Every finding on record at Shelbyville Healthcare & Senior Living

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from misappropriation of property by a staff member for 21 of 21 residents (R1-R21) reviewed for misappropriation in the sample list of 21. This failure resulted in $12,091.78 being misappropriated from R1 through R21's pooled resident trust fund. All 21 residents affected are vulnerable with Dementia and/or Mental Illness/Disability diagnoses. A reasonable person would likely suffer psychosocial harm, such as emotional distress and lack of trust as a result of misappropriation of funds. The Past Noncompliance occurred from 9/30/25 to 4/29/26. The Findings Include:The Immediate Jeopardy began on 9/30/25 when V4 (Business Office Manager) began writing checks for cash without resident approval. V1 (Administrator) was notified of the Immediate Jeopardy on 5/6/26 at 2:40PM. The facility presented an abatement plan to remove the immediacy on 5/6/26. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 5/7/26, and the survey team accepted the abatement plan on 5/7/26. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 4/29/26 and the deficient practice corrected on 4/29/26 prior to the start of the survey and was therefore Past Noncompliance. The Facility's Identifying Exploitation, Theft and Misappropriation of Resident Property Policy dated April 2021 documents Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The Facility's Management of Resident Funds Policy dated March 2021 documents the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident, and copies of all financial transactions are filed in the resident's permanent records.The Police Department witness statement dated 4/28/26 documents V3 (Regional Director of Operations) stated she was notified by V1 (Administrator) about concerns with discrepancies in the resident trust fund accounts, specifically involving cash withdrawals and lack of supporting documentation. V4 (Business Office Manager) was involved in transactions that could not be accounted for. V4 was suspended pending an investigation and a full audit was initiated.The facility interview of V4 (Previous Business Office Manager) dated 4/22/26 documents V4 has residents sign a form and then V4 takes cash out. V4 states R15's money was used to purchase a television that R15 does not currently have in R15's possession. V4 confirmed she used resident trust money for other people, and that she did not have receipts for all monies spent. V4 stated she could not recall where most of the cash requested was spent.The facility final report dated 5/5/26 documents during a routine audit of the resident trust fund account that started the week of 4/22/26, discrepancies were identified among transactions reviewed and compared to receipts and cash requests. Transactions that were reviewed spanned a period from 9/30/25 to 4/15/26. The full audit was completed, and findings were prepared for the report on 4/28/26. Due to the discrepancies noted, a report was filed with the state surveying agency, and a full investigation was initiated. Residents and POAs (Power of Attorney)/responsible parties were notified of the discrepancies and restitution on 4/29/26. Several of the 28 reviewed transactions did not have corresponding receipts on file. Several disbursements could not be matched to fund requests submitted through the home office or had names of residents without funds in the resident trust. The facility business office manager was unable to locate or provide receipts for several recent transactions. She did provide the resident binders she had in her office with some transaction forms, previous logs of transactions and quarterly statements. She verbally stated that she was resigning at that time. The cash box was counted at the start of the audit and had $226 in it. The full audit showed that a total of $12,091.78 could not be supported by receipts or verified spending.R1's admission Record dated 5/4/26 documents R1 has medical diagnoses that include Multiple Personality Disorder, Anxiety Disorder, and bipolar disorder. The Facility Resident Trust Audit, undated, documents R1 had 11 cash transactions with $1,385.13 unaccounted for.R2's admission Record dated 5/4/26 documents R2 has medical diagnoses that include Multiple Sclerosis, Alzheimer's Disease, and Dementia. The Facility Resident Trust Audit, undated, documents R2 had three cash transactions with $946.39 unaccounted for.R3's admission Record dated 5/4/26 documents R3 has medical diagnoses that include Emphysema, Epileptic Syndrome, Major Depressive Disorder, and Anxiety. The Facility Resident Trust Audit, undated, documents R3 had four cash transactions with $380.00 unaccounted for.R4's admission Record dated 5/4/26 documents R4 has medical diagnoses that include Cerebral Palsy and Schizoaffective Disorder. The Facility Resident Trust Audit, undated, documents R4 had eight cash transactions with $918.97 unaccounted for.R5's admission Record dated 5/4/26 documents R5 has medical diagnoses that include Major Depressive Disorder, and absence of right leg above the knee. The Facility Resident Trust Audit, undated, documents R5 had four cash transactions with $433.18 unaccounted for.R6's admission Record dated 5/4/26 documents R6 has medical diagnoses that include Major Depressive Disorder, and Vascular Dementia. The Facility Resident Trust Audit, undated, documents R6 had one cash transaction with $60.00 unaccounted for.R7's admission Record dated 5/4/26 documents R7 has medical diagnoses that include Major Depressive Disorder and Alzheimer's Disease. The Facility Resident Trust Audit, undated, documents R7 had 11 cash transactions with $1029.36 unaccounted for.R8's admission Record dated 5/4/26 documents R8 has medical diagnoses that include Major Depressive Disorder and Dementia with Behavioral Disturbances. The Facility Resident Trust Audit, undated, documents R8 had four cash transactions with $227.00 unaccounted for.R9's admission Record dated 5/4/26 documents R9 has medical diagnoses that include Depression and Anxiety Disorder. The Facility Resident Trust Audit, undated, documents R9 had one cash transaction with $100.00 unaccounted for.R10's admission Record dated 5/4/26 documents R10 has medical diagnoses that include Major Depressive Disorder, Alzheimer's Disease, and Dementia. The Facility Resident Trust Audit, undated, documents R10 had two cash transactions with $300.00 unaccounted for.R11's admission Record dated 5/4/26 documents R11 has medical diagnoses that include Vascular Dementia and Anxiety Disorder. The Facility Resident Trust Audit, undated, documents R11 had one cash transaction with $50.00 unaccounted for.R12's admission Record dated 5/4/26 documents R12 has medical diagnoses that include Schizophrenia and Anxiety Disorder. The Facility Resident Trust Audit, undated, documents R12 had one cash transaction with $60.00 unaccounted for.R13's admission Record dated 5/4/26 documents R13 has medical diagnoses that include Dementia and Moderate Intellectual Disability. The Facility Resident Trust Audit, undated, documents R13 had seven cash transactions with $933.24 unaccounted for.R14's admission Record dated 5/4/26 documents R14 has medical diagnoses that include Dementia and Hallucination Disorder with Violent Behaviors. The Facility Resident Trust Audit, undated, documents R14 had one cash transaction with $85.00 unaccounted for.R15's admission Record dated 5/4/26 documents R15 has medical diagnoses that include severe Dementia with Psychotic Disorder and Alzheimer's Disease. The Facility Resident Trust Audit, undated, documents R15 had 12 cash transactions with $2580.00 unaccounted for.R16's admission Record dated 5/4/26 documents R16 has medical diagnoses that include Cerebral Palsy and Profound Intellectual Disability. The Facility Resident Trust Audit, undated, documents R16 had one cash transaction with $200.00 unaccounted for.R17's admission Record dated 5/4/26 documents R17 has medical diagnoses that include Dementia and Alzheimer's Disease. The Facility Resident Trust Audit, undated, documents R17 had ten cash transactions with $1220.00 unaccounted for.R18's admission Record dated 5/4/26 documents R18 has medical diagnoses that include Psychoactive Substance Abuse and Hepatic Failure. The Facility Resident Trust Audit, undated, documents R18 had two cash transactions with $813.51 unaccounted for.R19's admission Record dated 5/4/26 documents R19 has medical diagnoses that include Severe Dementia with agitation and Epileptic Seizure Disorder. The Facility Resident Trust Audit, undated, documents R19 had one cash transaction with $60.00 unaccounted for.R20's admission Record dated 5/4/26 documents R20 has medical diagnoses that include Parkinsonism and Depression. The Facility Resident Trust Audit, undated, documents R20 had two cash transactions with $160.00 unaccounted for.R21's admission Record dated 5/4/26 documents R21 has medical diagnoses that include schizoaffective disorder and Major Depressive Disorder. The Facility Resident Trust Audit, undated, documents R21 had one cash transaction with $150.00 unaccounted for.On 5/5/26 at10:15AM V5 (Regional Administrator) stated that V4 (Previous Business Office Manager) started working with the resident trust fund in September of 2025 until she resigned on April 28, 2026, during questioning of missing money. V5 stated V4 was forging resident signatures and altering requested amounts with whiteout.On 5/5/26 at 1:13PM, R1 was very tearful stating she isn't sure who to trust now.The Immediate Jeopardy that began on 9/30/25. The immediacy was removed on 4/29/26 when the facility secured the facility cash box and transferred $12,091.78 back into the pooled resident trust fund. The deficient practice was corrected on 4/29/26 after the facility took the following actions:On 4/28/26 Access to Resident Funds and the Cash Box by V4 (Previous Business Office Manager/BOM) was removed by V5 (Regional Director) and V4 resigned from position which was immediately updated by V5 in facility payroll system. On 4/28/26 V3 (Regional Director of Operations) reported concerns with discrepancies in the resident trust fund accounts, specifically involving cash withdraws and lack of supporting documentation to the police.On 4/28/26 a dual verification/signature requirement was implemented for all trust fund transactions requiring two staff members to sign for all transactions. These transactions will then be verified by V16 (Regional Business Office Manager).On 4/28/26 resident fund access was restricted to designated personnel including the Administrator, the Facility Business Office Manager, the Regional Business Office Manager (RBOM) and the regional directors.On 4/28/26, V16 (RBOM) implemented a new facility procedure for trust fund management processes that includes implementation of a dual verification/signature requirement for any withdrawals, and a requirement that all transactions be fully documented with supporting receipts prior to reconciliation.On 4/28/26 all the cash box funds were maintained in a secured, controlled location with limited access in a locked closet within the administrator's office by V5 (Regional Director).On 4/28/26 an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was conducted to discuss corrective actions to implement as well as steps to identify other potential residents impacted by deficient practice.On 4/28/26 V3 (Regional Director of Operations) conducted an in-service with all management staff who handle resident funds on financial exploitation, failures, new expectations, and identifying and reporting abuse.On 4/28/26 V1 (Administrator) in-serviced all staff on types of nursing home abuse and reporting requirements. Badge cards were provided that list the types of abuse and instructions to call the administrator immediately with any abuse concerns.On 4/28/26 V1 (Administrator) conducted an in-service with all staff on Financial Abuse.On 4/28/26 the facility policy on management of resident's personal funds, deposit of funds and limitations of charges to personal funds was reviewed and new procedures were implemented by V5 (Regional Director).On 4/28/26 V3 (Regional Director of Operations) completed the first audit on the resident trust fund account for compliance with newly implemented procedures which include verification of withdrawals and receipts, ledger accuracy, and reconciliation. These audits with be completed twice a week for four weeks and then monthly for four months.On 4/29/26 V1 (Administrator), and V16 (RBOM) conducted a resident trust reconciliation.On 4/29/26 at 11:27AM the facility transferred $12,091.78 from facility operating account into the pooled resident trust checking account.On 5/1/26 the facility conducted a follow up Ad Hoc QAPI to confirm new processes and completion of education.On 5/11/26, V5 (Regional Director) provided audits completed on 5/1/26, 5/5/26, 5/7/26, and 5/8/26 for resident trust account.

