Every finding on record at The Haven of Farmer City

Based on interview and record review, the facility failed to ensure accurate accountability and reconciliation of a controlled substance medication for one (R5) of three residents reviewed for medication administration in the sample list of five. Finding include: Electronic Health Record (EHR) and June Medication Administration Record (MAR) reviewed documents R5 had an active physician order for Morphine Sulfate Concentrate Oral Solution 100 mg(milligrams/5 mL(milliliters) with instructions to administer 0.5 mL by mouth every three hours as needed for pain. The medication had been in use since December 2025 as part of R5's hospice plan of care.On 6/23/26 at 1:00 PM, V3 (Licensed Practical Nurse/LPN) conducted a review of R5's morphine supply and controlled substance records. V3 confirmed the morphine bottle contained approximately 24 mL of medication. V3 further reviewed the facility's narcotic accountability records and determined the Narcotic Check-Out Sheet reflected a remaining balance of 19.5ml.This review of the morphine record documents a discrepancy of approximately 4.5 mL between the amount of morphine documented on the controlled substance accountability record and the amount present in the medication bottle.R5's Electronic Health Record (EHR) documents R5 had received documented administrations of morphine since initiation of the medication in December 2025. Review of administration records from December 2025 through June 22, 2026 documents morphine had been documented as administered 19 times. Based upon the ordered dose of 0.5 mL per administration and a 30 mL bottle, calculations indicated the expected remaining volume did not correspond with the amount documented on the narcotic accountability record.On 6/23/26 at 1:00 PM, V3 stated there should be no discrepancy between the controlled substance log and the actual amount of medication remaining in the bottle. V3 confirmed the narcotic accountability record, and medication supply should reconcile at all times.On 6/24/26 at 10:15 AM, V2 (Regional Nurse Consultant) stated discrepancies involving controlled substances should not occur and require immediate investigation. V2 confirmed the discrepancy identified with R5's morphine supply was not consistent with facility expectations for narcotic accountability. V2 stated the pharmacy has been notified regarding the discrepancy.

Based on interview and record review the facility failed to adequately assess, monitor, document, and respond to a significant change in condition for one of three residents (R5) reviewed for quality of care in the sample list of five. This failure resulted in R5 experiencing a delay in treatment for respiratory symptoms and increased lethargy. Findings Include: The Facility's Change in Resident's Condition or Status Policy revised on August 2008 documents, the Director of Nursing or designee will notify the resident attending physician or On-Call Physician when there has been, a significant change in the resident's physical/emotional/mental condition. This document also states that the Director of Nursing or designee will notify the resident/legal representative when there is a significant change in the resident's physical, mental, or psychosocial status. Notification will be made as soon as possible (within 24hours) of a change occurring in the residents medical/mental condition or status. Record review revealed R5 had diagnoses that included Chronic Respiratory Failure, Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation, Orthopnea, Congestive Heart Failure, Dysphagia, and Hospice Services for Respiratory Failure. R5's care plan indicated R5 elected hospice services on 12/18/25 for Terminal Respiratory Failure and had a Do Not Resuscitate (DNR) order.R5's Nursing Notes document a decline in respiratory status beginning on 6/20/26. On 6/20/26 at 9:37 AM, Nursing Notes document, (R5) continues to cough up stringy, thick green phlegm. The nurse contacted hospice and inquired about obtaining an antibiotic order due to R5's continued respiratory symptoms. On 6/20/26 at 10:20 AM, hospice instructed nursing to administer a nebulizer treatment for phlegm and indicated the hospice physician would be consulted regarding a possible antibiotic order.Nursing Progress note dated 6/22/26 at 1:00 AM, documents R5 was observed repeatedly removing R5's oxygen, R5 was spitting on R5's self and R5's bedding, R5 requested a nebulizer treatment for cough, and complained of ongoing symptoms. Oxygen saturation readings obtained on 6/22/26 were 91% while receiving oxygen via nasal cannula.On 6/23/26 at 9:47 AM, nursing progress note documented R5 was coughing and wheezing, had bilateral bronchial lung sounds, was expectorating a small amount of green sputum, and remained on oxygen at 2 liters per minute via nasal cannula with an oxygen saturation of 96%. The nurse documented hospice was notified and staff were awaiting a return call.On 6/23/26 at 10:05 AM, V4 (Certified Nursing Assistant/CNA) stated on 6/16/26, CNAs (V5 and V6) requested assistance because they were concerned about R5's condition. V4 stated V4 observed R5 in a very lethargic state and performed a sternal rub in an attempt to awaken R5.On 6/23/26 at 11:05 AM, V5 (CNA) stated V5 entered R5's room on 6/16/26 to serve breakfast and noted R5 was not responding to verbal stimuli as R5 normally would. V5 stated, It looked like (R5) wasn't breathing. V5 reported the change in condition to the nurse. V5 stated V7 (Licensed Practical Nurse/LPN) responded that the resident had received morphine at approximately 5:00 AM and instructed staff to elevate the R5's head. V5 stated no vital signs were obtained, and V5 was unaware of any assessment completed by V7 at that time.On 6/23/26 at 11:10 AM, V6 (CNA) stated on 6/16/26 V6 was called to R5's room because something seemed off. V6 stated V6 was unable to awaken R5 and notified V7. V6 stated V6 heard V7 instruct staff to just keep (R5's) head up. V6 further stated R5 had been experiencing a significant cough, and nursing staff were aware of the respiratory symptoms.On 6/23/26 at 1:00 PM, V7 (LPN) stated V5 and V6 informed V7 that R5 was not responding to verbal stimuli and that this was not R5's baseline. V7 stated V7 instructed staff to reposition R5 and elevate the head of the bed. V7 stated that upon entering the room, R5 appeared drowsy but awakened when spoken to. V7 acknowledged V7 did not notify the physician, did not notify the responsible party, did not complete documentation regarding the episode, and did not document a nursing assessment. V7 stated V7 contacted hospice and was informed a hospice nurse would visit later that day. V7 further stated the R5 had received 0.5 mL (milliliters) of morphine at approximately 5:00 AM and believed this may have contributed to the drowsiness.R5's medical record failed to reveal documentation of a nursing assessment, respiratory assessment, physician notification, responsible party notification, vital signs, oxygen saturation monitoring related to the lethargic episode, or physician orders obtained following the R5's decreased responsiveness on 6/16/26.R5's oxygen saturation records revealed readings of 90% on 6/21/26, 91% on 6/22/26, 92% on 6/23/26 at 7:23 PM and 9:21 PM, and 93% on 6/24/26 at 4:47 AM while receiving oxygen via nasal cannula.On 6/23/26 at 7:32 PM, nursing progress notes in the electronic medical record documented R5 continued to have a productive cough with thick green phlegm. On 6/24/26 at 4:48 AM, nursing documented the resident continued to produce thick green phlegm and had crackles throughout all lung fields. R5 remained on oxygen at 2 liters at this time. R5's medical record documents the Medical Director was not notified until 6/24/26 at 8:48 AM, at which time nursing documented, (R5) continues to have productive cough. Medical Director has been notified of ongoing condition. New order received to start Z-Pak (antibiotic).On 6/24/26 at 9:45 AM, V8 (R5's Power of Attorney), stated V8 did not receive notification of R5's lethargy, decreased responsiveness, oxygen use, or worsening respiratory symptoms. V8 stated the first notification V8 received was on 6/23/26 regarding cough medication and again on 6/24/26 regarding initiation of antibiotic therapy.On 6/24/26 at 10:15 AM, V2 (Regional Nurse Consultant) confirmed that with a resident exhibiting lethargy, decreased responsiveness, oxygen use, and productive green and yellow sputum, nursing staff should have completed and documented a respiratory assessment, obtained vital signs, notified the physician and responsible party, documented the change in condition, and obtained additional orders as clinically indicated.

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 48 residents in the facility. Findings include:On 3/17/2026 at 9:58AM, V12 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V12 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. V12 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). V12 reported only completing a two-day course on food service sanitation (Certified Food Protection Manager) which did not include any instruction on clinical nutrition. V12 denied having any qualifications in clinical nutrition. V12 denied:-being a dietician;-being a certified dietary manager;-having an associate's or higher degree in food service management or in hospitality;-having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting;-being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. The Facility Assessment (4/10/2025) documents the facility will employ a Dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services. From 3/17/2026 through 3/19/2026, the facility failed to effectively sanitize dishes, failed to prevent physical cross-contamination of ice, and failed to serve therapeutic diets as ordered. On 3/18/2025 at 11:42AM, V12 reported the food in the kitchen is available for all residents to eat and the facility dietician only works in the facility one day per month. The facility Long-Term Care Facility Application for Medicare and Medicaid (3/17/2026) documents 48 residents reside in the facility

Based on observation, interview, and record review, the facility failed to effectively sanitize dishes and failed to prevent physical cross-contamination of ice. These failures have the potential to affect all 48 residents residing in the facility. Findings include:1. On 3/17/2026 at 10:08AM, V14 (Dietary Aide) was washing multiple loads of dishes in the kitchen mechanical sanitizing dishwasher. V14 retrieved a chemical sanitizer test strip to test the sanitizer concentration in the dishwasher. The test strip did not detect any sanitizer was present in the operating dishwasher (a concentration of zero parts per million). A Survey Agency chemical test strip also tested zero sanitizer was present in the dishwasher. A manufacturer's nameplate was present at eye level on the front of the dishwasher and documented a minimum concentration between 50-100 parts per million of sanitizer is necessary to effectively sanitize dishes in the dishwasher. A five gallon bucket of liquid sanitizer was present on the floor beneath the dishwasher to supply sanitizer solution to the dishwasher. The bucket was entirely empty and did not contain any remaining sanitizer solution. 2. On 3/17/2026 at 10:00AM, the three-basin sink in the kitchen was in use and dishes were present in the basin immersed in a sanitizer solution. V12 (Dietary Manager) was present and reported the kitchen uses the three-basin sink to wash dishes and to fill wiping buckets used to sanitize kitchen food contact surfaces and resident dining tables. The sanitizer solution concentration tested 100 parts per million by facility chemical sanitizer test strip and also 100 parts per million by Survey Agency test strip. A gallon jug of liquid sanitizer was present beside the sink and supplied a dispenser attached to the third basin. The manufacturer's label on the sanitizer jug documented a sanitizer level between 200-400 parts per million is necessary to effectively sanitize dishes at the three-basin sink. 3. On 3/17/2026 at 10:04AM, the ice machine located in the facility kitchen was deteriorated and had missing pieces of plastic along the front edge of the ice bin where ice is stored. The front edge of the bin had an approximate quarter inch high lip of plastic designed to prevent contaminants from entering the ice bin. An approximate eight-inch section of the plastic lip was missing and a two-inch and a four-inch section of the lip were peeling and protruding into the ice bin. Mineral deposits were located along the sides and front of the evaporator/condenser attached above the ice bin indicating condensate drain water had been overflowing down the sides of the ice machine instead of to the sewer and potentially entering the ice bin where ice was stored. On 3/19/2026 at 12:03PM, the ice machine remained as above. The same four inch section of the ice bin lip from above was peeling inward and was in direct contact with the ice. V12 was present and stated yes when asked if the plastic was contaminating the ice. On 3/18/2025 at 11:42AM, V12 reported the food in the kitchen is available for all residents to eat.The facility Long-Term Care Facility Application for Medicare and Medicaid (3/17/2026) documents 48 residents reside in the facility

