Every finding on record at Waterford Care Center, The

Based on interview and record review, the facility failed to protect one resident (R2) from sustaining physical abuse from R3 who hit R2 in the head. This failure affected 1 of 3 residents reviewed for abuse. Findings Include: R2's face sheet documents a diagnosis of but not limited to unspecified inflammatory spondylopathy- thoracic region, abnormal posture, difficulty walking not elsewhere classified, other ossification of multiple sites, and personal history of benign neoplasm of the brain. R2's progress notes, dated 4/14/2025 at 4:30 PM, documented by V3 (Former Registered Nurse) R2 reported R3 physically made contact with him (R2) and R2 was sent to the hospital.R2's Minimum Data Set section C, dated 6/20/2026, documents a BIMS (Brief Interview Mental Status) Score of 15, which indicates an intact cognition.R2's Minimum Data Set section GG, dated 6/20/2026, documents R2 has functional limitations of supervision or touching assistance with upper body and lower body dressing and sitting to lying. R2's hospital after visit summary, dated 4/14/2026, documents R2's diagnosis is assault, scalp hematoma, and abrasion. R3's progress note, dated 4/14/2026 at 4:30 PM, documents R3's roommate (R2) was yelling for help and upon entering the room R2 and R3 share, R3 was at R2's bedside with physical aggression towards R2. Police report, dated 4/14/2026, with an incident titled Battery to the complainant (R2).R3's face sheet, dated 7/1/2026, documents a diagnosis of but not limited to unspecified psychosis not due to a substance or known physiological condition, type 2 diabetes mellitus without complications, cognitive communication deficit, unspecified dementia-unspecified severity-with other behavioral disturbance, and generalized anxiety disorder. R3's Minimum Data Set section C100, dated 3/8/2026, documents R3 rarely/never understood.R3's progress noted, dated 4/14/2026 at 8:51 PM, documents V3 heard R2 yelling and upon entering R2's room, R3 was at R2's bedside showing physical aggression toward R2. R3's progress note, dated 4/10/2026 at 12:53 PM, documents R3 was observed with agitation; received orders from nurse practitioner for haloperidol 2 milligrams every 8 hours as necessary for 14 days and haloperidol lactate Injection solution 5 milligrams/milliliter injected per intramuscular 0.4 milliliters every 4 hours as needed for agitation x 14 days; and consent obtained from R3's wife.R3's progress note, dated 4/14/2026 at 5:06 PM, documents R3 was administered a haloperidol oral tablet 2 mg orally for agitation.R3's progress note, dated 4/14/2026 at 7:06 PM, documents R3 was administered a haloperidol oral` tablet 2 mg orally for agitation.On 7/1/2026 at 10:25 AM, R2 stated on 4/14/2026, he awoke in his room after lunch to find R3 going through his belongings. When R2 told him to stop, R3 assaulted him, striking him several times in the head. R2 stated he was unable to defend himself due to pre existing back and arm conditions and called for nursing assistance. V3 (Registered Nurse) nurse noted contusions on his head. R2 stated the facility did not attempt to find ways to discharge him (R2) to another nursing home after the incident. R2 was unsure whether R3 had a history of violent behavior and reported sharing the room with him for only a few weeks. R2 also reported being legally blind; can speak clearly and hold conversations without difficulty. Law enforcement responded asking how he was feeling and offered medical evaluation.On 7/1/2026 at 1:26 PM, V11 (Registered Nurse) said she has had in-services on falls and abuse, and residents should be free from abuse. On 7/2/2026 at 10:24 AM, V1 (Administrator) stated R2 stated R3 went to his (R2's) side of the bed and removed some items, as R2 and R3 sometimes share snacks. R2 yelled for the nurse and reported R3 hit him. Police and fire department responded. R2 gave a statement to the police; R3 was moved to another room but could not be interviewed due to inability to give a statement. R2 wanted R3 arrested and the police stated at this time they could not arrest R3. R3 has no known history of violent outbursts, and R2 is not legally blind to her (V1's) knowledge.On 7/6/2026 at 12:19 PM, V14 (Nurse Practitioner) stated he (V14) is aware of R2 being physically assaulted by R3. R3 has a psychiatric history but unaware of any violent history. to the best of V14's knowledge, R2 sustained minor discoloration to his (R2's) head from R3's physical aggression on 4/14/2026. Residents should be kept free from physical abuse in the facility. Facility's policy titled Abuse Prevention, dated 2001 (Reviewed December 2025), documents as part of the resident abuse prevention, the administration will protect their residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Facility's policy titled Abuse Prevention dated 2001 (Reviewed December 2025) documents our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom of corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Facility's policy titled Resident Rights dated 2001 (Reviewed December 2025) documents Federal and stated laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation.

Based on observation, interview, and record review, the facility failed to ensure food items were properly labeled and dated and manufacturer guidelines followed. These failures have the potential to affect all 129 residents receiving food prepared in the facility's kitchen. Findings include:On 01/20/26 at 9:21 AM, V11 (Dietary Manager) stated all prepared or opened containers are labeled with a prepared or opened date and a use by date or expiration date. V11 stated prepared or opened food items are discarded after seven days and the kitchen follows manufacturer use by and/or expiration dates printed on the product. V11 stated different foods have different expiration dates depending on what the product is. V11 stated it is important for the food items to be labeled and dated with an open and use by date, so the staff knows how long the product is good for so spoiled food does not get served. V11 stated it is safe practice for all opened items to be labeled and dated and discarded after expiration date.On 01/20/26 at 9:25 AM, observed the following items inside the walk-in refrigerator:Opened 128-fluid ounce bottle of Lemon Juice labeled in handwriting with delivery date 08/22/25, opened date 01/08/26, and use by date 01/08/27. Printed on the bottle by the manufacturer was expiration date 01/12/2026. V11 viewed manufacturer's expiration date printed on the bottle and stated, This should be discarded and removed the item from the walk-in refrigerator.Opened 5- pound container of cottage cheese labeled with delivery date 12/23/25, opened date 01/16/26 and use by date 01/23/26. Manufacturer labeled best by date 12/31/25 printed on the cottage cheese container. V11 viewed the best by date 12/31/25 printed on the outside of the container and stated, This isn't usable. It should have been discarded.On 01/20/26 at 9:38 AM, observed the following items in the milk cooler:Unopened 5-pound container of cottage cheese. Labeled with delivery date 12/29/25. Printed on container by manufacturer best by date 01/14/26.Unopened 5-pound container of cottage cheese. Labeled with delivery date 12/30/25. Printed on container by manufacturer best by date 12/31/25.On 01/20/26 at 9:39 AM, V11 looked at the manufacturer best by dates printed on the containers of cottage cheese in the milk cooler and stated both items should have been used or discarded by the manufacturer's best by date printed on the outside of the container.On 01/20/26 at 9:45 A, observed in the cooking prep area the following items:Opened bottle of Ground Coriander labeled with delivery date 05/12/23 and best by date 10/24/24 printed by manufacturer on the side of the bottle. Not able to decipher opened date.Opened bottle of Basil Leaves labeled with best by date 10/02/25 printed by manufacturer on the side of the bottle. Not able to decipher opened date.Opened bottle of Ground Oregano labeled with delivery date 09/09/23, opened 12/11/24. Best by date 03/17/25 printed on bottle by manufacturer.Opened bottle of Celery Salt labeled with delivery date 07/19/22. Not able to decipher opened date. Best by date 02/17/25 printed on bottle by manufacturer.Opened bottle of Oregano Leaves labeled with delivery date 05/26/23. Not able to decipher opened date. Best by date 02/11/25 printed on bottle by manufacturer.On 01/20/26 at 9:57 AM, V11 stated the kitchen should be following the best by date printed on the spice bottle by the manufacturer. V11 stated all those spices have expired and will be thrown out.On 01/20/26, V11 provided list of diet orders for all residents in the facility. The diet order list indicates there is six residents receiving nothing by mouth (NPO).Facility provided policy titled, Labeling ad Dating Foods dated 2021which documents to decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded and for dry storage room canned food and other shelf stable items such as cake mixes are labeled with the date received. If the product does not have expiration date, the product is labeled with a discard or use by date. Refer to the following chart for the use by recommendations.Facility provided policy titled Refrigerated Food dated 2021 which documents Refrigerated Potentially Hazardous Food (PHF) or Time/Temperature Controlled for Safety (TCS) foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date. If opened the cold food item is labeled with the date opened and the date by which to discard or use by. Refer to the following chart for the use by recommendations.Facility provided document titled, Use by Date Recommendations (undated) which lists different food items and documents in part,Ground spices 2-3 years recommended maximum storage period if opened and expiration date not exceeded.Herbs, dried 1-2 years recommended maximum storage period if opened and expiration date not exceeded.

Based on interview and record review, the facility failed to ensure accurate information were included in the residents' Level I Pre-admission Screening and Record Review (PASRR) and failed to refer residents to the appropriate state-designated authority for a PASRR Level II Screen evaluation and determination with known mental illness for four (R2, R8, R62, R81) residents out of a final sample of 28 reviewed for PASRR screenings. Findings include: 1.R8's face sheet documents R8 was admitted to the facility on [DATE], with admission diagnoses not limited to Dysarthria following Cerebral Infarction. R8's diagnoses of Bipolar Disorder has onset date of 6/19/18, Major Depressive Disorder and Anxiety Disorder onset dates of 10/30/19, and Unspecified Dementia with other Behavioral Disturbance onset date of 10/1/22. R8's PASARR screening, dated 7/15/22, documents R8 has no mental health diagnosis is known or suspected. It also documents in part, The Level 1 screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new scree must be submitted. 2.R62's face sheet documents R62 was admitted to the facility on [DATE] with admission diagnoses not limited to Major Depressive Disorder, Restlessness and Agitation. R62's PASARR screening, dated 8/11/22, documents R62 has no mental health diagnosis is known or suspected. It also documents in part, The Level 1 screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new scree must be submitted. 3.R81's face sheet documents R81 was admitted to the facility on [DATE], with admission diagnoses not limited to Unspecified Psychosis, Neurocognitive Disorder with Lewy Bodies, and Unspecified Dementia with Other Behavioral Disturbance. R81's diagnosis of Major Depressive Disorder onset date was 11/1/24. R81's PASARR screening, dated 11/25/23, documents R81 has no mental health diagnosis is known or suspected. It also documents in part, The Level 1 screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new scree must be submitted. On 1/21/26 at 3:34 PM, V20 (Social Service Director) reviewed R8, R62, and R81's active diagnoses. V20 stated R8, R62, and R81 have mental illness diagnoses that should have been indicated in their PASRR Level I screenings. 4.R2's electronic health records (EHR) indicate R2 was initially admitted to the facility on [DATE], discharged to home on [DATE] and readmitted to the facility on [DATE]. R2's Face sheet documents R2 was originally admitted to the facility on [DATE], with diagnosis including but not limited to Dementia, Anxiety Disorder. R2 was readmitted to the facility on [DATE] with additional diagnoses Unspecified Psychosis. R2's PASARR Level I Screen, dated 11/08/2024, documents, your level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and experience a significant change in treatment needs. R2's MDS (Minimum Data Set), dated 11/10/24, documents R2's active diagnoses include but not limited to Non-Alzheimer's Dementia, and Psychiatric/Mood Disorder (Anxiety Disorder). R2's PASRR Level I Screen, dated 05/01/25, documents, your level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and experience a significant change in treatment needs. R2's MDS (Minimum Data Set), dated 05/22/25, documents R2's active diagnoses include but not limited to Non-Alzheimer's Dementia, and Psychiatric/Mood Disorder (Anxiety Disorder, Psychotic Disorder). R2's Physician Order Sheet, dated 01/21/26, includes but not limited to Sertraline HCl 25 mg daily related to Adjustment Disorder, Sertraline HCl 50 Mg one time a day related to Adjustment Disorder, Seroquel Oral Tablet 25 mg (Quetiapine Fumarate) every 12 hours related to Unspecified Psychosis Not Due to A Substance or Known Physiological Condition. On 01/21/2026 at 3:26 PM, V20 (Social Service Director) stated PASRR is a screening that is completed prior to admission that helps to determine if the resident is appropriate to be living in a nursing home type setting and would also identify any accommodations needed to meet the resident needs. V20 stated all residents require a PASRR Level I Screen prior to admission. V20 stated a PASRR Level II screening is required if the resident has a Severe Mental Illness (SMI) diagnosis such as Schizophrenia, Major Depressive Disorder, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder. V20 stated the facility reviews the PASRR Level I Screen completed at the hospital to make sure the information used to complete the screen is correct. V20 stated it is important that the facility makes sure the information used to fill out the PASRR Level I Screen is correct to ensure residents with a SMI diagnosis are referred for a PASRR Level II Screen to ensure the resident is appropriate for admission to the facility. V20 stated she has picked up mistakes in the past wherein the facility receives a PASRR Level I Screen that was negative because the hospital did not enter in the resident's SMI diagnosis, but upon review the resident did in fact have a SMI diagnosis, thereby requiring a PASRR Level II to be requested and completed. V20 reviewed R2's PASRR Level I Screen, dated 11/08/2024 and 05/01/25 and R2's MDS active diagnosis list dated 11/10/24 and 05/22/25. V20 stated R2's PASRR Level I Screens were not completed correctly. V20 stated the facility should have picked this up when R2 was admitted initially and then readmitted again in 05/2025. V20 stated the potential problem is that since R2's SMI diagnoses were not listed the facility was not able to assess R2 properly to determine if the facility is appropriate for her. On 01/22/26 at 8:10 AM, V1 (Administrator) stated the purpose of PASRR is to get information regarding the resident to make sure the facility is appropriate fit and can provide the care the resident needs. V1 stated a PASRR Level I Screen is completed prior to the resident being admitted to the facility. V1 stated she or V20 will review the PASRR screening to make sure the information on it is accurate and then refer them back to the state-designated authority for a PASRR Level II Screen to be done if needed. Facility provided document titled, Pre-admission Screening and Resident Review (PASRR), dated [DATE], which documents it is the policy of this facility to comply with federal, state and the appointed screening agency in standards addressing the PASRR assessment/screening process and to review the PASRR documents to help assess/ascertain what type of problems, needs and issues need to be addressed to help the resident function at his/her maximum level of well-being and as indicated, the screening material should be reviewed as a component of the assessment process and treatment suggestions/recommendations should be identified and appropriately addressed.