Based on observation, interview and record review the facility failed to ensure Narcotic medications are kept under a double lock system, failed to ensure medications are stored properly and failed to ensure medications remain in a locked environment. These failures have the potential to affect all 38 residents residing in the facility. Findings include: The facility daily midnight census dated 2/17/26 documents 38 residents reside in the facility. 1.R6's Minimum Data Set (MDS) dated [DATE] documents R6 as severely cognitively impaired. R6's Medication Administration Record (MAR) dated February 2026 documents Physician orders to administer Divalproex Sodium Extended Release (ER) 500 milligrams (mg) daily at 8:00 PM, Rosuvastatin 40 mg daily at bedtime, Mirtazapine 15 mg daily at 7:00 PM, Glipizide 5 mg every morning at 7:00 AM, Apixaban (anticoagulant) twice daily at 7:00 AM and 7:00 PM, Metformin Hydrochloride (HCL) 500 mg twice daily at 8:00 AM and 8:00 PM, Benadryl Allergy Extra Strength 50 mg three times per day at 8:00 AM, 2:00 PM and 8:00 PM, Gabapentin 100 mg three times per day at 7:00 AM, 2:00 PM and 7:00 PM. On 2/17/26 at 11:00 AM, R6 was sitting on the side of her bed. A clear medicine cup with nine various medications and a blue cup of water was sitting on R6's bedside dresser. On 2/17/26 at 11:10 AM, V2 (Director of Nurses/DON) displayed all nine medications found unattended in R6's room to show that three of the medications in R6's medicine cup were one tablet each of Remeron, Divalproex, Rosuvastatin which are all prescribed to administer in the evening and one tablet each of Eliquis, Metformin, Gabapentin, Glipizide and two tablets of Benadryl which are all to be administered in the morning. On 2/17/26 at 11:20 AM, V2 (DON) stated V3 (Licensed Practical Nurse/LPN) was passing medications to residents earlier this morning when V3 had to leave the facility abruptly. V2 stated she took over passing medications for V3. V2 stated she did not know if V2 or V3 passed R6 her morning medications. V2 stated R6 is known to hoard medications. V2 stated the nurses do not stay with R6 as they should, then R6 will take some of her medications and not others. V2 stated the reason R6 had some of her evening medications along with some of her morning medications is that the nurse last night (2/16/26) and the morning nurse (2/17/26) did not stay with R6 so she (R6) 'just mixed them up because she hoards them'. On 2/19/26 at 12:15 PM, V3 (LPN) stated she had started to pass one wound liquid supplement on another hall for another resident on 2/17/26 when she began to feel ill. V3 stated she left immediately after that. V3 stated she did not pass any medication for any resident on the hall that R6 resides on. On 2/19/26 at 8:00 AM, V1 (Administrator) stated the nurses should stay with every resident to ensure all medications are taken. V1 stated R6 is not cognitively intact enough to administer her own medications. 2.On 2/19/26 at 7:10 AM, a facility medication cart was sitting in a resident hallway. This medication cart was unlocked. V13 (LPN) walked out of a resident room and stated Oh. That is my cart. I meant to lock it up but forgot. V13 opened the main medication drawer without a key and found that the lid to the narcotic box was not locked. V13 stated she had just opened the narcotic box for the previous resident she administered medications to and closed the narcotic box. V13 stated she thought the narcotic box would close/lock when the main drawer was closed but it did not. V13 confirmed the medications were not stored properly and the narcotics were not locked as they should be. On 2/19/26 at 11:28 AM, V14 (LPN) unlocked the narcotic box on a separate medication cart and then closed the main medication drawer. V14 then opened the same medication drawer to find that the narcotic box was not locked in place. V14 stated it is important to always lock up all the medications but especially the narcotics. On 2/19/26 at 1:15 PM, V12 (Regional Registered Nurse/RN) stated she did not know that the medication carts were not locking correctly. V12 stated she was going to call the pharmacy to have them fix and/or replace the carts. The facility policy titled Medication Labeling and Storage revised February 2023 documents compartments including but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes containing medications and biologicals are locked when not in use. Controlled substances and other drugs subject to abuse are separately locked in permanently affixed compartments. 3. On 2/17/26 at 10:20 AM, a medicine cup containing six pills were sitting on a bedside table in R47's room. This cup of medication was unsecured and accessible to others. R47 who was lying in the bed stated he did not know what kind of pills were in the cup. On 2/17/26 at 10:25 AM, V2 (Director of Nursing) stated she handed the cup of medications to R47 and left the room. V2 stated V2 did not ensure that R47 took the medication before leaving the room. The facility's Labeling and Medication Storage policy dated February of 2023 documents all medications will be stored in locked compartments.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 38 residents in the facility. Findings include:On 2/17/2026 at 9:35AM, V10 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V10 reported being the full-time manager of the facility food service (person in charge) and reported not being a clinically qualified Certified Dietary Manager (also known as Certified Food Protection Professional) or having equivalent training. V10 denied meeting the State of Illinois standards to be a food service manager or dietary manager (required in states that have their own established standards to be a food service manager or dietary manager (483.60(a) (2)ii)). V10 reported only completing a two-day course on food service sanitation (Certified Food Protection Manager) which did not include any instruction on clinical nutrition. V10 denied having any qualifications in clinical nutrition. V10 reported the facility dietician only works for the facility remotely on a consulting basis, part-time, and does not work directly in the facility.V10 denied:-being a dietician.-being a certified dietary manager.-having an associate's or higher degree in food service management or in hospitality.-having two or more years of experience in the position of director of food and nutrition services in a nursing facility setting.-being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition. -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician. -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. The Facility assessment dated [DATE] documents the facility will employ a Dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services. On 2/17/2026 at 9:52AM, V10 reported food prepared in the kitchen is available for all residents in the facility to eat. The facility Midnight Census Report dated 2/18/2026 documents 38 residents reside in the facility.

Based on observation, interview, and record review the facility failed to track and monitor employee illnesses. This failure had the potential to affect all 38 residents that reside in the facility.Findings include: On 02/18/2026 at 11:20 AM, V3 (Infection Preventionist) opened an Infection Control binder which contained resident infection logs and facility illness graphs. This binder did not contain logging of staff illness. V3 stated the facility does not document the signs and symptoms the employee is experiencing when sick or the type of illness if known. V3 stated she is only aware of nursing staff illnesses due to call offs. V3 showed a schedule where call offs were circled. V3 stated she is not aware of illnesses for other departments who work in the facility. V3 stated the facility does not formally track or monitor employee illnesses. At that time, V2 (Director of Nursing) grabbed a binder off a shelf, opened the binder, and flipped to a list from September of 2025. V2 stated this is a list of call offs of nursing staff for September. This list documented staff names and dates but did not document the type of illness or the signs and symptoms of illness the staff was experiencing. V2 confirmed that this list only contained call offs for September for the nursing staff and that this list did not document the type of illness. V2 and V3 stated this was the only documentation they had for tracking and monitoring of employee illnesses. On 2/19/26 at 1:30 PM, V1 (Administrator) stated V3 should be monitoring and tracking all staff illness and/or signs and symptoms of illness. The facility's Communicable/Contagious Diseases, Employee policy dated December of 2024 documents the facility's infection preventionist is responsible for the oversight of the staff illnesses. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 2/17/26 signed by V12 (Regional Registered Nurse) documents there are 38 residents residing in the facility.

Based on interview and record review the facility failed to offer the staff COVID vaccinations and document the staff's COVID vaccination status. This failure has the potential to affect all 38 residents residing in the facility. Findings include: On 02/18/2026 at 11:20 AM, V3 (Infection Preventionist) stated the facility does not offer the staff COVID vaccinations or keep track of the staff's vaccination status. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 2/17/26 signed by V12 (Regional Registered Nurse) documents there are 38 residents residing in the facility.

Based on interview and record review the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level I for two of two residents (R6, R13) reviewed for PASRR's in a sample list of 29 residents. Findings Include: 1. R13's Medical Diagnoses List dated February 2026 documents R13 was admitted to the facility on [DATE] and had a new diagnosis of Major Depression added in November 2025. R13's Preadmission Screening and Resident Review (PASARR) Level II screening dated 12/13/24 documents a Level II screening is not indicated because there is no evidence of a serious behavioral health condition (Serious Mental Illness) however, if changes occur or new information refutes those findings the facility must submit a new Level I screening. On 3/23/25 at 9:25 AM, V12 (Regional Clinical Nurse) confirmed R13's Preadmission Screening and Resident Review (PASARR) Level II was completed on 12/13/24 and a new mental illness diagnosis was added in November 2025 so a new PASARR Level I assessment should have been completed. 2.The facility policy titled admission Criteria revised March 2019 documents all new admissions and readmissions are screened for Mental Disorders (MD), Intellectual disorders (ID) or related disorders (RD) per the Medicaid Preadmission Screening and Record Review (PASRR) process. R6's undated Face Sheet documents R6 admitted to the facility on [DATE]. R6's Electronic Medical Record (EMR) documents medical diagnoses as Psychotic Disorder with Hallucinations, Violent Behavior, Psychotic Disturbance, Mood disturbance, Anxiety, Depression and Major Depressive Disorder. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as severely cognitively impaired. R6's Electronic Medical Record (EMR) does not document a Level I or Level II Preadmission Screening and Resident Review (PASRR) being completed. R6's Interagency Certification of Screening Results dated 1/26/2024 documents R6's screening indicated supportive living services are appropriate. On 2/18/26 at 3:30 PM, V12 (Regional Clinical Nurse) stated the facility did request a Level I PASRR but the organization that completes all the facilities PASRR's withdrew the request. V12 stated the facility should have followed up to see why the PASRR testing date was withdrawn and obtained a Level I PASRR for R6 who probably has some disabilities.

Based on observation, interview, and record review the facility failed to perform hand hygiene and sanitize a needleless access device prior to flushing a peripheral inserted central catheter for one of one resident (R53) reviewed for infection control on the sample list of 45 residents. Findings include:On 2/19/26 at 9:58 AM, a beeping noise was heard from R53's room. At that time, V2 (Director of Nursing) grabbed and applied gloves when entering the room. V2 did not wash or sanitize her hands before putting on the gloves. After entering the room, while wearing the same gloves, V2 pushed a button on R53's intravenous pump to stop the beeping. V2 then flushed R53's peripheral inserted central catheter (PICC) with a prefilled saline flush and then flushed the catheter with a heparin flush. V2 did not sanitize the needleless access device prior to flushing the PICC line. When finished, V2 removed the gloves and walked out of the room without sanitizing her hands. On 2/19/26 at 10:05 AM, V2 stated hand hygiene should be performed prior to putting on gloves. V2 also stated the needleless access device should be sanitized before flushing a PICC line with saline or heparin.The facility's Central Venous Catheter Care and Dressing Changes Policy dated 2001 documents a procedure to perform hand hygiene before applying gloves and to disinfect the needleless access device before flushing the PICC line.