Based on observation, interview, and record review, the facility failed to provide physician ordered therapeutic supplements and diets. These failures affected 21 residents (R1, R2, R3, R4, R5, R9, R10, R12, R15, R18, R24, R26, R27, R35, R38, R39, R40, R41, R44, R45, R47) of 21 reviewed for therapeutic diets on the sample list of 34. Findings include: 1. R3's Minimum Data Set, dated [DATE] documents R3's Brief Interview of Mental Status score of four, out of a possible 15, indicating R3 has severe cognitive impairment. R3's current Diagnoses Sheet documents: Type II Diabetes Mellitus without Complications. R3's Dietary Nutrition/Wound Note dated 01/07/26 documents the following: Skin: Unstageable PW (pressure wound) of Right Heel. R3's same note documents R3's weight (wt) measurements as follows: Weight: 132 lbs. (pounds). 30 Day Wt. 12/07/25: 139 lbs. (5% sig wt. loss) (five percent significant weight loss), 90 Day Wt. 10/07/25: 144 lbs. (8% sig wt. loss) (eight percent significant weight loss). 180 Day Wt. 07/01/25: 135.4 lbs. (3% non-sig wt. loss) (three percent significant weight loss). R3's current Physician Order Sheet (POS) documents R3's diet order as follows: LCS - Low Concentrated Sweets Diet, Pureed texture, Regular (Thin) consistency. SF (Sugar Free) Ice Cream BID (Twice a day) at Lunch/Supper. On 3/18/26 at 12:15 pm R3 was seated in a wheelchair in the facility resident assistance dining room. R3's meal ticket documented R3's diet as low concentrated sweets, pureed texture diet with thin liquids. R3's meal ticket did not reflect the complete physician order as noted above. R3 did not have sugar free ice cream twice a day indicated on her meal tray. R3 stated I wonder where that is. I like ice cream. If it is paid for, I would eat that. On 3/18/26 at 12:20 pm V12 (Dietary Manager/DM) was at the resident's assisted dining room door and visualized R3's meal tray from the hall. V12 confirmed R3 did not have sugar free ice cream or a substitute supplement for the sugar free ice cream on R3's meal tray. V12, DM stated We do not have sugar free ice cream for her (R3). I found out last night (R3) is supposed to be getting it. We don't have a substitute available. I have not been able to purchase sugar free ice cream anywhere. It will be delivered on our truck this Friday. 2. On 3/17/2026 at 9:58AM, V12 (Dietary Manager) reported the facility did not have any residents who receive therapeutic diets. On 3/17/2026 at 10:20AM, V12 provided all of the current dietary spreadsheets the kitchen uses to prepare and serve resident meals. The spreadsheets documented the following diets: regular texture, puree texture, mechanical soft texture, mechanical soft texture-puree meat, and mechanical ground texture. No spreadsheet was present documenting any specific diet for residents who receive a low concentrated sweets diet (LCS). The facility Order Listing Report (3/20/2026) documents R1, R2, R3, R5, R10, R18, R24, R26, R27, R38, R40, and R44 are all ordered to receive a low concentrated sweets (LCS) diet. On 3/17/2026 at 11:45AM, R26 reported having a diagnosis of diabetes and not receiving sugar free drinks in the facility or sugar free condiments and reported wanting sugar free drinks. R26 stated I get juice all the time. On 3/20/2026 at 11:28AM, R26's meal slip for the lunch meal documented R26 should receive a LCS diet. On 3/18/2026 at 11:37AM, two bins containing powdered beverage mixes were located in the facility kitchen pantry. The following drink mixes were present: grape flavor containing sugar and grape flavor without sugar, fruit punch flavor containing sugar, lemonade flavor containing sugar, orange flavor without sugar. V12 (Dietary Manager) was present and was asked if residents who are diabetic or receive low concentrated sweets (LCS) diets are served sugar free beverages. V12 reported all drink mixes used by the kitchen are sugar free. V12 then began sorting through the above drink mix packets and reported thinking all the mixes were sugar free. The surveyor then asked V12 if the kitchen makes any changes to beverages for residents with diabetes or residents who receive a LCS diet. V12 reported all residents receive the same beverages during meal services. On 3/19/2026 at the noon lunch meal, all residents received an equal sized portion of a rice crispy treat for dessert. Residents ordered LCS diets did not receive a reduced portion size of the dessert. On 3/19/2026 at 12:32PM, V24 (facility Dietician) reported the facility absolutely has a specific menu spreadsheet for the kitchen to follow for residents with LCS diets and reported the facility should be serving half-size dessert portions and not adding extra sugars to food items for residents who receive a LCS diet. V24 reported recommending sugar free drinks for the same residents and the facility should be making sugar free beverages for residents receiving an LCS diet. 3. On 3/18/2026 at 11:47AM, no ground Swedish meatballs were present at the kitchen steam table during the noon lunch service. V15 (Dietary Aide) was present and reported no ground Swedish meatballs were prepared for today's lunch meal. No residents anywhere in the facility at the noon lunch meal received ground Swedish meatballs. The facility dietary spreadsheets (Week 4) documents residents who receive a mechanical soft diet should receive two ground Swedish meatballs during the lunch meal service on 3/18/2026. The facility Order Listing Report (3/20/2026) documents R4, R9, R12, R15, R35, R39, R41, R45, and R47 are all ordered to receive a mechanical soft diet. R4's Medical Diagnosis form (3/19/2026) documents diagnoses including Dysphagia (an inability to swallow that increases the risk of choking and/or death with symptoms including pain, food getting stuck, coughing, or choking while eating), Hemiplegia (severe or total paralysis of one side of the body caused by brain or spinal cord damage), and Cerebral Infarction (a type of ischemic stroke caused by a blockage in a blood vessel that disrupts blood flow to the brain, resulting in tissue necrosis or cell death). R4's Physician Order sheet (3/19/2026) documents R4 is ordered a mechanical soft diet. On 3/18/2026 at 12:28PM, R4 was eating a regular texture diet in the facility dining room. R12's Medical Diagnosis form (3/19/2026) documents diagnoses including Dysphagia (an inability to swallow that increases the risk of choking and/or death with symptoms including pain, food getting stuck, coughing, or choking while eating), Hemiplegia (severe or total paralysis of one side of the body caused by brain or spinal cord damage), and Cerebral Infarction (a type of ischemic stroke caused by a blockage in a blood vessel that disrupts blood flow to the brain, resulting in tissue necrosis or cell death). R12's Physician Order sheet (3/20/2026) documents R12 is ordered a mechanical soft diet. On 3/18/2026 at 12:13PM, R12 was independently eating a regular texture diet in the facility dining room. R15's Medical Diagnosis form (3/19/2026) documents diagnoses including Hemiplegia and Cerebral Infarction. R15's Physician Order sheet (3/19/2026) documents R15 is ordered a mechanical soft diet. On 3/18/2026 at 12:15PM, R15 was independently eating a regular texture diet in the facility dining room. R35's Medical Diagnosis form (3/19/2026) documents the diagnosis Dysphagia. R35's Physician Order sheet (3/19/2026) documents R35 is ordered a mechanical soft diet. On 3/18/2026 at 12:21PM, R35 was eating a regular texture diet in the facility dining room. R39's Dietician Assessment (3/19/2026) documents R39 is ordered a mechanical soft diet. On 3/18/2026 at 12:24PM, R39 was independently eating a regular texture diet in R39's room. R41's Medical Diagnosis form (3/19/2026) documents the diagnosis Dysphagia. R41's Physician Order sheet (3/19/2026) documents R41 is ordered a mechanical soft diet. On 3/18/2026 at 12:20PM, R41 was eating a regular texture diet in the facility dining room. R45's Medical Diagnosis form (3/19/2026) documents diagnoses including Dysphagia and Hemiplegia. R45's Physician Order sheet (3/20/2026) documents R45 is ordered a mechanical soft diet. On 3/18/2026 at 12:24PM, R45 was independently eating a regular texture diet in R45's room. R47's Medical Diagnosis form (3/19/2026) documents the diagnosis Dysphagia. R47's Physician Order sheet (3/19/2026) documents R47 is ordered a mechanical soft diet. On 3/18/2026 at 12:18PM, R47 was eating a regular texture diet in the facility dining room. On 3/19/2026 at 12:323PM, V24 (facility Dietician) reported Swedish meatballs need ground for residents who receive a mechanical soft diet.

Based on observation, interview and record review, the facility repeatedly failed to maintain Bilevel Positive Airway Pressure (BIPAP) ventilation mask, and tubing, Nebulizer (Neb) medication inhalation mask and tubing, oxygen humidification water bottles, oxygen administration tubing and nasal cannula equipment in a clean sanitary condition and according to the facility policy. These failures affect two of two residents (R1 and R38) reviewed for oxygen therapy on the sample list of 34.Findings include:1.R38's Minimum Data Set (MDS) dated [DATE] documents R38's cognitive status was completed by staff. R38's MDS documents R38 had no cognitive impairment and was independent in daily decision making.R38's Physician Order Sheet (POS) documents the following orders: BIPAP at HS (bedtime), (two liters per minute) 17/7 (inspiration positive pressure/ expiratory positive airway pressure) rate 14 (to deliver a minimum of 14 breathes per minute) with 2L (liters per minute), o2 (oxygen) bled (added supplemental oxygen into BIPAP machine for hypoxia).R38's same POS documents: Titrate 02 (oxygen) to maintain sats (blood oxygen saturation level) > (greater than) 90% (percent). Do not exceed 3 LM (liters per minute) without notifying the physician, every shift for Respiratory Management.R38's same POS documents: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 (vial) inhalation (per nebulizer), inhale orally every 6 (six) hours as needed for SOB (Shortness of Breath) related to Chronic Obstructive Pulmonary Disease With Acute Exacerbation.On 03/17/2026 at 11:10AM R38 was seated in a recliner bedside. R38's oxygen was dispensed at 3.0 liters per nasal cannula via a bedside oxygen concentrator. Though the oxygen /nasal cannula tubing was dated 3/17/256, the bedside concentrator had an empty humidifier water bottle attached to the tapered connector, that was not dated. R38 also had BIPAP machine with tubing and a heavily soiled BIPAP mask that was laying directly on R38's bedside table. R38 also had a nebulizer breathing treatment machine and a soiled mask on R38's bedside table. There was no date on the tubing or mask.R38 stated I have no idea when those masks were changed. It was not any time recently. You can tell by how dirty they are. R38 also stated I just got out of the hospital. I went for my Asthma and COPD. It cannot be good for my breathing to use dirty stuff for my breathing. R38 also stated My water bottle there has been running on empty since yesterday. I am not sure why they did not fill it when they changed my oxygen tubing. I should have been paying closer attention, and they would have filled it. That is when it usually gets changed.On 3/17/26 at 11:15 am V4 (Licensed Practical Nurse/LPN) confirmed R38's BIPAP and nebulizer treatment masks and tubing laying on R38's bedside table were undated and soiled. V4 confirmed R38's Oxygen humidifier water bottle was empty. V4 stated she changed R38's oxygen tubing and does not know what date was on them when changed. V4 said she got busy and forgot to change R38's BIPAP and Nebulizer treatment masks and tubing or fill R38's humidifier bottle. 2. R1's Minimum Data Set, dated [DATE] documents R1's Brief Interview of Mental Status score as 15 out of a possible 15, indicating no cognitive impairment.R1's current Physician Order Sheet (POS) documents R1 has had the oxygen administration order since 11/23/25.R1's same POS documents: Change oxygen tubing weekly, every night shift every Sunday.R1's same POS documents R1's nebulizer medication inhalation therapy order as follows: Ipratropium-Albuterol 0.5 (milligrams)-2.5 (milligrams (3) MG/3ML (per milliliters) Solution Inhale contents of one vial per Nebulizer twice daily, related to Chronic Obstructive Pulmonary Disease, Unspecified. The same POS documents Ipratropium-Albuterol 0.5 (milligrams)-2.5 (3) MG/3ML Solution, inhale contents of one vial per nebulizer every six hours as needed for shortness of breath or wheezing.On 03/17/26 at 10:15 am R1 was in bed with oxygen nasal canula in place. Oxygen was dispensing continuously at three liters per nasal cannula via a bedside concentrator. The date on R1's oxygen/nasal cannula tubing was 3/01/26. R1's oxygen concentrator had a humidifier refillable water bottle attached. R1's oxygen humidifier water bottle was empty. There was no label or date on R1's water bottle. R1 also had a soiled nebulizer medication inhalation face mask laying directly on the cluttered bedside table. R1's nebulizer tubing was also dated 3/01/26, to indicate the last time the respiratory equipment had been changed.R1 stated I have to have the humidified oxygen, so my nose does not get sore. R1 also stated The nurses rarely fill the water bottle or change the tubing like they are supposed to. On 3/17/26 at 10:25 am V4 (LPN) confirmed R1's humidifier bottle was empty, nebulizer mask and tubing were soiled and dated 3/1/26, and R1's oxygen/ nasal canula tubing was dated 3/01/26. V4, LPN confirmed the respiratory equipment should have been changed according to the facility policy and physician order.The facility Undated policy Respiratory Equipment Cleaning and Change Policy documents the following: PurposeTo reduce the risk of infection and ensure proper functioning of respiratory equipment by establishing standardized procedures for cleaning, disinfecting, and replacing oxygen delivery devices, nebulizer equipment, and BiPAP/CPAP apparatus.PolicyAll respiratory equipment must be maintained in clean and sanitary condition. Equipment will be cleaned, disinfected, and replaced according to manufacturer guidelines and the frequency outlined below. Staff will adhere to infection control practices during all handling of respiratory devices.The same policy directs staff to change respiratory equipment including Oxygen, BIPAP and Nebulizer tubing and mask/nasal cannula every seven days and as needed when soiled. The same policy documents to refill humidifier water bottles as needed.

Based on observation, interview and record review the facility failed to ensure resident's right to dignity while dining, for three of 15 (R9, R17, and R47) residents reviewed for dignity while dining on the sample list of 34. On 3/17/26 between 12:30 pm and 1:00 pm 15 residents were fed by staff in the assisted dining room. During this time period, V6 (Certified Nursing Assistant/CNA), V7 (CNA) and V8 (CNA) intermittently engaged in extensive personal conversations about what other facilities are getting paid out of town for CNAs working for agency. The same three CNAs discussed other numerous other topics some of which included relatives birthday activities, and a staff member's two year old's behaviors. V6, V7, and V8 (CNAs) talked to each other while feeding R9, R17 and R47. The same CNAs minimally spoke to the residents they were feeding only directing the residents to take a bite, or take a drink. The CNAs would return to their personal conversation with each other. All three staff were actively feeding residents while seated at R9, R17 and R47's table. R9, R17 and R47 were non-verbal throughout the meal. On 3/17/26 at 1:05 pm V6 (CNA) stated We should have been talking with the residents, not visiting with each other.On 3/17/26 at 1:07 pm V7 and V8 (CNAs) confirmed it is a dignity issue to be talking with the residents while feeding them, and not with each other about things outside of work.On 3/18/26 at 11:18 am V1 (Administrator) stated she had been informed yesterday by staff, that some of the CNAs were in the assisted resident dining room talking to each other about outside interests when they should have been conversing with the residents they were assisting with the meal. V1 further stated I agree this is a dignity issue and I started an in-service on dignity yesterday and plan to continue the education today. The facility RESIDENTS' RIGHTS for People in Long-Term Care Facilities pamphlet provided in the admission packet, dated as revised 11/18 documents the following: As a long-term care resident in Illinois, You are guaranteed certain rights, protections and privileges according to state and federal laws. The same pamphlet documents: Your rights to dignity and respect. You have a right to make your own choices. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source.

Based on interview and record review, the facility failed to accurately document resident advance directives in the resident's medical record. This failure has the potential to affect two (R10 and R41) of 16 residents reviewed for advanced directives in the sample list of 34. Findings include: 1. R10's Power of Attorney for Health Care dated 3/14/2025 and signed by R10 documents the following advanced directive for R10: I do not want my life to be prolonged, nor do I want life-sustaining treatment to be provided or continued if my agent believes the burdens of the treatment outweigh the expected benefits. I want my agent to consider the relief of suffering, the expense involved and quality as well as the possible extension of my life in making decisions concerning life-sustaining treatment.R10's Electronic Medical Record (EMR) banner documents R10's code status as Full Code.R10's Physician Order Sheet (POS) current documents R10's code status as Full Code.R10's Care Plan (current) documents R10's code status as Do Not Resuscitate (DNR).R10's Paper Medical Record, located at the nurses' station, has a DNR sticker on the binder.2. R41's EMR banner does not document any code status for R41.R41's POS and Care Plan (current) do not contain any code status for R41.R41's Paper Medical Record, located at the nurses' station, has a Full Code sticker on the binder.R41 did not have any advanced directives formulated in R41's EMR and/or paper medical record.On 3/18/26 at 10:54am, V11 (R41's Power of Attorney) stated R41 is full code and the facility should have the paperwork to note that. V11 confirmed V11 has decisional rights over R41. On 3/17/26 at 10:42am, V3 (Registered Nurse) stated staff look at the EMR banner and/or POS to determine a residents' code status. On 3/20/26 at 10am, V23 (Regional Nurse Consultant) confirmed R10's advanced directives are mismatched and R10's EMR banner and POS should reflect R10 as being DNR. V23 further confirmed advanced directives are not formulated in any medical record for R41.

Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage upon a resident discharge from Medicare Part A services. This failure affects one resident (R16) of three reviewed for beneficiary notifications in the sample list of 34. Findings include:The Beneficiary Notice-Residents discharged within the last six months form (undated) documents R16 was discharged from the facility on 2/27/26 and waived benefits.R16's Beneficiary Protection Notification Review form (undated) documents R16 initiated discharge from Medicare Part A services prior to R16's use of all covered Medicare benefit days. This same record documents R16 did not receive the required Notice of Medicare Non-Coverage (NOMNC). R16's Physical Therapy Discharge Summary for services provided 1/26/2026 through 2/26/2026 documents R16 was discharged from therapy due to R16 reaching the highest practical level/max potential achieved.R16's medical record (undated) did not document R16 received the Notice of Medicare Non-Coverage and the Advanced Beneficiary Notice of Non-Coverage following R16's discharge from Medicare. On 3/18/26 at 9:21am, V10 (Business Office Manager) stated R16 did not require a SNF ABN or a NOMNC therefore they were not provided. V10 stated R16 had benefit days remaining but waived benefits.On 3/18/26 at 3:23pm, V16 (Physical Therapist Assistant) stated R16 had returned to baseline/prior level and was discharged from therapy. On 3/19/26 at 8:25am, V1 (Administrator) stated R16 should have been given a NOMNC since the facility initiated the discharge from services and R16 had skilled benefit days remaining.

Based on interview and record review the facility failed to arrange for the required Preadmission Screening and Resident Review (PASRR) assessment to determine a resident need for nursing home and specialized services for a serious mental illness, post the thirty 30 days exempt admission PASRR status screening. This failure affects one of two resident (R38) reviewed for PASRR screening on the sample list of 34.Findings include:R38's current diagnoses list documents R38 was admitted with the following mental health conditions: Schizoaffective Disorder, and Unspecified and Major Depressive Disorder, Recurrent, Unspecified.R38's Notice of PASRR Level I Screen Outcome dated [DATE], documents the following: Maximus (Federal mandated assessment process) Notice You are receiving this notification because you received a Preadmission Screening and Resident Review (PASRR) screening. To learn more, read the additional PASRR information that came with this letter.Name of Evaluated Individual: (R38)Assessment ID number: (R38 screening number) PASRR Level I Reviewer: (V17, PASRR Screener)PASRR Level I Review Date: [DATE].PASRR Level I Determination: Exempted Hospital Discharge Number of Approved Days: 30 days.Suspected or confirmed PASRR Condition(s): (MH) Mental Health Disability.Note: If the documents required to support this decision are not submitted, the outcome of this Level screen will become invalidated. You will not be allowed to admit to or remain in a Medicaid-certified nursing facility.Enclosures: PASRR Outcome Explanation, Level I ScreenPASRR Outcome ExplanationNotice of Criteria Met for Exempted Hospital Discharge-No PASRR Level II Required.On behalf of the (State Agency), Maximus has reviewed the Preadmission Screening and Resident Review (PASRR) Level I screen completed for you by your health care professional. You received this screen because you are seeking to enter or continue to stay in a nursing facility that receives Medicaid funding. PASRR Level I screens are required by Federal law, 42 U.S.C. S 1396r(e)(7).Your Level I screen shows you have evidence of serious mental illness or intellectual/developmental disability (IDD). Further PASRR evaluation is not required because you meet criteria for an exempted hospital discharge. This means you may stay up to thirty (30) days in a Medicaid-certified nursing facility without further PASRR evaluation.If you or your care provider thinks you need to stay longer than thirty (30) days, a nursing facility staff member must submit a new Level I screen to Maximus. This must be completed by or before the 30 (thirtieth) day after your admission ([DATE]), (R38 continues to reside in the facility [DATE] without the required new PASSR screen).On [DATE] at 11:10 am V1 (Administrator) confirmed R38 should have had a new PASRR screen for her continued stay in the facility, since the Hospital exempt PASRR expired at 30 days.

Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for insulin and anticoagulant use and monitoring. This failure affects one (R5) of five residents reviewed for unnecessary medications in the sample list of 34.Findings include:The facility's Care Plans (Comprehensive) Policy (revised October 2022) documents the following: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident. Each resident's Comprehensive Care Plan has been designed to: Incorporate identified problem areas; incorporate risk factors associated with identified problems; and reflect treatment goals and objectives in measurable outcomes. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of resident's comprehensive assessment (MDS).R5's Face Sheet dated 3/20/26 documents R6 was admitted to the facility on [DATE].R5's Physician Order Sheet (current) documents the following orders: Xarelto 20 milligrams (mg), give 20 mg by mouth one time a day for anticoagulant; Insulin Glargine-yfgn 100 unit/ml (milliliter) Solution pen-injector, inject 45 units subcutaneously in the evening; and Insulin Lispro 100 unit/ml, inject 10 units subcutaneously.R5's Care Plan (current) does not include R5's anticoagulant medication use and/or monitoring. This same record does not include R5's insulin use and/or monitoring.R5's admission MDS was completed on 2/11/26.On 3/20/26 at 9:51am, V23 (Regional Nurse Consultant) stated the Regional MDS Coordinator is responsible for completing resident care plans. V23 confirmed R5 does not have a comprehensive care plan in place.

Based on observation, interview and record review, the facility failed to maintain an indwelling urinary catheter drainage bag and tubing, in a clean sanitary manner, off the floor. This failure affects one of one resident (R6), reviewed for urinary indwelling catheters/infection on the sample list of 34.Findings include:R6's current Diagnoses Sheet documents the following: Spastic Quadriplegic Cerebral Palsy, Other Obstructive and Reflex Uropathy, Benign Prostatic Hyperplasia With Lower Urinary Tract Symptoms, Atrophy Of Kidney (Terminal) and Personal History of Urinary Tract Infections.R6's current Physician Order Sheet documents the following: Change urinary catheter every (on) night shift every 10 days, 18f with 30cc (size 18 French catheter, with a 30 cubic centimeter balloon anchor) balloon.On 03/17/2026 at 11:35 am R6 lay asleep in a low bed, that was approximately one foot above the floor. R6 had a bedside, indwelling urinary catheter drainage bag on the right side of the bed. R6's bedside indwelling urinary catheter drainage bag laid flat on the floor without a dignity/protective drainage bag cover. R6's indwelling urinary catheter tubing coiled on the floor under R6's low bed. R6's indwelling urinary catheter, drainage bag contained an undetermined amount of dark yellow urine.On 3/17/26 at 11:40 am V5 (Certified Nursing Assistant) confirmed R6's urinary catheter drainage bag was on the floor. V5 stated (R6) has a dignity bag on his bed. I thought I put it (urinary drainage bag) in there when I left the room. I know one of the nurses did his (R6's) wound treatments, after me. I guess it (urinary drainage bag) must have fallen out of the bag (dignity/protective) then. We have to keep the catheter off the floor, so it does not get contaminated with germs.The facility undated Urinary Catheter Drainage Bag Protocol documents the following: Purpose: Proper care of a catheter drainage bag is essential to reduce the risk of infection and ensure proper urinary drainage. All staff must follow these guidelines consistently and adhere to any additional provider-specific instructions.Required Practices1. Ensure Unobstructed Flow* Arrange catheter tubing to prevent twisting, kinking, or looping.* Check tubing regularly to maintain continuous urine flow.2. Proper Positioning While in Bed* Securely hang the urine drainage bag on the side of the bed using appropriate hooks or holders.* Do not place the bag on the mattress or linens.3. Maintain Correct Bag Level* Always keep the drainage bag below the level of the bladder to prevent backflow and reduce infection risk.4. Prevent Contamination* The urine drainage bag must never touch the floor.* Ensure the bag is handled with clean technique during emptying and repositioning.Key ReminderFailure to follow these practices increases the risk of catheter-associated urinary tract infections (CAUTIs) and may result in negative resident outcomes and regulatory deficiencies.

Based on interview and record review, the facility failed to offer and administer a COVID-19 vaccine to ensure a resident was up to date for vaccines for one (R6) of five residents reviewed for immunizations in the sample list of 34.Findings include:R6's Face Sheet dated 3/20/26 documents R6 was admitted to the facility on [DATE], is [AGE] years old and has Chronic Obstructive Pulmonary Disease.R6's Immunization tab documents R6 last received a Covid-19 vaccine on 10/25/24.R6's Covid-19 Vaccine Consent form dated 8/18/25 documents V20 (R6's Power of Attorney) verbally consented for R6 to receive a Covid-19 vaccine.There is no documentation in R6's Medical Record of any attempts to provide R6 with the Covid-19 vaccine.On 3/20/26 at 9:51am, V23 (Regional Nurse Consultant) stated R6 did not receive the Covid-19 vaccine during the facility vaccine clinic. V23 stated unsure why R6 was missed during the vaccine clinic and R6 should have received a Covid-19 vaccine. V23 stated the facility follows current Centers for Disease Control (CDC) vaccine guidelines.The CDC 2025-2026 Covid-19 Vaccination Guidance documents the following: 1e. Ages 65 years and older; previously vaccinated before 2025-2026 vaccine: Administer 2 doses of 2025-2026 vaccine with dosing intervals dependent on the manufacturer of the vaccine received.

Based on interview and record review, the facility failed to offer and administer an influenza vaccine to ensure a resident was up to date for vaccines for one (R6) of five residents reviewed for immunizations in the sample list of 34.Findings include:R6's Face Sheet dated 3/20/26 documents R6 was admitted to the facility on [DATE], is [AGE] years old and has Chronic Obstructive Pulmonary Disease.R6's Immunization tab documents R6 last received an influenza vaccine on 10/25/24.R6's Influenza Vaccine Consent form dated 8/18/25 documents V20 (R6's Power of Attorney) verbally consented for R6 to receive an annual influenza vaccine.There is no documentation in R6's Medical Record of any attempts to provide R6 with the influenza vaccine.On 3/20/26 at 9:51am, V23 (Regional Nurse Consultant) stated R6 did not receive the influenza vaccine during the facility vaccine clinic. V23 stated unsure why R6 was missed and R6 should have received an influenza vaccine. V23 stated the facility follows current Centers for Disease Control (CDC) vaccine guidelines.The facility's Guideline for Influenza Vaccine Policy reviewed 7/2025 documents the following: It is the policy of this facility that annually all residents will be offered the influenza vaccine. This facility follows the Centers for Disease Control (CDC) guidelines for influenza vaccinations. Each resident will be offered the vaccination annually between October 1 thru March 31, unless the immunization is contraindicated, already immunized, or refuses after receiving education on the risk versus benefits of the vaccination.