Based on observation, interview, record review, the facility failed to properly (a) discard a multi-dose insulin 28 days after opening, (b) store in the refrigerator unopened multidose insulin and (c) date / label multi dose inhalers after opening. These failures affected six (R25, R48, R93, R102, R117 and R132) residents reviewed for medication storage and labeling in three of six medication carts. The findings include:R25's admission record / face sheet showed admit date on [DATE], with diagnoses not limited to Chronic obstructive pulmonary disease (COPD), Parkinsonism, and Hypertensive chronic kidney disease.R48's admission record / face sheet showed original admit date on [DATE], with diagnoses not limited to Emphysema, Other sequelae of cerebral infarction, Chronic obstructive pulmonary disease, and Typical atrial flutter.R93's admission record / face sheet showed original admit date on [DATE], with diagnoses not limited to Secondary parkinsonism, Type 2 diabetes mellitus with hyperglycemia, and Essential (primary) hypertension.R102's admission record / face sheet showed admit date on [DATE], with diagnoses not limited to Chronic obstructive pulmonary disease, Gout, Age-related osteoporosis, Chronic kidney disease, Hypertensive chronic kidney disease, Atherosclerotic heart disease of native coronary artery, Hyperlipidemia, and Hypothyroidism.R117's admission record / face sheet showed admit date on [DATE], with diagnoses not limited to Asthma, Type 2 diabetes mellitus, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Hypertensive heart and chronic kidney disease, and Obstructive sleep apnea.R132's admission record / face sheet showed admit date on [DATE], with diagnoses not limited to Other sequelae of cerebral infarction, Type 2 diabetes mellitus, and Essential (primary) hypertension.On [DATE] at 9:59AM, 3rd floor [NAME] medication cart inspected with V4 (RN / Registered Nurse) and found the following inside the medication cart:R25's Spiriva Respimat multidose inhaler spray with open date on [DATE]. R25's POS (Physician Order Sheet) dated [DATE] showed order not limited to Spiriva HandiHaler Capsule (Tiotropium Bromide Monohydrate) 2.5 mcg inhale orally in the morning for COPD.R48's Incruse Ellipta multidose inhaler opened with no date. Pharmacy labelled indicated discard as label instructs. R48's POS dated [DATE] showed order not limited to Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 MCG/ACT (Umeclidinium Bromide) 1 inhalation inhale orally one time a day related to chronic obstructive pulmonary disease.R102's Stiolto Respimat multidose inhaler spray opened with no date. R102's POS dated [DATE] showed order not limited to Stiolto Respimat inhal, 60 dose{4 gm}. Give 2 inhalation by mouth in the morning related to chronic obstructive pulmonary disease.V4 (RN) said inhalers should be dated once they are opened.On [DATE] at 10:21AM 3rd floor Fargo med cart inspected with V5 (RN / Registered Nurse) and found the following inside the medication cart:R93's Basaglar 100u/ml kwikpen multi dose insulin not opened and was kept inside the medication cart. Pharmacy label showed refrigerate till open then room temperature. Discard unused med after 28 days. R93's POS dated [DATE] showed order not limited to Basaglar KwikPen Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously at bedtime related to type 2 diabetes mellitus.R93's Basaglar 100u/ml kwikpen multi dose insulin with open date on [DATE]. Pharmacy label showed discard unused medication after 28 days.R117's Lispro multidose insulin vial with open date on [DATE] and discard date on [DATE] was kept inside the medication cart. Pharmacy label showed discard after 28 days. R117's POS showed order not limited to HumaLOG Solution 100 UNIT/ML (Insulin Lispro)Inject 5 unit subcutaneously with meals Inject per sliding scale if 200-250 + 2units, 251 - 300 + 4 units. V5 (RN) said insulin beyond discard / expiry date should have been removed from the medication cart or discarded. She said unopen insulin should be kept inside the refrigerator.On [DATE] At 10:33AM, 1st floor [NAME] medication cart inspected with V6 (LPN / Licensed Practical Nurse) and found:R132's Lantus multi dose insulin pen was not opened and was kept inside the medication cart. Pharmacy Label indicated refrigerate till open then room temperature. Discard unused medication after 28 days.R132's POS, dated [DATE], showed order not limited to Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 16 unit subcutaneously in the morning related to type 2 diabetes mellitus.V6 (LPN) said unopen insulin should be refrigerated.On [DATE] at 9:25AM, V2 (DON / Director of Nursing) stated nurses are expected to properly store and label medications. V2 said it is important to date medication once opened to remind when the expiry is and when to discard the medication. V2 stated nurses should be aware of the expiration date and not administer expired meds to the residents. V2 said when medication is beyond the expiry / discard date, it should be removed from the medication cart or discarded to avoid confusion and to prevent administration of expired medication. V2 said Insulin if not opened yet should be kept in the fridge. V2 said most of the insulin expires within 28 days after opening and should be discarded. V2 stated Inhaler should be dated once opened then follow pharmacy recommendations. V2 said inhalers are usually discarded within 3-6months after the medication is opened. V2 stated nurses should follow pharmacy instruction or recommendation to maintain potency of the medication.Facility's Storage and Labeling of Medications policy dated 4/2025 showed: Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.Facility's medication storage guidance dated 2023 showed: Spiriva Respimat Inhalation Spray - Discard 3 months after first use or when the locking mechanism is engaged (indicating all actuations have been used), whichever comes first. Stiolto Respimat Inhalation Spray - Discard 3 months after first use or when the locking mechanism is engaged (indicating all actuations have been used), whichever comes first. Incruse Ellipta Inhalation Powder - Date when foil tray is opened and discard after 6 weeks or when the counter reads 0, whichever comes first. Basaglar pen - Unopened at room temperature - 28 days. Opened 28 days. Insulin Lispro - Unopened at room temperature - 28 days. Opened 28 days. Lantus - Unopened at room temperature - 28 days. Opened 28 days.

Based on observation, interview, and record review, the facility failed to follow the pureed menu spreadsheets for five residents (R1, R12, R54, R83, R89) out of 12 residents receiving a pureed diet consistency in a total sample of 28.Findings Include:On 01/21/26 between 10:10-11:15 AM, observed V27 (AM Cook) prepare pureed food items for lunch including pureed bread.On 01/21/26 at 11:45 AM, observed V27 put prepared pureed bread on the tray line for service.On 01/21/26, observed lunch tray line between 11:45 AM - 12:00 PM. V27 did not put pureed bread on any of the trays going to the 2nd floor.On 01/21/26, during lunch observations on the 2nd floor, R1, R12, R54, R83, R89 did not receive pureed bread on their lunch trays.On 01/21/26 at 12:24 PM, observed R83 eating his pureed lunch tray. R83 stated he likes to eat and usually eats everything. R83 stated if he received pureed bread; I'd probably eat it.On 01/21/26 at 12:35 PM, observed R83's lunch tray. R83 had consumed 100% of the pureed food served to him and was continuing to bring the spoon to his mouth even though there was no food left on his plate to eat.On 01/21/26 at 4:45 PM, V11 (Dietary Manager) stated all the items listed on the spreadsheets should be served to the residents, and residents on pureed diet should receive the same items served on the regular diet but in pureed form. V11 stated this is important for menu variety, taste, and to provide better nutrition. V11 stated residents require a certain amount of calories to complete their nutritional requirements, and all pureed diets today should have received pureed bread. V11 stated pureed bread was prepared by the [NAME] and was on the tray line, but the [NAME] must have just forgotten to serve to the carts going to the 2nd floor. V11 stated once the [NAME] realized that he forgot to serve pureed bread to the 2nd floor, he should have alerted V11, and then V11 would have portioned out the pureed bread and brought it up to the residents on the 2nd floor.On 01/22/26 at 9:10 AM, V35 (Registered Dietitian) stated via telephone interview, the kitchen should be following the spreadsheets and recipes. V35 stated if the spreadsheet lists pureed bread the residents on pureed bread should receive the pureed bread. V35 stated it is important for the menus to be followed for consistency and variety. V35 stated the menus and spreadsheets should be followed to be in alignment with the nutritional breakdown for the meal that day, that cycle.Kitchen document titled, Daily Spreadsheet (Week 4, Wednesday) which indicates for lunch pureed diets to receive pureed bread (1slice = #16 scoop).Facility provided document titled Diet Type Report printed 01/21/26 which documents R1, R12, R54, R83, R89 on pureed diet texture.Facility job description for position title [NAME] undated, documents the cook provides patient specific nutritional meals according to care plan, and duties/responsibilities include but not limited to understand therapeutic diets, their importance and serves correctly.

