "