Every finding on record at Winston Manor CNV & Nursing

Based on observation, interview, and record review, the facility failed to implement measures to minimize hazards and reduce risks associated with the facility's non functioning elevator. Staff interviews indicated the facility did not consistently train staff on the proper use of assistive devices and on the facility's emergency evacuation procedures. This lack of training is necessary to prevent accidents and to ensure that residents-particularly those who use wheelchairs-were adequately prepared for evacuation while the elevator remained inoperable. This failure has the potential to affect fourteen residents (R4, R5, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19) residing in the facility. This is placing residents at increased risk of injury and unsafe evacuation conditions.Findings include:On 08/04/2026 at 10:26 AM, the elevator in front of the receptionist office with document that read out of service elevator. This elevator is currently out of service. Do not use. This surveyor pressed the elevator, and the button did not turn on, or the elevator did not open.On 08/04/2026 at 12: PM, V2 (Director of Nursing) stated the facility also has a chair that can be used to transport residents down the stairs. V2 reported that the facility purchased it on Monday, August 3rd, 2026.On 08/05/2026 at 9:37 AM, 2 (Director of Nursing) stated the freight elevator has not been operational at any time during her employment at the facility, which began in 2009. V2 stated the only elevator in use was the one located in front of the receptionist's office, and that elevator is currently not functioning.On 08/05/2026 at 10:18 AM, observed the stairs chair in the administrator's office. On 08/05/2026 at 10:19 AM, an 'Out of Order' sign was still posted on the elevator in front of the receptionist office. The elevator button was pressed, and no indicator light turned on.On 08/05/2026 at 10:26 AM, while on the smoking patio, no wheelchair bound residents were observed.On 08/05/2026 at 12:50 PM, with V4 (Certified Nursing Assistant), the freight elevator did not appear to be operational. V4 pressed the elevator button, and the indicator light did not turn on. V4 stated the elevator does not open, is sealed, and is not used by staff or residents.On 08/06/2026 at 12:31 PM, V12 (Registered Nurse/agency nurse) stated residents who are non ambulatory would be moved to the stairwell and positioned behind the banister in the designated safety evacuation area. V12 stated, Hopefully we can get assistance from EMS (emergency medical services) to come and get them. V12 stated she is not aware whether the facility has a stair chair. On 08/06/2026 at 10:37AM, V9 (Medical Director) stated it is important for staff to be familiar with the emergency evacuation plan because V9 is not present in the facility to assist with moving residents to the stairwell; this responsibility falls on the nurses and nurse aides. On 08/06/2026 at 9:51 AM, V13 (Certified Nursing Assistant) stated that for residents who use wheelchairs, two staff would assist the resident down the stairs while another staff member would bring the wheelchair downstairs separately. V13 stated they have not yet encountered a situation requiring such an evacuation, but she is pretty sure it would be two people helping them downstairs. V13 reported she has not received any training related to the elevator being out of service. When asked when she last received emergency preparedness training, V13 stated the facility conducted a fire drill last week. She stated all residents were instructed to return to their rooms and close their doors, and all items were removed from hallways. She stated the facility did not review evacuation procedures during that drill. On 08/06/2026 at 10:05 AM, V14 (Certified Nursing Assistant) stated that in the event of an emergency evacuation, the only plan she is aware of involves using the stairways or, if necessary, the windows carefully. V14 stated the facility recently obtained a lifting device, but she has not yet been trained on its use. V14 stated an emergency can occur without warning, and if staff are not trained on the equipment, including themselves, it poses a risk to residents because they may not be evacuated safely. She stated, Honestly, I wouldn't feel safe if the staff is not fully trained. V14 stated she does not know which residents should be evacuated first. On 08/06/2026 at 10:12 AM, V15 (Certified Nursing Assistant) stated she has not received training in emergency preparedness or evacuation procedures. She reported no additional training has been provided since the elevator became nonfunctional. V15 stated she does not know what equipment would be needed for wheelchair bound residents who cannot stand and stated she does not believe the facility has a stair chair.On 08/06/2026 at 10:22 AM, V16 (Registered Nurse/agency nurse) stated she did not know whether the facility had a ramp and was not aware that the building has only stairways. V16 stated she has not received any emergency preparedness or evacuation training from the facility. On 08/06/2026 at 10:29 AM, V17 (Psychosocial Rehabilitation Director) stated it is the staff's responsibility to ensure resident safety, especially because some residents may not be fully coherent or aware of what is happening during an emergency. She stated she would collaborate with activities staff, smoking monitors, social services, housekeeping, management, and the nursing department, particularly CNAs, during an evacuation. V17 stated it is important for all these staff members to know the procedure.On 08/06/2026 at 12:19 PM, V18 (Licensed Practical Nurse) stated that for residents who use wheelchairs, staff would use some type of safety chair designed to assist residents down the stairs. V18 stated she received training on this device about a week ago but could not recall the exact date. She stated the chair was purchased last week. Facility document dated 07/27/2026- 08/06/2026 documents in part, elevator outage incident log. Facility document dated 07/31/2026 documents the list of residents on wheelchairs. It documents a total of fourteen residents (R4, R5, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19). R4's minimum data set section G assessment dated [DATE] documents in part, R4 uses a wheelchair and/or scooter.R5's minimum data set section G assessment dated [DATE] documents in part, R5 requires supervision or touching assistance for chair/bed-to-chair transfer. R8's minimum data set section G assessment dated [DATE] documents in part, R8 requires supervision or touching assistance for chair/bed-to-chair transfer. Facility document dated 07/29/2026 documents in part, emergency preparedness plan. The facility will have a policy and procedure to address natural and man-made emergency that may potentially affect the individual facility. These policies will outline safe evacuation which would include standards addressing consideration of care and treatment needs of the evacuees; staff responsibilities; transportation; identification of evacuation locations; and primary and alternate means of communication with external sources of assistance.Facility document dated August 2025 documents in part, this facility prepares for evacuations well in advance of a crisis or disaster situation requiring partial or complete evacuation, regardless of whether the evacuation is planned or spontaneous.Evacuate residents based on the following priority:1.Residents in immediate danger. 2.Ambulatory residents. 3.Residents requiring one-person assistance. If residents must be moved down stairs:1.Use evacuation chairs for wheelchair users whenever available. 2.Use evacuation sleds or mattresses for non-ambulatory residents. 3.Assign a minimum of two trained staff members per resident when using evacuation equipment. 4.Never attempt to carry residents down stairs unless there is an immediate life-threatening danger and no safer alternative. All staff should receive annual education and hands-on practice on: Horizontal and vertical evacuation procedures. Operation of evacuation chairs and sleds. Resident prioritization during emergencies. Accountability procedures. Incident Command System roles. Regular evacuation drills that include a simulated elevator outage help ensure staff are prepared to safely evacuate residents when elevators cannot be used.

Based on observations, interviews, and record reviews, the facility failed to ensure reasonable accommodation of resident needs and preferences for three residents (R4, R5, and R8) out of six residents reviewed for accommodation of needs in a total sample of 19. Since July 27, 2026, the facility's non functioning elevator has prevented these residents from going outside to smoke, resulting in unmet resident preferences and a decline in their psychosocial well being. The residents reported feeling sad and restricted because they were unable to go downstairs, go outside, and smoke while the elevator remained inoperable.Findings include:On 08/04/2026 at 10:26 AM, the elevator in front of the receptionist office with document that read out of service elevator. This elevator is currently out of service. Do not use. This surveyor pressed the elevator, and the button did not turn on, or the elevator did not open.On 08/04/2026 at 10:56 AM, R4 was sitting on a wheelchair, alert, oriented, and Spanish speaking. R4 stated that he is currently unable to go outside to smoke due to a malfunctioning elevator. R4 expressed strong dissatisfaction with his current living situation, stating, I don't like it here, I feel bad. He shared that he deeply enjoys going outside to watch and pet dogs walked by community members near the smoking area. R4 noted that he misses his four pitbulls back home in Puerto Rico and explained that the current inability to smoke and access the outdoors is causing him to feel sad and depressed. On 08/04/2026 At 11:10 AM, R5 was seated in a wheelchair, alert, oriented, and primarily Spanish speaking. R5 stated she has not smoked since the elevator stopped working. She reported, They told me I can't go down. R5 expressed that this made her feel very sad because she enjoys being outside and getting fresh air. She stated she used to go outside every day to smoke. R5 also reported that she likes to eat in the first floor dining room but has not been able to due to the nonfunctioning elevator. On 08/04/2026 at 12:42 PM, R8 was observed sitting in a wheelchair in the second-floor dining area. R8 was alert and oriented. R8 stated the elevator was broken and reported that he is a smoker. R8 stated that when the elevator stopped functioning, he had to crawl up the stairs. R8 stated he had been getting sleepy and needed to use the bathroom to urinate and defecate. R8 denied sustaining any injuries and stated staff assisted him in obtaining his wheelchair once he reached his floor. R8 stated his preference would be to use the elevator. R8 reported he feels safe in the facility and denied any concerns of abuse.On 08/04/2026 At 10:31 AM, V4 (Certified Nursing Assistant) stated if V4 was a resident, I (V4) would feel bad, after so long, I (V4) wouldn't want to be stuck here. On 08/04/2026 at 12: PM, V2 (Director of Nursing) stated residents who are non ambulatory may experience psychosocial distress when the elevator is not functioning, as they are unable to freely move between units. On 08/05/2026 at 12:50 PM, with V4 (Certified Nursing Assistant), the freight elevator did not appear to be operational. V4 pressed the elevator button, and the indicator light did not turn on. V4 stated the elevator does not open, is sealed, and is not used by staff or residents.On 08/06/2026 at 12:31 PM, V12 (Registered Nurse/agency nurse) stated the nonfunctioning elevator affects non ambulatory residents who smoke, emotionally, because they look forward to smoking, having a change of scenery, and accessing the dining room downstairs. She stated residents are used to using the elevator freely. V12 stated, I would say it is a ticking bomb because most of them utilize smoking as a coping mechanism, and when they cannot use that coping method, they can have auditory outbursts because they cannot go smoke.On 08/06/2026 at 12:19 PM, V18 (Licensed Practical Nurse) stated residents must use the stairs, which is particularly challenging for those in wheelchairs because they must eat upstairs and participate in activities upstairs. She stated the situation could cause mental harm, explaining residents may feel trapped or feel they have limited mobility. On 08/05/2026 at 1:04 PM, V10 (smoking monitor) stated the wheelchair bound residents that are smokers cannot smoke until the elevator gets fixed. V10 stated the outcome could be that the residents will be upset about it because it is a habit of them. V10 stated he spoke to R5 and R5 just stated that she wants to smoke, and she feels upset about it. In the mornings when I go clock in, when she sees me, she calls me out, and she says that she wants to smoke, and asks what is happening, and I tell her she can't. She has an upset face.On 08/06/2026 at 10:05 AM, V14 (Certified Nursing Assistant) stated the facility recently obtained a lifting device, but she has not yet been trained on its use. ON 08/05/2026 at 1:16 PM, V11 (smoking monitor) stated that since the elevator is broken, we cannot let the residents who use wheelchairs smoke until the elevator is fixed. V11 stated R8 suggested to V11 for R8 to smoke on the unit but V11 stated he said no. On 08/06/2026 at 2:18 AM, V17 (Psychosocial Rehabilitation Director) stated the facility would use the seated evacuation device ( the little chair) to assist residents outside if needed. She added that if a resident became extremely upset, staff would need to take the resident downstairs. V17 stated R4 has not reported concerns to her, and staff have not reported concerns to her. V17 stated she has not heard any reports of R5 becoming agitated due to not being able to smoke. She stated CNAs should report to her if residents become agitated because they are unable to smoke.V17 described R8 as calmer and stated she does not believe R8 would become upset or agitated due to not being able to smoke. V17 also stated that when residents feel desperate, they may attempt to find ways to bring cigarettes into the building. V17 stated she plans to bring the issue to the administrator to determine whether there is a plan in place to allow residents to smoke, noting it would require a collaborative effort and could not be handled by her alone. V17 stated R8 is also a smoker and uses a wheelchair for mobility. She described R8 as calmer and stated she does not believe R8 would become upset or agitated due to not being able to smoke. V17 stated the impact of smoking cessation varies by residents. She stated some residents may experience significant distress or depressive symptoms, while others may be only mildly affected.Facility document dated 07/27/2026- 08/06/2026 documents in part, elevator outage incident log. R4, R5, and R8 are listed on the facility's smoking log. Facility document dated 07/31/2026 documents in part, R4, R5, and R8 are on the list of residents on wheelchairs. R4's current face sheet documents R4 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: schizoaffective disorder, major depressive disorder, single episode, unspecified, violent behavior. R4's MDS/Minimum Data Set, dated [DATE] documents that R4 has a BIMS/Brief Interview for Mental Status score of 13/15, indicating that R4 intact cognitive response.R4's care plan documents in part, R4 has has a physical and psychological addiction to nicotine /smoking, has been provided education on the importance of engaging in safe smoking practices, on smoking cessation, and the negative health consequences associated with smoking. Despite this, the resident has expressed to continue to engage in smoking and has been included in the facility smoking program. R5's current face sheet documents R5 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: unilateral primary osteoarthritis, schizophrenia, other bipolar disorder, obesity, heart failure. R5's MDS/Minimum Data Set, dated [DATE] documents that R5 has a BIMS/Brief Interview for Mental Status score of 12/15, indicating that R5 has moderate cognitive impairment. R5's care plan documents in part, R5 has a physical and psychological addiction to nicotine/smoking and has a smoking routine that if interrupted may result in physical and psychosocial/behavioral disturbances. R8's current face sheet documents R8 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: schizoaffective disorder, acquired absence of left leg below knee, acquired absence of right leg below knee, bipolar disorder.R8's MDS/Minimum Data Set, dated [DATE] documents that R8 has a BIMS/Brief Interview for Mental Status score of 14/15, indicating that R8 has intact cognitive response.R8's care plan documents in part, R8 is a smoker and expresses the desire to smoke at this facility. 10/26/25 Compliant with smoking policy. 12/26/25 Remain compliant with smoking policy. no plans of quitting smoking at this time as claimed. Facility document dated October 2025 documents in part, our facility provides psychosocial-related social services to ensure that each resident can attain or maintain his/her highest practicable mental, or psychosocial well-being. 2.Factors that have a potentially negative effect on psychosocial functioning include:problems in coping with grief;disability or loss of function;presence of a progressive, chronic disabling condition (i.e., multiple sclerosis, chronic obstructive pulmonary disease, Alzheimer's disease, mental illness);incompatibility of roommate;behavioral problems (i.e., confusion, anxiety, loneliness, depressed mood, anger, fear, wandering, psychotic episodes);3. The social services department is responsible for:b. identifying individual social and emotional needs;c. assisting in providing corrective action for the resident's needs by developing and maintaining individualized social services care plans;d. maintaining regular progress and follow-up notes indicating the resident's response to the plan and adjustment to the institutional setting. Facility document dated 01/2025 documents in part, resident rights. Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence;b. be treated with respect, kindness, and dignity;e. self-determination;f. communication with and access to people and services, both inside and outside the facility;g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States;h. be supported by the facility in exercising his or her rights;exercise his or her rights without interference, coercion, discrimination or reprisal from the facility.

Based on observations, interviews and record review, the facility failed to ensure proper and sanitary storage and handling of clean linen and resident's laundry in the facility's laundry room in the way to prevent cross-contamination and infectious agents spreading and failed to follow facility's Infection Control and Prevention policy. These failures have potential to affect all 139 residents residing in the facility. Findings include:On 6/22/2026 at 9:30 AM, facility's presented Census documents 139 residents residing in the facility.On 6/22/2026 at 1:10 PM, observed the facility's laundry room with V5 (Housekeeper) who stated that V5 was covering for the laundry aide who on vacation. Observed Facility's laundry room being a shared room, one side was considered clean laundry area, and the other side soiled, washing area. The two areas were observed to be separated by a visible line on the floor of the laundry room; no other separation device or mechanism was observed.Observed the following on the clean side of the laundry room:A plastic bag with soiled residents' clothing inside laying on the floor of the clean side of the laundry room.A trash can bin on the floor of the clean side of laundry room next to the dryers.Observed folded, clean linen (Blankets, bed sheets, towels, pillowcases and gowns) stored on the linen cart, not covered and exposed to potential infectious agents.Observed folded, clean linen (Blankets, towels, pillowcases and gowns) stored on the bottom shelf of the folding table (approximately 2 inches from the ground), not covered and exposed to potential infectious agents.Observed the bottom shelf of the folding table covered with heavy dust particles and the shelf had brown, rusty stains right next to the clean, folded blankets.Observed underneath the whole bottom shelf of the folding table with heavy dust and dirt particles.On 6/22/2026 at 1:12 PM, V5 (Housekeeper) stated that the facility does not have additional laundry area or a laundry chute, and that the laundry room is separated only by the visible line on the floor. V5 stated that the area to the right of the separation line is considered soiled, washing area and the area to the left of the separation line is the clean side of the laundry room. V5 stated that the plastic bag with soiled resident's clothing should not be on the floor of the clean side of the laundry area. V5 stated that there should be nothing soiled or dirty stored on the clean side of the laundry room to prevent cross-contamination.On 6/23/2026 at 10:27 AM, observed facility's laundry room with V17 (Laundry Aide).Observed the following on the clean side of the laundry room:A trash can bin on the floor of the clean side of the laundry room next to the dryers.Observed folded, clean linen (Blankets, bed sheets, towels, pillowcases and gowns) stored on the linen cart, not covered and exposed to potential infectious agents.Observed three outdoor jackets (two black and one brown) hanging on two sides of the linen cart with the stored clean linen, directly touching clean blankets, sheets, pillowcases, towels and gowns. One black jacket was hanging on the left side of the linen cart, and the other two jackets were hung on the right side on the linen cart. Each of the jackets were directly touching the stored, clean linen.Observed three clean linen bins used for transportation of the clean linen in the clean area of the laundry room. Observed a black lunch box inside of one of the clean linen bins.Observed two plastic bags with residents' clothing on the floor of the clean side of the laundry room, next to the folding table. On top of the two plastic bags, observed a blue hoodie sweatshirt, not in the bag, touching the wall. The wall that the blue hoodie sweatshirt was touching was observed to be covered with brown stains.Observed on top of the folding table, a gray towel, folded, not covered, touching the wall that had brown stains observed on the wall.Observed folded, clean linen (Blankets, pillowcases and gowns) stored on the bottom shelf of the folding table (approximately 2 inches from the ground), not covered and exposed to potential infectious agents.Observed the bottom shelf of the folding table covered with heavy dust particles and the shelf had brown, rusty stains right next to the clean, folded blankets.Observed underneath the whole bottom shelf of the folding table, heavy dust and dirt particles and empty plastic water bottle.On 6/23/2026 at 10:45 AM, V17 (Laundry Aide) stated that there should not be a plastic bag with soiled clothing, or the trash can bin on the floor of the clean side of the laundry room. V17 stated that the black outdoor jacket on the left side of the clean linen cart belongs to V17, and the other two jackets belong to other staff members but was not sure which ones. V17 stated that V17's jacket and the other two jackets are not considered clean and should not be hanging on the clean linen cart touching the clean linen because the staff jackets could potentially transmit infectious agents to the clean linen that residents will use. V17 stated that all stored clean linen should be covered and stored in the way to prevent contamination and that the current way that the facility is storing clean linen does not prevent cross-contamination or infectious particles spread. V17 also said that the black lunch bag found inside of the clean linen bin belongs to V17 and should not be placed inside of the clean linen bin. V 17 said that V17's lunch box could have potential infectious particles on it and the clean linen bin should be properly cleaned. V17 stated that the clean linen bin should be wiped with a towel and water, V17 did not state that disinfectant agents should be used to properly clean the linen bin. V17 also stated that the staff has a break room available for storage of jackets and lunch boxes but is located on the far opposite side of the laundry room and it is too far to walk. V17 also said that V17 is not sure who put the plastic bags with residents' clothes on the floor next to the folding table, but the bags should not be on the floor of the clean side of laundry room, and the blue hoodie should not be uncovered and touching the stained wall. V17 also said that the folded, clean towel that was placed on top of the folding table should not be touching stained wall and that the bottom shelf of the folding table with the uncovered clean linen stored, should be properly cleaned and all the clean linen covered. V17 agreed that V17 would not want to use the pillowcase stored on the dirty bottom shelf underneath the folding table, because it could contain microorganisms or bacteria and could potentially cause infection spreading.On 6/23/2026 at 10:56 AM, V6 (Laundry and Housekeeping Supervisor/Director) walked in the laundry room and observed the clean and soiled areas of the facility's laundry room. V6 stated that the visible line on the floor separates the clean from dirty sides of the laundry room and that soiled clothing, and linen should be only on the soiled side of the laundry room. V6 said that a plastic bag with soiled clothing should not be on the floor of the clean side of the laundry room. V6 said that trash bin should be on the soiled side and not the clean side of the laundry room to prevent cross-contamination. V6 said that there should be no staff lunch box stored inside of the clean linen bins and that whole bin should be cleaned with disinfecting cleaner and wipe down properly. V6 also affirmed that employees' outdoor jackets should not be hanging on the clean linen carts and should not be touching stored clean linen. V6 said that clean laundry and linens should be stored separately from soiled laundry and should be covered at all times to prevent infection spread and cross contamination. V6 affirmed that clean linen and laundry should not be stored on the dirty shelf or be touching stained wall and that the whole clean side of the laundry area should be properly cleaned and disinfected including underneath the folding table. V6 also said that V6 would not want to use clean linens that were stored on the dirty shelves. V6 stated that V6 has to provide more education for the housekeeping and laundry staff about the proper storage and handling of clean laundry and linens.On 6/23/2026 at 11:46 AM, V18 (Infection Preventionist/IP/Consultant) stated that in the laundry room, the clean laundry and linen should be always separated from the soiled laundry and that the clean laundry side should not contain trash bin containers or soiled clothes on the floor. V18 also said that all clean and folded linen stored in the clean laundry areas should be covered at all times to prevent contamination. V18 affirmed that employee's outdoor jackets should not be hanging on the clean linen carts touching the clean linen, because the jackets could cause potential contamination of the clean linen that is used for all residents in the facility. V18 also affirmed that clean linen bins used for transportation of clean linen should not contained employee's lunch boxes because of possible cross contamination and should be properly cleaned and disinfected. V18 also affirmed that the clean area of the laundry room, including the walls, folding table, the shelf and area underneath the folding table, should be routinely cleaned and should not contain thick dust particles or stains and the clean linen should not be stored on top of the dirty surfaces. V18 also said that clean, washed and folded resident clothes should be stored inside of clear plastic bag and should not be on the floor or uncovered and touching a stained wall. V18 said that if the facility's clean linen is stored inappropriately, it could cause potentially risk to all residents and cause infection spread, because all residents use the facility's sheets, blankets, gowns, towels and pillowcases. V18 stated that V18 will have to provide further education to staff on proper storage and handling of the facility's and resident's laundry services. On 6/23/2026 at 11:50 AM, V2 (Director of Nursing/DON) agreed that clean laundry and linens should be stored appropriately and should not be contaminated with soiled laundry, employee's jackets, lunch bags, dust or stains and that all clean and folded linen should be covered at all times to prevent cross-contamination and infection spreading.Facility's Document titled Departmental (Environmental Services)-Laundry and Linen , (9/1/2024), showed in part that purpose is to provide for safe and aseptic handling, washing, and storage of linen and that all soiled linen should be considered potentially infectious and be handled with standard precautions. Policy also showed in part that the soiled and clean linen should be kept separate at all times and that clean linen should remain hygienically clean (free of pathogens) through measures designed to protect it from environmental contamination such as covering clean linen carts.Facility's document titled Infection Prevention and Control Program, (9/1/2024), showed in part that infection prevention and control program should be established and maintained to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy also showed in part that important facts of infection prevention include but are not limited to identifying possible infections or potential complications, educating staff and ensuring that the staff adhere to proper techniques and procedures and following established general and disease specific guidelines.Facility's document titled Infection Control (Standard Precaution), (Undated), showed in part policy statement that standard precautions presume that all blood, body fluids, secretions and non-intact skin and mucous membranes could contain transmissible infectious particles and that standard precautions apply to the care of all residents in all situations no matter if suspicion or confirmation of presence of infectious disease. Policy also showed in part in number seven that linen should be handled to prevent contamination and transfer of microorganisms.Facility's document titled Laundry Aide Job Description, (Undated), showed in part that the laundry Aide is responsible for ensuring that all resident linens, clothing, and facility laundry are properly cleaned, sanitized, folded and returned and to maintain cleanliness and support the overall health and well-being of residents. Laundry Aide should follow infection control and sanitation guidelines to prevent contamination and maintain laundry areas clean and report equipment malfunctions.Facility's document titled Laundry Aide Responsibilities, (Undated), showed in part that laundry aide is responsible for sweeping and mopping laundry room and stocking linen room.Facility's document titled Housekeeper Job Description, (Undated), showed in part that the Housekeeper is responsible to keep the facility clean, safe and in accordance with current federal and state standards and essential duties include but are not limited to cleaning floors (sweeping, mopping) and disinfecting in accordance with proper safety precautions; clean walls and ceilings by washing, wiping, dusting, spot cleaning, disinfecting and deodorizing; removing dirt and dust from surfaces using proper cleaning/disinfection solutions and assuring that established infection control and standard precaution practices are maintained when performing housekeeping tasks.Facility's document titled Laundry/Housekeeping Supervisor, (Undated), showed in part that the Laundry/Housekeeping Supervisor's responsibilities include but are not limited to overseeing the laundry and housekeeping operations, Ensuring that all resident linens, clothing and facility's laundry are properly cleaned and sanitized, Ensuring for clean, safe and sanitary environment while maintaining compliance with federal, state and facility's regulations, Monitoring laundry staff's quality and addressing concerns, Following infection control and sanitation guidelines to prevent contamination, Maintaining cleanliness and organization of the laundry department, Supervising housekeeping staff and department operations, Conducting routine inspections of facility's cleanliness and environmental safety, and Educating staff on proper cleaning, disinfection, and safety procedures.Facility's document titled Infection Preventionist (10/2020), showed in part that primary purpose of the position is to plan, organize, develop, coordinate and direct the facility's infection prevention and control program in accordance with current federal, state and local standards, guidelines and regulations and to provide staff's orientation and training on the facility's exposure control program and to meet with the staff to help with identification and correction of problem areas and improvement opportunities when necessary.Facility's document titled Director of Nursing, (Undated), showed in part the primary purpose is to plan, organize, develop and direct the overall operation of facility's Nursing Department in accordance with current federal, state and local and federal standards and regulations and to assist with infection control monitoring and ensuring the department's policy and procedures are followed and coordinating continuing education/In-service training for nursing department.

Based on observations, interviews and record review, facility failed to ensure that dietary staff is covering facial hair in the kitchen area and failed to follow the facility's policy and procedures for hair covering. These failures have potential to affect all 139 residents receiving oral diets in the facility.Findings include:On 6/22/26 the facility census was 139 residents. All 139 residents residing in the facility were consuming oral food of various textures.On 6/22/26 at 12:55 pm, observed V10 (Dietary Aide) with facial hair walking in kitchen area handling food during lunch time without wearing facial hair covering. On 6/22/26 at 1:00 pm, observed V9 (Dietary Aide) with facial hair walking in kitchen not wearing facial hair covering while performing various kitchen tasks. V9 stated, I do not cover my facial hair, but all hair should be covered so it does not get into the resident's food.On 6/22/26 at 1:15 pm, surveyor inquired to V8 (Food Service Supervisor) if all hair including facial hair be covered while working in the kitchen? V8 stated, All facial hair does not have to be covered but that's my opinion. It depends on what you are doing. I have to look at the policy.On 6/24/26 at 11:30 am, observed V10 (Dietary Aide) in kitchen not wearing facial hair covering while performing various kitchen tasks in the cooler room in the kitchen. V10 stated, I normally have my mask on to cover my facial hair. I just took it off. All hair should be covered.On 6/24/26 at 11:35 am, observed V25 (Dietary Aide) with facial hair prepping food tray carts not wearing facial hair coverings. V25 stated, All hair should be always covered in the kitchen. If the hair is not covered it can fall in the resident's food and that would be terrible for the residents.On 6/24/26 at 11:55 am, V8 (Food Service Supervisor) stated the policy says facial hair should be covered as needed. Surveyor inquired to V8 what does as needed mean? V8 stated that if they are doing certain tasks with handling or preparing foods if should be covered. Surveyor asked V8 should V25's facial hair be covered with the task that V25 is doing? V8 stated, Yes, his (V25's) facial hair should be covered. Facility's policy titled Hair Restraints/Jewelry/Nail Polish dated 2010, documents in part, Policy: To reduce the spread of microorganism, employees shall use effective hair restraints.Procedure Hairnets will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated if needed.Facility job description titled Dietary Aide dated 4/20/25 documents in part, Summary: The Dietary Aide is responsible for providing assistance in all food functions as directed/instructed and in accordance with established food policies and procedures.Facility job description titled, Dietary Manager undated, documents in part, Summary: The primary propose of the Dietary Manager is to assist the Dietitian in planning, organizing, developing an directing the overall operation of the Dietary Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Dietary Department is maintained in a clean, safe, an sanitary manner.

Based on observation, interview, and record review, the facility failed to ensure privacy curtains were in place. This deficient practice affected 4 residents (R22, R45, R106, and R132) reviewed for privacy in a total sample of 66 residents.Findings include:R22's admission record includes but is not limited to bipolar, schizophrenia, chronic kidney disease, cerebral infarction, hypertension, hemiplegia and hemiparesis affecting the left non dominant side. R22's Brief Interview of Mental Status (BIMS), dated 5/15/26, documents R22 have a BIMS score of 13, which indicates R22 is cognitively intact.On 6/22/26 at 11:30 am, R22 observed in room sitting on side of bed. No privacy curtain observed hanging from the ceiling to cover R22's Bed. The tract used to hang the privacy curtain was not a full tract to cover R22's living space. R22 stated, I do not like I don't have a curtain. I want my privacy. If I leave the door open, you can look right in my room and see me. I want it fixed. Surveyor inquired V6 Maintenance/Housekeeping Director about R22 not having a privacy curtain in R22's room. V6 stated, I need to fix the tract to hang the privacy curtain in this room. It's been like that. The tract does not go all around the bed to give privacy.R45's admission record includes but is not limited to COPD (Chronic Obstructive Pulmonary Disease), anxiety, asthma, embolism and thrombosis. R45's Brief Interview of Mental Status (BIMS), dated 4/22/26, documents R45 have a BIMS score of 10, which indicates R45 has moderate cognitive impairment.R106's admission record includes but is not limited to schizophrenia, and epilepsy.R106's Brief Interview of Mental Status (BIMS), dated 4/4/26, documents R106 have a BIMS score of 15, which indicates R106 is cognitively intact.R45 and R106 share a room. On 6/22/26 at 11:42 am, R45's bed and R106's bed were noted side by side and there was no privacy curtain in place to separate the two living spaces.R132's admission diagnoses include but are not limited to COPD, schizoaffective disorder, anemia, depression, diabetes, and osteoarthritis.R132's Brief Interview of Mental Status (BIMS), dated 4/29/26, documents R132 have a BIMS score of 14, which indicates R132 is cognitively intact.On 6/23/26 at 12:20 pm, R132 observed from hallway lying in bed with no privacy curtain hanging from the ceiling to cover R132's bed. R132 stated, I've been in this room for nine months and have not had a curtain. They tried to put a curtain up two months ago and it would not fit. I want my privacy. I feel like, l am in the open with having two other roommates.On 6/24/26 at 11:00 am, V6 Maintenance/Housekeeping Director stated, Every room should have a privacy curtain to provide the residents their privacy, even if they don't use the curtain, they should still have one. On 6/24/26 at 10:45 am, V7 RN (Registered Nurse) stated, Every resident should have a privacy curtain to provide privacy during care or if the resident prefers to just have privacy if sharing a room.On 6/24/26 at 1:53 pm, V2 DON (Director of Nursing) stated, All residents should have a privacy curtain because this is their home, and they should have their own space. All residents should be able to have their privacy. Privacy curtains should still be available to all residents, even if the residents do not use the privacy curtains. An emergency may happen that requires them to have privacy.The absence of privacy curtains for R22, R45, R106, and R132 were noted on 6/22/26, 6/23/26, and 6/24/26. Facility's Policy titled Resident Right dated 6/1/22, documents in part, 1. Federal and state laws guarantee certain basis rights to all residents of this facility. These rights include the residents' rights to o. privacy and confidentiality.Facility's policy titled Dignity dated January 2025, documents in part, Policy Interpretation and Implementation: 12. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observations, interviews and record review, the facility failed to ensure that a window (without a screen or safety bars) was not opened 14 inches in a common area; failed to ensure that residents' (R5, R87 and R103) room window (without a screen or safety bars) was not opened 15 inches. This failure has affected three residents reviewed for safety and has the potential to affect 20 residents with unspecified psychosis, schizophrenia or schizoaffective disorder on the third floor.The facility also failed to reassess one resident (R25) for safe smoking after being noted with cigarette burn holes in clothing. This failure has affected one resident of 41 residents reviewed for safe smoking in a total sample of 66 residents. R25's admission date is documented as 5/21/26. R25's Face Sheet documents the following medical diagnoses: Diabetes mellitus, Asthma, Hepatitis C (Viral), Absence of Left Leg below Knee, Seizures, Major Depressive Disorder, Schizophrenia, Vitamin D deficiency, Hypertension and Gastro Esophageal Reflux Disease. On 6/22/26 at 10:30am, R25 complained about upper extremity shaking that affects his eating and smoking. On 6/23/26 at 12:00pm, R25 was wearing a pair of light brown jogging pants that had cigarette burn holes on the right thigh. R25 indicated that it was because he shakes so bad and the ashes get on his clothes. On 6/24/26 from 10:30am to 10:45am, R25 was outside during smoking break. R25 had a lit cigarette in his right hand and his hand was visibly shaking. The ash from the cigarette was falling onto his lap. The smoking area had four smoke monitors: V23 (Smoke Monitor), V28 (Activity Aid), V29 (Activity Aid) and V30 (Smoke Monitor). V29 and V30 were passing out cigarettes and V23 and V28 monitored the residents for safety. On 6/24/26 at 10:35am, V23 indicated that he did not see any burn holes in R25's clothing. This surveyor pointed out the burn holes and V23 confirmed that he sees them on R25's jogging pants. V23 stated, When monitoring, we just keep an eye on them and that they're okay when smoking. Burn holes in clothing is reported to the nurse. It means they're not safe to smoke. On 6/24/26 at 1:40pm, V30 stated, If I see burn holes, it means that ash is falling on them. If I see this, I'll let (V23) know because he is the head of the smoke monitoring. I would also tell (social services). On 6/24/26 at 1:47pm, V29 was present as a smoke monitor on 6/24/26 and indicated that the activity department helps the smoking monitors. V29 stated, If I see burn holes, I would tell the social services director and the PRSC (Psychiatric Rehabilitative Service Coordinator) right away. R25's Smoking Risk Review dated 5/21/26 documents that R25 may independently be able to handle smoking materials. R25's Smoking Care plan dated 6/2/26 documents, in part: GOAL: (R25) will engage in safe smoking practices, and properly follow the smoking policy and procedures included in the agreement and will not suffer injury from unsafe smoking practices. Interventions: Evaluate/screen to determine safest smoking status upon admission, quarterly, and as required. On 6/24/26 at 10:42am, V24 (PRSC-Psychiatric Rehabilitative Service Coordinator) stated, Nobody let me know that (R25) had burn holes in his clothing. They should let me know so I can assess him for safety. Smoking monitors job is to make sure that the residents safely smoke. And to make sure that no one injures themselves while smoking. An intervention for someone that has burn holes would be for them to wear a smoking vest or have a smoking blanket. V24 indicated that she has not reassessed R25 for safety while smoking. A facility policy with a review date of 9/1/24 and titled, Smoking Policy – Residents documents, in part: Policy Statement: This facility shall establish and maintain safe resident smoking practices. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. An undated facility job description for Smoking Monitor reads: Position Summary: The Smoking Monitor is responsible for supervising residents during designated smoking times to ensure compliance with facility policies and maintain a safe environment for residents, staff, and visitors. This position monitors resident activity within designated smoking areas, observes safety concerns, and communicates any issues to nursing or facility leadership as appropriate. Facility undated document titled Smoking Log documents, in part, a list of the 41 sample residents which includes R25 assessed as smokers. R5 is [AGE] year old with diagnosis including but not limited to: schizophrenia, major depressive disorder, altered mental status and type II diabetes mellitus with unspecified complications. R87 is [AGE] year old with diagnosis including but not limited to: schizoaffective disorder, anxiety disorder, major depressive disorder and essential hypertension. R103 is [AGE] year old with diagnosis including but not limited to: major depressive disorder, chronic obstructive pulmonary disease, essential hypertension and type II diabetes mellitus with unspecified complications. On 6/23/26 at 2:50 pm, Surveyor noted residents' (R5, R87, and R103) bedroom window open and without a screen or safety bars. On 6/23/26 at 3:15 pm, Surveyor and V6 (Maintenance Director) went to third floor to measure window opening in residents' room. The window was observed with an air conditioner nailed to the window seal and a wide opening on the side of the air conditioner with no screen or safety bars. At that time, V6 measured the opening with a tape measurer at 12.5 x 15 (length x width). On 6/24/26 at 12:47 pm, Surveyor observed window near third floor nurses' station wide open without a screen or safety bars. At that time, V26 (LPN/ Licensed Practical Nurse) stated the following, The window is opened pretty high. I closed it but I don't know who reopened it. It is a safety hazard because there are psych patients here. On 6/24/26 at 1:00 pm, V6 (Maintenance Director) measured the window opening near the third floor nurses' station with a tape measurer at 14 inches. On 6/25/26 at 12:16 pm, V2 (DON/ Director of Nursing) stated the following, A resident can experience auditory hallucinations. Voices telling them to do things like harm or kill themselves. We have elopement risk residents in the facility who exit seek. Yes, windows can be considered an exit. A window without safety bars or screen is not acceptable. I wouldn't want residents to try to jump through the windows. R5's Care Plan dated 2/3/26 documents, R5 is an adult living with chronic psychiatric illness and determined to have disturbed thought processes, disorganized thinking, poor emotional responses /expressions of emotions, hallucinations, delusions, poor judgement /ability to perceive /interpret the intentions of others and lack of personal hygiene related to schizophrenia disorder. R87's Care Plan dated 6/4/26 documents, R87 is an adult living with chronic psychiatric illness and determined to have ineffective coping modalities that include disorganized thought processes and mood patterns, delusions, hallucinations, difficulty meeting basic physiological/ self-care needs, and having reduced insight and judgement related to schizoaffective disorder. R103's Care Plan dated 11/26/25 documents, R103 has been formally diagnosed with depression, a mood disorder characterized by persistent sadness, hopelessness, loss of interest in previously enjoyed activities, changes in sleep and appetite, fatigue, difficulty concentrating and impaired daily functioning. Facility Diagnosis Report documents twenty residents on the third floor diagnosed with unspecified psychosis, schizophrenia or schizoaffective disorder. Policy titled Hazardous Area, Devices and Equipment (undated) documents, any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous.

Based on observation, interview and record review, the facility failed to ensure that staff utilized insulin pens correctly and failed to notify a physician when blood pressure medications were not administered. There were 27 opportunities with four medication errors, resulting in a 14.81% (percent) error rate which affected three residents (R54, R99, R111) of eight residents observed during Medication Pass.Findings include:R54's Face Sheet does not include a medical diagnosis of Hypertension. R54's Physician Order Sheet (POS) documents two medications ordered for Hypertension: Amlodipine Besylate 2.5 mg (milligrams) one tablet by mouth one time a day and Fenofibrate 48 mg one tablet by mouth in the morning.On 6/22/26 at 11:35am, V7 (RN-Registered Nurse) checked R54's blood pressure with a result of 98/69. V7 (RN-Registered Nurse) stated, I am not going to give him the Amlodipine and the Fenofibrate because his blood pressure is too low.R54's POS did not document parameters for when to hold R54's blood pressure medication.R54's Medication Administration Record (MAR) denotes that R54's Amlodipine and Fenofibrate pills were not administered on the morning of 6/22/26.R54's blood pressure was not reassessed until the morning of 6/23/26 with a result of 113/70. From 6/22/26 morning until 6/23/26 morning, there are no documented blood pressures for R54.R54's Progress Notes dated 6/22/26 do not document that R54's physician was notified regarding withholding the blood pressure medications and there is no order to hold R54's blood pressure medications.On 6/23/26 at 10:25am, V7 indicated that she did not call R54's doctor after holding R54's medications on 6/22/26. V7 stated, We can hold medications if the blood pressure is below 110/70. It's a standing order. If blood pressure is too high or above 150/90, we call the doctor. Or if it is too low. Those are the times we call. V7 indicated that the doctor is not usually called if it is just one low blood pressure reading.R54's POS did not document a standing order for withholding R54's blood pressure medications.On 6/24/26 at 1:00pm, V2 (DON -Director of Nursing) stated, The nurses are taught that they should call the doctor if they are holding a medication. They can hold the medication, but they have to let the doctor know immediately. R99's Face Sheet documents, in part, a medical diagnosis of Diabetes Mellitus Type 2 with Hyperglycemia.R99's Physician Order Sheet (POS) documents the following medications for Diabetes: Admelog 38 units subcutaneously (SQ) before meals, Basaglar 48 units SQ two times a day, Jardiance 25 mg (milligrams) orally one time a day, Metformin 1000 mg by mouth two times a day and Trulicity 0.75 mg SQ one time a day every Tuesday.On 6/23/26 at 11:37am, V7 (RN-Registered Nurse) prepared R99's scheduled Admelog insulin via flex pen. V7 placed the insulin pen against R99's right upper arm and slowly injected the insulin. At the end of administration, V7 immediately removed her thumb from the injector button and removed the needle from R99's skin.R99 did not receive his lunch meal until 12:28pm on 6/23/26. R99 was followed from the 4th floor to the dining room immediately after he received his insulin injection. R99 sat in the 1st floor dining room without food or drink until 12:28pm.On 6/24/26 at 9:50am, V7 confirmed that she was supposed to keep her thumb on the injector button and hold the needle in place for six seconds. R111's Face Sheet documents, in part, a medical diagnosis of Diabetes Mellitus Type 2 with Ketoacidosis.R111's POS documents an order for Insulin Aspart Flex pen via sliding scale which starts with a blood sugar result of 150 or higher.On 6/22/26 at 12:15pm, V12 (LPN-Licensed Practical Nurse) performed R111's glucose test with a result of 173. According to R111's POS: 150-200 = 2 units of insulin Aspart via flex pen.V12 prepared R111's insulin pen without performing the air shot to ensure that all the air is expelled from the insulin pen. V12 dialed the insulin pen to two units, placed the insulin pen against R111's upper right arm, placed thumb on the injector button and administered the insulin. V12 kept her thumb on the injector button and held the pen in place for three seconds then removed the needle from R111's skin.On 6/22/26 at 12:35pm, this surveyor spoke to V12 regarding an airshot prior to the administration of insulin and holding the injector button for a period of time. V12 responded in referenced to the airshot, How do I do that?. V12 also did not know how long to hold her thumb on the injector button.An undated facility policy titled, Medication Hold Policy documents, in part: All medication holds shall be based on a clinical assessment, physician/provider orders, established hold parameters, resident condition, or resident refusal. Medication holds shall be documented appropriately, communicated to the prescribing practitioner when indicated, and monitored to ensure resident safety and continuity of care. PROCEDURE: The licensed nurse shall notify the prescribing practitioner when: 2. There are no established hold parameters and clinical judgment indicates withholding is necessary.An undated and untitled facility policy documents, in part: ADMELOG (Insulin Lispro): Key manufacturer recommendations: Rapid acting insulin analog used for glycemic control in adults and children with diabetes. Administer within 15 minutes before a meal or immediately after a meal.The facility provided a facility procedure titled, Novolog PenFill: Instructions for Use which reads, in part: How to Use: Giving the airshot before each injection: To prevent that injection of air and to make sure insulin is delivered, you must do an airshot before each injection. Hold the device with the needle pointing up and gently tap the PenFill cartridge holder with your finger a few times to raise any air bubbles to the top of the cartridge. Do the airshot as described in the device instruction manual. Giving the injection: 7. Insert the needle into the skin. Inject the dose by pressing the push button all the way in. Keep the needle in the skin for at least 6 seconds, and keep the push button pressed all the way in until the needle has been pulled out from the skin. This will make sure the full dose has been given.On 6/23/26 and 6/24/26, multiple requests were made for a facility protocol for administration of Admelog or Lispro insulin via flex pen. As of 6/25/26, the facility did not submit the requested documentation prior to exit of the survey.

Based on observations, interviews, and record reviews, facility failed to ensure activities of daily living (ADL) of showering is provided to maintain abilities of a resident assessed for staff supervision or touch assistance. This failure affected one resident (R4) out of 66 residents reviewed for ADL care.On 6/22/2026 at 10:50 AM, surveyor observed R4 at the fourth-floor nurse's station. R4's hair appeared to be oily, clumped together with several visible knots located at the top and back of the head. Shower Schedule and Log folder for the month of June 2026 was reviewed. Shower schedule for R4 is Wednesdays and Saturdays. Shower Log has no written documentation if shower was done or if it was refused from 6/1/2026 to 6/22/2026.On 6/22/2026 at 10:50 AM, V7 (Registered Nurse) stated that on the shower sheet, if the name of the resident is not written next to a calendar date, then it means the resident didn't get a shower or may have refused a shower. V7 also stated that if there was a refusal on the shower, family member or POA (Power of Attorney) is notified, and documentation of refusal and will be offered again. No documentation of R4's refusal or completion of shower on the 4th floor assignment sheet for R4's assigned shower dates provided: 6/1/2026, 6/2/2026, 6/9/2026, 6/13/2026, 6/14/2026, 6/16/2026, 6/18/2026, 6/20/2026, 6/22/2026.On 6/22/2026 at 11:55AM V15 (Certified Nursing Assistant/CNA) stated that she gets assigned to different floors of the building. V15 stated that part of her job duty but is not limited to assist activities of daily living, help on incontinence care and serve food trays. V15 stated that showers are offered on shower days and if the resident refuses, the nurses are notified.R4's Minimum Data Sheet Section C (5/18/2026) documents in part: R4 has a Brief Interview of Mental Status (BIMS) score of 7. R7 is moderately impaired. R4's Care Plan included to document refusals, acceptance, and contributing factors with date initiated: 11/17/2025. R4's Minimum Data Sheet Section GG (5/18/2026) documents in part: Functional Abilities score of 4 on Shower/ Bathe Self which is equivalent to Supervision or touching assistance. The ability to bathe self, including washing, rinsing and drying self (excludes washing of back and hair). Helper provides verbal cues and/or touching/ steadying and / or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.R4's Minimum Data Sheet Section GG (5/18/2026) documents in part: Functional Abilities score of 4 on Personal hygiene which is equivalent to Supervision or touching assistance. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands. Helper provides verbal cues and/or touching/ steadying and / or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.On 6/22/2026 at 12:30 PM, R4 observed in her bedroom having lunch. When asked questions about ADL care, including taking showers, R4 replied, Okay and then stared at the surveyor and proceeded to eat lunch.On 6/24/2026 at 12:31 PM, V32 (Restorative Nurse) stated that she is managing 4 facilities and has been at the facility for over a year and a half. V32 stated that R4 has a diagnosis of dementia and R4 might forget to shower, so R4 needs to be reminded on shower days based on the shower schedule.Facility's undated Activities of Daily Living (ADLs) policy documents in part: 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. C. the refusal and information are documented in the resident's clinical record. 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. 5. B. Supervision- oversight, encouragement or cueing provided 3 or more times during the last 7 days.