Based on observation, interview, and record review, the facility failed to provide thickened liquids as ordered by the physician for four residents (R1, R87, R89, R123) and failed to ensure mechanically altered diet was followed as ordered to one resident (R81) on a pureed diet in a total sample of 28.Findings Include: 1.R1 diagnosis includes but not limited to Chronic Respiratory Failure with Hypoxia, Dysphagia, Oropharyngeal Phase, Cognitive Communication Deficit, Dependence on Supplemental Oxygen, Dementia. R1's MDS (Minimum Data Set) dated 12/02/25 reveals R7 is moderately cognitively impaired, has a swallowing disorder (complains of difficulty or pain with swallow) and requires a mechanically altered diet – require change in texture of food or liquids. R1's Physician Order Report dated 01/21/26 documents in part, diet order as general diet, puree texture, nectar thick consistency ordered 12/11/25. R1's meal ticket list diet order as General Pureed, Nectar Thick Liquid. R1's nutrition care plan initiated 12/11/25 documents in part, nectar thick liquid added to diet and interventions include but not limited to provide and serve diet as ordered. R89 diagnosis includes but not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Speech and Language Deficits Following Cerebral Infarction, Dysphagia Following Cerebral Infarction, Chronic Respiratory Failure with Hypoxia Cognitive Communication Deficit. R89's MDS dated [DATE] reveals R89 is rarely/never understood, has signs/symptoms of possible swallowing disorder (complaints of difficulty or pain with swallowing) and requires a mechanically altered diet – require change in texture of food or liquids. R89's Physician Order Report dated 01/21/26 documents in part, diet order as puree diet, pureed texture, honey thick consistency ordered 01/21/26. R89's meal ticket list diet order in part as General Pureed, Honey Thick Liquid. R123 diagnosis include but not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Dysphagia Following Cerebral Infarction, Cognitive Communication Deficit. R123's MDS dated [DATE] reveals R123 is rarely/never understood, has signs/symptoms of possible swallowing disorder (complaints of difficulty or pain with swallowing) and requires a mechanically altered diet – require change in texture of food or liquids and feeding tube meeting 51% of more of total calorie needs. R123's Physician Order Report dated 01/21/26 documents in part, diet order as pureed diet pureed texture, honey thick consistency, small portions dated 05/01/25. R123's meal ticket General Pureed, Honey Thick Liquid, Pleasure Feeding. R123's nutrition care plan documents in part, diet to be followed as prescribed. On 01/21/26 at 12:05 PM, R89 received her lunch tray, which contained pureed food and applesauce. R89 did not receive any liquid(s) on her tray. R89's meal ticket read General Pureed, Honey Thick Liquid. On 01/21/26 at 12:08 PM, R1 received his lunch tray which contained pureed food, pudding, and a closed 8-ounce carton of milk. The milk was not thickened. R1's meal ticket read General Pureed, Nectar Thick Liquid. On 01/21/26 at 12:33 PM, R123 received his lunch tray which contained pureed food, applesauce and a closed 8-ounce cart of milk. The milk was not thickened. R123's meal ticket read General Pureed, Honey Thick Liquids. On 01/21/26 at 12:12 PM, observed nursing staff including V30 (Certified Nursing Assistant) passing out hot beverage and juice to residents from a beverage cart. Did not observe any pre-thickened liquids or food thickener on the beverage cart. On 01/21/26 at 12:20 PM, V30 stated the nursing staff goes room to room and passes out coffee, tea, and juice to the residents during meals. V30 stated the kitchen puts thickened liquids on the tray of those residents who require it, so that when the trays arrive on the unit, the thickened liquids are already on the trays, and the nursing staff just pass out the trays. V30 stated there is no food thickener on the beverage cart and there are no pre-thickened liquids delivered on the beverage cart for them to give out. V30 stated there is food thickener on the nurse's cart. On 01/21/26 at 12:25 PM, V7 (Registered Nurse) stated the trays come up from the kitchen with thickened liquids already on them. V7 stated the nurses have food thickener stored in their medication cart. Observed V7 go to his medication cart drawer and pull out an unmarked plastic container with a white powdery substance in it. There were no instructions or guidelines posted on the outside of the container. V7 looked around in medication cart and stated he could not find any recipe or guidelines on how much thickened is needed to reach the different types of thickened liquids. V7 stated if he had to thicken liquids for a resident on honey thick liquids versus nectar thick liquids, he would have to estimate how much thickener to add. V7 stated no recipe or guidelines were given to them. On 01/21/26 at 12:37 PM, V31 (Certified Nursing Assistant) stated the potential problem with regular milk being put on a tray for a resident on thickened liquids is that if there is an agency CNA (Certified Nursing Assistant) who does not know the resident well and they see the milk on the tray, they may open the carton of milk and give it to the resident not realizing the milk should be thickened. On 01/21/26 at 12:40 PM, V32 (Certified Nursing Assistant) stated R89 did not receive any liquids on her lunch tray today so she went and got juice off the beverage cart and gave it to R89. V32 stated the juice was not thickened. V32 stated for residents on thickened liquids, the kitchen sends the liquids up already thickened on their tray, so it is already there when the CNAs go to feed the resident. V32 stated if the thickened liquids were on R89's tray, then that is what she would have given to R89. V32 stated she did not know R89 was on thickened liquids. On 01/21/26 at 12:55 PM, V4 (Registered Nurse) stated at meal the resident trays come up to the unit with thickened liquids on the tray for those residents who require it. V4 stated she has food thickener in her medication cart. Observed V4 open the drawer to her medication cart and pull out an unmarked plastic container with a white power inside. There were no instructions or guidelines posted on the outside of the container. V4 said, I don't have any type of guide to follow. V4 stated she just adds thickener to what liquid needs to be thickened, she is not sure the difference between nectar and honey consistency, and sometimes the liquid she is thickening comes out too thick. On 01/21/26 at 12:48 PM, V33 (Dietary Aide) stated, I forgot to put the thickened liquids on the trays today. Sorry, sorry. On 01/22/26 at 8:50 AM, V35 (Registered Dietitian) stated via telephone interview, residents may need to be on a pureed diet based on dysphagia and any chewing or swallowing impairments. V35 stated the consistency of the pureed food should be smooth. V35 stated a resident on a pureed diet should not receive diced peaches or canned fruit unless specified in the doctor's order. V35 stated the doctor is the one who orders the diet and the diet ordered should be followed as ordered; whatever is in the orders should align with what the resident receives. V35 stated she does not know the process of how the liquids are supposed to be thickened. V35 stated if the resident has an order for a thickened liquid, then they should receive that liquid thickened as ordered, not thin. On 01/22/26 at 11:06 AM, V37 (Speech Language Pathologist) stated if a resident is having signs or symptoms of aspiration then thickened liquids may be indicated. V37 stated thickened liquids go down slower and provide time for the neuro response to protect the airway and thereby prevent aspiration. The different liquid consistencies are thin, nectar, honey, and pudding. V37 stated if there is an order for a resident to be on a thickened liquid that that is what the resident should receive as a preventative and safety measure. V37 stated if a resident on thickened liquids was given a thin liquid, there is potential that the resident could aspirate meaning the liquid would go down too fast and go into upper airway and possibly down into the lung which could potentially cause pneumonia. V37 it is the staff's responsibility to thicken liquids for the resident ahead of giving them to the resident. V37 stated if a resident on thickened liquids received a regular carton of milk on their tray it is possible that the staff could open the milk carton and give to the resident not realizing the milk needed to be thickened. V37 stated giving a resident milk would be more of a significant aspiration risk than giving them water because the milk contains protein and sugar which has a higher risk of cultivating a pneumonia. V37 stated there are not any residents in the facility currently on the Frazier Free Water Protocol so any resident with an order for thickened liquids should have all their liquids including water thickened to the appropriate consistency as ordered by the physician. V37 stated if the liquids are not thickened by the kitchen, then the nurses on the unit can thicken the liquid with food thickener. V37 usually stated directions on how much thickener needs to be added to what amount of liquid to reach the desired consistency is printed on the can of the thickener and these directions should be followed so the residents receive the correct consistency. V37 stated pureed diet consistency should be smooth with no chunks. V37 stated diced peaches is not pureed and someone on a pureed diet should have received pureed peaches, not diced peaches. V37 stated a resident on a pureed diet who eats diced peaches has the potential risk of aspirating and choking on the diced peaches. On 01/21/26 at 4:45 PM, V11 (Dietary Manager) stated the kitchen orders pre-thickened water and juice but manually thicken the milk by hand using a food thickener. V11 stated residents on thickened liquids get their thickened liquids put on their tray by the kitchen staff before delivery to the unit. V11 stated the residents on thickened liquids should not have gotten regular cartons of milk, it should have been thickened in the kitchen. V11 said, It was a mistake. V11 stated the nurses have thickener on the unit and they should be following instructions on how to thicken the liquids. V11 stated there used to be a poster with directions on the unit on how to use the food thickener but he did not see it when he went up to the units today, so he provided them with instructions. V11 stated if the staff does not have instructions for the food thickener, then they do not have a way of knowing the difference between honey and nectar and then the resident may not receive the correct thickened liquid consistency. V11 stated if the nursing staff does not check the resident's meal ticket to see that they are on a thickened liquid and they just see the regular milk on the resident's tray the staff could assume the resident is okay to get the milk and give them the regular milk which could cause the resident to aspirate. V11 stated the pureed diets should have received pureed peaches, not diced peaches. V11 said, That was a mistake. V11 stated the potential problem is the resident on a pureed diet could choke on the diced peaches. On 1/20/26 at 12:15 PM, during lunch meal rounds observed R81 sitting in the dining room feeding herself pureed food. Observed a cup of diced peaches on R81's lunch tray. Observed R81's meal ticket which read NAS [No Added Salt] Pureed. R81's face sheet included diagnoses but not limited to dysphagia and neurocognitive disorder with Lewy bodies. R81's Minimum Data Set assessment dated [DATE] shows R81 has severe impairment with cognitive skills for daily decision making. R81's physician order report dated 1/20/26 documents in part, diet order pureed consistency texture (ordered 5/17/24). R81's nutrition progress notes dated 1/14/26 at 11:22 pm documents in part: Resident is on a general diet with pureed texture and thin liquids. The facility's TRAY CARD/MEAL TICKETS policy (2021) documents: the diet is served as indicated on the tray card/meal ticket. 2.R87's admission record / face sheet showed admit date on 8/9/2024, with diagnoses not limited to Parkinson's disease, Type 2 diabetes mellitus, Chronic obstructive pulmonary disease, Dysphagia. MDS (Minimum Data Set), dated 11/15/2025, showed R87's cognition was rarely or never understood. He needed supervision or touching assistance with eating. R87's POS (Physician Order Sheet) dated 1/20/26 showed active order not limited to Mechanical soft consistency texture, Nectar – mild thick consistency. Care Plan dated showed R87 has a swallowing problem r/t (related to) Parkinson's disease. Mechanical soft/nectar liquid consistency. Care plan interventions included but not limited to Ensure compliance and tolerance of diet consistency. All staff to be informed of resident's special dietary and safety needs. Diet to be followed as prescribed. Resident to eat only with supervision On 1/20/26 At 12:29PM, Observed R87 sitting up on side of the bed, alert and verbally responsive, eating lunch by himself with no staff supervision. R87 ate 100% of the food served. Observed with regular water not thickened at bedside table. There was no thickener powder at bedside. R87 stated thickened liquid is very thick at times and he is using the regular water to mix with thickened liquids. Requested V4 (Registered Nurse / RN) in R87's room and seen regular water at the bedside table. V4 said R87 is on thickened liquids and regular liquids should not be at the bedside. On 1/22/26 at 9:25AM, V2 (DON / Director of Nursing) stated she has been working in the facility for almost 3 years. V2 said when resident is on thickened liquids, staff should make sure that it is the right consistency provided to the resident. V2 said regular water should not be kept at bedside if resident is on thickened liquids. Stated water should be mixed with thickener powder to ensure the right consistency. V2 stated staff should always follow doctor's order for diet or liquid consistency. She said if thickened liquid consistency is not followed according to doctor's order, resident could potentially have coughing episodes and possible aspiration. Facility provided policy titled, Thickened Liquid Preparation, dated 2017, which documents thickened liquids are provided for clients the speech therapist has identified as needing thickened liquids to address swallowing problems. Thickened liquids may be nectar, honey or pudding thick. Thickened liquids may be prepared per the directions on the commercial thickening product. Or pre-thickened liquids may be used. All food that is liquid at room temperature is thickened to the appropriate viscosity. This includes water, juice, milk, soup and beverages. Liquids may be thickened by food and nutrition services or by nursing services. Facility provided policy titled Tray Cards/Meal Tickets, dated 2021, which documents the diet is served as indicated on the tray card/meal ticket.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two residents (R7 and R45) reviewed for reasonable accommodation of needs out of a sample of 28.Findings include:1.R7 has diagnosis which includes but not limited to Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure with Hypoxia, Morbid (Severe) Obesity due to Excess Calories, Asthma, Dependence on Supplemental Oxygen, Anxiety Disorder, Senile Degeneration of Brain, History of Falling. R7's MDS (Minimum Data Set), dated 12/30/25, documents intact cognition, functional limitation impairments to both sides of upper and lower extremities, dependent for toileting hygiene, personal hygiene, dressing, bathing, and chair/bed to chair transfer.R7's activities of daily living care plan for ADL self-care performance deficit plan documents intervention- encourage the resident to use bell to call for assistance.R7's fall risk evaluation, dated 12/22/25, classifies R7 fall category as High Fall Risk.R7's care plan documents R7 is at risk for falls and intervention be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance,On 01/20/26 at 11:29 AM, observed R7 lying in bed with call light out of reach. R7 stated if she needs to get in touch with the staff for help, she uses her call light. R7 looked around and said, I cannot reach it right now. It's usually pinned to me. R7 stated if her call light is not left where she can reach it, then she would have to yell to get the staff's attention. On 01/20/26 at 11:34 AM, V8 (Certified Nursing Assistant/CNA) stated after providing care before leaving the room she makes sure the resident call light is within reach so they have easy access and can get a CNA if they need help. V8 stated she will usually clip the call light to the resident's gown. On 01/20/26 at 11:36 AM, V8 observed R7's call light out of R7's reach. V8 said, She cannot reach that. V8 stated R7's call light should be clipped on her so she can reach it. V8 stated the problem with her not being able to reach her call light is she could not reach out and we wouldn't know there was a problem.2.R45's diagnoses includes but not limited to Paraplegia, Lack of Coordination, Vascular Dementia. R45's Minimum Data Set (MDS) dated [DATE] documents intact cognition, functional limitation impairments to both sides of upper and lower extremities, dependent for toileting hygiene, personal hygiene, dressing, bathing, and chair/bed to chair transfer.R45's activities of daily living care plan for ADL self-care performance deficit plan documents intervention- encourage the resident to use bell to call for assistance.R45's fall risk evaluation, dated 12/10/25, classifies R45 fall category as High Fall Risk.R45's care plan documents R45 is at risk for falls and intervention, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance,On 01/20/26 at 11:50 AM, observed R45 lying in bed with call light out of reach.On 01/20/26 at 12:15 PM, R45 asked V7 (Registered Nurse) to get his call light off the floor for him because he could not reach it. V7 bent down on the side of R45's bed and picked up R45's call light.On 01/20/26 at 12:16 PM, V7 stated he picked up R45's call light for him up off the floor. V7 stated his call light should have been within his reach so that if anything happens or if R45 needs anything, he can call staff for help. V7 stated if resident call lights are not within their reach they cannot ask for help. V7 stated there is also a risk the resident will try to get up on their own, which could pose a fall risk.On 01/21/26 at 4:20 PM, V2 (Director of Nursing) stated the purpose of the call light is to make sure the resident's needs are met so they call for help and/or assistance. V2 stated the call light should be located within their reach and the call lights have clips on them, so the staff can clip it to the pillowcase by their head or rolled around the 1/2 side rail if they have it. V2 stated the potential problem if the call light is out of reach is the resident cannot call for help and they are unable to communicate their needs to the staff. V2 stated if the resident cannot reach their call light and they need to go to the bathroom there is a risk they will try to get up on their own, and that would put them at risk for falling and possible injury.Facility provided document titled Resident Rights, dated 2001, which documents the federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence, be treated with respect, kindness dignity and self-determination.Facility provided policy titled, Routine Resident Checks & Call Light Response, dated July 2025, which documents to ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit and to ensure that call-light is working and within easy reach.

Based on interview and record review, the facility failed to ensure a resident's (R51) wishes were consistent across medical records and failed to redo R51's Advanced Directive for one out of 28 residents. Findings include: On [DATE] at 12:58 PM, R51's [DATE] IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life-Sustaining Treatment (POLST) form documents: Yes CPR: Attempt cardiopulmonary resuscitation (CPR). R51's 'admission Record' documents: Advance Directive: DNR (do not resuscitate). R51's 'Medication Review Report' (physician orders) documents: Advance Directive: DNR. R51's 'Care Plan Report' documents: [R51] received education on advanced directives, end of life care options, and establishing a health care representative. Pursuant to resident rights, the advanced directives status of DNR has been selected. V20 (Social Service Director) last revised this focus on [DATE]. On [DATE] at 1:00 PM, R51 was oriented to person, place, time, and situation. R51 stated facility educated R51 regarding Advanced Directives. R51 remembered filling out an Advanced Directive and giving it to V20. R51 stated he elected no CPR and discussed it with V38 (primary doctor). Surveyor requested R51's most recent POLST form from V1 (Administrator). On [DATE] at 11:34 AM, facility provided a copy of R51's [DATE] POLST form, but it now had the Yes CPR option with an extra line over it and error followed by V20's initials. There was a new circled x on the No CPR option. On [DATE] at 12:11 PM, V20 (Social Service Director) recalled R51 speaking with V39 (Nurse Practitioner) regarding the Advanced Directive. V20 also recalls speaking with R51 regarding Advanced Directives. V20 stated R51 elected DNR - No CPR. When surveyor asked about R51's [DATE] POLST form, V20 stated, I think that one was an error. The wrong thing was selected. [R51] stated [R51] wanted to be DNR. V20 stated speaking with R51 that morning to clarify, and R51 reiterated wanting to be DNR, so V20 corrected the POLST form. On [DATE] at 3:27 PM, V2 (Director of Nursing) stated the facility is to follow the residents' wishes. V2 stated residents' wishes should be consistent with the POLST and throughout their medical record. V2 stated V20 should have reviewed R51's POLST and created a new form to reflect R51's wishes. Facility's Advance Directives policy (Version 1.3) documents, Advance directives will be respected in accordance with state law and facility policy. The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). R51's last annual assessment was [DATE]. Facility failed to review POLST form during this time.

Based on interview and record review, the facility failed to ensure a resident was referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation/determination and an Annual Resident Review/yearly review was completed for 1 (R74) resident reviewed for PASARR in a sample of 28.Findings Include:R74 was originally admitted to the facility on [DATE], with a readmission date of 01/02/21. R74 has diagnoses not limited to Chronic Kidney Disease, Stage 3, Paranoid Personality Disorder, Peripheral Vascular Disease, Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Major Depressive Disorder, Insomnia, and Dementia. R74's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicate R74 is rarely/never understood.Review of R74's Diagnoses Information document: Bipolar Disorder, Major Depressive Disorder, Recurrent and Paranoid Personality Disorder with an onset date of 12/28/23.On 01/22/26 at 09:51 AM, V20 (Social Services Director) stated, (R74) has been here for quite some time. (R74's) PASARR screening for mental health determination is dated 04/25/95. I would have to see what diagnosis they originally assessed (R74) for. If (R74) was diagnosed with Bipolar Disorder, Major Depressive Disorder, Recurrent and Paranoid Personality Disorder after the initial screen, that would be a change in condition. (R74) should have been evaluated again and another PASARR should have been done. If the PASARR was not completed the resident may not be appropriate for living in this facility and they would not be getting the appropriate services.On 01/22/26 at 11:42 AM, V20 (Social Services Director) stated, I am still looking up (R74's) diagnosis. The three diagnoses are from 2023.On 01/23/26 at 11:38 AM, the facility has not provided any additional information for R74's diagnosis or PASARR screening.Policy:Titled PASSAR Guideline revised 04/25 documents: It is the practice to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Annually and with any significant change of status, the facility will complete the PASARR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly. The objective of the PASARR guideline is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals identified. Coordination of Care: iv. The facility will refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a level II review upon a significant change in status assessment to the State PASARR representative: 1. The resident individualized person centered care plan will be adjusted to reflect the identified changes evident in the signification change in status assessment and information obtained through the level II determination.

Based on observation, interview, and record review, the facility failed to ensure a dependent resident received timely assistance with ADL's (activities of daily living) related to incontinence care for one (R32) resident reviewed for ADLs in a sample of 28.Findings Include:R32 has diagnoses not limited to Anxiety Disorder, Insomnia, Functional Dyspepsia, Migraine, Intractable, Cervicalgia, Spondylosis, Cervical Region, Major Depressive Disorder, Recurrent, Morbid (Severe) Obesity Due to Excess Calories, Personal History of Urinary (Tract) Infections, Chronic Pain, Rotator Cuff Tear or Rupture of Unspecified Shoulder, Spinal Stenosis, Lumbar Region, Bipolar Disorder, Low Back Pain, Diaphragmatic Hernia and Tension-Type Headache. R32's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response.R32's Care Plan document, Focus: Skin: Resident has potential for skin breakdown r/t (related/to) incontinence and impaired mobility. Interventions: Provide skin care after each incontinent episode. Focus: R32 has an ADL self-care performance deficit r/t dx (diagnosis) CAD (coronary artery disease), HTN (Hypertension), DM (Diabetes Mellitus), bipolar disorder, chronic back pain, headaches. Interventions: Personal hygiene x1 staff assist. Toileting Use/Hygiene x1 staff assist. Focus: R32 exhibits bowel and bladder incontinence r/t decreased mobility, bouts of anxiousness; dx overactive bladder; hx (history) UTIs (urinary tract infections). Interventions: Incontinent: Check every two hours, upon request, as needed for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. Clean peri-area with each incontinence episode. Focus: The resident has potential/actual impairment to skin integrity r/t decreased mobility, incontinence. Interventions: Keep skin clean and dry. Use lotion on dry skin.R32's MDS Section GG Functional Abilities documents: Roll left and right: Substantial/maximal assistance. Section H Bowel and Bladder documents: Urinary Continence: Occasionally incontinent.On 01/20/26 at 11:26 AM, R32 stated, I have not been changed for 14 hours. It was before the pm and night shift changed last night. I am sopping wet; the bed is wet right now and I have an active urinary tract infection. I have been yelling and screaming but they come in and turn off the call light. They are not going to change me because they are passing trays.On 01/20/26 at 11:53 AM, V23 (Licensed Practical Nurse) stated, (R32) is incontinent and told me she had not been changed since last night. The residents are changed when they ask. I asked (V24, Agency Certified Nurse Assistant) and another certified nurse assistant that (R32) wanted to be changed. (R32) said that she had not been changed for over 14 hours when I came in at 08:00 am. I did apologize and said I was sorry (R32) was not changed on the 11 pm- 7 am shift. (R32) said after she eats, she wants her shower.On 01/20/26 at 12:09 PM, R32 asked V23 (Licensed Practical Nurse) and V24 (Agency Certified Nurse Assistant) how would they like to eat your lunch smelling like poop. V24 (Agency Certified Nurse Assistant) left the room then returned with a fitted sheet, towels, an under pad and a diaper. R32 said, I would like to have been changed at 5am. They changed my roommate but did not offer to change me. A strong smell of urine was noted while standing next to R32's bed. V24 stood on the left side of R32's bed. R32 turned to her right side and an under pad and green brief were underneath R32. The green brief was saturated with urine. The white fitted sheet was observed with a brown ring that extending beyond the brief and under pad that was observed beneath R32. V24 was asked was there a brown ring on the white fitted sheet and V24 responded yes. R32 removed the gown, handed it to V24 and said this gown is saturated with urine. V24 took a towel and cleaned R32's buttocks and between R32's legs from behind. V24 removed the fitted sheet from the left upper and lower corners of the mattress then began rolling the white fitted sheet, brief, and under pad under R32, exposing a large wet area observed on R32's mattress. V24 obtained some paper towels from the bathroom then wiped and dried the wet area on the mattress. V24 then applied a clean fitted sheet to the left upper and lower corners of the mattress, put an under pad and brief on top of the sheet, then began to roll it underneath R32. R32 turned to her left side, V24 removed the wet fitted sheet, brief, and under pad from R32's bed then placed the soiled items in a bag. V24 began pulling the diaper between R32's legs and R32 said, you did not clean the front. V24 wet the towel and wiped under R32's abdominal fold then vaginal area with the same towel. R32 said, That (abdominal fold) is where the fungus is and now, you're putting the fugus in the vagina. V24 said, I am agency, and I don't know; I am not going to go back and forth with her, I am going to have someone else come and do you. At 12:16 PM, V24 exited the room. R32 said, I told her (V24) precisely what to do and she did not listen.On 01/20/26 at 12:52 PM, V23 (Licensed Practical Nurse) stated, (V24) told me when (R32) turned, (R32) said 'you are not wiping my private parts properly.' (V24) said that she did not want to argue with (R32), and she (V24) left the room.On 01/21/26 at 02:23 PM, V26 (Certified Nurse Assistant Orientee) stated, The staff said (V24, Agency Certified Nurse Assistant) had problems with (R3) earlier that morning. I was sent in (R32's) room with (V24) for observation. That was the first time that I went in (R32's) room. (V24) was rolling the sheet, and the mattress was wet, so (V24) used some paper towels to dry the mattress because (V24) did not have any wipes.On 01/21/26 at 03:18 PM, V2 (Director of Nursing) stated, My expectations are proper resident care per schedule. To change the residents as necessary and be in compliance with the schedule. Incontinent care and checks are done every 2 hours, but some residents have more frequent incontinence. If a resident is left in urine there is a potential for skin break down and compromised skin. If there is a brown ring on the bed sheet under the resident it can be from stool or old urine.On 01/22/26 at 09:17 AM, per telephone interview, V24 (Agency Certified Nurse Assistant) stated, I made rounds in (R32's) room at 07:30 AM and she said that she needs to be changed but wanted her pain medication before she was changed. (R32) said that she did not want me taking care of her because she did not like the way that I talked to her. I went and told (V23, Licensed Practical Nurse) and told me not to go back in (R32's) room. (V23) said they would have someone else take care of (R32). No one else wanted to take care of (R32), so I went in (R32's) room after 12:00 PM to change her. I did not provide any care or change (R32) before 12:00 PM.Policy:Titled Activities of Daily Living (ADL's) Support Care, Reviewed 02/25, document: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care): c. Elimination (toileting). 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.Titled Incontinence Care reviewed 09/25 documents: Incontinence care is provided to keep the residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. 5. Clean peri area with appropriate cleanser and dry. Cleaning should always be from front to back.Job Description: Job Title: Certified Nurse Assistant (CNA) documents: Job Summary: The Certified Nurse Assistant (CNA) helps patients/residents with comprehensive and personalized health care needs. The CNA assist patients/residents with activities of daily living including bathing, dressing, eating, grooming and toileting. Duties/Responsibilities: Provide physical support for patients/resident's daily activities and personal hygiene. Answers to patient calls and needs.

Based on observation, interview, and record review, the facility failed to provide timely and appropriate assistance with care needs in a timely manner, check and change one (R32) incontinent resident every 2-3 hours, resulting in prolonged exposure to urine/feces.Findings Include:On 01/20/26 at 11:26 AM, R32 stated, I have not been changed for 14 hours. It was before the pm and night shift changed last night. I am sopping wet; the bed is wet right now and I have an active urinary tract infection. I have been yelling and screaming but they come in and turn off the call light. They are not going to change me because they are passing trays.During interview on 01/20/26 at 11:53 AM, V23 (Licensed practical Nurse) stated, (R32) told me she had not been changed since last night. (R32) is incontinent. The residents are changed when they ask. I asked (V24, Agency Certified Nurse Assistant) and (V26, Certified Nurse Assistant Orientee) that (R32) wanted to be changed. (R32) said that she had not been changed for over 14 hours when I came in at 08:00 am. I did apologize and said I was sorry (R32) was not changed on the 11 pm-7 am shift.On 01/20/26 12:09 PM, R32 asked V23 (Licensed practical Nurse) and V24 (Agency Certified Nurse Assistant) how would they like to eat your lunch smelling like poop. V24 (Agency Certified Nurse Assistant) left the room then returned with a fitted sheet, towels, an under pad, and a brief. R32 stated, I would like to have been changed at 5am. They changed my roommate but did not offer to change me. (V24, Agency Certified Nurse Assistant) was the one that was nasty and not helpful. A strong smell of urine was noted when standing next to R32's bed. V24 stood on the left side of R32's bed. R32 turned to her right side revealing an under pad and green brief underneath R32. The green brief was saturated with urine. The white fitted sheet was observed with a brown ring that extending beyond the brief and under pad observed beneath R32. V24 was asked was there a brown ring on the white fitted sheet and V24 responded yes. R32 removed the gown, handed it to V24, and said, this gown is saturated with urine. V24 took a towel and cleaned R32's buttocks and between R32's legs from behind. V24 removed the fitted sheet from the left upper and lower corners of the mattress, then began rolling the white fitted sheet, brief, and under pad under R32, exposing a large wet area observed on R32's mattress. V24 obtained some paper towels from the bathroom, wiped and dried the wet area on the mattress. V24 then applied a clean fitted sheet to the left upper and lower corners of the mattress put an under pad and brief on top of the sheet, then began to roll it underneath R32. V26 (Certified Nurse Assistant Orientee) was observed standing at the foot of R32's bed with her arms folded observing the procedure. R32 turned to her left side, V24 removed the wet fitted sheet, brief, and under pad from R32's bed. V26 exited the room and obtained a plastic bag. V24 placed the soiled items in the bag. V24 began pulling the brief between R32's legs and R32 said, You did not clean the front. V24 said, I did clean the front. V24 asked V26 to retrieve a gown and towels. V24 wet the towel and wiped under R32's abdominal fold then vaginal area with the same towel. R32 said, That (abdominal fold) is where the fungus is and now, you're putting the fugus in the vagina. V24 said, I am agency, and I don't know, I am not going to go back and forth with her. I am going to have someone else come and do you. At 12:16 PM, V24 and V26 exited the room. R32 said, I told (V24) precisely what to do and she did not listen. (V24) is agency and the worse of all of them. The nurse promised they would get someone else, so you are not one on one with (V24). R32 laid in the bed for 10 minutes with the bed in a high position before a staff member entered the room at 12:26 PM to inform R32 he would be taking care of and giving R32 a shower.On 01/21/26 at 03:18 PM, V2 (Director of Nursing) stated, My expectations is proper resident care per schedule. To change the residents as necessary and be in compliance with the schedule. Incontinent care and checks are done every 2 hours, but some residents have more frequent incontinence. If a resident is left in urine there is a potential for skin break down and compromised skin. If there is a brown ring on the bed sheet under the resident it can be from stool or old urine.On 01/22/26 at 09:17 AM, per telephone interview V24 (Agency Certified Nurse Assistant) stated, I made rounds in (R32's) room at 07:30 AM and she said that she needed to be changed but wanted her pain medication before she was changed. (R32) said that she did not want me taking care of her because she did not like the way that I talked to her. I went and told (V23, Licensed Practical Nurse) and (V23) told me not to go back in (R32's) room. (V23) said they would have someone else take care of (R32). No one else wanted to take care of (R32) so I went in (R32's) room after 12:00 PM to change her. I asked that someone else come in the room with me because (R32) had refused for me to take care of her. When (R32) turned on her right side, I cleaned her from front to back. (R32) said I did not clean her properly, so I asked (V26, Certified Nurse Assistant Orientee) to get me some towels and a gown. When I cleaned (R32's) front she said I wiped the fungus from under her stomach to her vagina. I told (R32) I was agency and would get someone else to take care of her then I left the room. I went and told the nurse and (V1, Administrator) that I did not feel comfortable and that I was leaving.Titled Incontinence Care reviewed 09/25 documents: Incontinence care is provided to keep the residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. 5. Clean peri area with appropriate cleanser and dry. Cleaning should always be from front to back.Job Description: Job Title: Certified Nurse Assistant (CNA) documents: Job Summary: The Certified Nurse Assistant (CNA) helps patients/residents with comprehensive and personalized health care needs. The CNA assist patients/residents with activities of daily living including bathing, dressing, eating, grooming and toileting. Duties/Responsibilities: Provide physical support for patients/resident's daily activities and personal hygiene. Answers to patient calls and needs.