Based on observation, interview and record review the facility failed to provide a minimum of 80 square feet of floor space per resident bed. This failure affects 33 residents (R2-R6, R8, R10, R13-R20, R22-R30, R32-R35, R37, R38, R40, R49 and R50) out of 45 residents in the sample list. Findings include:The facility daily Midnight Census Report dated 2/17/26 documents 33 residents (R2-R6, R8, R10, R13-R20, R22-R30, R32-R35, R37, R38, R40, R49 and R50) reside in the undersized rooms. Historical room size documentation and actual measurements demonstrate the facility's rooms 101 through 111, 201 through 210, and 301 through 311 do not provide 80 square feet per resident bed. Rooms 101 through 111 and 201 through 210 provide 73 square feet per resident bed, and rooms 301 through 311 provide 78 square feet per resident bed.On 2/19/26 at 7:10 AM, R35 and R29 both stated they are roommates. R35 and R29 both stated their room is too small. R29 stated it would be nice to have a larger room to have more room to move around.On 2/19/26 at 7:30 AM, R13 and R14 both stated they are roommates. R13 and R14 both stated they do not have enough room for their belongings. R13 stated both R13 and R14 'have a lot of stuff' that there is nowhere to put away. R13 stated We have to just stack our stuff up because there isn't any room for extra tables since the rooms are so small. On 2/17/26 at 11:00 AM, V1 (Administrator) stated the facility has rooms that are not regulatory size. V1 stated any of the residents could be housed in any of the rooms. V1 stated all of 100, 200 and 300 halls rooms are too small. V1 stated the 400 hall is typically reserved for short term residents but many times the 400 hall is empty because we like to keep everybody together on the same halls. On 2/18/26 at 2:00 PM, V12 (Regional Registered Nurse) stated the facility has always got the room size tag due to the facility has rooms that are too small.

Based on interview and record review the facility failed to provide timely treatment of a resident's left lower back and left hip skin tears. The facility also failed to update the resident's skin care plan with the facility acquired skin tears. These failures affected one (R3) out of three residents reviewed for Accidents in a sample list of three residents. Findings include:R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 is dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R3's Skin Integrity Care plan initiated 2/17/25 does not include updated interventions for R3's Left Lower Back and Left Hip skin tears obtained at facility on 7/3/25. R3's Physician Order Set (POS) dated July 2025 documents a physician order starting 7/7/25 to monitor R3's Left Hip skin tear for decrease in size/severity and signs and symptoms (s/s) of infection (increased warmth, drainage, smell, decreased function) daily until healed. This same POS documents a physician order starting on 7/10/25 with no end date to apply Zinc cream every shift to R3's Left Hip skin tear. This same POS documents a physician order starting 7/7/25 and ending 7/10/25 to cleanse R3's Left Lower Back skin tear and cover with dry dressing daily and as needed. R3's Wound Assessment and Plan dated 7/3/25 documents R3's Left Lower Back skin tear as measuring 4.0 centimeters (cm) long by 4.0 cm wide by 0.1 cm deep with an onset date of 7/3/25. This same assessment documents R3's Left Hip skin tear as measuring 4.0 cm long by 1.6 cm wide by 0.1 cm deep with an onset date of 7/3/25. This same wound assessment documents physician orders to cleanse R3's Left Hip and Left Lower Back skin tears, cover with a dry dressing daily and as needed. R3's Treatment Administration Record (TAR) dated July 2025 documents R3's treatments for skin tears starting 7/7/25. There is no physician orders documented on R3's TAR prior to 7/7/25 for the treatment of R3's skin tears. On 8/1/25 at 12:15 PM V9 (Wound Nurse/Licensed Practical Nurse/LPN) stated R3 obtained his Left Lower Back and Left Hip skin tears at the facility. V9 stated she first noted R3's two skin tears on 7/3/25 when rounding with V10 (Wound Physician Assistant/PA). V9 stated she received orders for treatment on 7/3/25 but did not enter V10's verbal orders until 7/7/25 when she received V10's written orders. V9 (Wound Nurse/LPN) stated she should have entered R3's wound treatment orders on 7/3/25. V9 stated R3's two skin tears were caused by staff pulling on R3's incontinence brief or linens too hard when providing incontinence cares causing a shearing effect. V9 stated she should have completed an incident report or risk management but did not. V9 stated R3's care plan should have been updated with his two new facility acquired skin tears to help prevent further incidents. The facility policy titled Skin Condition Monitoring revised January 2018 documents upon notification of a skin lesion wound, or other skin abnormality, the nurse will assess and document the findings in the nurses' notes and complete the Quality Assurance (QA) form for Newly Acquired Skin Condition. The nurse will obtain a treatment order that includes the type of treatment, location of area to be treated, frequency of how often treatment is to be performed, how area is to be cleansed and stop date if needed. Any skin abnormality will have a specific treatment order until area is resolved. The facility will provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. The facility policy titled Preventative Skin Care revised January 2018 documents staff will practice care in moving and lifting residents, prevent shearing forces during moving and transfers, prevent pulling resident across the sheets and avoid scratches, bruises and skin irritation.

Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects four of four residents (R1, R2, R3, R4) reviewed for abuse in a sample list of four residents. Findings include: 1. The facility policy titled Abuse Prevention Program with revision date of 11/2016 documents the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and 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 mistreatment, exploitation, neglect or abuse of our residents. The same policy documents residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately be evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. R2's undated Face Sheet documents medical diagnoses of Cerebral Infarction, unspecified and Unspecified Dementia, Moderate with Agitation. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 requires a wheelchair for mobility. R1's undated Face Sheet documents medical diagnoses of Parkinsonism, unspecified, Major Depression Disorder and Anxiety Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired. This same MDS documents R1 requires a wheelchair for mobility. R1's Care Plan dated 4/28/25 and revised on 5/5/25 documents Behavior: R1 is/has the potential to be physically and verbally aggressive toward staff and residents related to Dementia and poor impulse control. Interventions on R1's care plan include If agitation continues take resident to a calm, quiet area and turn TV on, date initiated 4/28/25 and When R1 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 5/14/25 at 8:10 AM R1's Progress notes documented by V2 (Previous Director of Nurses/DON), state R1 had an aggressive event this morning and R1 was taken to the dining room for breakfast to try to let R1 calm down. R2 was wheeling herself to the kitchen serving window and was headed towards R1's table, which caused R1 to become upset and more agitated and when R2 was close enough to the table R1 reached out and grabbed R2's hand and slammed R2's hand down onto the table. On 6/22/25 at 1:05 PM V6 (Certified Nurse Assistant/CNA) stated in interview I was sitting at the table feeding another resident when (R1) was placed at the table. (R2) was wheeling herself to the kitchen serving window to get a drink and (R1) became very agitated when he saw her move toward the table, when (R2) was close enough (R1) grabbed her hand and slammed it down on the table. I immediately got up and asked very calmly for (R1) to please let (R2's) hand go and (R1) did. I ask (R2) if she was hurt and (R2) stated no and went up to the serving window to get a drink. V6 stated she reported the incident to the charge nurse. On 6/22/25 at 1:45 PM V4 (Social Service Designee) stated I am usually the one who takes (R1) to another place in the building for (R1) to calm down. When I heard they took (R1) to the dining room I did not understand why because we are to take (R1) to a calm area, not a noisy one like the dining room. On 6/22/25 at 2:15 PM V1 (Administrator) stated (R1) had a medication change that week and I believe it made (R1) more agitated than usual. (R1) was transferred to the ED (Emergency Department) for evaluation of medication but the ED sent (R1) right back and gave (R1) a shot of Haldol (antipsychotic) for his aggression. 2. The Facility Incident Report dated 5/28/25 describes a resident-to-resident incident taking place on 5/21/25 at 7:30 PM. The Incident Report documents R4 was walking toward R3's table and R3 struck R4 on the hand because R4 was walking toward the table. R3's MDS (Minimum Data Set) dated 6/5/25 documents R3 is cognitively impaired and can walk with assistance. R3's Care Plan dated 5/22/25 documents the following diagnoses for R3: Psychotic Disturbance with Mood Disturbance, Unspecified Dementia Moderate with Behavioral Disturbance and Psychotic Disorder with Hallucinations. R3's Care Plan addresses R3's issues with others approaching her area around the table R3 sits at. The Care Plan documents interventions to implement when R3 becomes aggressive with residents or staff. R4's MDS dated [DATE] documents R4 as being cognitively impaired and walks about the facility. R4's Care Plan revision date of 5/28/25 documents the following diagnoses for R4: Unspecified Dementia, Unspecified Severity without Behavioral Disturbances, Psychotic Disturbance, Mood Disturbances and Anxiety. The Care Plan addresses R4 as having wandering behaviors and directs staff to keep R4 busy so R4 will not wander about the facility into other resident's rooms. On 6/22/25 at 1:00PM V1 (Administrator) stated they are contacting R3's family to have a meeting about R3's aggressive behavior toward residents and staff. V1 stated the new intervention is to have a staff member available whenever R3 goes to the dining room.