Based on interview and record review the facility failed to allow a resident to refuse a blood glucose check and failed to provide privacy for blood glucose monitoring and insulin administration for one (R1) of three residents reviewed for resident rights on the sample list of five. Findings include:The undated resident rights policy documents on page three (3) the section titled Your rights to dignity and respect: You have a right to make your own choices. The same document states - Your rights to participate in your own care: You have the right to request, refuse, and/or discontinue any treatment.The Medication Administration policy dated 10/25/2014 documents residents may actively refuse medications.R1's Care Plan dated 04/01/2025 documents an admission date of 04/01/2025. The same document lists R1's diagnoses as Cerebral Infarction, Dysphagia Following Cerebral Infarction, Hypertension, Dementia, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Chronic Kidney Disease, Stage 3, and Type 2 Diabetes Mellitus with Hyperglycemia.The Facility Incident Report dated 1/22/26 at 08:35AM documents R1 was refusing to have her blood glucose level taken by a nurse. V3 (License Practical Nurse/LPN) approached R1 and took R1's hand and took the blood glucose level while resident was refusing. The report further states Interviews with staff indicated that V3 checked R1's blood glucose level and administered insulin after R1 told V3 she did not want it completed. The report documents V3 stated that V3 was doing what V6 (Power of Attorney/POA) wanted done.On 02/27/2026 at 11:00AM R1 declined interview.On 02/27/2026 at 11:47AM, V7 (Certified Nursing Assistant/CNA) stated on 1/22/26 at breakfast R1 refused the blood glucose level check and insulin. V7 stated V4 (Registered Nurse) left the dining room and V3 (LPN), returned to R1 stating V6 (POA) wants the blood glucose checked and insulin given, then V3 pulled the cover back from R1 and checked the blood glucose level in using blood V3 obtained from R1's finger and left R1's side. V3 then returned with a syringe, pulled the cover back, peeled the sleeve of R1 up and administered the insulin. V7 stated R1 looked at V5 (CNA) and R1 stated my rights were violated.On 02/27/2026 at 12:25PM V2 (Director of Nursing) stated staff should not be performing cares or medical test such as blood glucose monitoring or administering medications if a resident does not want it done. V2 stated nurses should not be checking blood glucose levels or injecting medications such as insulin in the dining room. V2 stated the residents should be provided privacy for medication administration.

Based on interview and record review, the facility failed to safely transfer a resident (R1) from the bed to the wheelchair. This failure resulted in R1 sustaining a broken arm requiring emergency evaluation and treatment at the hospital. R1 is one of three residents reviewed for accidents in the sample list of four. This past non-compliance occurred from 8/13/25 to 8/14/25. Findings Include: The facility Safe Lifting and Movement of Residents Policy (revised August 2008) documents the following: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses mechanical lifting devices for the lifting and movement of residents. Mechanical lifting devices shall be used for any resident needing a two person assist. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. R1's Face Sheet dated 8/22/25 documents R1 was admitted to the facility on [DATE] and R1's diagnoses include: Presence of Right Artificial Shoulder Joint, Paraplegia, Glaucoma, Osteoarthritis, Rheumatoid Arthritis, Contracture, and Dementia. R1's Comprehensive assessment dated [DATE] documents R1 is moderately cognitively impaired, has bilateral lower extremity impairments, uses a wheelchair (motorized) for mobility, and is dependent on staff for all activities of daily living (ADL) including transfers.R1's Care Plan (current) documents R1 has an ADL self-care performance deficit related to Paraplegia, Rheumatoid Arthritis, Weakness and cognitive decline. Further documents R1 is totally dependent on physical assist of two staff for transferring (bed-to-chair/chair-to-bed, toilet transfers, tub/shower transfers) with use of mechanical lift.R1's Injury of Known Cause Report dated 8/13/25 documents R1 was transferred from R1's bed to wheelchair without the use of a mechanical lift. This same report documents R1 was manually transferred from R1's bed to wheelchair by V5 (Certified Nursing Assistant/CNA) and V6 (CNA) when a pop was heard during said transfer and R1 complaining of right shoulder pain. This same report documents R1 would not allow V4 (Licensed Practical Nurse/LPN) to assess for injuries and R1 stating, it hurts, it hurts, please don't touch it and R1 sent out to the emergency department for evaluation and treatment. R1's Hospital Record dated 8/13/25 documents R1 was seen for upper arm trauma and R1 had an acute comminuted periprosthetic fracture of the proximal humerus (upper arm). This same record documents R1 received four intravenous (IV) injections of Hydromorphone (narcotic medication used to treat severe pain) and one IV injections of Ketorolac (nonsteroidal anti-inflammatory drug used for the short-term treatment of moderate to moderately severe acute pain) while in the emergency department. V5 (CNA) witness statement dated 8/13/25 documents, went into [R1's] to assist V6 with [R1]. We sat resident up on side of bed and two person assisted to wheelchair. As we transferred resident, I heard a loud pop. Immediately alerted nurse to assess.On 8/22/25 at 10:45am, R1 was lying in bed with an immobilizer present on R1's right arm. R1 stated, I told them I was a mechanical lift. I told them to use a mechanical lift. They dropped me in my chair. R1 stated R1 has no use of lower extremities.On 8/22/25 at 10:52am, R4 (R1's Roommate) stated R4 witnessed the incident. R4 stated staff (V5 and V6 CNAs) did not use a mechanical lift to transfer R1. R4 stated, they dropped [R1] in [R1's] wheelchair and [R1] hit arm on chair. On 8/22/25 at 11:13am, V6 (CNA) stated on the date of the incident (8/13/25) V6 had mechanical lift sling underneath R1 and the mechanical lift in the room ready to hook R1 up to the mechanical lift. V6 stated, [V5 CNA] entered the room and said 'we need to get [R1] up. Can you lift?' V6 stated V6 advised V5 not to lift R1, we have mechanical lift and need to be doing it the proper way. V6 stated V5 already started lifting R1 and V6 then assisted. V6 stated R1 started screaming immediately once in chair. V6 stated V5 ran out of the room at that time and V6 stayed with R1. V6 stated V4 (Licensed Practical Nurse) came into the room to assess R1 and R1 was sent out to the emergency department. V6 stated, I didn't feel the transfer was proper or correct. V6 stated V6 went by what the CNA communication book stated for resident transfer status. V6 stated V7 (Assistant Director of Nursing/ADON) made a cheat sheet for staff to use that listed resident transfer status. On 8/22/25 at 11:35am, V9 (Director of Physical Therapy) stated after a resident is screened for their transfer status, the recommendations are given to the nursing department who updates residents care plan with the appropriate transfer status. V9 stated if a resident is a mechanical lift transfer, the lift should be done with two staff, and the resident should never get transferred any other way especially a stand and pivot. V9 stated there is a reason they are a mechanical lift transfer. V9 confirmed R1 is a two staff assist mechanical lift transfer.On 8/22/25 at 11:47am, V4 (LPN) stated on the date of the incident (8/13/25) V4 was either at the nurses' station or the medication cart when V5 approached claiming V4 need to come to R1's room due to an emergency. V4 stated when V4 entered R1's room, R1 was sitting upright in R1's wheelchair screaming, it hurts, it hurts, don't touch it. V4 stated V4 asked R1 what hurts and R1 stated my right shoulder. V4 stated R1 would not let V4 assess R1. V4 stated R1 was sent out to the emergency department at that time for evaluation and treatment. V4 stated both V5 and V6 admitted to transferring R1 without a mechanical lift. V4 stated V6 was ready to go with the mechanical lift and the mechanical lift sling was present under R1. V4 stated, [V5 stated] ‘they weren't going to use that (sling), we don't have time.' V4 stated staff are aware R1 is a mechanical lift transfer and has been since admission to the facility. On 8/22/25 at 11:01am, V7 (ADON) stated nursing staff have transfer competency done upon hire and yearly. V7 stated nursing staff are provided a cheat sheet with resident transfer status listed on it and it is documented in the CNA communication binder. Prior to the survey date of 8/22/25, the facility had taken the following actions to correct the non-compliance: 1. On 8/13/25, R1 was sent to the hospital for evaluation and treatment and then returned to the community.2. On 8/13/25, the Quality Assurance Committee developed a Plan of Correction for the 8/13/25 incident and a Performance Improvement Plan.3. On 8/13/25, the Director of Nursing provided in-service education to nursing staff on the transfer policy, following individualized transfer procedures, baseline care plans and how to communicate ADL needs of residents.4. Starting on 8/13/25, the Director of Nursing will audit resident transfers four times a week for four weeks to ensure staff are appropriately transferring.5. Starting on 8/13/25, the Director of Nursing will audit resident charts for current transfer status in baseline and/or comprehensive care plan four times a week for four weeks.6. The facility QAPI Committee will continue to monitor the facility's performance to ensure corrective actions to the 8/13/25 incident is effective.7. Completion date of substantial compliance: 8/14/25.

Based on interview and record review the facility failed to develop a discharge plan for administration of diabetic medications and wound care for one of three residents (R2) reviewed for discharge in the sample list of six. Findings include: The facility's undated Transfer and Discharge Policy documents the facility will assure resident transfers and discharges will be conducted in accordance with resident's rights, physician orders, and in such a manner as to maintain continuity of care for the resident. The Medication Administration Record dated 3/12/25 documents orders for R2 to have blood glucose checks before meals and at bedtime, Metformin (antidiabetic)1000 milligrams (mg) in the morning and at bedtime, Trulicity (antidiabetic) 3mg subcutaneously every Thursday, and Lantus insulin 10 units (subcutaneously) every morning. The Treatment Administration Record dated 3/12/25 documents and order for R2 to have a dressing change to R2's right great toe wound daily. The facility's Release of Responsibility for Discharge against Medical Advice (AMA) form dated 3/13/25, contains R2's signature on the resident signature line, and at the bottom of the document a handwritten statement documents the consent form was read out loud to R2 because resident is unable to read. R2's medical record does not contain a discharge plan or notification of the physician of R2's discharge. On 3/17/25 at 9:40 AM, V1 (Administrator) stated R2 was homeless prior to his admission from the hospital on 3/12/24. V1 stated the facility ran R2's background check prior to admission and nothing concerning came back so R2 was admitted on [DATE]. V1 further stated on 3/13/25 V1 was made aware that R2's CHIRP (Criminal History Information Response Process) came back that R2 was an identified offender. V1 stated she went to R2's room to discuss the CHIRP with him and R2 confirmed the report. V1 stated she told him that she needed to make room moves and put R2 in a private room. V1 stated V1 made R2 aware they would have to look for different placement because R2 would not be able to stay at the facility with his conviction. V1 stated R2 asked if there were any local facilities that would take R2 because he wanted to stay in the area. V1 stated she told R2 that individuals convicted as sex offenders usually go to Northern facilities, and they probably could not find a facility in the area. V1 stated R2 stated then just take him back to the (homeless shelter) because R2 did not want to leave the area. V1 stated V1 told R2 that he would have to sign out against medical advice (AMA) if that's what he wanted to do. V1 stated R2 was not able to read or write so they read him the AMA paperwork and R2 signed the papers and then the facility took R2 to the shelter with a bag of food and dropped him off. V1 stated that no referrals to outside agencies were done, and discharge planning was not initiated because R2 signed an AMA paper. V1 stated the facility did not consult the physician or law enforcement prior to discharge. On 3/17/25 at 11:00 AM, R2 stated V1 (Administrator) told R2 that he had to go and that R2 was not able to stay at the facility because of a past conviction. R2 stated V1 asked where R2 wanted to go and then dropped him off at the (homeless shelter) because that's where R2 was before admission to the hospital. R2 stated he cannot read and did not understand what he was signing. R2 stated he told V1 that he could not read the document, but V1 told R2 he had to sign the paper, and then they would take R2 where he wanted to go. R2 further stated he was not given medications or any wound care supplies, so he walked from the homeless shelter to V12 (Nurse Practitioner's) office to try and get some medications. R2 stated V12 admitted R2 to the hospital for wound care where he remains on 3/17/25. On 3/17/25 at 9:55 AM, V4 (Hospital Social Worker) stated V4 was covering the emergency room (ER) on 3/14/25 and V4 received a phone call from V12 (Nurse Practitioner) that R2 showed up at her office with a wound on his foot and needing medications, so V12 sent R2 to the ER (emergency room ) because V12 felt R2 couldn't manage at a shelter. V4 stated R2 told V4 he was at a nursing home facility but was told he had to leave. V4 stated R2 told V4 he was interested in going back to the facility. V4 stated V1 (Administrator) told hospital staff R2 signed paperwork to leave AMA but R2 told us he does not read or write, so he did not know what he signed. V4 stated she felt concerned that he is having issues managing his medical care, he is staying at warming center he has no bed there, so he is unable to manage his care. V4 stated R2 takes insulin and needs dressing changes. V4 stated R2 was admitted to hospital on 3/14/25 and is currently still in the hospital for wound management because the hospital has no way to safely discharge R2. On 3/17/25 at 3:00 PM, V12 Nurse Practitioner stated that she sent R2 to the emergency roiagnom on [DATE] from her office. V12 stated that R2 is homeless. V12 stated R2 has diabetes and has developed a pressure ulcer on his right great toe from walking around town and wearing a hole in his shoes. R2 is not able to read and has vision issues due to his diabetes. V12 stated R2 also is not able to manage wound care to his foot. V12 stated she referred R2 to the nursing home facility for wound care. V12 stated the facility discharging R2 the way that they did put R2 at risk for developing an infection or losing his toe as R2 is unable to manage his own wound care. V12 stated R2 is currently in the local hospital after walking to her office. V12 stated it's not safe for R2 to be in the homeless shelter as there is no bed for him to sleep on and his toe is going to get worse without medical care. V12 also stated she was not made aware of R2's discharge from the facility until he walked to her office from the homeless shelter.