Based on observation, interview, and record review the facility failed to a.) label/date food items in resident personal refrigerator, b.) discard undated and expired foods in resident personal refrigerator, c.) ensure resident refrigerator is in proper working order. This has the potential to effect one resident (R45) in a total sample of 28.Findings include:On 01/20/2026 at 11:50 AM, observed R45 with large amount of food around room including along the windowsill. Also observed that he had a personal refrigerator in his room. R45 stated he orders food from Uber Eats on a regular basis and prefers to eat that food to the food served at the facility. R45 stated he is not able to walk and that the staff put the leftover food for him in his refrigerator. R45 stated someone looks inside his refrigerator every other day. He is not sure if anyone checks the temperature of his personal refrigerator and/or if there is a thermometer inside. On 01/20/2026 at 11:52 AM, surveyor asked R45 for permission to look inside his personal refrigerator and he said okay. When surveyor opened R45's refrigerator it felt warm inside. Surveyor located thermometer inside R45's refrigerator which read 60 degrees F. Observed very large amount of ice buildup around freezer compartment of refrigerator. Did not observe temperature log on or near R45's refrigerator. There were a lot of food stains on the inside of the refrigerator.On 01/20/2026 at 11:55 AM, surveyor found the following items inside R45's personal refrigerator:Unopened 2-ounce package of corned beef dated with expiration date 01/06/26 printed on the outside of the packaging.Unopened 2-ounce package of smoked turkey dated with expiration date 01/03/26 printed on the outside of the packaging.Opened 16-ounce bottle of Thousand Island salad dressing not labeled or dated with an open or use by date.Opened package of raw marinated salmon fillets with one fillet missing dated on packaging purchase date 01/17/26 and sell thru date 01/21/26. The surface of the salmon fillet was coated with a slick, wet film that appeared slimy and milky brown in color. The flesh of the salmon appeared soft and mushy. Part of the salmon was stuck to half-gallon container of milk which was laying on top of the opened packaging of raw salmon.On 01/20/2026 at 12:01 PM, V9 (Certified Nursing Assistant/CNA) stated she has been working at the facility for 20 years. V9 stated the night CNAs are supposed to clean out the resident's refrigerators. V9 stated R45 cannot walk so the staff is the one who puts his food in the refrigerator for him. V9 stated the CNAs are not responsible for checking the temperatures of the resident's refrigerators; she does not know who does that. V9 is not sure who labels and dates the food.On 01/20/2026 at 12:03 PM, V7 (Registered Nurse) stated he does not know if the food items in resident personal refrigerators are getting labeled and dated but it should be staff monitoring if items go beyond their expiration date. V7 stated R45 is not the one taking the food items in and out of the refrigerator, the staff is doing that. V7 stated he does not know if any staff are taking the temperature of the refrigerators. V7 observed the thermometer inside R45's refrigerator which now read 64 degrees F and stated that it felt warm inside the refrigerator. V7 stated the temperature of the refrigerator should be 40 degrees or below to prevent food from spoiling and if the temperature is higher than this then the food is not being properly stored which means there is a potential for bacteria to grow in the food and this could cause a food-borne illness if the food item was given to the resident. V7 stated the foods should be labeled and dated so the staff would know when the item should be thrown out.On 01/21/26 at 4:04 PM, V2 (Director of Nursing) stated if a resident has a personal refrigerator in their room the temperature of the refrigerator should be checked every day and documented on a daily log. V2 stated it is the activity staff responsibility to check the temperature of the refrigerator and document the temperature on the log and to make sure all the items inside are labeled and dated. It is housekeeping staff responsibility to clean the refrigerator and defrosting as needed. V2 stated the food items being stored inside the refrigerator should be labeled and dated and it is a shared responsibility between the activity department and nursing (whomever is receiving the food). V2 stated it is important that the temperature is checked to make sure the refrigerator is working properly because if the refrigerator is not being kept at the proper temperature, then food spoils quickly and this could lead to food borne illness if the food is not thrown out before given to the resident. V2 stated it is important for items put into the residents personal refrigerators are labeled and dated to make sure the food items are not expired and given to the resident.On 01/21/2026 at 4:27 PM, V29 (Activity Director) the activity staff is responsible to checking the temperature inside daily and the temperature is documented on a log that is kept in her office so they do not get thrown away. V29 stated refrigerator temperature should be between 35-41 degrees, not higher than 41 degrees. V29 stated it is important for the refrigerator to be the correct temperature, so the food inside does not spoil. V29 stated if the staff notice that the refrigerator temperature is higher than 41 degrees, the staff informs her so she can notify maintenance and they would then go and check the refrigerator to see what is wrong with it. V29 stated the activity staff is not responsible for labeling and dating any of the food, only checking the temperatures. V29 stated she went to see R45's refrigerator yesterday and saw that the thermometer was 60-65 degrees F. V29 stated yesterday, the activity staff had not yet checked his refrigerator yet but the day before it was fine. V29 checked his refrigerator this morning and the temp was 41 degrees; she thinks it is now working again because it was defrosted.On 01/21/2026 at 4:40 PM, V11(Dietary Manager) stated his staff does not have anything to do with monitoring of the resident personal refrigerators. V11 stated all food items in resident refrigerators should be labeled and dated for safety so the staff knows when to throw out food, so the residents do not get sick. V11 stated it is very important for them to check the temperatures because if the refrigerator is not 41 degrees or below that is considered the danger zone which is when bacteria in the food can grow. On 01/22/26 at 8:03 AM, V1 (Administrator) stated the activity department is supposed to be monitoring the resident personal refrigerators and checking the temperatures daily, and monitoring the items for the expiration dates, and cleanliness of the refrigerator. V1 stated they are also responsible for making sure all the items inside are labeled and dated. V1 stated if the activity staff notices an item not labeled and dated, then they should alert nursing. V1 stated whoever is working when the food is put inside the refrigerator or opens an item has the responsibility of labeling and dating it. V1 stated if the temperature of the refrigerator is warm the food is not being stored at the proper temperature and therefore the food could spoil.R45's diagnosis includes but not limited to Paraplegia, Lack of Coordination, Vascular Dementia. R45's Minimum Data Set (MDS) dated [DATE] documents in part, intact cognition and is dependent on staff for chair/bed to chair transfers. Facility provided policy titled, Foods Brought in by Family or Visitors Personal Refrigerators dated [DATE] documents in part, food or beverages brought in by family or visitors may be stored in the client's personal refrigerator, personal refrigerator temperatures are maintained at 41 degrees F or below, refrigerators are cleaned regularly to maintain a safe and sanitary environment for food storage, refrigerated foods that have been opened or left-over foods stored in the refrigerator will be marked with use-by date. The use-by date is six days from the day the food was opened or the day the left-over food was put in the refrigerator, perishable foods are discarded on the sixth day after preparation/opening or on the expiration date.

Based on observation, interview, and record review, the facility failed to place a resident (R143) with wounds on enhanced barrier precautions (EBP). The facility also failed to ensure staff performed hand hygiene during meal tray distribution/feeding for one (R12) resident in a total sample of 28 residents.Findings Include: 1.R12 has diagnosis not limited to Hyperlipidemia, Long Term (Current) use of Insulin, Long Term (Current) use of Oral Hypoglycemic Drugs, Glaucoma, Mild Intellectual Disabilities, Tachycardia, Metabolic Encephalopathy, Chronic Respiratory Failure with Hypoxia, Protein-Calorie Malnutrition, Dementia, Dysphagia, Lack of Coordination, Abnormal Posture, Type 2 Diabetes Mellitus with Hyperglycemia, Anxiety Disorder, Vitamin D Deficiency, Acute Kidney Failure, Anemia, Difficulty in Walking, and Peripheral Vascular Disease. R12's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicate R12 is rarely/never understood. R12's Care Plan documents: Focus: The resident has nutritional problem or potential nutritional problem of inadequate energy intake related to mechanical soft diet, cognitive impairment. Interventions: Provide and serve diet as ordered. Provide, serve diet as ordered. Monitor intake and record q (every) meal. R12's MDS Section GG Functional Abilities documens: Eating: Dependent. 01/20/26 at 12:38 PM, R12 was observed in bed in a semi-Fowlers position. V8 (Certified Nurse Assistant) was asked if R12 needed assistance to be fed and had R12 been fed. V8 stated, yes. V8 was asked to check the food cart for R12's meal tray. V8 began checking the dirty food trays that were placed on the food cart. V8 touched, removed, and read the meal ticket on three of the seven meal trays observed in the food cart. V8 then checked the meal ticket on the top meal tray and said, This is (R12's) tray, I will try to feed (R12). V8 removed the meal tray without performing hand hygiene, entered R12's room and began feeding R12. 01/20/26 at 12:52 PM, V23 (Licensed practical Nurse) stated, (R12) is a feeder, and (V24, Agency Certified Nurse Assistant) was R11's certified nurse assistant. V23 was informed R12's meal tray was in the food cart with six dirty meal trays that were returned to the food cart. V23 stated, They should have told me so I could have called down and gotten (sic) (R12) another tray because that is not policy. I am not sure what could have happened, definitely, cross contamination. On 01/21/26 at 03:18 PM, V2 (Director of Nursing) stated, A residents meal tray should not be on the food cart with dirty trays. Never mix dirty and clean because of contamination. (V8, Certified Nurse Assistant) should have washed her hands and called the kitchen for a new tray because of food contamination. Policy: Titled Standard Precautions reviewed 10/25 documents: Standard precautions are used in the care of all residents regardless of their diagnosis or suspected or confirmed infection status. 1. Hand Hygiene: b. Hand hygiene is performed with ABHR (alcohol-based hand rub) or soap and water (3) after contact with items in the resident's room. Titled Handwashing/Hand Hygiene, dated 08/25, documents: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; o. Before and after eating or handling food; p. Before and after assisting a resident with meals. Titled Food and Nutrition Services, reviewed 11/25, documents: 7. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued. 2.R143's 'admission Record' documents in part diagnosis of open wound to the right lower leg. R143's 'Medication Review Report' (physician orders) contains orders for wound care. No orders for enhanced barrier precautions (EBP). R143's 'Care Plan Report' documents R143 requires enhanced barrier precautions related to presence of blisters and right leg wound. Facility initiated the focus on 1/14/2026. Intervention includes ensuring appropriate signage is present to notify staff and visitors of the necessary precautions (1/14/2026). On 1/20/2026 at 10:56 AM, R143 was oriented to person, place, time, and situation. R143 stated admitted to the facility for wound care to right lower leg. There was no EBP signage posted on R143's door or living area. On 1/20/2026 at 3:11 PM, V3 (Assistant Director of Nursing / Infection Preventionist) provided a list of residents on EBP. R143's name was not on the list. On 1/21/2026 at 2:30 PM, R143's room remained without EBP signage. On 1/21/2026 at 2:35 PM, V6 (Nurse) stated R143 is not on EBP. On 1/21/2026 at 3:29 PM, V2 (Director of Nursing) stated anybody with an open wound should be on EBP. V2 stated R143 should be on enhanced barrier precautions and should have an EBP sign on the bedroom door. Facility's Isolation – Categories of Transmission-Based Precautions policy (Version 2.1) documents: When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room, or in the room by the bedside indicating the type of Precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves.