Deficiencies at this level require more than one deficiency practice statement. A. Based on interview and record review the facility failed to transcribe and implement physician ordered wound treatments, failed to ensure wound supplies were provided and treatments were completed as ordered. The facility failed to accommodate a request for physician ordered wound treatments to be supplied or changed to an alternative treatment. The facility also failed to notify the provider of the facility changing the dressing orders, not transcribing/implementing Wound Physician Assistant (PA) orders, and not notifying the Wound PA of a resident request to change wound dressing orders for one (R1) resident out of five residents reviewed for wound care in a sample list of five residents. R1 experienced pain, embarrassment and worsening of his bilateral extremity wounds resulting in a 15-day hospitalization for the treatment of his BLE wounds and infection. B. Based on observation, interview, and record review the facility failed to assess, monitor, notify the physician of a wound and failed to obtain treatment orders. The facility also failed to prevent cross contamination during wound care for one (R2) resident out of five residents reviewed for wound care in a sample list of five residents. Findings include: A. R1's undated Face Sheet documents admitted to the facility on [DATE] and lists R1's medical diagnoses as Lymphedema, Chronic Venous Hypertension with ulcer of lower extremity, Diabetes Mellitus Type II, Parkinson's Disease, Cellulitis of Right and Left Lower Limbs, Morbid Obesity, Chronic Kidney Disease Stage 3, Acute Kidney Failure and Chronic Congestive Heart Failure. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 as requiring supervision with bathing and putting on and removing footwear. R1's care plan intervention dated 9/19/24 instructs staff to Keep skin clean and dry. 9/19/24 Follow facility policies/protocols for the prevention/treatment of skin breakdown. R1's Physician Order Sheet (POS) dated December 15-31, 2024, January 1-31, 2025, and February 1-20, 2025, document physician orders to cleanse R1's bilateral lower extremities (BLE) with soap and water, apply zinc to peri wound, (Brand name dressing used to absorb wound drainage) with silver to open wounds, cover with (Brand name compression bandage system) twice per week and as needed. Once (Brand name compression bandage system) is tolerated, then change to weekly if drainage slows and dressing is intact. R1's Physician Order Sheet (POS) dated February 21-28 documents a physician order to cleanse R1's BLE with soap and water, apply (Brand name petroleum impregnated gauze) soaked gauze to open areas, (Brand name semi-rigid compression bandage), zinc oxide to peri wound then wrap with dry gauze from mid foot to high calf with compression gauze twice per week and as needed. R1's Wound Assessment and Plan dated 1/2/25, 1/9/25, 1/23/25 documents a physician order to cleanse R1's BLE, apply Zinc oxide to peri wound, apply (Brand name dressing used to absorb wound drainage) Silver followed by two- or four-layer compression wraps depending on what is available twice per week or sooner if dressings are saturated and as needed. R1's Wound Assessment and Plan dated 1/30/25 document a physician order to cleanse R1's BLE, apply Zinc Oxide to peri wounds, apply (Brand name petroleum impregnated gauze) cut to fit to open areas, cover with absorbent gauze, two- or three-layer compression wraps depending on what is available three times per week or sooner if dressings are saturated and as needed. This same plan documents R1's newly acquired Right and Left Dorsal open areas to cleanse, apply Calcium Alginate, cover with absorbent pad, and wrap daily and as needed. R1's Wound Assessment and Plan dated 2/6/25 and 2/20/25 documents a physician order to cleanse R1's BLE, apply Zinc Oxide to peri wounds, apply (Brand name petroleum impregnated gauze) cut to fit to open areas, cover with absorbent gauze, two- or three-layer compression wraps depending on what is available three times per week or sooner if dressings are saturated and as needed. This same plan documents in addition to R1's BLE dressing orders the facility is to provide (Brand name semi-rigid compression bandage) when available, Calcium Alginate and compression wraps three times per week or sooner if saturated. R1's Wound Assessment and Plan dated 3/13/25 documents a physician order to cleanse R1's BLE and bilateral dorsal feet, apply Zinc Oxide to peri wounds, apply absorbent gauze, wrap with dry gauze and then compression gauze three times per week and as needed. R1's Skin Evaluation assessment dated [DATE] documents R1's Left Lower Extremity (LLE) Cellulitis/Venous Lymphedema wounds measuring 22.0 centimeters (cm) long by the entire circumference of R1's LLE by 0.1 cm deep as macerated with heavy serosanguinous drainage that is painful to R1. This same assessment documents R1's Right Lower Extremity (RLE) Cellulitis/Venous Lymphedema wounds measuring 20.0 centimeters (cm) long by the entire circumference of R1's RLE by 0.2 cm deep as macerated with heavy serosanguinous drainage that is painful to R1. This same assessment lists R1's Right Dorsal Foot open lesion measures 6.0 cm long by 6.0 cm wide by 0.1 cm deep as macerated with moderate serosanguinous drainage and R1's Left Dorsal Foot open lesion measures 8.0 cm long by 8.0 cm wide by 0.1 cm deep as macerated with minimal serosanguinous drainage. R1's Final Culture and Sensitivity report dated 2/9/25 documents R1's Right Leg culture showed Proteus Mirabilis, Providencia Stuartii, Stenotrophomonas Maltophilia and Diptheroids. The undated facility Sign Out/Acceptance of Responsibility for Leave of Absence form documents R1 signed himself out on 3/16/25 at 9:30 PM. This same form documents R1's destination was to the hospital. R1's Nurse Progress Note dated 3/16/25 at 9:54 PM documents R1 signed himself out at 9:30 PM to go to the emergency room for bilateral lower extremity (BLE) pain. This same note documents R1 stated he can't stand the pain anymore. R1's Nurse Progress Note dated 3/17/25 at 1:44 AM documents the hospital called to report to the facility R1 was being admitted to the hospital for BLE wounds. R1's Hospital Records document R1 had multiple ulcers stage 2 through 3 on both lower legs, the rest of the affected area on both lower legs had Moisture Associated Skin Dermatitis (MASD). This same report documents R1's dressings were saturated and R1's bilateral lower legs were weeping. R1's Hospital Record dated 3/16/25 documents R1 as wearing garbage bags around his legs and plastic booties, for which he is sitting in about two inches of yellow serous fluid from his legs. This same record documents R1's extremities show no cyanosis, claudication with +4 bilateral lower extremity and pedal, extensive weeping consistent with his Lymphedema history, multiple non-healing venous stasis wounds, macerated tissue to the Left foot and ankle. This same record documents (R1's) dressings are saturated through and he is dressed with plastic bags over his wound dressings. R1) is not getting appropriate wound management for not only his Cellulitis and nonhealing wounds but also his Lymphedema. (R1's) Bilateral lower extremities are erythematous and edematous. Multiple scattered shallow full-thickness skin loss noted. Most of the wound beds are red and moist. There is a wound on the Right Lower Leg that has a small amount of slough noted. There is a large amount of serosanguinous drainage present. Scattered areas of maceration noted. Circumference of the right calf is 51 centimeters (cm). Circumference of the left calf is 53 cm. On 4/2/25 at 8:30 AM V10 (Licensed Practical Nurse/LPN) stated R1 complained of pain on 3/16/25 to his BLE. V10 stated she administered pain medication to R1. V10 stated R1 asked for more pain medication 20 minutes later and she instructed R1 to give the pain medication time to work. V10 stated R1 reported he was 'in too much pain that he could not stand it'. V10 stated R1 would occasionally refuse dressing changes if the facility did not have the appropriate dressings. V10 stated R1 had a friend take him to the hospital that night (3/16) and he was admitted for the treatment of his wounds. V10 stated she did not have a chance to change R1's dressings that evening. On 4/3/25 at 9:45 AM R1 stated the facility did not follow the physician orders for his dressing changes to his BLE. R1 stated he had asked for V11 (Wound Physician Assistant/PA) to be called and asked for a different type of dressing and was told the facility does not have a way to contact V11. R1 stated he was told to wear garbage bags on his lower legs to catch the drainage. R1 stated the staff would use rolled gauze to wrap his leg and then use the same gauze to tie the garbage bags onto his legs so that they would stay up. On 4/3/25 at 10:20 AM V11 (Wound PA) stated the facility did not notify her of R1's request for different treatments, her dressing orders not being completed as ordered, the facility not having the correct wound supplies or that the facility was using garbage bags to contain the drainage. V11 stated R1 was alert and oriented and would sometimes refuse dressings. V11 stated the facility should have investigated why the dressings would be refused to prevent deterioration of R1's BLE wounds. V11 stated garbage bags should not have been used to contain wound drainage and would have caused harm to R1 by keeping the drainage next to the wounds and exposing R1's feet to unnecessary maceration due to sitting in wound drainage. On 4/3/25 at 11:00 AM V14 (Wound Nurse/LPN/Infection Preventionist/IP) stated V11 (Wound PA) would see R1 weekly and change his dressing orders according to what R1 would agree to. V14 stated many time the dressing order was changed but V14 did not change the order in the computer due to being told by the corporation that R1's specific types of dressings were too costly and could not be ordered. V14 stated she did not reach out to V11 (Wound PA) to report the dressings were not ordered and that R1 had been getting the wrong dressings. V14 stated R1's wounds did deteriorate during his stay in the facility due to the wrong dressings being put on, the staff not changing R1's dressings more frequently due to cost of the supplies and not re-approaching R1 if he did refuse to see why R1 was refusing his dressing changes. B. R2's undated Face Sheet documents medical diagnoses as Morbid Obesity, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, Peripheral Vascular Disease, Paroxysmal Atrial Fibrillation, Chronic Venous Hypertension, Acute Nephritic Syndrome, Lymphedema, Cellulitis and Body Mass Index (BMI) greater than 70. R2's care plan intervention dated 10/17/23 documents staff are to Monitor/document location, size, and treatment of impairment. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to Physician. R2's Physician Order Sheet (POS) dated March and April 2025 does not document a treatment order for R2's open Left Elbow wound. R2's Nurse Progress Note dated 3/24/25 documents R2 has sores on her Left Elbow/Bicep area. On 4/2/25 at 10:30 AM R2 stated she has open sores on her Right Lower Leg due to her Lymphedema. R2 stated she has blisters on her Left Elbow area that popped. R2 stated the staff have been aware of this area for about a week but have not put any dressing on yet. On 4/2/25 at 10:35 AM R2 was laying in her bed with her arms exposed, above the covers. R2's Left Elbow had two nickel sized intact blistered areas and one quarter sized open area draining clear/yellow fluid onto R2's sheets. R2's Left Elbow wounds did not have any dressing in place. On 4/2/25 at 1:15 PM V10 (LPN) and V14 (Wound Nurse/LPN/IP) completed R2's dressing change to her Right Lower Extremity (RLE) open wounds. V10 cleansed R2's RLE, applied antibiotic ointment and Calcium Alginate rope. V10 turned away from R2 to get the absorbent gauze, then turned back and saw that R2's Calcium Alginate rope had dropped onto the towel below R2's leg. R2's Calcium Alginate rope dropped directly onto the section of R2's towel that was soiled with blood and serous fluid from R2's open wounds. V10 picked up the contaminated Calcium Alginate rope and placed it again on the wound and continued to finish the dressing change. On 4/2/25 at 2:00 PM V10 Licensed Practical Nurse (LPN) stated she cross contaminated R2's open draining wound due to V10 saw the Calcium Alginate rope sitting in the wound drainage on the towel and continued to put that contaminated rope back on R2's open wound. V10 stated she should have gotten a new piece of rope. V10 stated cross contaminating an open wound could cause an infection. On 4/3/25 at 2:30 PM V14 (Wound Nurse/LPN/IP) stated she was informed on 4/2/25 of R2's Left Elbow open wounds. V14 stated staff should have obtained an order for a protective dressing when this area was first observed last week (3/24/25) and then gotten an order change after it opened three days ago (3/31/25). V14 stated the facility is conducting a house wide training next week on wound care, following physician orders, timely reporting of any new skin areas and other areas of concern. The facility policy titled Skin Conditioning Monitoring revised 3/16/23 documents upon notification of a skin lesion wound, or other sin abnormality, the nurse will assess and document the findings in the nurses' notes and complete a skin evaluation. The nurse will then implement the following procedure: notify the physician, obtain treatment order which includes type of treatment, location of area, frequency of how often treatment is to be performed, how area is cleansed and a stop date if needed. The facility policy titled Dressing Change revised 3/16/23 documents staff should follow the physician order for treatments.

Based on observation, interview, and record review the facility failed to employ a Full Time Director of Nurses (DON). This failure has the potential to affect all 37 residents residing in the facility. Findings include: The Facility Midnight Census Report dated 4/1/25 documents 37 residents reside in the facility. On 4/1/25-4/3/25 at various times there was no DON present in the facility. On 4/1/25 at 9:50 AM V1 (Administrator) stated the facility has not had anyone in the Director of Nursing role since early February 2025. V1 stated the DON plays an important role in the quality of care every resident receives. On 4/3/25 at 1:10 PM V14 (Wound Nurse/Licensed Practical Nurse/Infection Preventionist) stated she is struggling to keep up with all her duties because she is managing programs, working the floor, the wound nurse, the infection control nurse and 'all around' person to answer questions. V14 stated having a DON would reduce some of the problems in the facility due to the DON could assist with resident concerns and monitor programs so that nothing would get missed.