Based on observation, interview, and record review, the facility failed to monitor walk-in refrigerator and freezer temperatures and failed to prevent food contamination by storing utensils in bulk food containers. These failures have the potential to affect all 44 residents residing in the facility. Findings Include: The facility's Storage policy dated October 2020 documents Food should be stored at the proper temperature and utensils or tools should not be left in food containers. The facility's Equipment Temperatures policy dated September 2008 documents all refrigerators and freezers shall be monitored regularly to ensure that they are working properly and to correct any mechanical difficulties quickly to prevent food spoilage. The temperatures should be recorded on the corresponding Temperature Charts. On 12/15/24 at 8:30 AM there were scoops and spoons observed in multiple multi-use food containers. A plastic scoop was inside the thickener container with the handle of the scoop in direct contact with the powder. A plastic scoop was inside the oatmeal container with the handle of the scoop in direct contact with the oats. A metal spoon was inside the brown sugar container with the handle in direct contact and partially covered with brown sugar. A metal spoon was inside the hot cocoa container with the handle in direct contact with the powder. On 12/15/24 the Freezer Temperature Log for December 2024 was only filled out on 12/2/24 for the morning shift and from 12/4-12/8, and 12/11-12/12/24 on the evening shift. On 12/15/24 the Walk-in Refrigerator Temperature Log for December 2024 was only filled out on 12/2/24 for the morning shift and from 12/4-12/8, and 12/11-12/12/24 on the evening shift. On 12/16/24 at 3:28 PM V17 (Dietary Manager) confirmed the dietary staff should be completing temperature logs for the walk-in refrigerator and freezers twice per day. V17 also confirmed staff should not be storing scoops or spoons in containers of food products. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/16/24 documents 44 residents reside in the facility.

Based on observation, interview, and record review the facility to ensure the least restrictive restraint was used for the least amount of time for one resident (R8) of one resident reviewed for restraints in a sample list of 25. Findings Include: The facility's Physical Restraint/Enabler policy revised 7/24/18 states Policy: To allow residents to be free of physical restraints which are not required to treat medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience. It is recognized that there may be emergency situations in which restraints may be required. Under the heading Procedures the policy also states Place physical restraint problem on the resident's Care Plan. The Care Plan must address the duration, type, and circumstances under which the restraint can be used. After initial documentation, all physical restraints require quarterly documentation regarding the type of physical restraint used, resident's response to the physical restraint, and if any reduction plan has been attempted. Initiate Restraint Elimination/Reductions Program ninety days after application. R8's Physician's Order Sheet (POS) for December 1, 2024 to December 31, 2024 included the following diagnoses: Dementia, Anxiety, Depression, Coronary Artery Disease, Atrial Fibrillation, and Pelvic Tilt. R8's MDS (Minimum Data Set) dated 11/22/24 documents R8 as severely cognitively impaired with two restraints under chair that prevents rising and two restraints under other restraints. R8's Care plan updated 6/5/24 documents (R8) Least restrictive measure to ensure safety include use of device that limits movement and accessibility (meets definition of physical restraint). Device in place: Self-releasing safety belt and busy tray while up in wheelchair. (R8) has unsafe sitting balance and leans forward and sideways in (R8's) wheelchair. (R8) attempts to pick up off the floor making safety an issue. R8's reclining seat and back wheelchair with bilateral trunk supports is not addressed in the Care Plan. On 12/16/24 at 11:00AM R8 was observed being transferred to reclining seat lifted wheelchair with bilateral trunk supports in place by V11 (Certified Nursing Assistant/CNA) and V12 (CNA). A sling type mechanical lift was being utilized. R8 was placed in the wheelchair with the seat lifted and the back reclined. The bilateral trunk supports were placed on either side of R8. A seat belt was fastened across R8's lap. A rigid tray was put in place extending outward from R8's waist. When asked if R8 could stand, V11 stated not very well anymore. But (R8) can wiggle forward and fall that is why her (family member) insists we have the seat belt and the tray on when (R8) is up. V12 nodded in agreement stating (R8) can't stand, but she can get out of this chair without the belt and tray. (R8) has fallen that way before and gotten a couple of big lumps on (R8's) head. (R8's) husband had us add the lap tray because (R8) was fiddling with the buckle on the safety belt. R8's Physical Enabler/Restraint Use/Reduction Evaluation last updated 11/22/24 does not include the lap tray, the reclining raised seat wheelchair, or the trunk supports. On 12/17/24 at 12:00PM V2 (Director of Nursing) verified R8 is Care Planned for restraints and only the seat belt has been assessed. V2 stated V2 believes these are not restraints but are for positioning. On 12/17/24 at 2:00PM V1 (Administrator) stated (R8's) husband insists (R8) have these (devices) and I don't think they are restraints. When asked why they are coded on the MDS as restraints V1 indicated V1 did not know.

Based on interview and record review, the facility failed to notify the physician of a new pressure ulcer and nausea/stomach pain for two residents (R5, R247) of two residents reviewed for reporting changes in status in the sample list of 25. Findings include: 1.) R5's Care Plan dated 12/6/24, documents R5 is high risk for Pressure Ulcers due to Osteoarthritis, Weakness, and Incontinence. This same Care Plan documents if open skin is assessed, report to the doctor and responsible party. R5's Nursing Notes by V14 (Registered Nurse) dated 12/8/24 at 4:00 AM, documents open area noted to right coccyx, barrier applied and covered bony prominence with (an absorbent foam dressing). No further documentation is in the nursing notes about the area. On 12/15/24 at 2:29 PM, V3 (Resident Care Coordinator/Licensed Practical Nurse), stated V3 did not know about an open area on R5, and nothing was reported and V3 was not even aware of any orders being documented. V3 stated V14 should have filled out a new skin sheet and notified the doctor and whoever was on call. 2.) R247's undated diagnoses list documents R247's diagnoses as: wound infection of left lower extremity related to tibia/fibula fracture and open distal left tibia/fibula fracture status post open reduction and internal fixation (ORIF). R247's Nursing Notes dated 12/13/24 at 8:00 PM, document: resident complaining of nausea and stomachache, nurse faxed primary care provider on change and will continue to monitor. There is no further documentation regarding nausea being addressed. On 12/16/24 at 11:40 AM, V2 (Director of Nursing) stated the nurse should have called the doctor or on-call nurse to get an order. The facility's Notification for Change in Resident Condition or Status Policy dated Revised 12/7/17, documents the facility staff shall promptly notify the Administrator, Director of Nursing, Physician, Health Care Power of Attorney of changes in the resident's status.

Based on observation, interview, and record review the facility failed to identify repeated episodes of verbal abuse of R28 by V11 (R28's Spouse) and failed to protect the resident's right to be free from verbal, mental, and physical abuse by V11. These failures resulted in V11 being allowed unsupervised visits with R28, subjecting R28 to repeated incidents of verbal and mental abuse by V11, and R28 being hit in the mouth by V11 resulting in psychosocial harm. R28 is one of five residents reviewed for abuse in the sample list of 33. The Immediate Jeopardy began on 10/26/23 at 6:50 PM when V11 was witnessed hitting R28 in the mouth. V1 (Administrator) was notified of the Immediate Jeopardy on 11/8/23 at 9:30 AM. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on 11/13/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The facility's Abuse Prevention policy revised 11/28/16 documents: The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The 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. This facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, or humiliation and threats of punishment or deprivation. Physical Abuse including hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The Facility Reported Incidents report form dated 10/27/23 at 5:27 PM documents on 10/26/23 V9 (Visitor) reported that V11 was feeding R28, R28 refused and pushed V11's hand away, and V11 hit R28 in the mouth. The facility's (State Surveying Agency) Notification Form dated 11/1/23 documents the incident between V11 and R28 occurred on 10/26/23 at 6:50 PM. This form documents the facility found no intentional abuse on V11's part. The facility instructed V11 not to feed R28 again, the staff will feed R28, and V11 was educated on Dementia and R28 not wanting to eat. The Incident Investigation Form dated 10/26/23 at 10:00 PM documents V2's (Director of Nursing/DON) interview. V2 was approached by V9 who reported that V11 struck R28 in the mouth with V11's hand at the dining room table, and V11 was swearing at R28. V2 immediately approached V11 and R28. V11 stated (R28) won't eat. (R28) don't got a brain in (R28's) head. V11 continued to belittle R28. V11 and R28 were separated. V11 went home. V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth. R28 had no signs of injury or pain. The Incident Investigation Form dated 10/27/23 at 9:45 AM documents: V1 interviewed V10 (Visitor), V10 witnessed V11 feeding R28 in the dining room, and R28 kept moving R28's head back not wanting to eat. R28 pushed V11's hand away and V11 hit R28 in the mouth and told R28 if you don't want to (expletive) eat, you (R28) can starve. The Incident Investigation Form dated 10/30/23 at 12:05 PM documents V1 interviewed V9 regarding the incident, and V9 stated that V9 witnessed V11 trying to force R28 to eat while R28 kept tilting R28's head back. It looked like V11 had food in V11's hand and was holding it up to R28's mouth. R28 said No, no I (R28) don't want it and V11 kept trying to feed R28. V11 then hit R28 in the mouth with V11's fist. V9 yelled out for V11 to stop and V9 sent V17 (Visitor) to get a nurse. The Incident Investigation Form dated 10/27/23 at 11:30 AM documents: V1 interviewed V11 regarding the incident, V11 denied hitting R28 and V11 said V11 was trying to feed R28 a cookie. V11 stated V11 might have cursed at R28. V11 said R28 is going to starve and V11 just wants R28 to eat, and R28 has not been the same since R28 fell at home and broke R28's hip. V1 tried to explain Dementia to V11 and will provide V11 with additional support. V1 asked for V16 (R28's Power of Attorney) to come to the facility with V11 after the investigation and put a plan in place to keep R28 safe while V11 visits. The Incident Investigation Form dated 10/27/23 at 2:00 PM documents: R28 was interviewed by V4 (Social Services Director). R28 was asked if R28 could remember V11 visiting the night before. R28 replied yes. R28 was asked if R28 could tell V4 what happened and R28 did not answer. R28 was asked if V11 hollered at R28 and R28 replied yes. R28 was asked if V11 hit R28 and R28 said no, that V11 fell on (R28). R28 was asked if V11 hit R28 at home and R28 replied yes all the time. R28 stated He has been hitting me since I was a little girl. The Incident Investigation Form dated 10/31/23 at 9:15 AM documents the Interdisciplinary Team reviewed the incident and agreed that V11 can continue to visit, but V11 is not to feed R28 during V11's visits. R28's Admission Minimum Data Set, dated dated dated [DATE] documents R28 has severe cognitive impairment. R28's November 2023 Physician Order Summary documents R28 has Dementia. R28's medical record does not contain a comprehensive care plan to address R28's risk for abuse or incidents of abuse from V11. There is no documentation that the facility implemented increased supervision of R28 during V11's visits. V11 and R28 were in R28's room unsupervised and without staff present on 11/05/23 at 11:00 AM and 11:40 AM, on 11/6/23 at 9:43 AM, 9:58 AM, 10:00 AM, 10:15 AM, 11:03 AM, and on 11/7/23 at 10:48 AM. On 11/06/23 at 9:15 AM V7 (Certified Nursing Assistant/CNA) stated V11 and R28 are hateful towards each other and this was prior to the incident on 10/26/23. V7 stated V11 is no longer allowed to feed R28, and V11 visits with R28 in R28's room or in the dining room without staff supervision. On 11/6/23 at 9:22 AM V8 (CNA) stated V11 has been frustrated with R28 while feeding R28. V11 has called R28 stupid, idiot, [NAME] and R28 was tearful. V11 stated this used to happen daily during V11's visits prior to the physical abuse of V11 hitting R28 in the mouth. V8 stated R28 has told V8 that R28 and V11 have been together since R28 was 16 and that V11 has always been that way. V8 stated the incidents have occurred on second shift. V8 stated V8, V18 (CNA), and a few other unidentified CNAs on second shift have reported the incidents to V3 (Assistant DON) on several occasions and was told that V11 had been spoken to. At 10:39 AM V8 stated abuse allegations are reported immediately to V1 and usually V1 is gone in the evenings. V8 stated V3 was working in the facility when the incidents occurred, which is why V8 reported to V3. V8 confirmed V8 specifically told V3 the names that V11 called R28. V8 confirmed V8 did not report the incidents to V1. On 11/06/23 at 9:48 AM V9 stated during supper on 10/26/23 R28 was sitting at a table that was directly in front of (family member's) table where V9 was sitting, and V9 had a clear view of R28 and V11. V9 stated R28 moved R28's head back multiple times while V11 fed R28. V9 heard R28 say stop, stop, I don't want it. V9 stated V9 then witnessed V11 pull V11's hand back, there was no food in V11's hand, and V11 hit R28 in the mouth with V11's closed fist. V9 stated V9 told V11 to stop and sent V17 to get a nurse. V9 stated V17 did not witness the incident. V10 was also present and may have witnessed the incident. V9 stated there was no staff present in the dining room during the incident. V9 stated V11 said that R28 was worthless, made belittling comments, and said you're stupid to R28. V9 stated it was very mean what (V11) did to (R28). R28 was just quiet and did not say anything back to V11. At 1:03 PM V9 stated V9 did not know R28 or V11 prior to their family member being admitted to the facility. V9 stated V9 does not know V11 and R28 personally. On 11/06/23 at 10:10 AM V18 (CNA) stated prior to that night (10/26/23) on multiple occasions, almost every night V11 would feed R28, call R28 stupid, yell at R28 and degrade R28. V18 stated R28 would cry or go silent in response to V11's actions. One night V11 asked R28 why R28 was crying and R28 stated because you (V11) yelled at me (R28). V18 stated it was verbal abuse the way (V11) treated (R28). V18 stated V19 (CNA), V25 (CNA), V26 (CNA), and V27 (Unit Aide) have also witnessed these interactions as well. V18 stated V18 reported V11's actions to V3 (Assistant DON). V3 said V3 would talk with V1 (Administrator), and V3 later told V18 that V1 was made aware. V18 stated V18 asked V3 about separating V11 and R28 and was told that V11 is R28's spouse who pays for R28 to live in the facility. On 11/06/23 at 3:32 PM V19 (CNA) stated when V11 would feed R28, V11 would raise V11's voice at R28 and call R28 ignorant and stupid. V19 stated it happened often, and confirmed the incidents were prior to the 10/26/23 incident. V19 stated R28 would get upset and ask V11 why V11 was talking to R28 like that. V19 confirmed V19 did not report the incidents to V1. On 11/06/23 at 10:29 AM V3 was asked about V11's interactions with R28. V3 stated there are constant issues and V11 gets frustrated with R28 not wanting to eat. V3 stated unidentified staff mentioned in general to V3 that V11 would get frustrated and general concerns with how V11 would speak to R28. V3 stated V3 reminded V11 to be mindful of how V11 spoke to R28. V3 stated V3 discussed during the morning interdisciplinary team meetings to pay attention to V11's interactions with R28. V3 stated V3 would have reported immediately to V1 if staff told V3 that V11 called R28 names such as idiot, stupid, or [NAME]. On 11/6/23 at 10:44 AM V2 (DON) stated the night of the incident V17 reported to V2 that V11 was trying to force food into R28's mouth, R28 wouldn't eat, and V11 hit R28 in the mouth. V2 witnessed V11 say, with R28 present, that R28 doesn't have a brain, in reference to R28 not eating. V2 described V11 as being really frustrated that R28 would not eat, and R28 was sitting there with R28's eyes closed. V2 stated V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth. V2 stated V9's family member has only been in the facility for about a week, and V2 has no reason not to believe V9's description of the incident. On 11/06/23 at 11:06 AM V1 stated during a morning meeting, V3 mentioned that V3 had spoken to V11 about V11 getting overwhelmed with R28 not eating. V1 stated nothing was brought up about V11 being abusive towards R28. V1 confirmed calling a resident an idiot, stupid, [NAME] would be verbal abuse. V1 stated V1 would have initiated investigations into V11's interactions with R28 just like the incident on 10/26/23, suspended V11's visits during the investigations, restricted V11 from feeding R28, and V1 possibly would have implemented supervised visits for V11 and R28. V1 stated V1 interviewed V10 and V10 witnessed V11 trying to make R28 eat, as R28 moved R28's head away (V11) went like this, and V1 demonstrated a close fist touching her mouth. V1 confirmed V10 reported hearing V11 say you (R28) can (expletive) starve then. V1 stated V11 told V1 that V11 may have cursed at R28 but did not hit R28. V11 reported that V11 had a piece of a cookie pushed up against R28's mouth. V1 stated V1 interviewed V9 and V9 told V1 that V11 kept trying to feed R28, R28 did not want to eat, and V11 hit R28 in the mouth. V1 stated abuse was not substantiated; the incident was discussed with the interdisciplinary team, and it was decided that V11 is no longer allowed to feed R28. V1 confirmed the facility has not implemented supervised visits for V11 and R28 after the 10/26/23 incident. On 11/07/23 at 9:52 AM V16 (R28's Power of Attorney) stated R28 has Dementia, and this has affected R28's ability to recognize hunger. V16 stated V16 has tried to explain that to V11, but V11 thinks R28 will get better and return home. V16 was asked prior to R28's dementia, how would R28 have felt or responded to V11's verbal treatment and being hit in the mouth in front of other residents and visitors. V16 stated R28 would have yelled back at V11. V16 was asked if R28 would have felt humiliated, embarrassed, upset, or tearful and V16 replied R28 would have probably felt all those things. The Immediate Jeopardy that began on 10/26/23 was removed on 11/13/23 when the facility took the following actions to remove the immediacy: 1.) On 11/9/23 at 8:55 am, V1 (Administrator) confirmed the facility held a care plan meeting with V16 (R28's POA) on 11/8/23 to inform V16 that V11 (R28's spouse) will have to check in with the manager on duty before the start of each visit, only be allowed to visit in common areas, and that staff will check on R28 after each visit to ensure R28's safety. 2.) On 11/9/23 between 8:30 am - 8:55 am, V29 (Licensed Practical Nurse/LPN), V30 (CNA), V31 (Activity Director) and V1 all confirmed that a staff member would be assigned to make visual checks on R28 every 15 minutes while V11 was at the facility visiting. On 11/13/23, these visual checks were provided to the survey team. The visual checks dated 11/9/23, 11/11/23, and 11/12/23 document R28 was checked on every 15 minutes. On 11/13/23 between 9:00 AM and 9:30 AM, V1, V3, and V28 (Licensed Practical Nurse) stated that V11 did not visit on 11/10/23. 3.) On 11/9/23 at 1:10 PM, V1 provided an in-service sheet dated 11/8/23 that documents V41 (Regional Director of Clinical Operations) provided education to V1 and V2 regarding the facility Abuse and Neglect Policy. 4.) On 11/9/23 at 1:10 PM, V1 provided in-service sheets dated 11/8/23 and 11/9/23 that document all but six staff have been in-serviced by V1 and V2 on the facility Abuse Prevention Policy and Procedure. At this time, V1 stated the six staff that are not educated yet will not be allowed to work until they have received the education. On 11/13/23 at 9:15 am, V1 provided a phone listing for in-services completed over the phone for the remaining six staff. Five were provided education on 11/9/23 however one Agency CNA, V37, has not received the abuse in-service training. At this time, V1 explained V37 is an agency staff and has not returned the phone call, but that V37 will not be allowed to work at the facility until V37 has received the training. 5.) On 11/9/23 at 2:00 PM, V1 provided Abuse Risk Assessments for all but two residents. V1 stated V1 was waiting for families to get back with V1 to complete the assessment for these residents. At this time, V1 also stated that any resident who answered yes to any of the questions will have an abuse risk care plan developed with specific interventions however that has not been done yet. On 11/13/23 at 9:00 am, V1 provided the Risk for Abuse Care Plans for all at risk residents and stated the facility is still waiting to complete two assessments. On 11/13/23 between 10:20 - 10:23 am, V1 provided the final two Abuse Risk Assessments dated 11/13/23, to make 100% of the residents now being assessed. 6.) On 11/13/23 between 9:00 am - 9:30 am, V1 stated V1 will continue to in-service staff on abuse monthly and the next in-service is schedule for 11/25/23. 7.) On 11/13/23 between 9:00 am - 9:30 am, V1 stated that no new employees have been hired, but that V1 is responsible for providing Abuse Prevention training for all new employees during their orientation.