Based on interview and record review, the facility failed to ensure an allegation of injury of unknown origin was reported to the abuse coordinator and to the State Agency (SA) for 1 (R1) out of 3 residents reviewed for abuse. Findings Include: R1's clinical records show a re-admitted [DATE], with included diagnoses not limited to long term use of anticoagulants, malignant neoplasm of large intestine, cognitive communication deficit, and encounter for attention to colostomy. R1's Minimum Data Set, dated dated [DATE] ,shows R1 was cognitively impaired. R1's comprehensive care plan and progress notes from 4/8/25 to 5/10/25 revealed no documentation of R1's vaginal bruising and bleeding. No documentation of bruising on R1's groin and perineal area. R1's progress notes, dated 4/8/25 and 4/19/25, show R1 was noted with bruising on both lower and upper extremities. On 5/22/25 at 9:33 AM, a phone interview was conducted with V3 (Hospital emergency room Nurse). V3 stated she was the ER (emergency room ) nurse in charge of R1 when R1 was hospitalized on [DATE]. V3 stated a head to toe assessment was completed for R1, and R1 was assessed with bleeding and bruising on her vaginal area. V3 stated she did not know where it was coming from, and R1 could not verbalize what happened. V3 stated she also noted bruising on R1's right thigh from front to back, and around her groin and perineal (peri) area. V3 stated R1 was complaining of generalized pain. V3 further stated, I called the nursing home and spoke to the nurse. I told her that there was bruising noted on [R1's] vaginal area, her right thigh, and around her groin and peri-area. I talked to the nurse who was taking care of [R1] that day. I also notified the nurse of the bleeding noted on [R1's] vaginal area. The nurse told me that she was not aware of the bruising and bleeding on her vaginal and peri-area. On 5/22/25 at 10:25 AM, V4 (Wound Care Nurse/Licensed Practical Nurse) stated R1 got bruising when she was readmitted from the hospital in April. R1 had bruising around her right thigh front and back, her groin area, on her arms, but no bleeding. V4 stated R1 can't really say where she got the bruising from. V4 stated she informed everyone the next day during the morning meeting about R1's bruising. V4 stated she saw R1 on 5/9/25, the day before R1's hospitalization , and V4 did not see bruising or bleeding on her vaginal area. On 5/22/25 at 11:53 AM, a phone interview was conducted with V9 (Registered Nurse). V9 stated she was the nurse in charge of R1, and she sent R1 to the hospital on 5/10/25. V9 stated, When I did my rounds in the morning, [R1] was not herself. [R1] was not at her baseline. [R1] was usually alert and oriented times 2 to 3, but that morning it took a long time for her to respond. I did vitals. I called the doctor. I sent her [R1] out via 911. [R1] went to [acute hospital]. The ER nurse called me, and she wanted to know about the bruising she saw on [R1]. I did tell her that [R1] was puffy and had bruises. A couple of days after her [R1] readmission in April, I saw bruising all over her both arms, some on her both legs front and back, and her thighs. I did not see bruises on the groin. She [R1] had pitting edema, and she's [R1] on Xarelto. The nurse from the ER she said there are bruises all over [R1]. The ER nurse told me that [R1] was found with bruises on her groin and peri-area, and I told her I don't know about that. I don't remember her mentioning about the bleeding on her vaginal area. She called during 3-11 shift. It was probably around before dinner. I don't remember the ER nurse's name. I notified [V2, Director of Nursing] a week after, not immediately though. I told her [V2] about the ER nurse calling the facility asking about [R1's] bruises on her vaginal and peri-area. V9 stated the Abuse Coordinator is the Administrator [V1], and an injury of unknown origin is a type of abuse that should be reported right away. V9 stated bruises can be considered injury of unknown origin if the resident cannot tell what happen. On 5/22/25 at 1:26 PM, V2 (Director of Nursing) stated she did not receive any notification from V9 about the hospital calling the facility that R1 was found with vaginal bleeding and bruises. V2 stated that facility staff is expected to report to the supervisor immediately if they witness or hear any abuse allegation. V2 stated the supervisor will notify V1 (Administrator) to do reporting and further investigation. V2 stated bruising from an unknown source, the facility would investigate and interview staff. V2 stated when R1 was readmitted in the facility in April, V2 received a nursing report from the hospital that R1 had bruising on her arms, bluish discoloration from right hip down to the legs, and upper arms. V2 stated she saw R1 the next day of her re-admission, and R1 had bluish discoloration on right thigh front and back. V2 stated she did not see any bruising or bleeding on R1's vaginal area. V2 stated R1 could not tell what happened to the bruises on her thigh, but R1 said her upper arms were possibly from the needles in the hospital. On 5/22/25 at 1:41 PM, V1 (Administrator) stated based on the facility's abuse prevention policy and procedure, staff must report to V1 immediately if they witness or hear any type of abuse. If V1 is not in the building, report it to the charge nurse. The charge nurse will report to V1. V1 stated the abuse investigation begins immediately. Initial reporting is sent to IDPH (Illinois Department of Public Health) immediately; less than two hours. V1 stated abuse reporting and investigation apply to injury of unknown origin, for example, an unexplained bruising on the resident. V1 stated that final reporting and investigation is done within five days. V1 stated she was notified about R1's bruising on her arms and legs that were found upon re-admission. V1 stated she was not notified about the hospital calling the facility about her vaginal bleeding and bruising. The facility's ABUSE PREVENTION PROGRAM dated 10/24, documents: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. The facility's Abuse Investigation and Reporting dated 12/24, documents: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on interview and record reviews the facility failed to ensure an allegation of injury of unknown origin was investigated for 1 (R1) out of 3 residents reviewed for abuse. Findings Include: R1's clinical records show a re-admitted [DATE], with included diagnoses but not limited to long term use of anticoagulants, malignant neoplasm of large intestine, cognitive communication deficit, and encounter for attention to colostomy. R1's Minimum Data Set, dated dated [DATE], shows R1 was cognitively impaired. R1's comprehensive care plan and progress notes from 4/8/25 to 5/10/25 revealed no documentation of R1's vaginal bruising and bleeding. No documentation of bruising on R1's groin and perineal area. R1's progress notes, dated 4/8/25 and 4/19/25, show R1 was noted with bruising on both lower and upper extremities. On 5/22/25 at 9:33 AM, a phone interview was conducted with V3 (Hospital emergency room Nurse). V3 stated she was the ER (emergency room ) nurse in charge of R1 when R1 was hospitalized on [DATE]. V3 stated head to toe assessment was completed for R1, and R1 was assessed with bleeding and bruising on her vaginal area. V3 stated she did not know where it was coming from, and R1 could not verbalize what happened. V3 stated she also noted bruising on R1's right thigh from front to back, and around her groin and perineal (peri) area. V3 stated R1 was complaining of generalized pain. V3 further stated, I called the nursing home and spoke to the nurse. I told her that there are bruises noted on [R1's] vaginal area, her right thigh, and around her groin and peri-area. I talked to the nurse who was taking care of [R1] that day. I also notified the nurse of the bleeding noted on [R1's] vaginal area. The nurse told me that she was not aware of the bruising and bleeding on her vaginal and peri-area. On 5/22/25 at 10:25 AM, V4 (Wound Care Nurse/Licensed Practical Nurse) stated R1 got bruising when she was readmitted from the hospital in April. R1 had bruising around her right thigh front and back, her groin area, on her arms, but no bleeding. V4 stated R1 can't really say where she got the bruising from. V4 stated she informed everyone the next day during the morning meeting about R1's bruising. V4 stated she saw R1 on 5/9/25, the day before R1's hospitalization , and V4 did not see bruising or bleeding on her vaginal area. On 5/22/25 at 11:53 AM, a phone interview was conducted with V9 (Registered Nurse). V9 stated she was the nurse in charge of R1, and she sent R1 to the hospital on 5/10/25. V9 stated, When I did my rounds in the morning, [R1] was not herself. [R1] was not at her baseline. [R1] was usually alert and oriented times 2 to 3, but that morning it took a long time for her to respond. I did vitals. I called the doctor. I sent her [R1] out via 911. [R1] went to [acute hospital]. The ER nurse called me, and she wanted to know about the bruising she saw on [R1]. I did tell her that [R1] was puffy and had bruises. A couple of days after her [R1] readmission in April, I saw bruising all over her both arms, some on her both legs front and back, and her thighs. I did not see bruises on the groin. She [R1] had pitting edema, and she's [R1] on Xarelto. The nurse from the ER she said there are bruises all over [R1]. The ER nurse told me that [R1] was found with bruises on her groin and peri-area, and I told her I don't know about that. I don't remember her mentioning about the bleeding on her vaginal area. She called during 3-11 shift. It was probably around before dinner. I don't remember the ER nurse's name. I notified [V2, Director of Nursing] a week after, not immediately though. I told her [V2] about the ER nurse calling the facility asking about [R1's] bruises on her vaginal and peri-area. V9 stated the Abuse Coordinator is the Administrator [V1], and an injury of unknown origin is a type of abuse that should be reported right away. V9 stated bruises can be considered injury of unknown origin if the resident cannot tell what happen. On 5/22/25 at 1:26 PM, V2 (Director of Nursing) stated she did not receive any notification from V9 about the hospital calling the facility that R1 was found with vaginal bleeding and bruises. V2 stated facility staff is expected to report to the supervisor immediately if they witness or hear any abuse allegation. V2 stated the supervisor will notify V1 (Administrator) to do reporting and further investigation. V2 stated bruising from an unknown source, the facility would investigate and interview staff. V2 stated when R1 was readmitted in the facility in April, V2 received a nursing report from the hospital that R1 had bruising on her arms, bluish discoloration from right hip down to the legs, and upper arms. V2 stated she saw R1 the next day of her re-admission, and R1 had bluish discoloration on right thigh front and back. V2 stated she did not see any bruising or bleeding on R1's vaginal area. V2 stated R1 could not tell what happened to the bruises on her thigh, but R1 said her upper arms were possibly from the needles in the hospital. On 5/22/25 at 1:41 PM, V1 (Administrator) stated based on the facility's abuse prevention policy and procedure, staff must report to V1 immediately if they witness or hear any type of abuse. If V1 is not in the building, report it to the charge nurse. The charge nurse will report to V1. V1 stated the abuse investigation begins immediately. Initial reporting is sent to IDPH (Illinois Department of Public Health) immediately less than two hours. V1 stated abuse reporting and investigation apply to injury of unknown origin, for example, an unexplained bruising on the resident. V1 stated final reporting and investigation is done within five days. V1 stated she was notified about R1's bruising on her arms and legs that were found upon re-admission. V1 stated she was not notified about the hospital calling the facility about her vaginal bleeding and bruising. The facility's ABUSE PREVENTION PROGRAM dated 10/24, documents: Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in a investigation. For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence or injuries over time. The facility's Abuse Investigation and Reporting dated 12/24, documents: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on interview and record review, the facility failed to notify a resident's state guardian when the resident experienced a change in condition for one (R6) resident out of four residents reviewed for notification of changes in a total sample of six. Findings include: R6's face sheet documents R6 is a [AGE] year-old individual with diagnoses not limited to: dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, schizoaffective disorder, depressive type, and major depressive disorder. R6's Minimum Data Set (MDS), dated [DATE], documents R6 has a Brief Interview for Mental Status (BIMS) of 09 out of 15, indicating R6 has moderately impaired cognition. R6's nurses note, dated 02/27/2025 at 5:44 PM, documents, resident (R6) was observed with a choking episode while eating dinner in the dining room. Resident was unable to swallow or cough out the obstructing food. The nurse on duty performed Heimlich maneuver and cleared her airway. Resident was assessed and noted to be saturating at 89-90% at room air. Supplemental oxygen administered at 2L/minute (liters per minute) via nasal cannula per order. Post oxygen administration, saturation at room air appreciated to 97%. Resident stable at this time and verbally responsive with no discomfort or pain verbalized. Vital signs were stable. No documentation within 24 hours that R6's guardian was notified regarding R6's choking incident and R6's change in oxygen saturation. On 04/10/2025 at 12:03 PM, via telephone, V10 (Registered Nurse) stated he remembers when R6 choked on the food. V10 stated, I was passing medication. The CNA (certified nursing assistant) called me that she (R6) was choking. I went there and noticed that she was struggling, and I performed the [NAME] maneuver. I was able to get the food to come back up to her mouth. She (R6) removed it with her hand when it came up to her mouth. It was like a bun/or something like bread. I checked her vitals and she was desaturating. I administered oxygen to her. When I was monitoring her, her oxygen level was within range. I called her provider. I was not able to reach her, so I notified the in-house Nurse Practitioner. The in-house Nurse Practitioner asked if she was OK, and she was ok. Staff monitored her the rest of the shift, and endorsed it to the next shift. No I didn't reach out, there was a time she kept saying that we shouldn't let people know her business. It wasn't this time, but a time before. V10 stated he was not aware R6 has a state guardian. V10 stated if he would have known, he would have notified the state guardian. On 04/10/2025 at 12:35 PM, V2 (Director of Nursing) states when a resident experiences a change in condition, the nursing staff or nurse on duty are supposed to call the doctor, then notify the resident's family or guardian. V2 stated, A resident unfortunately choking on food is a change in condition or an incident. It should be reported to the resident's family or guardian because they need to know, to let them know that something happened. Give the family or guardian an update and how the resident is doing now. V2 stated the nursing staff usually have around the same day/24 hours to notify the family or guardian of the update. Facility document, dated 05/2024, titled change in a resident's condition or status documents our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. R6's state guardianship document, dated 12/16/2021, documents nursing home protocol office of the public guardian. The nursing home must provide immediate notice to the office of the public guardian on a 24-hour basis regarding hospitalization , incident/accident, consent, and changes in our ward's physical or mental condition.

Based on observation, interview, and record review, the facility failed to provide care according to professional standards and properly label medication that had been open for resident use. These failures affect one (R1) resident out of three residents reviewed for medications. Findings Include: R1's physician order sheet/POS documents the following orders: Baclofen Tablet 10 MG- Give 1 tablet by mouth one time a day for musculoskeletal therapy agents. On [DATE] at 9:54 AM, V3 (Registered Nurse/RN) stated he has begun his medication administration pass already and is about to prepare R1's medications to administer. A medication bingo card was labeled Baclofen 5 mg, with a residents' name torn off of the label. R1's name was handwritten in black marker on the Baclofen medication bingo card. On [DATE] at 10:04 AM, V3 stated there was an issue with R1's Baclofen medication. V3 stated he was the nurse assigned to care for R1 on [DATE], and noticed R1's Baclofen medication was not available in the facility, and for some reason got lost. V3 stated he then called the pharmacy, and the pharmacy informed him R1's Baclofen medication was dispersed on [DATE], and was not due to be refilled until [DATE]. V3 stated later, the DON/Director of Nursing (identified as V2) brought a substitute bingo card with Baclofen medication inside to administer to R1 until R1's Baclofen medication can be refilled on [DATE]. On [DATE] at 10:41 AM, R1 stated the facility informed her her Baclofen medication was not available in the facility. R1 stated she receives a 10 mg tablet of Baclofen, but the facility only had 5 mg tablets. On [DATE] at 3:41 PM, V11 (General Manager of Pharmacy) stated a 30-day supply of R1's Baclofen 10mg medication was dispensed to the facility on [DATE] at 2:40 PM, and signed by a facility staff member. V11 stated R1's Baclofen 10mg medication cannot be refilled at this time because it is too soon to be refilled. V11 stated since a 30-day supply was dispensed, R1's Baclofen 10mg medication should not have run out and should still be available in the facility. On [DATE] at 4:33 PM, V2 (DON) stated she was just made aware today R1's Baclofen 10mg medication was not available in the facility. V2 stated she is now made aware the nurses tried to reorder R1s' Baclofen medication, but it was too soon to be refilled. V2 stated she also just found out the nurses found a medication bingo card consisting of Baclofen 5mg and felt the need to administer this medication to R1 because they did not want R1 to miss a dose of medication. V2 stated she is aware the Baclofen 5mg bingo card has a residents' name torn off the label and R1's' name handwritten on it. V2 stated this is not a professional standard of practice, and nurses are not supposed to borrow medications from one resident and administer it to another resident. V2 stated this should never happen because residents could potentially be given the wrong medication or given expired medication. V2 stated she never supplied the nurses with the Baclofen 5mg medication bingo card to administer to R1. V2 stated she collects a lot of discontinued medication bingo cards and keeps them in her office until the pharmacy arrives to pick them up. Facility policy, dated ,d+[DATE], titled Storage and Labeling of Medications, documents, 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Facility policy, dated ,d+[DATE], titled Administering Medications, documents, 26. Medications ordered for a particular resident may not be administered to another resident