Based on observation, interview, and record review the facility failed to initiate Enhanced Barrier Precautions (EBP) for four residents (R2, R3, R4, R5) out of five residents reviewed for EBP in a sample list of five residents. Findings include: 1. R2's Care plan intervention dated 10/17/23 does not document a focus area, goal nor interventions for Enhanced Barrier Precautions (EBP). On 4/1/25 at 10:00 AM R2 does not have a sign on her door indicating she is on Enhanced Barrier Precautions (EBP). R2 does not have any Personal Protective Equipment (PPE) outside of her room or any adjacent rooms. On 4/2/25 at 10:15 AM V10 (Licensed Practical Nurse/LPN) and V14 (Wound Nurse/Infection Preventionist/IP) gathered wound supplies, walked into R2's room and stated they were ready to provide wound care for R2. V10 and V14 were not wearing gowns. On 4/2/25 at 11:05 AM V10 and V14 both stated they should have worn gowns. V14 stated R2 should have been on EBP and was not. V10 stated there was no EBP sign on R2's door so she did not think R2 needed EBP. 2. R3's Electronic Medical Record (EMR) documents R3 has open sores on both feet due to Lymphedema. R3's Physician Order Sheet (POS) dated April 2025 does not document a physician order for R3 to be placed on Enhanced Barrier Precautions (EBP) prior to 4/2/25. R3's Care plan initiated 3/7/25 does not include a focus area, goal nor interventions for EBP. On 4/2/25 at 12:30 PM R3 was sitting in his recliner chair in his room. R3's bilateral feet were wrapped with compression wraps which left toes exposed. R3's feet were resting directly on the floor. R3 was not wearing any socks or shoes. R3's floor was littered with debris and spills of food particles. R3 did not have a sign on his door indicating he is on Enhanced Barrier Precautions (EBP). R3 does not have any Personal Protective Equipment (PPE) outside of his room. On 4/2/25 at 12:35 PM R3 stated the staff will 'usually' wear gloves to change his dressings on his feet and have never worn a gown of any sort. 3. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively intact. R4's Electronic Medical Record (EMR) documents R4 has an open Stage 3 Pressure Ulcer on her Left Heel that drains serous fluid. R4's Care plan dated 4/2/25 does not include a focus area, goal nor interventions for EBP. On 4/1/25 at 12:00 PM R4 did not have an Enhanced Barrier Precautions (EBP) sign posted on her door nor Personal Protective Equipment (PPE) supplies accessible to staff. On 4/2/25 at 3:30 PM R4 did not have an Enhanced Barrier Precautions (EBP) sign posted on her door nor Personal Protective Equipment (PPE) supplies accessible to staff. 4. R5's Medical Record documents medical diagnoses as Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), history of pressure ulcers and Staphylococcus infection and open draining Hematoma to Right Lower Extremity. R5's Care plan initiated 9/16/24 does not document a focus area, goal nor interventions to address R5's open draining Right Lower Extremity (RLE) wound nor Enhanced Barrier Precautions (EBP). On 4/1/25 at 12:05 PM R5 did not have an Enhanced Barrier Precautions (EBP) sign posted on her door nor Personal Protective Equipment (PPE) supplies accessible to staff. On 4/2/25 at 3:35 PM R5 did not have an Enhanced Barrier Precautions (EBP) sign posted on her door nor Personal Protective Equipment (PPE) supplies accessible to staff. On 4/3/25 at 1:20 PM V14 (Wound Nurse/LPN/IP) stated R2, R3, R4 and R5 should have been placed on EBP and were not. V14 stated she was not aware of EBP until 4/2/25. V14 stated she is going to research it and ensure all residents who are supposed to be on EBP will be placed on EBP. V14 stated there are other residents in the facility who would meet the same criteria but have not been on EBP. V14 stated EBP has not been monitored or tracked since the she was not aware of what EBP was. The facility policy titled Enhanced Barrier Precautions dated 4/24/24 documents Enhanced Barrier Precautions (EBP) should be used when contact precautions do not apply for residents with open wounds that require a dressing change. EBP requires use of a gown and gloves during high-contact resident care activities that provide opportunities for the transfer of Multi Drug Resistant Organisms (MDRO) to staff hands and clothing. High contact care activities include wound care (pressure ulcers, diabetic ulcers, unhealed surgical wounds, chronic venous stasis wounds).

Based on interview and record review the facility failed to ensure the dignity of one (R1) resident out of five residents reviewed for resident rights in a sample list of five residents. Findings include: The undated facility pamphlet titled Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long Term Care Facilities documents the facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. R1's undated Face Sheet documents admitted to the facility on [DATE] and lists R1's medical diagnoses as Lymphedema, Chronic Venous Hypertension with ulcer of lower extremity, Diabetes Mellitus Type II, Parkinson's Disease, Cellulitis of Right and Left Lower Limbs, Morbid Obesity, Chronic Kidney Disease Stage 3, Acute Kidney Failure and Chronic Congestive Heart Failure. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 as requiring supervision with bathing and putting on and removing footwear. R1's care plan intervention dated 9/19/24 instructs staff to Keep skin clean and dry. 9/19/24 Follow facility policies/protocols for the prevention/treatment of skin breakdown. R1's Skin Evaluation assessment dated [DATE] documents R1's Left Lower Extremity (LLE) Cellulitis/Venous Lymphedema wounds measuring 22.0 centimeters (cm) long by the entire circumference of R1's LLE by 0.1 cm deep as macerated with heavy serosanguinous drainage that is painful to R1. This same assessment documents R1's Right Lower Extremity (RLE) Cellulitis/Venous Lymphedema wounds measuring 20.0 centimeters (cm) long by the entire circumference of R1's RLE by 0.2 cm deep as macerated with heavy serosanguinous drainage that is painful to R1. This same assessment lists R1's Right Dorsal Foot open lesion measures 6.0 cm long by 6.0 cm wide by 0.1 cm deep as macerated with moderate serosanguinous drainage and R1's Left Dorsal Foot open lesion measures 8.0 cm long by 8.0 cm wide by 0.1 cm deep as macerated with minimal serosanguinous drainage. R1's Hospital Record dated 3/16/25 documents R1 as wearing garbage bags around his legs and plastic booties, for which he is sitting and about two inches of yellow serous fluid from his legs. On 4/2/25 at 2:00 PM V14 Wound Nurse/Licensed Practical Nurse (LPN)/Infection Preventionist (IP) stated V14 did tell R1 he was to wear garbage bags over his lower legs to help control the mess from the drainage. V14 stated R1 would walk the halls and leave wet footprints everywhere from all the drainage in his legs. V14 stated that was the only thing she could think of to help because the facility did not have the budget to be able to re-wrap his lower legs multiple times per day. V14 stated she realizes that wasn't the best method and should have changed R1's dressings instead of putting garbage bags over his legs. On 4/3/25 at 9:47 AM R1 stated the facility told him he had to wear garbage bags over both of his lower legs to help contain all the drainage from his open wounds on his bilateral lower legs and feet. R1 stated he was told he could not come out of his room unless he wore the garbage bags. R1 stated the nurses would put plastic booties on his feet and then have him put each lower leg inside a garbage bag. R1 stated the nurses would wrap gauze around his lower leg and then tie the gauze in a knot around his leg just below his knees to help keep the garbage bag from falling. R1 stated That was embarrassing. How would you like to wear something like that. But I couldn't come out of my room otherwise. People would stare at my legs. They (facility) said they couldn't afford to keep wrapping my legs all day so that was their way of keeping the drainage off the floor. One nurse (unknown) even told me they (staff) didn't have time to keep mopping up after me.

Based on interview and record review the facility failed to ensure residents were treated with dignity for two (R2, R3) residents out of three residents reviewed for abuse in a sample list of six residents. Findings include: The Illinois Long Term Care Ombudsman Program pamphlet titled Resident Rights for People in Long Term Care Facilities revised November 2018 documents the facility must treat the resident with dignity and respect and must care for the resident in a manner that promotes the residents' quality of life. R2 and R3's shared Final Report to the State Agency dated 2/18/25 documents R2 and R3 reported that at times V13 (Licensed Practical Nurse/LPN) could be short with her responses but denied that she was mentally or verbally abusive to (R2, R3). R2 and R3's shared abuse investigation documents V13 (LPN) was in-serviced on 2/17/25 on Tone of voice when responding to residents' customer service, communication, and interacting with residents during medication pass. 1. R2's Minimum Data Set (MDS) date 1/4/2025 documents R2 as cognitively intact. On 2/14/25 at 2:10 PM R2 stated V13 (LPN) is a night nurse at the facility. R2 stated V13 is rude and pushy. R2 stated I get up in the night to use the bathroom and most times I can do things on my own. Some nights I need a little help. When V13 comes in my room, the whole atmosphere changes. V13 tells me to hurry up and quit wasting her time. R2 stated V13 has a very bad attitude and does not want to take care of residents. R2 stated he feels safe living at facility. R2 stated V13 never physically abused me or anything like that. But V13 treats me like a dog, and I don't like it. 2. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. On 2/14/25 at 2:25 PM R3 stated V13 is rude, hateful and mean to R3. R3 stated I am a smoker. I know the smoking times. The last time to smoke in the evening is 7:00 PM. When I ask V13 to go out to smoke, V13 tells me to 'go sit down' or 'go away' or 'I don't have time for you. Leave me alone.' V13 hasn't called me any names but she is just so hateful. R3 stated V13's bad attitude and rudeness to the residents was discussed in the last Resident Council Meeting (1/22/25). R3 stated no one has talked to her about her concerns with V13 LPN's rude statements towards R3. R3 stated I don't feel like I was abused. I feel safe here. But I also don't deserve to be talked to like that especially by someone in authority like a nurse. On 2/18/25 at 11:30 AM V1 (Administrator in Training/AIT) stated R2 and R3 both reported that V13 (LPN) can be 'short' and 'rude' when having interactions with R2 and R3. V1 stated when V1 spoke with V13, V13 stated sometimes she does get tired and that could be taken as rude and/or pushy. V1 stated V1 in-serviced V13 on appropriate behavior and tone of voice when interacting with residents. V1 stated the conclusion of her investigation was that R2 and R3 were not mentally and/or verbally abused but also do deserve better from the staff. V1 stated V13 LPN's behavior was not appropriate and she has now been in-serviced and expected to do better.