Based on interview and record review the facility failed to ensure repetitive allegations of verbal and mental abuse and an injury of unknown origin were reported to the administrator, and timely report an allegation of abuse to the state survey agency. These failures affect two (R28, R45) of five residents reviewed for abuse in the sample list of 33. These failures resulted in R28 being subjected to repeated incidents of verbal/mental abuse, and physical abuse by V11 (R28's Spouse) resulting in psychosocial harm for R28. Findings include: The facility's Abuse Prevention policy revised 11/28/16 documents: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, or humiliation and threats of punishment or deprivation. Physical Abuse including hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property to a supervisor and administrator. Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries, of unknown origin as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. 1.) The Facility Reported Incidents report form (initial notification to state survey agency) dated 10/27/23 at 5:27 PM documents on 10/26/23 a visitor (V9 Visitor) reported that V11 was feeding R28, R28 refused and pushed V11's hand away, and V11 hit R28 in the mouth. The facility's Notification Form dated 11/1/23 documents the incident between V11 and R28 occurred on 10/26/23 at 6:50 PM. The Incident Investigation Form dated 10/26/23 at 10:00 PM documents V2's (Director of Nursing/DON) written interview. V2 stated V2 was approached by V17 (Visitor) who reported that V11 struck R28 in the mouth with V11's hand at the dining room table and V11 was swearing at R28. V2 immediately approached V11 and R28 and V11 stated (R28) won't eat, (R28) don't' got a brain in (R28's) head. V11 continued to belittle R28. V11 and R28 were separated. V11 went home. V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth. The Incident Investigation Form dated 10/27/23 at 9:45 AM documents V1 interviewed V10 (Visitor) and V10 witnessed V11 feeding R28 in the dining room, and R28 kept moving R28's head back not wanting to eat. R28 pushed V11's hand away and V11 hit R28 in the mouth and told R28 if you don't want to (expletive) eat, you (R28) can starve. The Incident Investigation Form dated 10/30/23 at 12:05 PM documents V1 (Administrator) interviewed V9 regarding the incident and V9 witnessed V11 trying to force R28 to eat while R28 kept tilting R28's head back. It looked like V11 had food in V11's hand and was holding it up to R28's mouth. R28 said No, no I (R28) don't want it and V11 kept trying to feed R28. V11 then hit R28 in the mouth with V11's fist. V9 yelled out for V11 to stop and V9 sent V17 to get a nurse. V1 (Administrator) provided the facility's undated abuse log that was requested for September-November 2023. There is no documentation of abuse allegations involving V11 and R28 besides the incident on 10/26/23. R28's Admission Minimum Data Set, dated dated dated [DATE] documents R28 has severe cognitive impairment. R28's November 2023 Physician Order Summary documents R28 has Dementia. On 11/6/23 at 9:22 AM V8 (Certified Nursing Assistant/CNA) stated V11 has been frustrated with R28 while feeding R28. V11 has called R28 stupid, idiot, [NAME] and R28 was tearful. V11 stated this used to happen daily during V11's visits prior to the physical abuse of V11 hitting R28 in the mouth. V8 stated R28 has told V8 that R28 and V11 have been together since R28 was 16 and that V11 has always been that way. V8 stated the incidents have occurred on second shift. V8 stated V8, V18 (CNA), and a few other unidentified CNAs on second shift have reported the incidents to V3 (Assistant DON) on several occasions. At 10:39 AM V8 stated abuse allegations are reported immediately to V1 and usually V1 is gone in the evenings. V8 stated V3 was working in the facility when the incidents occurred, which is why V8 reported to V3. V8 confirmed V8 specifically told V3 the names that V11 called R28. V8 confirmed V8 did not report the incidents to V1. On 11/06/23 at 9:48 AM V9 stated during supper on 10/26/23 R28 was sitting at a table that was directly in front of (family member's) table where V9 was sitting, and V9 had a clear view of R28 and V11. V9 stated R28 moved R28's head back multiple times while V11 fed R28. V9 heard R28 say stop, stop, I don't want it. V9 stated V9 then witnessed V11 pull V11's hand back, there was no food in V11's hand and V11 hit R28 in the mouth with V11's closed fist. V9 stated V9 told V11 to stop and sent V17 to get a nurse. V9 stated V17 did not witness the incident. V10 was also present and may have witnessed the incident. V9 stated there was no staff present in the dining room during the incident. V9 stated V11 said that R28 was worthless, made belittling comments, and said you're stupid to R28. V9 stated it was very mean what (V11) did to (R28). R28 was just quiet and did not say anything back to V11. At 1:03 PM V9 stated V9 did not know R28 or V11 prior to their family member being admitted to the facility. V9 stated V9 does not know V11 and R28 personally. On 11/06/23 at 10:10 AM V18 (CNA) stated prior to that night (10/26/23) on multiple occasions, almost every night V11 would feed R28, call R28 stupid, yell at R28 and degrade R28. V18 stated R28 would cry or go silent in response to V11's actions. One night V11 asked R28 why R28 was crying and R28 stated because you (V11) yelled at me (R28). V18 stated it was verbal abuse the way (V11) treated (R28). V18 stated V19 (CNA), V25 (CNA), V26 (CNA), and V27 (Unit Aide) have also witnessed these interactions as well. V18 stated V18 reported V11's actions to V3 (Assistant DON). V3 said V3 would talk with V1 (Administrator), and V3 later told V18 that V1 was made aware. V18 stated V18 never spoke with V1 regarding V11's interactions with R28. On 11/06/23 at 3:32 PM V19 (CNA) stated when V11 would feed R28, V11 would raise V11's voice at R28 and call R28 ignorant and stupid. V19 stated it happened often, and confirmed the incidents were prior to the 10/26/23 incident. V19 stated R28 would get upset and ask V11 why V11 was talking to R28 like that. V19 confirmed V19 did not report the incidents to V1. On 11/06/23 at 10:29 AM V3 was asked about V11's interactions with R28. V3 stated there are constant issues and V11 gets frustrated with R28 not wanting to eat. V3 stated staff have mentioned in general that V11 would get frustrated and general concerns with how V11 would speak to R28. V3 stated V3 reminded V11 to be mindful of how V11 spoke to R28. V3 stated that staff did not specifically tell V3 what V11 said to R28. V3 stated V3 did not ask staff what V11 has said to R28. V3 stated V3 would have reported immediately to V1 if staff told V3 that V11 called R28 names such as idiot, stupid, or [NAME]. V3 stated V3 discussed during the morning interdisciplinary team meetings to pay attention to V11's interactions with R28. On 11/05/23 at 1:45 PM V2 (DON) stated on 10/26/23 around 6:00 PM V17 approached V2 and reported that V9 witnessed V11 hit R28 in the mouth. V2 stated V1 notified the police and sent in the initial report to the state survey agency. On 11/6/23 at 10:44 AM V2 stated on the night of 10/26/23 V2 went to separate V11 and R28 and witnessed V11 say, with R28 present, that R28 doesn't have a brain, in reference to R28 not eating. V2 described V11 as being really frustrated that R28 would not eat, and R28 was sitting there with R28's eyes closed. V2 stated V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth. V2 stated nothing had been reported previously about V11's treatment of R28. V2 stated V2 has not been attending morning meetings due to working night shift. On 11/05/23 at 2:40 PM V1 stated the initial report to the state survey agency for the incident on 10/26/23 was not sent in until 10/27/23. V1 stated it was a miscommunication and V1 thought V2 had submitted the report. V1 stated the time frame for reporting abuse allegations to the state survey agency is two hours. On 11/06/23 at 11:06 AM V1 stated during a morning meeting, V3 mentioned that V3 had spoken to V11 about V11 getting overwhelmed with R28 not eating. V1 stated nothing was brought up about V11 being abusive to R28. V1 confirmed calling a resident an idiot, stupid, [NAME] would be considered verbal abuse. V1 stated if staff had reported these prior incidents, V1 would have initiated investigations into V11's interactions with R28 just like the incident on 10/26/23, suspend V11's visits during the investigations, restricted V11 from feeding R28, and V1 possibly would have implemented supervised visits for V11 and R28. On 11/07/23 at 9:52 AM V16 (R28's Power of Attorney) stated R28 has Dementia, and this has affected R28's ability to recognize feeling hungry. V16 stated V16 has tried to explain that to V11, but V11 thinks R28 will get better and return home. V16 was asked prior to R28's dementia, how would R28 have felt or responded to V11's verbal treatment and being hit in the mouth in front of other residents and visitors. V16 stated R28 would have yelled back at V11. V16 was asked if R28 would have felt humiliated, embarrassed, upset, or tearful and V16 replied R28 would have probably felt all those things. 37813 2. R45's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Dementia with Behavioral Disturbance, Depression, Anxiety, Insomnia, and History of Fall with Hip Fracture. R45's Minimum Data Set (MDS) dated [DATE] documents R45 is severely cognitively impaired, is wheelchair bound, and requires moderate to maximum staff assistance to complete Activities of Daily Living (ADLs). R45's skilled nurse's note date 6/18/23 at 7:15AM documents Noted Bruising on (R45's) left hand that extends up to forearm. Area measures 21 centimeters by 14 centimeters. Purple and black in color. (R45) denies pain or discomfort. (R45) is unsure how (R45) obtained bruise. Staff will monitor for changes until resolved. Nurse Practitioner notified and family notified. Power of Attorney voiced understanding. R45's skilled nurse's note date 6/19/23 at 3:10PM documents CNA advised writer about large hematoma and bruising to left wrist. Writer observed (R45) to have a golf ball sized hematoma to left wrist and bruising covering most of the arm to the elbow. Resident complains of pain to the hematoma. Will advise day nurse to get X-ray orders from Nurse Practitioner. Writer attempted to apply ice pack. (R45) refused and wouldn't leave ice pack on. On 11/6/23 V1 (Administrator) stated I've checked with (V2) the Director of Nursing and this injury was not reported. We do not have an investigation for an injury of unknown origin.