Based on interview and record review, the facility failed to ensure medications were administered as ordered by the residents' physician for one (R1) resident out of three residents reviewed. Findings Include: R1's physician order sheet/POS documents the following order: Ambien Oral Tablet 5 MG (Zolpidem Tartrate) *Controlled Drug*- Give 1 tablet by mouth at bedtime for Sleeplessness. On 03/23/2025 at 10:41 AM, R1 stated she did not receive her Ambien medication for 2 days after returning to the facility from completing her knee surgery at the hospital. R1 stated V2 (Director of Nursing/DON) told her that her Ambien medication was not available, and V2 was in the process of trying to get it. On 03/23/2025 at 3:33 PM, V7 (Registered Nurse/RN) stated when R1 came back from the hospital, R1 was prescribed Ambien, but it was not available. V7 stated she then called the pharmacy and made the DON aware. V7 stated she did not administer R1's Ambien to R1 on 03/05/2025, because it was not available. V7 stated if there is not a check mark documented on R1s' medication administration record/MAR, then it means the medication was not given. On 03/23/2025 at 3:41 PM, V11 (General Manager of Pharmacy) stated a 30-day supply of R1's Ambien 5mg medication was dispensed to the facility on [DATE] at 2:45 AM, and signed by a facility staff member. V11 stated R1's Ambien 5mg medications should have lasted until 03/20/2025. V11 stated the pharmacy received a refill request for R1's Ambien 5mg medication on 03/14/2025. V11 stated R1's Ambien 5mg medication was dispensed to the facility on [DATE] and signed by V10 (RN). V11 stated based on his records, R1 had a sufficient supply of Ambien 5mg medications, and there should not have been any lapses in R1 receiving her Ambien 5mg medication. On 03/23/2025 at 4:11 PM, V8 (RN) stated he did not administer R1's Ambien 5mg on 03/06/2025 because he could not find the medication in the facility. V8 stated if there is not a check mark documented on R1's medication administration record/MAR, then it means the medication was not given. On 03/23/2025 at 4:33 PM, V2 (DON) stated R1 went out for surgery on 02/24/2025, and was readmitted back to the facility on [DATE]. V2 stated she was not sure if all R1's medications were pulled from the medication carts and placed in a bag for pharmacy to pick up. V2 stated she spoke with R1 about her Ambien medication and checked herself, and did not see R1s' Ambien medication in the facility medication cart to administer to R1. V2 stated she is not sure if Ambien medication is kept in the facility emergency box, and did not check to see if it was located inside the emergency box. V2 stated it is important to administer all medications to residents as prescribed by their physician. Record review documents R1 was hospitalized from 02/24/2025 to 03/04/2025. Nursing progress note, dated 03/05/2025, written by V7 (RN) at 9:58 PM, documents, Post Admission Charting: (R1) in a stable condition with no distress noted. Ambien tablet not supplied by pharmacy. Follow up call made to pharmacy and the DON made aware of the update. R1s' medication administration record/MAR documents R1s' Ambien medication was not administered on 03/05/2025 and 03/06/2025. Facility policy, dated 04/2024, titled Administering Medications, documents, 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices as evidenced by food not properly labeled, and food not properly stored. These deficient practices have the potential to affect all 128 residents receiving food prepared for the nursing skilled facility. Findings include: On 12/17/24 at 9:11 AM, during initial kitchen tour with V17 [Dietary Manager], the following items were found in walk-in freezer: Box of turkey [NAME] hot dogs uncovered with no open or discard date. Box of chicken patties uncovered with no open or discard date. Box of chicken leg quarters uncovered with no open or discard date. On 12/17/24 at 9:33 AM, on the clean dish rack, surveyor and V17 observed two cell phones and pair of eyeglasses next to the clean dishes. On 12/17/24 at 9:45 AM, V17 [Dietary Manager] stated, All food items, once removed from the box, the items need to be dated. The food items should have a label with an open date and expiration date. If dietary staff prepare food, not knowing how long the food has been open, it could potentially cause a food born illness. The two cell phones and eyeglasses belong to dietary employees, and personal food items should not be stored in the dietary kitchen to prevent cross contamination. Policy: Documents in part Food Storage dated 2017. -This policy outlines safe food handling and storage practices for the Food and Nutrition Services Department. First in, first out. If taken out of original container, food is tightly wrapped and labeled with the name of the item and the use by date. -Open products that have not been properly sealed and dated are discarded. -Frozen foods can deteriorate in quality the longer they are stored. Frozen food is discarded after three months. Storage of Employee Personal items: Food services employees should not store or keep any personal belongings in the kitchen. Food and nutrition services and employee will store their personal items in the locker room, or another location designated for that use.

Based on interview and record review, the facility failed to initiate a new Level I screen for four (R6, R7, R11, R32) residents reviewed for Pre-Admission Screening and Record Review (PASARR) in a total sample of 26 residents reviewed. Findings include: 1. R11s' Face sheet documents R11 was admitted to the facility on [DATE], with diagnoses not limited to: schizoaffective disorder, bipolar type, major depressive disorder, and bipolar disorder. On 12/18/2024 at 10:30AM, surveyor requests the PASARR screenings for R11 from V1 (Administrator). On 12/18/2024 at 11:00AM, V1 provided R11s' PASARR screenings to surveyor. R11s' PASARR screening, dated 12/18/2024, titled Notice of PASRR Level I Screen Outcome documents to refer R11 to Level II Onsite. There is no documentation to show R11 was referred to the appropriate state-designated authority for a Level I or Level II PASARR evaluation and determination prior to 12/18/2024. 39779 2.R6 was admitted to the facility on [DATE], with diagnoses onset date starting 10/01/13 not limited to Acquired Absence of Right Breast and Nipple, Personal History of Malignant Neoplasm of Breast, Parkinsonism, Hypokalemia, Fracture of Shaft of Right Tibia, Effusion, Right Knee, Cervical Disc Degeneration, Displaced Fracture of Lateral Condyle of Right Tibia, Displaced Fracture of Medial Condyle of Right Femur, Chronic Obstructive Pulmonary Disease, Dementia, Unspecified Severity, with Psychotic Disturbance, Hypertensive Heart Disease, Personal History of COVID-19, Gastro-Esophageal Reflux Disease, Anxiety Disorder, Allergic Rhinitis, Weakness, Limitation of Activities due to Disability, Overactive Bladder, Insomnia, Schizoaffective Disorder and Hypothyroidism. R6's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. R6's Care plan document in part: R6 is being prescribed psychotropic medications r/t (related/to) behavior/mood management, schizoaffective disorder, anxiety disorder, insomnia. R6's Notice of PASRR (preadmission screening and resident review) Level I Screen outcome dated 12/18/24 documents PASRR Level I Review date: 12/18/24. PASRR Level I Determination: Refer for Level II Onsite. Suspected or confirmed PASRR condition(s): (MH) Mental Health Disability. Your health care professional and Maximus completed a Preadmission Screening and Resident Review (PASRR) Level I screen for you. This screen shows that you need a face-to-face Level II evaluation. You need this evaluation because you may have serious mental illness or an intellectual/developmental disability. Reason for Screening: This nursing facility resident has never had a PASRR Level I screen. Level I outcome: Refer for Level II Onsite. Rationale: A PASRR Level II evaluation must be conducted. That evaluation will occur as an onsite/face-to-face. 3. R7 was admitted to the facility on [DATE] with diagnosis onset date starting 10/10/13 with diagnosis not limited to Bipolar Disorder, Vitamin D Deficiency, Peripheral Vascular Disease, Gout, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Anxiety Disorder, Schizoaffective Disorder and Major Depressive Disorder, Recurrent. R7's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. R7'sCare Plan documents: R7 has a history of self-harmful ideation (thoughts) and/or behavior. This appears related to a severe mental illness and poor impulse control. The resident has depression r/t Disease Process Bipolar. 02/27/23 Resident observed punching the nursing desk with right hand, upset about something that happened yesterday. R6 uses psychotropic medications r/t mood/behavior management; dx Bipolar, schizoaffective d/o anxiety disorder, depression. R7's Notice of PASRR (preadmission screening and resident review) Level I Screen outcome, dated 12/18/24, documents: PASRR Level I Review date: 12/18/24. PASRR Level I Determination: Refer for Level II Onsite. Suspected or confirmed PASRR condition(s): (MH) Mental Health Disability. Your health care professional and Maximus completed a Preadmission Screening and Resident Review (PASRR) Level I screen for you. This screen shows that you need a face-to-face Level II evaluation. You need this evaluation because you may have serious mental illness or an intellectual/developmental disability. Reason for Screening: This nursing facility resident has never had a PASRR Level I screen. Level I outcome: Refer for Level II Onsite. Rationale: A PASRR Level II evaluation must be conducted. That evaluation will occur as an onsite/face-to-face. 4. R32 has diagnoses not limited to Long Term (Current) use of Anticoagulants, Hemiplegia and Hemiparesis Following other Cerebrovascular Disease Affecting Right Dominant Side, Anemia, Chronic Kidney Disease, Blind Loop Syndrome, Diverticulosis of Large Intestine, Spondylosis, Atherosclerosis of Aorta, Calculus of Gallbladder, Gastro-Esophageal Reflux Disease, Hyperlipidemia, Insomnia, History of Falling, Interstitial Pulmonary Disease, Contracture of Muscle, Left Lower Leg, Gastrostomy, Dysphagia, Aphasia Following Cerebral Infarction, Major Depressive Disorder, Dementia, Unspecified Severity, with other Behavioral Disturbance, Hypertensive Chronic Kidney Disease, Psychosis, Dry Eye Syndrome of Bilateral Lacrimal Glands, Parkinson's Disease, Contracture of Muscle, Right Lower Leg, and Protein-Calorie Malnutrition. R32's Care Plan documents: R32 has the potential to be aggressive towards staff related to Dementia. R32 is aggressive during care and would scratch staff. R32 uses psychotropic medications r/t (related/to) Behavior/mood management; dx (diagnosis) depression, dementia, Parkinson's disease., hx (history) of behavioral s/s (signs/symptoms) such as pulling GT (gastric tube)/resisting care/spitting/scratching staff; dx insomnia, psychosis. R32's Notice of PASRR (preadmission screening and resident review) Level I Screen outcome, dated 12/18/24, documents: PASRR Level I Review date: 12/18/24. PASRR Level I Determination: Refer for Level II Onsite. Suspected or confirmed PASRR condition(s): (MH) Mental Health Disability. Your health care professional and Maximus completed a Preadmission Screening and Resident Review (PASRR) Level screen for you. This screen shows that you need a face-to-face Level II evaluation. You need this evaluation because you may have serious mental illness or an intellectual/developmental disability. Reason for Screening: This nursing facility resident has never had a PASRR Level I screen. Level I outcome: Refer for Level II Onsite. Rationale: A PASRR Level II evaluation must be conducted. That evaluation will occur as an onsite/face-to-face. On 12/19/2024 at 11:39AM, V10 (Social Services Director) stated she is responsible for completing and submitting the PASARR screenings to the screening agency. V10 stated residents should have a Level I PASARR screening prior to admission or upon admission to the facility. V10 stated a Level I PASARR screening determines if a Level II PASARR screening should be completed. V10 stated if a Level II PASARR is recommended, then the resident is referred for a Level II screening. V10 stated all residents should have a Level I PASARR screening. V10 stated there is no particular reason why the residents' PASARR screenings were not completed Facility Policy, dated 03/2024, titled Admission Criteria documents, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. c. upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