Based on observation, interview and record review, the facility failed to provide the required 80 square feet per bed for 5 resident rooms out of 68 resident rooms in the facility.Findings include: On 06/22/2026, at 11:05 AM, V1 (Administrator) states there are five rooms in the facility that do not meet the required square footage and provided a waiver. On 06/24/2026, at 11:06 AM, V6 (Maintenance Director) stated that the facility should have a waiver for those five rooms that don't meet the size requirement. We don't have any residents in one of the rooms. During tour of the facility with V6 on 06/24/2026 at 11:08 AM, surveyor observes all five resident rooms which did not meet the required square feet per bed. One room was not occupied by residents and was locked. R12, R14, R16, R32, R48, R84, R85, R93, R96, R116, R123, and R130, occupied the remaining four rooms. These residents stated that they have no concerns with their room square footage or the size of their rooms and can move about freely in their rooms. Facility document, undated, titled List of Rooms Under Room Waiver documents in part, four resident rooms with square footage measuring 15 x 17 and one resident room with square footage measuring 13 x 18. Facility document dated 02/11/2026, titled Illinois Department of Public Health documents in part, CMS (Centers for Medicare and Medicaid Services) is granting your facility a waiver of the federal requirement at 42 CFR 483.30 (1), tag F912.

Based on observations, interviews and record reviews, the facility failed to provide clean bathrooms and an environment free of urine, feces and body odors. This applies to 15 residents (R1, R2, R3 and R6 through R17) of 17 in the sample reviewed for safe, clean and homelike environment. Findings include: OBSERVATIONSUpon exiting the elevator of the 4th floor, it smelled like strong bodily, urine and feces odors. On 6/15/2026 at 11:44 AM, the small 4th floor handicap bathroom on the left side of the hallway smelled of strong bodily odors, urine and feces. There were brown-yellowish substances that hardened or dried in drizzling formation from the rim of the toilet seat to the floor. The entire hallway smelled of those strong odors extending from the elevator going left down the hall to the last room next to the window. Two rooms from the window contained a visibly open portable toilet next to the resident's bed. On 6/15/2026 at 12:38 PM, V4 (Housekeeper) who was cleaning the 4th floor handicapped bathroom could not smell the odors in the bathroom or throughout the hallway left of the elevator. V4 said V4 could not smell strong bodily odors due to V4's sinus problems. V4 explained V4 was trying to remove the stains and drops from the toilet. On 6/15/26 the 3rd floor's small central bathroom on the left side of the hall was in disarray: no toilet paper, brown paper towels in front of toilet, and yellowish-brown substance overflow on the outside of a toilet. On 6/16/2026 at 11:42AM, V4 (Housekeeper) was again in the handicap bathroom trying to clean and remove build-up debris from the toilet. While scrubbing, V4 said I can smell it today and it smells so bad. The bathroom had a strong stench odor. The stench started upon exiting the elevator and to the left hallway down to the window. On 6/15/2026 at 11:58AM, R1 stated the facility and bathrooms smelled like feces, urine, and a sewer. R1 stated feces are all over the floors and toilets. And R1 said the bathroom floors never dry and maintenance use bed sheets to soak up the mop water which is a mixture of urine/feces pushed around. Thus, causing the odors to linger throughout the bathroom and the facility. On 6/15/2026 at 12:47 PM, R2 (who resides on a different floor) stated the showers are horrible and there are usually 8-9 cockroaches in the showers. R2 said they do not clean the shower walls and there is always a stench smell in the toilets. There were visible chunks of feces on the outer rim of the toilet in one of the stalls of the 3-section shared bathroom as R2 took the surveyor throughout the bathroom. On 6/15/2026 at 1:20 PM, R3 stated there were no offensive odors from the bathroom today but they only clean them every three days. And they usually have a bad odor. R3 said the toilets are usually disgusting and visibly soiled. On 6/16/2026 at 10:26 AM, R6 stated initially you smell the urine and feces odors in the bathroom showers, but they dissipate as the steam increases. R1's Face Sheet documents R1's diagnoses of chronic obstructive pulmonary disease with paranoid schizophrenia, post-traumatic stress disorder, hypertension, insomnia and obesity. R1's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating some cognitive impairments. R2's Face Sheet documents R2's diagnoses of major depressive disorder, hypertension, anxiety, and asthma. R2's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 14 indicating some cognitive impairments. R4's Face Sheet documents R4's diagnoses of chronic obstructive pulmonary disease (COPD), asthma, neuropathy, and major depression. R4's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 10 indicating some cognitive impairments. V5 (Certified Nursing Assistant) and (V7 Registered Nurse) interviewed consecutively on 6/15/2026 starting at 12:39 PM stated they could smell the strong urine and feces odors coming from the 4th floor's elevator, hallway to the left of the elevator and the handicapped bathroom. V5 stated the 4th floor always smelled strong bodily odors. V7 pointed out a resident's room containing a portable toilet and another resident's room where urine was contained using a bed sheet that remained on top of the urine spill. 6/16/2026 at 4:21 PM, V1 (Administrator) stated it is their expectation that the facility be free of roaches, strange bugs and offensive odors because it is important that residents live in a clean sanitized homelike environment.R1,R2, R3, R6 through R17 all reside on units observed with odors and stains on toilets. Review of the facility's Resident Council Minutes for December 2025 documented request to clean the bathrooms. The facility failed to follow their Housekeeping Services policy dated 9/1/2025 that reads housekeeping and environmental surfaces will be clean and disinfected on a regularly basis when surfaces are visibly soiled and Clean spills of blood and bodily fluid as outlined in the established policy.

Based on observation, interview, and record review the facility failed to a.) ensure medications were locked and secured while unattended, b.) ensure controlled substance medications were double-locked and secured while unattended, and c.) properly waste and discard expired medications and controlled substance medications. These failures have the potential to affect all 143 residents residing in the facility reviewed for medications stored in the facility. Findings include: On 04/18/2026 at 12:43PM, V8 (Medical Records/Transportation) states he observed resident's medication stored inside of the basement in the facility. V8 states the medications are stored in an unlocked room although there is supposed to be a lock on the basement door. V8 states this door is accessible to all of the staff in the facility. V8 states resident's medication should only be accessible to people who are authorized.On 04/18/2026 at 12:52PM, surveyor located at the basement door, which is located down the hall from the kitchen and laundry room. Surveyor located at the basement door with V2 (Director of Nursing/DON) and V8. Surveyor observes V8 open the basement door by turning the handle. Basement door observed unlocked and V8 does not use a key or access pin code to open the basement door. Surveyor, V8, and V2 now located inside of the basement which appears to be an open auditorium/gym area. Surveyor observes multiple boxes with multiple medication bingo cards stored in the basement. V8 and V2 confirm that they both observe the multiple medication bingo cards. On 04/18/2026 at 12:55PM, V2 pick up a medication bingo card off of the floor and places it back in a box. Surveyor observes that the medication bingo card documents a resident's name with medication Aciphex written on the bingo card with a disperse date of 02/20/2010 and an expiration date of 02/18/2011. On 04/18/2026 at 12:58Pm, surveyor observes three Lorazepam medication vials lying on top of a box in the basement. Lorazepam medication vials observed with the following expiration dates, 10/2003,12/2004, and 04/2005. On 04/18/2026 at 12:59PM, V2 states Lorazepam is a controlled substance and should not be stored in the basement unlocked and unattended. V2 states none of the resident's medications should be stored in the basement because they are not properly stored. V2 states she has been the DON at the facility since September 2025, and she has been trying to properly destroy resident's medications that she is aware of. V2 states she has not been inside of the basement in a long time and is not aware that all of the resident's medications being stored in the basement. V2 states this must have been previously practiced by the facility, and she had no prior knowledge that resident's medications were being improperly stored. V2 states she has been recently destroying resident's medication using coffee grounds and was made aware that this method was also incorrect. V2 states she then reached out to the facility's pharmacy on 04/13/2026 to request a drug buster to use to destroy resident's medications in the facility. V2 states all resident's medications should be stored in a locked medication room and controlled substances should be double locked. V2 states since all staff have access to the basement room and the room is not locked, there is a potential for staff members to divert resident's medications in the facility. V2 states resident's medications can potentially be diverted to other residents or staff or even diverted outside of the facility. V2 states this process could potentially harm someone. V2 states she is not aware of any allegations of an agency nurse who has been diverting resident's medications. V2 states she has not had to terminate an agency nurse due to drug diversion.On 04/18/2026 at 3:56PM, V10 (RN) states the process for returning medications in the facility consists of the pharmacy sending bags with a seal to the facility. V10 states the nurses places the medications inside of the bag and press down the seal to ensure that it cannot be opened. V10 states the medications are then sent back to the pharmacy. V10 states controlled substances/narcotics that need to be destroyed are given to V2 (DON) and this process is handled only by V2. V10 states all resident's medications should be locked and narcotics should be double locked. V10 states if resident's medications are left unlocked and unattended in the basement, then anyone can go in there and get the medications and possibly divert them. V10 states there is also potential for residents to gain access to the medications and harm themselves. V10 states staff could even sell the resident's medications for profit.On 04/18/2026 at 4:01PM, V5 (Maintenance Director) states the basement is a gym area that is being used as a storage space. V5 states the basement has been this way since he began working at the facility 8 months ago. V5 states himself, his assistant, his supervisor, and a housekeeper have a key to the basement storage. V5 states the basement door has a lock on it but it is not locked and anyone can go into the basement door. V5 states he accesses the basement approximately twice a month and have noticed that there are resident's medication bingo cards located inside. V5 states he has never touched any of the medications inside the basement. V5 states he has never stolen resident's medications and is not aware of any agency nurse who has been diverting resident's medications in the facility either. V5 states he went inside of the basement today to assess which wheelchairs in the facility are in working condition. V5 states since resident's medications are left inside of the basement unlocked, then there is potential for staff to steal resident's medications. Facility policy dated 09/01/2024 titled Storage of Medications documents in part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Only persons authorized to prepare and administer medications have access to locked medications. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications.Facility policy dated 09/01/2024 titled Controlled Substances documents in part, Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises. Personnel who are authorized to handle controlled substances are approved by the director of nursing services. Controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications. Access to controlled medications remains locked at all times. The nurse on duty maintains the keys to controlled substance containers. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. Medications that are opened and subsequently not given (refused or only partly administered) are destroyed. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet. Medications returned to the pharmacy are recorded and signed by the director of nursing (or designee) and the receiving pharmacy. Policies and procedures for monitoring controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist.