Based on observation, interview, and record review, the facility failed to assess a resident's fall risk and ensure positioning safety measures were in place to prevent a fall for one of three residents (R1) reviewed for falls on the sample list of four. This failure resulted in R1 falling out of R1's wheelchair, hitting R1's head on the ground, and sustaining a laceration to the forehead requiring six sutures. Findings Include: 1. R1's IDPH (Illinois Department of Public Health) Notification Form dated 7/31/22 documents on 7/24/22, R1 was being assisted to supper in R1's wheelchair when R1 put R1's foot on the ground causing R1 to fall forward out of the wheelchair, hitting R1's head on the ground. R1 sustained a laceration to the middle of the forehead and bridge of the nose. R1 returned to the facility with sutures to R1's forehead. Foot pedals applied to wheelchair for proper positioning. R1's MDS (Minimum Data Set) dated 7/5/22 documents R1 has severe cognitive impairments, is non-ambulatory, requires extensive assist of two for transfers and is totally dependent of staff for locomotion. R1's OT (Occupational Therapy) Daily Treatment Notes by V11(Certified Occupational Therapy Assistant/COTA)/Program Manager documents the following: 4/25/22 - R1 was seen to change the type of wheelchair R1 used due to R1 leaning forward in wheelchair when R1 was tired. R1 transferred to a wheelchair that the back can be tilted back approximately 30 degrees for safety. Ball placed between R1's knees to increase abduction to keep bilateral feet on the foot pedals for safety. 4/28/22 - R1 seen for wheelchair positioning with staff education on reason for change of wheelchair and where to place propping items for R1 to be safe in wheelchair. On 8/8/22 at 10:30 am, R1 was lying in bed asleep with a scab to the middle of R1's forehead and bruising, brown/purple in color, to the left side of R1's face. On 8/8/22 at 11:50 am, V5 (Licensed Practical Nurse) stated R1 does not try to get up out of R1's wheelchair but R1 would lean forward and to the left, that is why R1 use to be in a high back reclining wheelchair with foot pedals prior to falling from the chair on 7/24/22. R1's Progress Notes dated 7/24/22 at 4:50 pm documents R1 was in wheelchair going to dining room and fell . R1 was sent to hospital per ambulance. R1's Hospital After Visit Summary dated 7/24/22 documents R1 was seen in the Emergency Department due to a head injury and facial laceration with orders to have sutures removed in 7-10 days. R1's Progress Notes dated 8/3/22 documents six sutures removed from R1's forehead. Area is now scabbed. On 8/9/22 at 8:45 am, V10 (Certified Nursing Assistant/CNA) stated on 7/24/22, V10 was pushing R1 in the wheelchair to the dining room. V10 explained, I'm not sure if (R1's) foot hit the floor or what but next thing I (V10) know, (R1) fell forward hitting (R1's) head on the floor. V10 stated R1 did not have foot pedals on the wheelchair at the time R1 fell from the chair, or anything between R1's knees. V10 explained V10 hadn't taken R1 out to the dining room before so V10 wasn't aware R1 needed foot pedals. On 8/9/22 at 8:50 am, V11 (COTA/Program Manager) stated back in April 2022, V11 recommended R1 have the high back, reclining wheelchair with foot pedals after R1 was evaluated for leaning forward in a standard wheelchair. V11 explained R1 is not able to self-propel the wheelchair and therefore should have had the foot pedals in place for proper positioning and safety. Had (R1) had them in place, it could have prevented (R1) falling out of the chair and hitting (R1's) forehead and sustaining the laceration. 2. The facility Fall Prevention Policy dated 11/10/18 documents fall assessments are to be completed the day of admission, quarterly and with a change in condition. R1's Fall Risk Assessments dated 11/12/21, 1/12/22 and 7/5/22, which were the only Fall Risk Assessments in R1's medical record, all document R1 is at high risk for falls. On 8/8/22 at 3:12 pm, V1 (Administrator) stated the above listed Fall Risk Assessments are all the facility has for R1. On 8/8/22 at 4:11 pm, V9 MDS (Minimum Data Set)/Care Plan Coordinator stated Fall Risk Assessments are to be completed every three months and confirmed R1 did not have one completed in April 2022, as R1 should have.