Based on interview and record review, the facility failed to ensure a totally dependent resident requiring a two plus person assist for bed mobility was provided the necessary assistance by failing to obtain help from another staff during resident care for 1 (R3) of 4 residents reviewed for falls. This failure resulted in R3 falling from the bed and sustaining a closed displaced spiral fracture of the shaft of the right humerus. Findings Include: R3 has diagnoses not limited to History of Falling, Polyosteoarthritis, Chronic Pain, Displaced Spiral Fracture Of Shaft Of Humerus, Right Arm, Subsequent Encounter For Fracture With Routine Healing Personal History of Covid-19, Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Acute and Chronic Respiratory Failure With Hypoxia, Acute and Chronic Respiratory Failure With Hypercapnia, Bipolar Disorder, Current Episode Mixed, Severe, With Psychotic Features, Type 2 Diabetes Mellitus With Hyperglycemia, Essential (Primary) Hypertension, Acute Embolism And Thrombosis of Right Popliteal Vein, Anxiety Disorder, Morbid (Severe) Obesity Due To Excess Calories, Hyperlipidemia, Type 2 Diabetes Mellitus With Diabetic Neuropathy, Major Depressive Disorder, Schizoaffective Disorder, Bipolar Type, Chronic Obstructive Pulmonary Disease, Asthma, and Senile Degeneration Of Brain. R3's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12, indicating moderate cognitive impairment. R3's MDS, dated [DATE], documents: Section G Functional Status: Bed Mobility: 4. Total dependence: 3. Two+ persons' physical assist. Transfer: 4. Total dependence: 3. Two+ persons' physical assist. Section H Bladder and Bowel: Urinary continence, 3. Always incontinent. Bowel Continence 3. Always incontinent. R3's Progress note, dated 09/30/2023 at 21:38, documents: During care, staff asked resident to turn to facilitate the diaper change, in the process resident made excessive turn that put half of the body (waist down) on the floor while upper body remains at the edge of the bed and both hands holding on to the rail and cabinet. When asked resident what happened, she said I think I overturned myself and fell out of bed. Staff helped resident back to bed. Assessment made; ROM was compromised on both arms. Reported to physician, order was made to send resident to hospital to rule out fracture. R3's Progress note, dated 10/01/23 at 14:35, documents: Nurses Note Text: Complain of pain to the left and Right arm. Noted with a bruise and swelling on the Left hand. Right arm has a sling. Tramadol administered for pain with fair results. dx (diagnosed ) w (with)/ closed displaced spiral fracture of right humerus; splint/cast intact. - keep arm elevated as tolerated. Pt (patient) has a sling/cast on her right arm; states that she is in a bit of pain, 4/10. R3's Incident Report Form IDPH (Illinois Department of Public Health) Notification, dated of Incident 09/30/23. Time of Incident 07:00 PM, documents: Location of Incident: Resident's room. Resident is alert and oriented, states she overturned herself which caused her to a position placing the lower part of her body (from the waist down) on the floor while the upper body remained on the edge of the bed with both hands holding onto the rail and the bedside cabinet. (R3) was sent to the hospital for further evaluation due to compromised range of motion of both upper extremities. (R3) was seen and examined with diagnosis of closed spiral fracture of shaft of right humerus, initial encounter, closed fracture of right upper extremity, initial encounter. OT (Occupational Therapy) assessment completed, OT intervention 3x/week for 30 days to provide ADL (Activities of Daily Living) retraining. Resident has right arm sling that's worn at all times except during activities and care. Type of accident: Fall. Type of injury: Fracture. R3's Root Cause Analysis, dated 10/01/23, documents: During care staff asked the resident to turn to facilitate diaper change and, in the process, resident made excessive turn. Waist down/half body on floor. Verbalized that she (R3) overturned self and fell out of bed. Root Cause: 1. Overturned during bed mobility task. Most recent documented weight dated 09/05/23 252.0 Lbs. Care Plan documents in part: (R3) is dependent on staff for meeting physical and emotional needs. (R3) has risk for an ADL self-care performance deficit. 10/02/23 Use of right arm sling for right arm pain/numbness. (R3) has limited physical mobility r/t (related /to) Weakness, L (left)/knee pain, DX.(Diagnosis) Asthma, COPD (Chronic Obstructive Pulmonary Disease), 01/14/21 resident reports 2 falls, 1) fell during transfer from bed to w/c (Wheelchair), reports slipped off bed, 2) transfer from w/c to toilet reports slid to floor, 01/21/21 reports fall, with staff assist was lowered to floor during transfer, reports while standing feet started slipping, 07/15/21 lowered to floor during transfer, legs weakened, abrasion R(Right)/upper back, 10/12/21 poor posture, poor positioning when up in w/c, 03/02/22 reports increased weakness, 2/10/23 decreased out of bed participation, caregiver dependency, total assist with ADL, 10/1/23 reports during care, made excessive turn and fell out of bed, sent to ER for evaluation. Intervention: 10/2/23 safety interventions: Staff to educate, review bed mobility support level, x2 staff assist with all positioning status, therapy for screening post fall for any changes, R/arm sling at all times, 04/26/23 safety interventions: x1-2 staff assist with ADL/mobility task, reclining chair, mechanical lift for mobility support, call light, assist rails. After Visit Summary, dated 09/30/23, documents: Diagnoses: Closed displaced spiral fracture of shaft of right humerus, initial encounter. Closed fracture of right upper extremity, initial encounter. Side Rail, Safety Assessment, dated 04/26/23, documents: A. 3. The resident has a history of falls from bed. 4. The resident currently use assist rails for positioning or support. C. 3. Assist rails are indicated for safety to provide barrier to edge of bed. On 10/10/23 at 1:16 PM, V4 (Licensed Practical Nurse) stated, (R3) uses a wheelchair and is incontinent. (R3's) fall from the bed was on the evening shift during patient care. (R3) is a two person assist with her care and uses the mechanical lift to transfer. On 10/10/23 at 1:57 PM, V7 (Certified Nurse Assistant) stated, (R3) is totally dependent, a two person assist with care, turning and repositioning. I was not taking care of (R3) when she fell out of the bed. On 10/10/23 at 2:25 PM, V9 (Certified Nurse Assistant) stated, I was not here when (R3) fell out of the bed. (R3) is sometimes a 1 person assist. Most of the time, I can handle (R3) on my own. We transfer (R3) with a mechanical lift and 2-person assist. I would give that extra push, and assist (R3) with turning. On 10/10/23 at 3:28 PM, V10 (Registered Nurse) stated, (R3) is a two person assist with putting in bed, and supposed to be a two person assist all the time with turning and repositioning. On 09/30/23, I was at the nurse's station, and the CNA (V15, Certified Nursing Assistant) came to me afterwards, telling me that (R3) fell out of the bed when she was giving (R3) care. (R3) was trying to turn, when she was trying to change (R3's) diaper. When I went to assess (R3), she was in bed. (R3's) right arm was warm to touch, swollen, and (R3) complained of pain when I was trying to do an assessment. The back of the two middle fingers on the left hand were bruised. (R3) tried to move the right arm, but she was in pain, so I told her not to move the arm. (R3) was trying to turn, and must have overturned herself, was holding onto the side rail, her upper part of the body was not on the floor, just her bottom part was on the floor. (R3) must have twisted her arm while holding onto the side rail and gotten the fracture. (V15) was in (R3's) room by herself when the incident happened. On 10/10/23 at 4:13 PM, V13 (Certified Nursing Assistant) stated, On 09/30/23, I was there to help (R3) get back in bed. When I saw (R3), the lower part of (R3's) body was out of the bed. I was on my set, and the other CNA said that she (V15) needed help. We looked for a sheet and put (R3) back to bed using the sheet. (R3) was afraid that she was going to hit her head, because of her position, and there was a small drawer between bed one and bed two. The mechanical lift could not go all the way to the floor, so we used the sheet to pull (R3) back in the bed. On 10/10/23 at 4:22 PM, V14 (Certified Nurse Assistant) stated, On 09/30/23, (V15, Certified Nursing Assistant) was assigned to (R3). I was not assisting (V15) to change (R3). (R3) was not on the floor when I went to (R3's) room; (R3) was about to fall out of the bed. (V15) called me to help her, and we went and got (V13, Certified Nursing Assistant) and (V16, Certified Nursing Assistant). When (V15) called me, (R3) was already hanging onto the siderail. (R3) was hanging off the bed, and we used the blanket to pull (R3) back to the bed. (R3) was holding onto the siderail so that she would not fall on the floor. When I was assigned to (R3), I normally do it by myself. Each person normally works with (R3) alone. On 10/11/23 at 9:34 AM per telephone interview, V15 (Certified Nurse Assistant) stated, I was about to provide care for (R3), and I had not started. I was going to change (R3's) diaper; (R3) is incontinent. I don't know why (R3) turned. I was telling her to wait, but it was too late. (R3) is a two person assist with bed mobility. After (R3) fell off the bed, I went to get the nurse. It happened so fast, and I was not able to stop her. I always do two-person assist and always get someone to help me. (R3's) top part of her body was partially on the bed because she was still trying to hold on to the side rail. The bottom part, her knees, were on the floor. (R3) was holding onto the side rail and never let go. The nurse checked (R3) out, and that's when we put (R3) back on the bed. The nurse assisted putting (R3) back to bed. We put the sling under (R3) from the mechanical lift, and used the mechanical lift to put (R3) back in bed. V15 got silent after being told staff that assisted R3 after the fall had a different version of events. V15 stated, I was waiting for (V14, Certified Nurse Assistant) because (V14) was busy. I told (R3) I was about to give her care. I told (R3) to turn, and when (R3) turned, that is when (R3) rolled off the bed. I went to get the nurse, (V10, Registered Nurse), but he was not coming right away. (V10) came in after (R3) was in the bed. (V13), (V14), and (V16) assisted me getting (R3) back in bed. We got (R3) in the bed using a sheet. (R3) is a 2 person assist for all her care. On 10/12/23 at 10:13 AM, V2 (Director of Nursing) stated, My expectations are that the staff follow the plan of care and provide safe care. If the MDS documents the resident is a 2 + person assist for bed mobility, there should be at least 2 people. If more assistance is needed, usually they will ask for help. (V15) was the closest to (R3's) room and (V15) went in by herself. If there were 2 plus persons in the room the fall and injury I think could have been prevented. On 10/12/23 at 10:53 AM, V17 (Physician Assistant) stated, I saw (R3) a couple of times, and I saw (R3) post fall for pain management. For (R3) to move the hand was painful. We kept (R3) on tramadol, but upped the dosage. (R3's) pain level with movement is pretty-high up there, moderate to severe, as expected post fall. (R3) had some bruising on the left hand, had a couple spots on the legs and right hand. (R3) had a decline with the fractured arm. If the MDS indicates that (R3) should be a 2+ person assist with bed mobility, there should have been 2 people providing care for (R3), likely I would agree. If there were 2 people providing care, it could have decreased the potential for a fall. On 10/12/23 at 11:15 AM, V20 (Licensed Practical Nurse/Restorative) stated, (R3) is a fall risk. (R3) has upper and lower body weakness, limitation of the shoulders because of pain. (R3) is a total assist as far as mobility, and the ADL (Activities of Daily Living) part. (R3) is supposed to be a two person assist with turning and repositioning. Because (R3) is obese and has upper and lower body weakness, she has difficulty turning by herself. The two-person assist is in place to help prevent any falls from the bed or injury. (V15) should have had at least 2 people assisting when providing care. Having a two-person assist could have potentially prevented (R3) from falling out of the bed and getting injured. (R3) is not in a regular bed; (R3) is in a full-size bed that is wider than the regular bed. On 10/12/23 at 1:26 PM, V2 (Director of Nursing) stated, When they did the 7 day look back, (R3) required two people assist for care. In-service titled S/P (Status Post) Fall, dated 10/02/23, documents, (R3's) bed mobility level of assist x2 staff and see posted instructions by bed. Policy: Titled Care Plans, Person Centered, reviewed 11/22, documents: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implement it for each resident. Procedure: 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The care planning process will: b. Include an assessment of the resident's strengths and needs. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The interdisciplinary team must review and update the care plan: a. when there has been a significant change and the resident's condition. d. At least quarterly, in conjunction with the required MDS assessment. Titled Falls and Fall Risk, Managing, revised 03/18, documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor, or other lower level, but not as a result an overwhelming external force. Titled Fall Risk Assessment, revised 03/18, documents: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Titled Activities of Daily Living, dated 03/18, documents: 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: b. Mobility (transfer, bed mobility, ambulation, including walking).

Based on record review and interviews the facility failed to ensure one resident in the sample (R10) received adequate supervision and assistance to prevent falls with injury. R10 sustained 2 unwitnessed fall that both resulted in fractures of the nose, right humerus, right hip, facial contusion and facial laceration. Findings include: R10 is a [AGE] year old resident with [DIAGNOSES REDACTED]. R10 has a history of falls. On 1/18/11, R10 was noted seated in the 2nd floor dining room waiting for lunch. R10 is non verbal, confused and has to be fed by staff. Review of the nurse's notes dated 5/21/10 at 6:55am, the nurse was called by the CNA (certified nurse's aide). R10 was observed on the floor in a sitting position. R10 complained of pain to the right foot. At 4pm, R10 still complained of pain to the right leg. Upon assessment the right knee, area was swollen and the right leg externally rotated and tender to touch. physician's orders [REDACTED]. R10 was admitted to the hospital with [REDACTED]. On 7/17/10 at 7:20am, R10 was observed by a CNA in a sitting position on the floor in the bathroom. Review of the care plan does not show this fall incident was addressed nor that new goals and approaches were developed. On 7/26/10 at 4:00am, R10 was observed sitting on the floor in the middle of the room with stains of blood. The bed alarm was still intact but detached from her gown. Upon assessment R10 sustained a 1.2cm skin cut to the nose bridge with minimal bleeding. R10 complained of pain to the right arm. physician's order [REDACTED]. R10 was admitted to the hospital with [REDACTED]. Review of the significant change in status MDS (minimum data set) assessment dated [DATE] indicates in the area of transfer scored 4/3 which indicates total dependence/2 person physical assist. Review of the care plan does not show individualized interventions for R10. There were no assessments or reassessments noted in R10's clinical record after each fall incident. On 1/25/11 at 3:15pm E2 (director of nursing) stated, "Fall assessments are done upon admission, 3 months, readmission or after a significant change. Staff is told that every resident, especially those on psychotropics are on fall precautions." There were no fall reassessments noted in R10's clinical record after the hospital readmissions in May 2010 and July 2010.

Based on record review, resident and staff interview, the facility failed to provide an accident-free environment by failing to ensure the safe operation of 1 resident's closet door, for 1 (R1) of 3 sampled resident's; this failure resulted in R2's closet door falling off and onto R2's foot, causing a fracture and hospitalization , as evidenced by the following: Findings include: On 10/13/10, R2 was interviewed, and she stated that back in June, she was in her wheelchair next to her closet and one of the closet doors fell off and onto her right foot, causing a fracture. She stated her right 2nd and 3rd toes were injured, and she required admission to the hospital and surgery. On 10/13/10, E1 (Admin) was interviewed, and stated that she was aware of the incident in which R2's closet door fell off. She stated that they investigated, and she believed the cause was felt to be a problem with the track the door slid in; she stated that their maintenance man purchased a new track and installed it. They also checked all other closets, and replaced a few other tracks. Review of Investigation note by E2 (DON) dated 6/3, reflects the following, "...according to R2, the closet door fell on her right foot while she was opening the closet door. .." Review of nursing notes dated 6/2/10 reflect the following, at 5:00 pm, "...screaming in bedroom due to severe pain to right foot. Observed with 1 1/2 cm cut to 2nd toe underneath with minimal bleeding noted. Pressure applied. ..." the note goes on to indicate that R2's physician was contacted and R2 was transferred to the emergency room for evaluation. At 10:30 pm, a nursing notes reflects that R2 was admitted to the hospital with a [DIAGNOSES REDACTED]. According to nursing notes, she returned to the facility with a dressing on her right foot and a boot in place. Nursing notes reflect she required multiple doses of pain medication to control her foot pain. Review of R2's 7/26/10 MDS (Minimum Data Set) reflects that R2 has impaired cognition, scoring a 2 for cognitive skills. It also reflects that R2 requires some level of staff assistance for all her ADLs. During a telephone interview with E5 (LPN) on 10/18, E5 stated that she was the nurse caring for R2 on 6/2, and she recalled the incident of the closet door falling. She stated that she came on duty at 3:00pm, and first saw R2 around 3:15, and R2 was in her wheelchair. She next saw her in her room around 4:14 for medication pass. Around 5:00pm, a CNA told her that there had been an incident with R2 and the closet door, and when she went to assess R2, she found her seated in her wheelchair right next tot he closet, complaining of severe toe pain. She saw some bleeding from one of her toes. One of the closet doors was off its track and leaning against the closet. She assessed R2, helped her to bed, cleansed the area, contacted R2's physician and after administering pain medication, transferred her to the hospital for evaluation. She learned the next day that R2 had sustained a fracture of her foot. On 10/13, E3 (maintenance) was interviewed, and he stated that he recalled the closet door falling on R2, and he was the person who repaired the door after it fell off. He was not aware of a problem with the door before it fell . He replaced the track and rollers to the door. He also checked the closets in all the rooms, and wound up replacing a few other tracks. Prior to this incident, he was doing random room checks, but only checked or worked on a closet door if he was aware of a problem or if someone reported a problem to him.