Based on observations, interviews and records review, the facility failed to ensure the confidentiality and security of residents' medical records. This failure has the potential to affect all 143 residents residing in the facility.Findings include:On 04/18/2026 at 12:22PM, V8 (Medical Records/Transportation) stated medical records are stored in the basement. During basement (gym) tour with V8, the door to the gym was not locked. Upon entering the gym, observed boxes upon boxes filled with medical records. The boxes were not sealed and were placed randomly around the gym. Some of the medical records papers observed spilling out of the boxed on to the floor. The medicals showed identifying medical and personal information of residents with different dates of when residents were in the facility. The gym was observed disorganized and filled with boxes and other miscellaneous items.V8 stated he found the gym piled with documents like this when he started working at the facility years ago. V8 stated he oversees thinning resident charts when they become too full. He puts the thinned charts in boxes and stores them in the gym. V8 stated the medical records are not stored properly because they are scattered all over the floor exposing residents' personal information. The door to the basement is not locked. It is possible for any staff to come in there and look at these documents.V8 stated medical records should be kept in a safe place which is not accessible to everyone else. The records should only be accessible to V8 because he oversees them. No one else should be accessing resident records without my knowledge. The danger is that some of the residents' information can be exposed to people who are not authorized to have access to them. HIPAA protects resident personal information and should be strictly followed. We are not following HIPAA rules by exposing resident health information. On 04/18/2026 at 5:00PM, V5 (Maintenance Director) stated the facility refers to the basement where medical records are stored in as the gym because there are basket hoops there. V5 stated the gym is used as storage for anything in the facility that needs to be put away. From old medical records to broken furniture and other miscellaneous items. V5 stated he found the gym like that when he was employed at the facility eight months ago. Housekeeping and maintenance staff have access to the gym room. There are eight housekeepers and two maintenance staff who frequent the gym to store items that are either broken or not needed anymore. V5 stated the door to the gym has a lock but was not locked earlier today. He had propped it open earlier today when he was working there. He did not lock it up when he went for lunch.V5 stated staff can access the gym if the door is left open because the kitchen laundry and staff rocker rooms are near the gym. If the gym is left open any staff member can get in there and access resident medical records which contain residents' personal and medical information. This would not be ok. It's the residents' private information which should not be left exposed. V5 stated there are residents' medical records in the gym in many boxes, most boxes are not sealed. Resident medical records are spilling out of the boxes on the floor. Resident information is visible to anyone who enters the gym. On 04/19/2026 at 1:46PM. V1 (Administrator) stated via phone that he found the gym full of the staff in there including medical records when he started working in the facility. V1 stated he is working to find a junk removal company to remove the junk stored in the gym. V1 stated medical records are not supposed to be accessible to anyone who is not taking care of the resident. Medical records are stored in the gym. Residents do not have access to the gym. There are three locked doors to go through before getting to the gym. Only staff can access that part of the building. V5, V8 and I are only ones with access to the gym. V1stated the door leading to the gym where medicals are stored was propped open yesterday because V5 was performing some work in the gym. V1 stated he is not going to say what would happen if staff not taking care of the residents have access to their medical records. HIPAA PRIVACY & SECURITY POLICY, no date document:To ensure the protection, confidentiality, and security of Protected Health Information (PHI) in compliance with federal regulations, including the Health Insurance Portability and Accountability Act.-Unauthorized access, use, or disclosure of PHI is strictly prohibited.Protected Health Information (PHI):-Any information that identifies a resident and relates to their health condition, treatment, or payment.-Only the minimum amount of PHI needed to perform a job may be accessed, used, or disclosed.-Unauthorized acquisition, access, use, or disclosure of PHI that compromises security or privacy.-Access is limited to staff with a legitimate job-related need-Access is monitored and audited. Policy titled Location and Storage of Medical Records, dated 12/2006 documents:-Our facility shall protect and safeguard all medical records.-Medical records are stored in a locked room and protected from fire, water damage, insects, and theft.-Archived medical records (those being retained for a specified period beyond the resident's discharge or death) will be clearly identified as archive records and stored appropriately.-Should this facility temporarily cease operation, all records shall be stored and maintained within the facility.

Based on interviews and record review, the facility failed to ensure that two residents (R3 and R14) were free from verbal abuse. This failure has affected two of four residents reviewed for abuse. Findings include:R3 is [AGE] year old with diagnosis including but not limited to: schizophrenia, generalized anxiety disorder, neuralgia and neuritis.R3 has a BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact.R14 is [AGE] year old with diagnosis including but not limited to: major depressive disorder, schizoaffective disorder, essential hypertension and hidradenitis suppurativa.R14 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.R4 is [AGE] year old with diagnosis including schizoaffective disorder and essential hypertension. On 2/10/26 at 10:58 am, V1 (Administrator) stated the following, R4 was sent out to the hospital today for aggressive behaviors towards other residents. It was just reported to me that on yesterday (2/9/26), R4 was said to have made sexually inappropriate comments to female residents. On 2/10/26 at 11:46 am, V13 (Agency Registered Nurse) stated the following, On 2/8/26 around 3:15pm R4 was on the third floor pacing the unit. He was unable to redirect and went down to the second floor. I was notified by the second floor staff that R4 was on the unit/ second floor harassing female residents. R4 returned to the third floor and was becoming loud and aggressive. I called V4 ADON (Assistant Director of Nursing) and was told to send R4 out for evaluation. I was not as rest because I don't know how he (R4) began following me around because he knew that I called 911. R4 was eventually sent to the hospital, but returned within a couple of hours. R4 was eventually sent to the hospital, but returned within a couple of hours. After bedtime, most of the residents were pacing and moving around.There are all men on the unit and no men staff on the floor. I don't know if I would go back to work there (facility) because there were no managers on the floor and no support. On 2/10/26 at 12:00 pm, R14 stated the following, R4 was just admitted to here on Friday (2/6/26) and started his behaviors on the first day that he came. He was on my unit (second floor) where he does not belong, making sexual remarks about his penis size and stating that he wanted someone to suck his penis at the nurses' station. He started to get aggressive because the staff was telling him that he could not take snacks from our unit (2nd floor). He started calling us all bitches and making treats, stating that he would kill us. He would leave and come back several times. Finally, he came back down close to bedtime and proceeded to follow me to see what room I was going to, but the nurse stopped him from following me. On Sunday (2/8/26), the staff bought residents pizza and chicken during the super bowl. We were in the 2nd floor dining room when R4 got up in my face and motioned toward me with his fist balled up and tried to intimidate me. He (R4) started calling me (R14) a fat bitch, stating that he would take a cane and shove it up my butt. I told him that he is acting like a pedophile and he proudly said that he was. I went to the third floor with V13 (RN) to report his behaviors. Even after the incidents on Sunday, he (R4) kept roaming around on the 2nd floor after bedtime. On 2/17/26 at 12:20 pm, R3 stated the following, On 2/6/26, I saw R4 in the hallway and he started following me, asking me to use my laptop and my headphones. I had never seen this guy (R4) before and felt uncomfortable. I told him no. At around 2:00 am, I heard my room door open and it was him trying to walk into my room. I told him to get out of my room and he started to calling me a b**** and telling me to suck his d***. He told me that he could come into my room if he wanted to. Later on 2/9/26 at around dinner time, he came back to my room and I asked him to leave. He was sent out to the hospital that night but came right back and came into my room once again around 2:00 am.On 2/11/26 at 1:30 pm, V6 (Agency Registered Nurse) stated the following, I was the nurse on the second floor on Saturday (2/7/26). R4 came down to the second floor several times during my shift making inappropriate remarks to R3 and R14. I asked him (R4) several times to return to his unit (third floor) and he became angry and began to yell. He then began call to call R3 and R14 bitches and making threats to punch them in the face. He eventually went back to the third floor after I asked him several times to leave.On 2/11/26 at 12:15 pm, V2 (DON/ Director of Nursing) stated the following, The residents have a right to not be harassed or verbally assaulted in the facility. All residents should feel safe in the facility.R4's Nursing Progress note dated 2/8/26 documents, R4 noted with agitation and aggressive behavior. R4 went to the second floor to harass a lady; Doctor was notified and gave order to send R4 out via petition (involuntary discharge) to hospital; 911 called and R4 taken to nearby hospital via paramedic.R4's Nursing Progress noted dated 2/8/26 documents, R4 returned to the facility via ambulance with no new orders.IDPH Report dated 2/9/26 documents, it was reported the R4 was verbally sexually inappropriate with persons in the facility on 2/8/26.Petition for Involuntary/ Judicial admission dated 2/8/26 documents, R4 is in need of immediate hospitalization for the prevention of such harm; R4 agitated and verbally aggressive towards peers; danger to self and others; unable to be redirected.Facility policy titled, Abuse Prevention Program documents the following, 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 from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The following is listed as one of the protocols that Administration is responsible for implementing: protect 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.