Based on interview and record review the facility failed to ensure the safety of one (R1) resident from physical abuse by a staff member out of three residents reviewed for abuse in a sample list of six residents. Findings include: R1's undated Face Sheet documents medical diagnoses as Dementia, Psychotic Disorder with Hallucinations, Muscle Weakness, Unsteady on Feet, Reduced Mobility, Restless and Agitation and Violent Behavior. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as independent in toileting, dressing, personal hygiene, bed mobility, moving from a sitting to standing position and able to self-propel her wheelchair 150 feet. R1's AIM for Wellness dated 1/29/25 documents R1 had an alleged unintentional change in plane and an altercation with a staff member (V3) Certified Nursing Assistant/CNA. This same report documents (R1) was arguing with (R5) and (V3) CNA. (R1) was also upset with (V3) CNA when V3 CNA tried to redirect and take (R1) back to her room. Possible precursors to event: (R1) agitated with (R5) and agitated with (V3) CNA. R1's Final Report to the State Agency dated 2/6/25 documents While (R1) was being taken to her room, she attempted to stand up so (V3) Certified Nurse Aide (CNA) placed her hand around (R1's) tricep in an attempt to prevent the fall, but (R1) landed on her bottom. (R1) stated that her arm hurt because (V3) grabbed her arm and pushed her down. Upon assessment a red handprint was found on (R1's) Right Arm. V3 (CNA) Employee file documents V3 CNA was Terminated due to attitude while being in the probationary period. On 2/14/25 at 10:20 AM R1 was sitting in her wheelchair in her room. R1 stated a girl (V3) (CNA) pushed her down. R1 used her Left Hand to rub the inside of her Right Upper arm while stating she bruised me hard. On 2/14/25 at 10:35 AM V4 (Licensed Practical Nurse/LPN) assessed R1's Right Upper Arm. V4 stated R1 did have several bruises in the same area. V4 stated R1 does have Dementia but is able to remember certain events. V4 stated R1 has mentioned her bruised arm several times since the event on 1/29/25. R1's Right Upper Inner Arm showed a quarter sized slightly yellow area. R1 stated during assessment That is the place. That is where she (V3) Certified Nurse Aide (CNA) hurt me. On 2/14/25 at 10:40 AM V5 (CNA) stated she was working the same night V3 (CNA) and R1 had some type of altercation. V5 stated she heard R1 hollering so she went to investigate and saw R1 laying on the floor with V3 standing next to R1. V5 stated R1 appeared to be very upset. V5 stated V3 was just saying I need to be sent home and Tell the nurse to send me home. On 2/14/25 at 11:40 AM V8 (LPN) stated V8 was the nurse for R1 on 1/29/25. V8 stated she was passing medications around 7:00 PM- 8:00 PM at the end of the 400 hall which conjoins with the end of the 100 hall. V8 stated she was in the corner where the 400 and 100 halls meet with her back to the 100 hall. V8 stated she heard R1 yelling out loudly. V8 stated she was never approached by any staff and did not hear any staff yelling out. V8 stated she only heard R1's voice and she sounded scared. V8 stated when she turned around to investigate why R1 was yelling, V8 saw R1 laying on the floor with V3 (CNA) standing over R1. V8 stated V3 CNA was visibly frustrated and mad looking and stating You need to send me home. Send me home right now! After I had made sure (R1) was stable, I went to get a statement from (V3) CNA because she had just walked away. V8 stated V3 was assisting another resident (R4). V8 stated V3 reported to V8 that R1 was upset due to an altercation with two other residents (R5, R6) at the dining room table. V8 stated (V3) CNA told me that (V3) had told (R1) to calm down or (R1) would have to go to her room. (R1) became more agitated so (V3) was trying to take (R1) to her room. (R1) stood up out of her wheelchair, became unsteady on her feet so (V3) tried to grab (R1) by the arm to prevent her from falling. (V3) said (R1) sat herself on the floor on her bottom. (R1) wasn't sitting on her bottom when I first saw her. (R1) was laying on her Left side. V8 stated V2 (Director of Nurses/DON) came to the facility that night to assess R1. On 2/14/25 at 12:20 PM V2 (DON) stated V8 (LPN) called V2 the evening of 1/29/25 to report a fall/incident between V3 (CNA) and R1. V2 (DON) stated she went to the facility and saw R1's arm to have two finger shaped contact/discoloration marks on R1's Right Upper Inner Arm. V2 stated the marks were consistent with V3 CNA's story, so she was not thinking that R1 had been subjected to abuse. V2 stated R1 reported to her the morning of 1/30/25 that She (V3) was a strong woman and (V3) pushed me down to the ground while pointing to her Right Arm. V2 DON stated, At that point, I called (V3) CNA and suspended her pending an investigation. V2 DON stated V3 had called V2 before V2 could arrive at the facility and stated I need to go home. I am so overwhelmed. V2 stated V3 had already left by the time V2 arrived at the facility. V2 stated V8 (LPN) reported that R1 had been upset with other residents (R5, R6) at her dining room table when V3 (CNA) attempted to deescalate the situation. V2 stated it was reported that V3 told R1 to stop her behaviors or V3 would take R1 to her room and when R1 was still agitated, V3 attempted to push R1 in her wheelchair to R1's room. V2 (DON) stated she was told R1 tried to stand up, was unsteady, V3 CNA grabbed R1's arm to try to keep her from falling and R1 put herself on the floor. On 2/14/25 at 12:30 PM V2 (DON) stated V3 (CNA) should have removed the other residents from R1's table to help deescalate a behavioral situation with R1. V2 stated V3 should have called on other staff when R1 was becoming more and more agitated. V2 stated Telling (R1) to go to her room because she is not behaving the way (V3) wanted her to is never appropriate. V2 stated V3 was suspended and subsequently terminated due to her poor attitude. On 2/14/25 at 12:50 PM V1 (Administrator in Training/AIT) stated V9 (Regional Director of Operations) spoke with V3 (CNA) on 1/30/25 when both V1 and V9 were informed of an incident between R1 and V3. V1 stated R1 was mad due to R5 was touching other residents' belongings at the dining room table where R1 was also sitting. V1 stated it was reported to V1 that R1 stood up and V3 grabbed R1's arm to keep her from falling but R1 fell on her bottom. V1 stated R1 told her on the morning of 1/30/25 that V3 was 'pushy'. V1 stated V3 was called and notified that she was suspended. V1 stated V3 was terminated due to poor performance, and she was still in her probationary period. V1 stated the facility is unable to provide any documentation of V3 having any Abuse or Dementia training from the facility. On 2/14/25 at 3:00 PM V3 (CNA) stated on the evening of 1/29/25 after supper, R1 was sitting at a dining room table with R5 and R6. V3 stated R5 was 'messing' with items on the table and R6's walker. V3 stated R1 was agitated about R5 messing with R6's belongings and started yelling at R5 to stop touching everything. V3 stated to R1 Stop yelling and calm down or I will put you in your room. V3 stated R1's behavior became worse after that, so V3 tried to push R1 in her wheelchair to R1's room. V3 stated We (R1, V3) didn't get very far in her wheelchair. (R1) was pushing against it trying not to go to her room. Then (R1) stood up out of the wheelchair and walked two to three steps. (R1) grabbed ahold of the water cart to gain leverage to get away from me. (R1) wouldn't let go of the water cart. I had to really grab her hard to make her let go of the water cart. I kept saying 'Calm down or you are going to your room!'. I walked around the front of the wheelchair. I grabbed (R1's) Right arm when she was facing me. I was right in front of (R1) and used my Right Hand to grab her Right Arm. That is when (R1) swung around and fell , landing on her Left side. I was trying to put (R1) back in her wheelchair to take her to her room. V3 stated R5 and R6 sat at the dining room table and witnessed the entire situation. V3 stated she has not had any Dementia or Abuse training with this facility. V3 stated V3 should have removed R5 and R6 to try to deescalate R1. V3 stated I was overwhelmed and frustrated that evening. I should have just gotten someone else to help so (R1) would never have fallen or gotten hurt. I hate that (R1) was bruised by me. I feel bad about that. I look back and see how many things I should have done differently. I should have just backed away from the whole situation because I was just as frustrated as (R1) and that is when things like that happen.

Based on interview and record review the facility failed to report a concern voiced in Resident Council Meeting of a staff members poor demeanor towards two (R2, R3) residents out of three residents reviewed for abuse in a sample list of six residents. Findings include: The facility policy titled Abuse Prevention Program revised May 2021 documents Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriate of resident property they observe, hear about, or suspect to a supervisor and the Administrator. Upon learning of the report, the Administrator or designee shall initiate an investigation. The facility Resident Council Minutes dated 1/22/25 document resident concerns of night nurse (V13) Licensed Practical Nurse (LPN) demeanor towards residents. These same minutes document V12 (Previous Activity Director) as the staff liaison for this resident council meeting. On 2/14/25 at 2:10 PM R2 stated V13's 'poor demeanor' was discussed in January's Resident Council meeting. R2 stated someone usually will come talk to him about concerns brought up during the meetings but this time no one ever asked him anything. R2 stated V12 (Previous Activity Director) was present and taking minutes for the January meeting. On 2/14/25 at 2:25 PM R3 stated V13's bad attitude and rudeness to the residents was discussed in the last Resident Council Meeting (1/22/25). R3 stated no one has talked to her about her concerns with V13 LPN's rude statements towards R3. On 2/14/25 at 2:40 PM V1 (Administrator in Training/AIT) stated she was not aware of the concerns documented on the January 2025 Resident Council Meeting. V1 stated V12 would conduct the meetings and then report any concerns to V1. V1 stated after reading the January Resident Council Minutes that there was a concern about V13's LPN behavior V12 should have reported to V1 immediately due to this as an allegation of mental/verbal abuse so that V1 could initiate an investigation.

Based on interview and record review the facility failed to provide Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 10 days in a total of 39 days reviewed. This failure affects 25 residents residing in the facility. Findings include: The Long-Term Facility Application for Medicare and Medicaid form CMS 671 dated August 7, 2024 documents the census for the facility as 25 residents. Reviewing the facility's nurse assignment sheets for the months of July and August 2024. The facility had 10 days out of the 39 days reviewed which did not document RN time of 8 hours per day. The facility did not have a RN working at least 8 consecutive hours a day on 7/6/24, 7/7/24, 7/13/24, 7/14/24, 7/20/24, 7/21/24,7/27/24, 7/28/24, 8/3/24 and 8/4/24. V2 (Director of Nurses) confirmed on 8/8/24 at 12pm, Yes, this is correct we do not have the RN coverage for the weekends.

Based on interview and record review, the facility failed to honor the resident's right to formulate advanced directives. This failure affects one resident (R179) out of 16 reviewed for advanced directives on the sample list of 28. Findings include: On [DATE] at 1:57 PM, R179's Electronic Medical Record did not include any information about R179's wishes or election of advanced directives (code status). This same record documents R179 was admitted to the facility on [DATE]. On [DATE] at 2:00 PM, R179 stated, No, no, no, I would not like to be resuscitated. R179 continued, I don't think I am being selfish about it; I am just in pain all the time and I wouldn't want to be brought back for that. R179's Face Sheet dated [DATE] documents R179 is his own responsible party. On [DATE] at 2:10 PM, V3 (Licensed Practical Nurse) looked through R179's Electronic Medical Record, as well as R179's paper chart, and stated, I don't see anything signed as DNR (Do Not Resuscitate) so he would be treated as a full code (all efforts to resuscitate) until there is a signed DNR. On [DATE] at 2:24 PM, V11 (Social Services Director) stated, I have talked with (R179) and he does want to be a DNR with select treatment. I took the POLST (Practitioner Ordered Life Sustaining Treatment) form to the doctor (V6) to have him sign it but what usually happens is I take the forms to his office on a Monday and go back on Friday to pick them up. V11 continued, Unfortunately (R179) would be treated as a full code until we get the signed POLST form. The facility's policy Advanced Directives dated as revised [DATE] documents, Any decision made by the resident shall be indicated in the chart in a manner easily understood by staff. Advanced directives specifying full code/ attempt resuscitation/ CPR (cardio-pulmonary resuscitation), or the absence of determination, shall be recorded as full code. Those residents indicating do not attempt resuscitation/ DNR shall be recorded as DNR. This same policy documents this information shall be obtained on the day of admission to this facility. Code status shall be entered on the physician order sheet. As of [DATE] at 11:57 AM, R179's Physician Order Sheet did not include R179's wishes to be DNR. R179's electronic header, viewable from any portion or screen of R179's Electronic Medical Record, did not indicate R179's code status.