Based on observation, interview, and record review the facility failed to provide treatment and services to prevent the development of pressure ulcers for one (R3) of three residents reviewed for wounds in the sample list of six. This failure resulted in the development and deterioration of R3's left plantar Stage IV pressure ulcer, and the development of unstageable, necrotic pressure ulcers to the left ankle, medial and lateral left foot, and left heel. Findings include: R3's physician's orders [REDACTED]. R3's Pressure Ulcer Risk assessment dated [DATE] documents R3 is at high risk for developing pressure ulcers. R3's Minimum Data Set ((MDS) dated [DATE] documents R3 has severe cognitive impairment, uses extensive assistance of two staff for bed mobility, and is dependent on two staff for transfers. R3's Treatment Administration Records (TARs) dated [DATE], [DATE], [DATE], [DATE] document to obtain weekly skin assessments. There is no documentation in R3's medical record that skin assessments were completed consistently between [DATE] and [DATE]. R3's Treatment Administration Records (TARs) dated April, October, November, [DATE], [DATE], and February 2021 do not consistently document that R3's pressure ulcer treatments were administered as ordered. R3's Initial Wound Evaluation & Summary dated [DATE] by V5 Wound Physician documents R3 had a pressure ulcer that was unstageable due to necrosis (dead tissue) to the left plantar ball of the foot. This note documents R3's wound measured 1.1 cm (centimeters) long by 2 cm wide by no measurable depth and was 100 % (percent) covered with necrotic tissue. This note documents an order to apply a skin protectant to the periwound, [MEDICATION NAME] to the pressure ulcer covered by a dry dressing twice daily, and a recommendation to wear heel protectors and no shoe worn on the left foot. R3's [DATE] TAR documents R3's left plantar pressure ulcer treatment was not implemented until [DATE]. R3's Wound Evaluation Notes by V5 document as follows: On [DATE] R3's left plantar pressure ulcer measured 3 cm by 3 cm by 0.1 cm, was debrided (removal of dead or infected tissue) exposing bone, and a wound culture was obtained. On [DATE] R3's left plantar pressure ulcer was unchanged and R3's x-ray and laboratory results were pending. On [DATE] R3's left plantar pressure ulcer measured 3 cm by 3 cm by 0.1 cm. R3's bone culture from last week was not done due to specimen integrity and V5 obtained another bone scraping from R3's wound. On [DATE] V5 documented V5 did not feel R3's left plantar pressure ulcer would heel, and the goal is to keep R3's wound from deteriorating or becoming infected again with ultimate treatment as being amputation. On [DATE] R3's wound measured 2.6 cm by 3 cm by 0.1 cm and is described as infected with copious soupy yellowish exudate (drainage) with pus and the bone is exposed at the base of the wound. This note documents R3's family is in agreement with palliative care and no new cultures will be sent. There is no documentation in R3's medical record that the facility discussed palliative care options with V11 (R3's Power of Attorney). V12 Registered Dietitian's Recommendation dated [DATE] documents R3 had weight loss at [DATE] days and a stage IV pressure ulcer with a recommendation to increase R3's nutritional supplement to 90 mililiters three times daily. This recommendation was signed by V1 Administrator on [DATE]. R3's [DATE] and [DATE] Medication Administration Records document V12's recommendation to increase the supplement was not implemented until [DATE]. On [DATE] at 3:41 PM V12 Registered Dietitian stated V12 would expect V12's recommendations to be implemented within 2 to 3 days. R3's Arterial Lower Extremity Duplex Scan dated [DATE] documents no evidence of hemodynamically significant stenosis (narrowing restricting blood flow). R3's Wound Culture dated as collected on [DATE] and reported on [DATE] documents the collection swab expired on [DATE] and the facility was notified the culture would need to be recollected. There is no documentation in R3's medical record that R3's wound culture was recollected until [DATE] (14 days after initially ordered/collected.) R3's Wound Culture dated as reported on [DATE] documents R3's left foot wound had moderate growth of [MEDICATION NAME] Faecalis (bacteria), light growth of Proteus Mirabilis (bacteria) and an order for [REDACTED]. leg from R3's left plantar pressure ulcer to R3's knee. This note documents R3's leg was warm to touch, painful and R3's wound had an odor. R3 was transferred to the local hospital for treatment. R3's left foot x-ray dated [DATE] documents an impression of severe osteopenia (bone loss) and mottling (red/purple blotchy appearance). R3's left foot wound aerobic culture dated [DATE] documents moderate growth of [MEDICAL CONDITION]-Resistant Stayphylococcus Aureus (bacteria resistant to common antibiotics) and small growth of Proteus Mirabilis. R3's Procedure Summary Notes dated [DATE] by V10 Podiatrist documents R3's preoperative [DIAGNOSES REDACTED]. There is no documentation in R3's hospital records from [DATE] - [DATE] that R3 had pressure ulcers to the left foot, other than the amputation site. R3's Nursing Notes document: On [DATE] R3 returned to the facility. On [DATE] R3's heel has slough and appears to be infected. There are no documented measurements of R3's heel wound after [DATE] until V5's notes on [DATE]. R3's Progress Notes by V10 document: On [DATE] continue strict off-loading, daily dressing changes, and daily skin checks. On [DATE] R3 was not wearing pressure relieving boots to R3's feet. We will try to prevent any sort of complications of infection or worsening wounds and treat them as appropriate. V10 documents R3 may require additional amputation if anything worsens with R3's foot. R3's Wound Evaluation Note by V5 document as follows: On [DATE] R3 has a pressure ulcer to the left ankle described as unstageable due to necrosis that measured 2 cm by 1.5 cm with no measurable depth, and an unstageable pressure ulcer due to necrosis to the left heel that measured 3 cm by 3 cm with no measurable depth. This note documents an order to apply [MEDICATION NAME] with a dry dressing twice daily to R3's pressure ulcers. On [DATE] R3's left ankle pressure ulcer deteriorated and measured 3 cm by 1.5 cm with no measurable depth, left heel pressure ulcer deteriorated and measured 3.5 cm by 3 cm with no measurable depth, and an unstageable pressure ulcer due to necrosis to the left lateral foot that measured 2 cm by 1.5 cm with no measurable depth. On [DATE] R3's pressure ulcers to the left ankle measured 3 cm by 2 cm, left heel measured 5 cm by 6 cm, left lateral foot measured 2 cm by 1.5 cm and R3 has an unstageable due to necrosis pressure ulcer to the left medial foot that measures 3 cm by 4 cm. R3's Care Plan reviewed on [DATE] documents R3 has a pressure ulcer to the left plantar foot with interventions dated [DATE] for weekly wound measurements and monitoring, treatments administered as ordered, dietary consults, assist with turning/repositioning, and monitor for signs/symptoms of infection and report to the physician. R3's Care Plan does not document R3's unstageable pressure ulcers to the left heel, left medial and lateral foot, and left ankle or any pressure reliving interventions implemented after [DATE] including V5's recommendations for heel protectors and no shoe worn to the left foot. R3's Care Plan documents R3 used a left ankle foot inversion/eversion brace until [DATE] with interventions to inspect skin and circulation when applying and removing the device. There is no documentation of the use of pillows or heel protectors implemented prior to [DATE] to prevent R3 from developing pressure ulcers to R3's lower extremities. There is no documentation in R3's medical record of when R3's left foot brace was applied/removed and that R3's skin and circulation was assessed with [REDACTED]. On [DATE] at 10:53 AM V3 LPN used scissors to remove R3' soiled dressing from the pressure ulcers to R3's left foot. There was a brown substance on the dressing. R3 did not disinfect the scissors and placed the contaminated scissors into R3's shirt pocket. R3's left foot had wounds to the ankle, medial foot, lateral foot, and heel that were covered with black necrotic tissue. R3 yelled out ow and you're cutting it off during R3's wound treatment. R3's left great toe had been amputated and R3 was not wearing a pressure relieving boot to R3's right foot. On [DATE] at 11:10 AM V3 confirmed V3 placed the potentially contaminated scissors into V3's pocket without disinfecting the scissors after use. V3 stated bleach disinfecting wipes should be used to disinfect scissors after use. On [DATE] at 1:25 PM V6 MDS/Care Plan Coordinator stated R3's pressure ulcers developed in the facility and R3 should wear pressure relieving boots to bilateral lower legs at all times. On [DATE] at 1:54 PM R3 was lying in bed with a pressure relieving boot on the left foot. There was no pressure relieving boot on R3's right foot. V6 confirmed R3 was not wearing a boot to R3's right foot and V6 found R3's pressure relieving boot on the floor between R3's bed and wall. On [DATE] at 2:14 PM V6 stated R3 used the orthotic brace until it was discontinued in [DATE] and that R3 would wear the boot for several hours at a time. V6 stated the brace could have contributed to R3's development of the left plantar pressure ulcer. V6 confirmed R3's care plan does not include R3's current stage IV pressure ulcers, interventions to prevent pressure ulcers to the lower extremities prior to or after [DATE]. On [DATE] at 11:07 AM V8 Nursing Assistant stated R3 wears pressure relieving boots to both lower legs and V8 has come on shift a few times when R3's boots were not on. V8 stated V8 has difficulty finding R3's boots at times. On [DATE] at 2:29 PM V2 Director of Nursing stated skin assessments should be completed weekly and documented on the residents TAR, and that is one thing we may fall behind on. V2 stated when a wound is identified it should be assessed and documented, the physician/resident's representative should be notified, and a treatment initiated. V2 stated wounds should be assessed/measured weekly by V5 or V6 and upon admission/readmission to the facility. V2 stated V2 usually discusses wounds during the morning meeting, but V2 has been working midnight shift since [DATE] and has not been reviewing wounds. V2 stated care plans should be updated to include current wounds and pressure relieving interventions. V2 stated V2 would expect a wound culture to be obtained the day it was ordered and stated R3's wound culture on [DATE] had to be recollected due to the test swab being expired. V2 stated R3's pressure ulcers were facility acquired and R3's orthotic splint could have contributed to the development of the left plantar wound. V2 stated there should be documentation in R3's medical record that R3's skin and circulation was monitored when the brace was applied and removed. V2 stated V2 has been working the night shift and there have been times where R3 was observed not wearing pressure relieving boots. On [DATE] at 12:38 PM V5 Wound Physician stated V5 would expect the facility to implement V5's recommendations and orders on the same day they are given. V5 stated if pressure relieving interventions and treatments are not being implemented or administered it could contribute to the development or worsening of wounds. V5 stated R3's left plantar wound was a stage IV pressure ulcer that had gotten down to the bone and had osteo[DIAGNOSES REDACTED]. V5 stated the facility staff had talked with R3's family (V11) who agreed with palliative care and the focus was on preventing the wound from worsening and getting infected. V5 confirmed R3's wound was not treated for [REDACTED]. On [DATE] at 10:24 AM V11 (R3's Power of Attorney) stated the facility told V11 on [DATE] that R3's left plantar wound infection was resolved. V11 stated V11 was not notified until [DATE] that there were any signs of infection to R3's left plantar wound. V11 stated no one at the facility had discussed palliative care with V11, and V11 would want R3's infections to be treated. On [DATE] at 3:25 PM V1 Administrator stated V1 would expect scissors to be disinfected with a bleach wipe after used to remove soiled dressings. Treatment administrations should be documented and signed out on the TAR. V1 stated if it is not signed out, then can't confirm that the treatment was done. V1 stated V1 thought the facility had 30 days to obtain the physician's orders [REDACTED]. On [DATE] at 8:50 AM V1 stated the nurses communicate V5's written notes to the resident's representative and it should be documented in the nursing notes. On [DATE] at 11:54 AM V1 stated V1 was unable to provide documentation that R3's skin/circulation was monitored while using the orthotic boot and that a wound culture was collected between [DATE] and [DATE]. The facility's Preventative Skin Care Policy revised on [DATE] documents residents who are at high risk for developing pressure ulcers will be turned and repositioned at least every 2 hours and specialty mattresses and chair cushions will be used. This policy documents pillows/blankets may be used between skin to skin contact or to elevate bony prominences off of the mattress, and pressure relieving devices may be used to protect heels and elbows. The facility's Skin Conditioning Monitoring policy revised [DATE] documents when a wound or skin abnormality is identified the nurse will assess and document the findings, notify the physician, and obtain a treatment order. Skin abnormalities will be assessed and documented weekly to include measurements, color, presence of granulation or necrotic tissue, treatment, and response to the treatment. The facility's Pressure Ulcers - Nutritional Intervention policy revised [DATE] documents nutritional interventions will be utilized to improve healing of pressure ulcers and prevent the development of new pressure ulcers. This policy documents residents with stage II, III, IV pressure ulcers are referred to the dietitian for nutritional needs.

Based on interview and record review the facility failed to prevent witness employee verbal, mental, and physical abuse of one of three residents (R9) reviewed for abuse on the sample of 12. This failure resulted in psychosocial harm to R9 as evidenced by R9's response to the employee's abusive actions including crying, screaming out, flailing, becoming agitated, upset, anxious and nervous. Findings include: On 5/8/18 at 9:08 AM, V4 (Housekeeper) stated on 5/5/2018 at 11:00 AM that she heard V3 (Registered Nurse) state V3 was going to give R9 a pain pill. V4 stated V3 sounded frustrated with R9 and that V3 stated to R9, That's it, you're getting a pain pill. V4 stated V3 grabbed R9's wheelchair and whipped it around and put the pill into R9's mouth. R9 spit the pill out and then V3 started yelling at R9 that R9 was going to take the pill. V4 stated V3 then picked the pill up off the wheelchair and put it back into R9's mouth in a very frustrated manner. V4 stated V3 grabbed R9's face and yelled, Don't spit it out again. V4 stated R9 then spit the pill out again and R9 was screaming out and crying. V4 stated V3 then yelled to R9, I am going to mash it up and put it in Applesauce and you are going to take it. V4 stated R9 continued to yell, scream, and cry. V4 stated V3 was straddling R9 and was in R9's face yelling, You are going to take it. V4 stated V3 grabbed R9's face again and was trying to shove the pill in R9's mouth. V4 stated V3 was screaming at the top of V3's lungs and visitors were coming out of resident's rooms in response to the screaming. V4 stated she told V3 that was enough and to leave R9 alone. V4 stated that V3 then stated, I don't give a f*** (expletive), they can turn me in. V4 stated to V3 again that was enough. V4 stated V3 then pushed R9's head back and threw water into R9's face. V4 stated she told V3 to walk away. V4 stated V3 then shoved R9's wheelchair back and V3 then went outside the building. On 5/8/18 at 1:00 PM, V12 (Family Member) stated on 5/5/18 before lunch, V12 was in R12's room visiting. V12 stated V12 walked out of R12's room. V12 stated V3 was screaming at R9. V12 stated R9 was going crazy and throwing a fit. V12 stated V3 was upset because R9 would not take R9's pills. V12 stated V3 was screaming for R9 to quit throwing R9's pills on the floor. V12 stated V3 was screaming at R9, You are going to take your pills! V12 stated when V12 walked out of restroom V3 was screaming, I'm not doing this anymore. V12 stated R9 was yelling this to V7 (Licensed Practical Nurse). V12 stated V7 was trying to get V3 to calm down. On 5/8/18 at 11:25 AM, V6 (Certified Nurse's Assistant) stated on 5/5/18 around lunch time, V6 walked towards the nurse's station. V6 stated R9 was in R9's wheelchair behind the nurse's station and V3 was standing directly in front of R9. V6 stated V3 was attempting to give R9 their medicine. V6 stated R9 was swinging her arms at V3. V6 stated was saying loudly to R9, You have to take your medicine. V6 stated V3 then said V3 was going to crush the medication. V6 stated V3 then attempted to give R9 the medicine again and R9 was crying and flailing R9's arms. On 5/8/18 at 10:16 AM, V5 (Activity Aide) stated V5 was getting ready to start an activity on 5/5/18 before lunch. V5 stated V4 (Housekeeper) came into dining room and was distraught and upset. V5 stated V4 was looking for V7 (Registered Nurse). V5 stated V4 said to V5 that it was crazy up front. V5 stated V5 went to nurse's station to see what was going on and saw V3 attempting to give R9 medicine. V5 stated V5 seen V3 tilt R9's head back to get R9 to swallow medicine. V5 stated V3 was trying to give R9 medicine but R9 was refusing. V5 stated V3 then crushed the medicine and gave R9 water. V5 stated R9 was spitting the medicine and water out. V5 stated V3 did manage to get the pill down R9 somewhat. V5 stated V3's voice was raised when talking to R9. On 5/9/18 at 2:06 PM, V3 (Registered Nurse) stated on 5/5/18, an unidentified Certified Nurse's Assistant brought R9 up to the nurse's station before lunch to give R9 a pain pill. V3 stated she attempted to give R9 the pill and R9 spit it out. V3 stated R9 grabbed the cup of water and water spilled everywhere. V3 stated V3 then crushed the pill and R9 took the pill. V3 stated at first R9 would open R9's mouth to take the pill but R9 would spit it back out at V3. V3 stated V3 lifted R9's forehead back to get R9 to swallow the pill. V3 stated R9 was agitated and grabbed the water glass and was throwing it around. V3 stated R9 was flailing R9's arms, resisting cares and hitting. V3 stated after the fourth time V3 gave R9 the pill, R9 swallowed it. V3 stated she was a little frustrated but wasn't screaming. V3 stated V3 never pinched R9's face, just held R9's head back. R9's nurse's notes dated 5/5/18 at 4:00 PM by V3 documents, (R9) verbally, physically aggressive (with) staff. Spitting out pills. Will not allow this writer (V3) to give eye (drops). (R9) hitting, biting, throwing water and spitting on staff. Administered pain med (medication) and (R9) calmed down (after) twenty min. (minutes). Will cont. (continue) to monitor. On 5/9/18 at 9:36 AM, V7 (Licensed Practical Nurse) stated on 5/5/18 sometime before lunch that V7 was in R12's room talking to the family. V7 stated V12 left the room and was gone for about ten minutes. V7 stated V7 then heard yelling in the hallway. V7 stated V7 could not tell what the yelling was, so V7 stated V7 stepped out into the hallway and someone said V3 is leaving. V7 stated V3 was at the nursing station crying repeating herself, I can't do this anymore. V7 stated V3 then went outside. V7 stated V4 told her that V3 held R9's nose and threw water on R9. V7 stated V7 went to check on R9 and R9 was upset. V7 stated R9 was fidgeting a lot in the wheelchair and rocking back and forth. V7 stated R9 appeared anxious and nervous. On 5/14/18 at 1:20 PM, V18 (R9's family member) stated that V18 would expect staff to stop care and reapproach later if R9 was having a bad reaction to cares. V18 stated a bad reaction means yelling out at staff. V18 stated V18 would not want the staff at the facility to force R9 to do anything. V18 stated R9 would not want someone repetitively asking R9 to do something that R9 didn't want them to do. V18 stated before R9 was cognitively impaired, if staff forced R9 to do something then R9 would fight them and call R9's family to report it. V18 stated it would have deeply upset R9 and that R9 would remember it because R9 was the type not to forget things like that.