Based on observation, interview, and record review the facility failed to promote resident's right to a safe, comfortable homelike environment. This failure affects one of two residents (R14) reviewed for the environment on the sample of 28. Findings include: R14's Minimum Data Set, dated dated dated [DATE] documents the following: R14's Brief Interview of Mental Status score as 14 out of a possible 15, which indicates no cognitive impairment. On 08/06/24 at 10:05 am, R14 was lying in bed. Between the head of R14's bed and R14's bedside dresser there was an unpainted, 10-inch hole. The hole had loose, crumbling white plaster-like substance. R14 stated I have gotten use to looking at that. It is not pretty. The hole in the wall has been there since I came to the facility, two years ago. It could use some attention. On 8/7/24 at 11:15 am, during a resident group meeting, R14 stated I told you yesterday about the hole in my wall. You saw it. It is terrible. I set on the side of my bed and eat. I can't help but see it. You should have looked at the ceiling. Rain came in and dripped down, leaving my ceiling is disrepair. The maintenance man (V9 Maintenance Director) said there was a plastic (private grocery company) bag in the gutter. He (V9) removed it and I have not had any leaks since. The ceiling still looks terrible. I have had leaks before, and the old owner never fixed the roof leaks. I would really like my whole room remodeled but that is an unreasonable request. The ceiling and hole in the wall should be repaired though. On 8/7/24 at 1:35 pm V9 (Maintenance Director) and surveyor entered R14's room. There was a three foot long by eight-inch-wide area of the ceiling that had dark brown stains that appeared to be from water seepage. There were also chunks of plaster, stained with water marks bulging at the wall and ceiling junction. The wall below the junction had a two-foot wide by one-foot-high section, above the top window frame with plaster chipped plaster and water like marks. V9 then confirmed the hole on the wall between resident bed and dresser was crumbling plaster. V9 stated The roof was repaired approximately three years ago. The damage to (R14's) ceiling, and wall above the window was a troubled area then and continues to be a troubled area. There was a plastic bag in the gutter and a ton of rain backed up to that troubled area of (R14's) window and ceiling. That was a few months ago. Corporate is very aware of these issues in (R14's) room. They have to release the funds in order for these areas to be fixed. They have not released the funds. The undated facility policy Physical Plant & Environmental Policy & Guidelines documents the following: Policy Statement: It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents. A well-maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA codes. This includes making certain a safe and hospitable environment as possible is maintained in the event of an emergency for sheltering in place. Policy Implementation: The facility Administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff. Ensure maintenance work orders are completed in a timely manner and ensure items necessary for repairs are ordered to complete repairs. Maintenance/Approved Contractors

Based on interview and record review the facility failed to ensure one resident (R1) was not subjected to misappropriation of money of three residents reviewed for abuse in a sample list of three residents. This failure caused R1 to experience financial harm due to loss of $238 cash stored in R1's bedroom and psychosocial harm expressed as anger, disappointment, and inability to trust care givers. Findings include: R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] document R1 is cognitively intact, and does not suffer from Dementia or Alzheimer's Disease. R1's Nurse's Note dated 6/15/22 at 2:15PM documents (R1) reported missing funds from room (two times) Staff searched room and unable to find (money). (R1) says he leaves it in his closet in a box. When staff (V6) Activity Assistant went to get the money (R1) realized it was missing. Power of attorney (POA), Medical Doctor (MD), Administrator, and Police Department notified of missing funds. On 7/7/22 at 9:45AM V4, Certified Nurse's Aide stated On Monday (6/13/22) (R1) had me count his money with him. He had $238.00. He had me separate it into two envelopes and put it in a box in his closet under some DVDs (Digital Video Discs). I saw and counted the money. He had it so he could send it with Activities when they went shopping on Wednesday. On 7/7/22 at 10:00AM (R1) stated My (POA) takes care of my money and brings it to me when I ask for it. On 6/1/22 (POA) brought me $320.00. (POA) went to the store and brought me some sodas, some (Sports Drinks), and some other things. Then I had $238.00 left. I hid it in my closet like I always have. On Monday (6/13/22) (V4) helped me count the money and there was still $238.00 left. (V4) helped me separate it into two envelopes. I was going to keep part of the money and send some of it with (V6), Activity Assistant when they went shopping Wednesday (6/15/22). On Wednesday (6/15/22) (V6) went to get the money for shopping and it was gone and so was the other envelope. I like to keep some of my money with me because it's hard to run them down to get it out of the bank here. I was real P***ed (expletive) off. I just can't trust anybody now. I thought the people here cared about me and I trusted them, but not anymore. They never offered me a lock box for my room. They said they would put it in my account or lock it in the Administrator's office, but those people aren't always around to get it when I need it. It still bothers me a lot. They say I will get it back from the nursing home, but I haven't seen it yet. It had to be one of three people who work here who took it. I didn't tell anybody else where it was. On 7/7/22 at 11:00AM V1, Administrator stated We are aware (R1) is missing $238.00 and we have agreed to replace it. (V4) saw $238.00 and then when they went to get it it was missing. We searched (R1's) room, but we didn't find it. We really don't know what happened to it. (R1) could have put it in his account or I would have locked it in the lock box in my office, but (R1) wants to keep his money with him. On 7/7/22 at 2:19PM (V8), (R1's) family member stated I brought (R1) $320.00 at the beginning of June. I got (R1) some drinks and a few other things last week. I didn't go in, but the facility brought me out the money from (R1) and I dropped off the things he wanted with his change. (R1) called me on 6/15/22 and was very angry and upset. (R1) said he had $238.00 missing. (R1) said (V4) had counted it Monday 6/13/22 and put it in two envelopes and put the envelopes in a box in his closet underneath some DVDs. They went to get it and it was all gone. I came over and we literally turned that room upside down. The money was gone. (R1) is not confused and is able to keep track of his money. Someone had to take it while he was out of his room or asleep. That is a lot of money for (R1). The police incident report dated 6/15/22 at 3:00PM documents Details of Complaint Theft of cash. (V3) reported (R1) reported $238.00 cash was taken from the closet. On July 27,2022 V8, Police Officer stated I believe it was a theft of $238.00. I was here in the office when it was called in. There is probably little chance we will ever know who took the cash, so our procedure is to take a report by phone. I mean the staff knew he had the money and it disappeared so someone had to have taken it.

Based on interview and record review the facility failed to develop and implement a guiding policy regarding how the facility will ensure a resident can safeguard their own personal money or property within the building. This security failure has led to R1's money being taken from R1's room, without permission. R1 suffered the loss of $238 cash. R1 is one of three residents reviewed for abuse in the sample of three. Findings Include: The facility's Abuse Prevention Program revised 11/28/16 states There are two specific instances where theft should be considered: (first bullet point) The 'theft' value of a piece of property. Any missing money, jewelry, watches, or other large, fixed property such as radios or TVs should be considered and treated as possible theft, until there are clear indications that the property was mislaid or lost by means other than theft. The facility's Abuse Prevention Program policy as written, fails to specify security measures that will be implemented to safeguard resident's money or personal belongings that residents choose to maintain control of. R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] document R1 is cognitively intact and does not suffer from Dementia or Alzheimer's Disease. On 7/7/22 at 10:00AM R1 stated My (POA) takes care of my money and brings it to me when I ask for it. On 6/1/22 (POA) brought me $320.00. (POA) went to the store and brought me some sodas, some (Sports Drinks), and some other things. Then I had $238.00 left. I hid it in my closet like I always have. On Monday (6/13/22) (V4) helped me count the money and there was still $238.00 left. (V4) helped me separate it into two envelopes. I was going to keep part of the money and send some of it with (V6), Activity Assistant when they went shopping Wednesday (6/15/22). On Wednesday (6/15/22) (V6) went to get the money for shopping and it was gone and so was the other envelope. I like to keep some of my money with me because it hard to run them down to get it out of the bank here. I was real P***ed off. I just can't trust anybody now. I thought the people here cared about me and I trusted them, but not anymore. They never offered me a lock box for my room. They said they could put it in my account or lock it in the Administrator's office, but those people aren't always around to get it when I need it. It still bothers me a lot. They say I will get it back from the nursing home, but I haven't seen it yet. It had to be one of three people who work here who took it. I didn't tell anybody else where it was. On 7/7/22 at 9:45AM V4, Certified Nurse's Aide stated On Monday (6/13/22) (R1) had me count his money with him. He had $238.00. He had me separate it into two envelopes and put it in a box in his closet under some DVDs (Digital Video Discs). I saw and counted the money. He had it so he could send it with Activities when they went shopping on Wednesday. On 7/7/22 at 11:00AM V1, Administrator stated We are aware (R1) is missing $238.00 and we have agreed to replace it. (V4) saw $238.00 and then when they went to get it the money was missing. We searched (R1's) room, but we didn't find it. We really don't know what happened to it. When asked if the facility has a policy to guide them when a resident exercises their right to possess significant sums of money in their room or on their person V1 stated We don't have a policy specific to that. I discussed that with corporate. (R1) could have put it in his account or I would have locked it in the lock box in my office, but (R1) wants to keep his money with him.

Based on observation, record review and interview, the facility failed to supervise a resident (R11), by leaving R11 unattended during toileting. This failure resulted in R11 falling and sustaining a pubic ramus fracture. The facility also failed to safely maintain toileting equipment (seat riser) for R10, which resulted in R10 falling while self-toileting. R11 and R10 are two of four residents reviewed for falls in the sample of 11. Findings include: 1. The Physician order [REDACTED]. R11's Minimum Data Set ((MDS) dated [DATE] documents R11 as being moderately cognitively impaired and needing the extensive assist of two when transferring and toileting. The same MDS documents that R11 needs the extensive assist of one for personal hygiene and uses a wheelchair for mobility purposes. R11's Fall Risk assessment dated [DATE] documents R11 as being high risk for falls. The facility report titled Incident Fall Log dated 7/24/16 through 8/18/17 documents R11 sustaining a fall on 12/29/16 at 5:40 pm in R11's room. The log also documents that R11 sustained a Hip Fracture. A facility report titled Final Report dated 1/03/17 and sent to the Illinois Department of Public Health, documents the following: Resident (R11) using restroom and was providing hygiene per self, lost balance and fell . (R11) complained of back and hip pain. Resident was sent to the (emergency room ). (E12) Licensed Practical Nurse states CNA (Unidentified Certified Nursing Assistant) reported resident on floor in bathroom. (R11) was found in front of the toilet lying on (R11's) left side, crying out get me up, complained of back and hip pain. There were no witnesses to the incident. Root Cause: (R11) got up from the toilet and lost balance while doing hygiene per self. A Radiology Report from the local Hospital dated 12/29/17 documents the following on R11: Examination - Pelvis and left hip, Clinical History - Patient fell off toilet. Pain in pelvis and bilateral hips. Impression - Suspect non-displaced left-sided pelvic fractures involving the left inferior pubic ramus and left illiopectineal line. Z1, Primary Care Physician documents the following on a History and Physical report on 12/29/17 at the local hospital: (R11) is an [AGE] year old white female who presented to the emergency room after having a fall at the nursing home. (R11) was evaluated in the emergency room and found to have an inferior pubic ramus fracture that was non-displaced. Apparently, for the last several weeks, (R11) has had repeated episodes of seizures and has been evaluated by neurology with no cause found. On 8/24/17 at 12:50 pm E2, Director of Nursing acknowledged that R11 had been left on the toilet unattended and R11 fell . On 8/25/17 at 10:00 am Z1, Primary Care Physician acknowledged that R11 was Z1's patient and did sustain a pubic ramus fracture from a fall in the facility on 12/29/16. Z1 stated the facility staff should not have left R11 on the toilet unattended due to R11's cognitive status and medical conditions. 2. The Physician order [REDACTED]. R10's Minimum Data Set ((MDS) dated [DATE] documents R10 as being moderately cognitively impaired and requires supervision of one staff when transferring and toileting. R10's Fall Risk assessment dated [DATE] documents R10 being at High Risk for Falls. The facility report titled Incident Fall Log dated July 2017, documents R10 sustaining a fall on 7/18/17 at 7:10 pm in 100 Hall Shower room. The facility report titled SBAR (Situation Background Assessment Recommendation) Communication Form dated 7/18/17 documents under the section Nursing Notes states (R10) fell in bathroom due to riser breaking off when getting up.(R10) landing on right hip. (R10) complains of pain to right hip . R10 stated on 8/24/17 at 12:15 PM I fell off the toilet because the toilet high rise seat came off the stool and I fell on the floor. On 8/24/17 at 12:20 PM the toilet riser in the 100 Hall Bathroom was not attached to the toilet and when touched the riser moved about the toilet rim, the riser was not secured to the toilet. E1, Administrator stated on 8/24/17 at 12:45 PM Yes the toilet risers should be attached to the toilet. This one is loose (Hallway 100 Bathroom). At 12:54 PM E1 also stated (E10) (Maintenance Supervisor) goes around and checks equipment every morning but I don't know if that includes the toilet risers. E10, stated on 8/24/17 at 1:38 PM Part of normal routine is to check both toilet rails and risers because some are attached together. I do the Hall bathrooms every morning when I do water temperatures. The riser in question on 7/18/17 which was nylon, bolts snapped. It broke and I replaced the riser attached to the toilet and then attached safety rails to the toilet with metal bolts. R10's care plan dated 7/18/17 documents as an intervention for the fall on 7/18/17 toilet handrails re-enforced.

Based on observation, record review and interview, the facility failed to thoroughly assess, and monitor the use of side rails, and failed to identify potential hazards related to side rail use, and failed to follow the Food and Drug Administration guidelines to reduce the risk for entrapment for 5 of 10 residents ( R1, R2, R5, R7, R11) reviewed for side rail entrapment hazards in the sample of 10 and 9 residents (R12, R13, R14, R16, R17, R19, R21, R22, R23) in the supplemental sample. The failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 6/27/13, the facility remains out of compliance at severity level two, while the facility continues to educate staff on side rail assessment and recognition of potential hazards related to the use of siderails as positioning devices. Findings include: 1. The U.S. Food and Drug Administration (FDA) publication "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment - Guidance for Industry and FDA Staff" issued March 10, 2006 documented " To reduce the risk of Head entrapment, opening in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped." The publication documented "FDA is therefore using a head breadth dimension of 120 mm (millimeters) (4 3/4 inches) as the basis for its dimensional limit recommendations." The publications documented regarding neck entrapment "To reduce the risk of neck entrapment, openings in the bed system should not allow a small neck to become entrapped." The publication documented "The FDA is recommending 60 mm (2 3/8 inches) as an appropriate dimension for neck diameter. The publication documented regarding chest entrapment "The openings in a bed system should be wide enough not to trap a large chest through the openings between split rails. The FDA's dimensional limit recommendations for the chest is 12 1/2 inches. 2. The Minimum Data Set, ((MDS) dated [DATE], documents that R2 is moderately impaired with cognition, long and short term memory impairment and impairment to upper and lower extremities. The MDS documents R2 needs extensive assistance with transfers and bed mobility with unsteady balance while standing. The physician's orders [REDACTED]. The Fall Risk assessment dated [DATE], documents R2 is a high risk for falls. R2's Siderail Consent dated 6/13/08, indicates R2 has 3/4 Siderails to be used at all times, related to physical condition, bed mobility and positioning. The Care Plan, dated 10/16/12, documents R2 has impaired cognition related to a [DIAGNOSES REDACTED]. Interventions include, 2 assist with gait belt for all transfers and moving resident close to the nurses station because she yells out when she needs help. On 6/27/13 at 1:20 PM R2 was observed to have a 3/4 fan shaped side rail attached to R2's bed. Zone 1 of the side rail measured 7 3/4 inches within the rail. The right side of R2's bed was against the wall. According to the U.S. Drug Administration publication, the FDA uses a head breadth dimension for Zone 1 of 4 3/4 inches.as the basis for its dimensional limit recommendations. 3. On 6/27/13 the facility had the following side rail systems on the beds in the facility which did not meet the FDA dimensional limit recommendations: Type A: Fan Fold 3/4 length system and Fan Fold 1/2 length system with an opening in Zone 1 of 7 3/4 inches within the rail. R1, R2, R7, R11,R12,R13,R14,R16, R17, R21, R22 and R23 reside in the beds with these side rail systems. Type B: Full Metal side rails with horizontal metal bars with an opening in Zone 6 of 5 1/4 inches at the top of the side rails and an opening in Zone 6 of 12 inches at the foot of the side rails. R5 resides in the bed with this side rail system. Type C: A full metal side rail system with an opening in Zone 1 of 5 inches and an opening in Zone 2 of 5 1/2 inches. R19 resides in the bed with this side rail system. 4. An interview on 6/27/2013 at 3:15 PM with E1, Administrator, E1 stated that " the rails have been here for a very long time, probably since the 70"s. They were here when I started. E1 also stated that there have been no incidents of entrapment. Some residents use them, some don't." E14, Regional Nurse confirmed the same information. The Immediate Jeopardy situation was identified and determined to have begun on 6/27/2013, at 1:00 PM, when an evaluation and measurement of the side rails in the facility was started by the survey team. Measurements indicated the rails to be a potential entrapment hazard. E1, Administrator and E14, Regional Nurse were notified of the Immediate Jeopardy at 3:20 PM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy. 1. On 6/27/2013, the facility re-assessed all residents using side rails to verify they were necessary for mobility and are a reflection of the needs of the residents. 2. On 6/27/2013 side rails were either adjusted or removed and replaced with appropriate rails. 3. At 8 PM on 6/27/2013, the survey team and facility personnel completed an audit of all facility beds to verify any remaining side rails were safely attached and did not present any hazards to the residents using them. 4. On 6/27/2013 the facility inserviced all direct care staff, and staff that perform functions in residents rooms, on recognition, and reporting of potential bed related hazards.

Based on record review and interview, the facility failed to re-evaluate for the effectiveness of interventions, attempt alternative interventions and supervise a resident to minimize the risk for a recurring fall and serious injury for 1 of 5 residents (R1) reviewed for falls in the sample of 10. This failure resulted in R1 fracturing her right wrist. Findings include: R1's Minimum Data Set (MDS), dated [DATE], documented limited to extensive assistance of one person physical assistance with mobility, transfers and toileting, and an inability to stabilize balance without staff assistance. R1's Care Plan, goal date of 10-31-12, documented a potential for falls related to fall history, unsteady balance and gait, decline in mobility and poor safety awareness. In an interview with E3, Licensed Practical Nurse (LPN), 7-25-12 at 9:15a.m., E3 stated R1 did not have safety awareness. In an interview of E9 (LPN), on 7-25-12 at 9:45a.m., E9 stated R1 did not have safety awareness. R1's fall history, in part, documented R1 fell during self toileting, on 1-30-12, and fractured her left shoulder/clavicle and she that fractured her left ulnar, on 2-26-12, when she fell to the floor near her bed. R1 received abrasion/bruising on 4-17-12 during self toileting after multiple times that R1 attempted to self transfer with her alarm sounding and not sounding, a right middle finger skin tear, on 4-18-12, during self toileting and falling off the side of her bed, on 4-25-12, with her alarm sounding. R1's Incident Report, dated 5-4-12, documented R1 fell out of bed with her bed alarm sounding. R1 was sent to a local hospital for evaluation and returned with a cast in place for a fractured right wrist. R1's Incident Report, dated 5-22-12, documented R1 stated she hit her head on her bed receiving left temple bruising and, on 7-11-12, R1 received a left wrist skin tear during attempted self-toileting. The facility's Fall Prevention policy and procedure, revised date 12-09, documented, in part, that it was the policy of the facility to provide for resident safety and to minimize injuries related to falls. R1's Fall Risk Assessments, dated 4-3-12 and 6-26-12, and her Physical Restraint/Enable Assessment, dated 5-4-12, do not document re-evaluation of the effectiveness of fall interventions in place. Interview of E1, Administrator, on 7-27-12 at 10:25a.m., E1 stated the initiation of a low bed and alarming self release belt was not initiated until after R1's last fall (5-4-12) based on family preference.

Based on record review and interview the facility failed to follow implemented interventions on the plan of care for R1 for two of four falls. R1 is one of two residents sampled and assessed to be at risk for falls in a sample of six. Findings include: The physician's orders [REDACTED]. The facility's form titled "Fall Risk Assessment" dated 6/29/12, 9/6/12, and 9/8/12 states R1 is at high risk for falls. The Minimum Data Set ((MDS) dated [DATE] states R1 requires extensive assistance with two plus person physical assist for bed mobility, transfers and toileting. The same MDS states R1 is not steady with balance and walking and R1 is only able to stabilize with staff assistance. The facility's form titled "Investigation Report for Falls" dated 8/19/12 for R1 states R1 had a fall on 8/19/12 at 10:20 AM. The section titled "What was the resident doing or trying to do at the time of the fall" reads " (R1) tried to transfer self to wheelchair from toilet." "Root Cause Analysis" reads "(R1) lost balance - has poor safety awareness and (E8), CNA (Certified Nurses Assistant) had her back turned away from resident." R1's Nurses Notes dated 8/19/12 states " (R1) was sitting on toilet in bathroom, CNA (E8) stuck head out of door to tell another CNA she needed clothes for (R1). (R1) stood up and lost balance and fell on to floor onto left side with head closest to door...." R1's plan of care dated 7/11/12 under the category titled "Falls" states the following intervention "Observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed." R1 sustained another fall on 9/13/12 at 2:35 PM, the facility's "Investigation Report for Falls" dated 9/13/12 states "(R1) was in her wheelchair and was going to bed and fell ". Section titled "Root Cause Analysis " states "(R1) not to be left alone in room except in bed. Offer to lay (R1) down at 2 PM." R1's plan of care dated 8/19/12 new intervention reads" (R1) 1:1 (one to one) when alarms not on during toileting and activities of daily living, and visual contact must be maintained at all times. Never to be left unattended or not within visual site (sight)..." E2, DON, (Director of Nurses) stated on 9/28/12 at 3 PM "(E8) CNA did turn her back on (R1) and (R1) fell off the toilet and hit her head on the floor. The CNA (E8) did not follow (R1)'s plan of care by leaving her alone at anytime." E2, DON confirmed on 10/2/12 at 12:55 PM that R1 should have not been in her room on 9/13/12 by herself, R1 should be in visual sight of the staff at all times except when lying down in bed.