Based on interviews and record review, the facility failed to ensure that the residents' bathroom floor was dry and free of a liquid substance. This failure has resulted in one resident (R1) slipping on the bathroom floor and sustaining fractures to her ankle. Findings include:R1 is [AGE] year-old with diagnoses including but not limited to: morbid obesity, epilepsy, vitamin D deficiency, type 2 diabetes mellitus and hypertension.R1 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.On 1/5/26 at 2:43 PM, R1 stated the following, I was discharged from the hospital on October 9, 2025, and am now at a different nursing facility. My ankle was broken in three places while in the last nursing home (named facility). I was going to the restroom in the middle of the night about 2:00 AM. The bathroom is down the hall from my bedroom. I was walking into the bathroom and there was no light or wet floor sign. The floor was really wet with water. I slipped and fell and began to yell for help. When I slipped and fell, the CNAs (Certified Nurse Assistants) called 911 and the EMTs (Emergency Medical Technicians) got me off the floor and transferred me to the hospital. The x-rays at the hospital revealed that my ankle was broken in several places. I am still recovering from the fracture.On 1/7/26 at 11:28 am, V2 DON (Director of Nursing) stated the following, I was told that R1 slipped and fell on the bathroom floor on water. The agency nurse (V28) told me that the bathroom floor was wet. I would expect the nursing staff to get the water up from the floor and place a wet sign there to prevent a patient from falling. I cannot contact V28 (agency nurse). She (V28) is the nurse that was assigned to R1 on the night of the fall.On 1/8/26 at 12:25 pm, V29 (Nurse Practitioner) stated the following, fall prevention should be in place for all residents. The floors should be free of waste, rugs or carpets. Liquid on the floor is considered a fall risk. The liquid is a risk because resident can slip and fall on the liquid.Some long-term effects of a bone fracture may include weakness in extremity, difficulty walking, chronic pain and low bone density. Un-witnessed Fall report dated 10/5/25 documents the following nurse's description by V28, during rounds, RN (Registered Nurse/ V28) was alerted by the sound of someone calling for help emanating from the bathroom. The resident (R1) was found lying on the floor, the fall was unwitnessed. An immediate physical assessment was conducted. The resident (R1) reported experiencing pain and exhibiting a limp left foot.Emergency Department Provider note dated 10/5/25 documents, R1 states she lives in named nursing facility and was walking to the restroom. During this time, R1 states that the floor was wet and that she (R1) tripped and fell, landing on her ankle.Emergency Department Provider noted dated 10/5/25 documents the following: Left ankle deformity and ecchymosis present; tenderness present; decreased range of motion.Emergency Department Imaging results dated 10/5/25 documents, left ankle trimalleolar fracture with mild posterior displacement of the distal fibula fracture fragments.Facility policy titled Housekeeper Job Description documents the following as part of essential duties and responsibilities: clean floors, to include sweeping, damp/ wet mopping, stripping, waxing, buffing and disinfecting in accordance with proper safety precautions.

Based on observation, interview and record review the facility failed to provide a homelike environment for the residents. This failure applies to all 139 residents in the facility. Findings include: On 1/5/26 at 2:43 PM, R1 stated the following, The bathrooms and shower rooms in this facility are terrible and do not seem to be up to code. The showers never seemed to be cleaned and sometimes do not have shower curtains. There is also peeling drywall in the bathrooms. On 1/5/26 between 3- 3:30 pm, Surveyor conducted tour of second, third, and fourth floor residents' bathrooms. At that time, the following was noted: On 1/5/26 at 3:02 pm in second floor shower room, shower walls were noted with a black and brown substance; at 3:15 pm in the third-floor shower room, shower walls were noted with black and brown substance. Surveyor also noted a hole in the shower room ceiling with dry wall and paint peeing from ceiling and walls; and at 3:26 pm in the fourth-floor shower room, the shower walls were noted with a black and brown substance. On 1/6/2026 between 11:00- 11:35 am, V12 (Maintenance Director) toured the second, third and fourth floor shower rooms with Surveyor. On 1/6/2026 at 11:23 am, V12 stated the following, I don't believe that the black substance is mold or mildew (referring to black substance on shower walls in all shower rooms). I believe that it may be a build-up of soap or grime and rust. The housekeeping staff are responsible for cleaning the shower walls during daily cleaning. We are working on repairing the ceiling and walls as we do some cosmetic work to the shower rooms. First, we had to repair the leak in the roof before doing cosmetic work. Otherwise, the leaky roof would ruin the walls again. No, the residents may not feel comfortable showering in the shower rooms with the peeling paint and dark spots on the shower walls. On 1/7/26 at 12:11 pm, V19 (Housekeeper) stated the following, There a usually four housekeepers working daily 7-3:30 pm or 8- 4:30 pm, in the evening the laundry staff will pick up any spills and works until 11:30 pm. When I work in the bathrooms, I clean the sinks, the showers and the toilets. The black substance in the showers looks like soap build-up. We are supposed to scrub the showers daily to keep the black substance away. It looks uncomfortable with the black substance in it. On 1/07/2026 at 11:05am tour of the third-floor unisex restroom, located adjacent to room [ROOM NUMBER]. Observed a hole in the wall behind the restroom door, a roll of paper towel used by the residents to dry their hands sitting on top of the restroom garbage can; the roll of paper towel was not contained in a paper towel holder. On 1/07/2026 at 11:15am V31(Maintenance Technician) stated I have worked at this facility for four months. The men and females use the same bathrooms and shower rooms on the floors. V31 observed the hole in the wall behind the door of the third-floor restroom and stated the hole in the wall was caused by the residents opening the door too far and the doorknob hitting the wall. Surveyor pointed out to V31 the roll of paper towels the residents use to dry their hands with sitting on top of the garbage can located in the restroom. V31 stated this does not represent a homelike environment. I will have to get a paper towel holder put up in this bathroom. On 1/07/2026 at 12:46pm V12(Maintenance Director) observed the hole in wall behind the door of the third-floor restroom. V12 stated the hole in the wall just happened recently. The hole was caused by the residents slamming the door into the wall. V12 observed the roll of paper towel sitting on the garbage can in the third-floor restroom. V12 stated the roll of paper towel the residents used to dry their hands with should not be sitting on the garbage can, that is unsanitary. I will need to put up a paper towel dispenser in this restroom. On 01/07/2026 at 11:05am tour of the second-floor shower room observed the first toilet stall in the second-floor shower room with missing toilet seat. On 1/07/2026 at 12: 40pm V12(Maintenance Director) stated the toilet is functioning, the seat is just missing. There is a bolt on this toilet bowl that I can't get out, so I can't put a new seat on the toilet. I guess I will have to replace the entire toilet bowl, for a toilet seat to be on the toilet bowl. I would not want my toilet at home to not have a toilet seat. On 1/07/2026 at 11:15am tour of the fourth-floor shower room, observed a white colored shower curtain, which separates the shower stalls from the toilet stalls, the white shower curtain observed torn with black spots on the shower curtain. Observed the light fixture in the ceiling on the fourth-floor shower room, the light fixture had a black stringy substance adhering to the light fixture and the ceiling. On 1/07/2026 at 12:44pm V12(Maintenance Director) observed the fourth-floor shower room light fixtures and shower curtain. V12 stated that it looks like spider webs on the light fixture in the ceiling. V12 stated housekeeping is responsible for cleaning the light fixtures in the ceiling. The housekeeper can tell me that the light fixtures in the ceiling are dirty, and I can clean them if the housekeeping staff does not want to climb up there to clean the fixtures in the ceiling. The housekeeping and maintenance are responsible for changing torn or damaged shower curtains. V12 stated it was not brought to my attention that the shower curtain in this shower room was damaged. On 01/08/2026 reviewed the undated Maintenance Director job description which documents in part, the primary purpose of the maintenance director is to plan, organize, develop, and direct the overall operation of the maintenance department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the administrator, to assure that our facility is maintained in a safe and comfortable manner. On 01/08/2026 reviewed the facility's undated maintenance service policy which documents in part, 2. Functions of maintenance personnel include, but are not limited to: b. maintaining the building in good repair and free from hazards. On 01/08/2026 reviewed the facility's Homelike Environment policy with a revision date of 09/01/2025, which documents in part, residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Facility policy titled Housekeeper Job Description documents the following as part of essential duties and responsibilities: remove dirt, grease, film, etcetera from surfaces using proper cleaning and disinfecting solutions. Facility policy titled Housekeeping Services documents, the facility shall provide routine and thorough housekeeping services to prevent infection, promote resident comfort, and comply with federal, state and local regulations.

Based on interview and record review the facility failed to prevent resident to resident verbal and physical abuse for one [R1] out of three residents reviewed for abuse. This resulted in R1 sustaining physical pain and mental anguish.Findings Include: R1's clinical record indicates the following in part: R1's medical diagnoses of post -traumatic stress disorder, chronic obstructive pulmonary disease, anxiety disorder, schizoaffective disorder, and overactive bladder.R2's clinical record indicates the following in part: Medical diagnoses: Schizoaffective disorder and major depressive disorder.R2's progress notes in part:V6 [Licensed Practical Nurse] note:12/26/2025 3:46 AM Note Text: This writer heard loud yelling in R2's room around 1:45 AM. R2 noted to be verbally aggressive with her roommate [R1]. R2 pulling back her roommate privacy curtains, playing loud music on her phone and putting on bright lights. R2 noted to be highly agitated. This remains to be a threat to staff and other residents. resident sent for psych eval. R2's Petition for Involuntary Judicial admission: [DATE] at 2:18 AMR2 is verbally and physically agitated with other resident [R1] R2 remains a threat to staff and other residents.R2's Care plan in part:On 11/13/25, 11/26/25, 12/1/25, 12/2/25, and 12/26/25 R2 was sent to the hospital for psych evaluation due to behaviors.On 12/30/25 at 11:40 AM, R1 stated, On Christmas night, I was sleeping when my roommate [R2] hit me all in my back, everywhere on my body. Then R2 started throwing items at me, and some of the items hit me on my arm. R2 was cursing at me and yelling, she called me names I never been called before. I finally was able to get out of bed, and then I was yelling and screaming for help. I got out of bed and grabbed my walking cane to help me walk so I could get out of the room. R2 then tried to grab my cane out of my hands as she was pushing the cane towards my face trying to hit me with my own cane. I was holding on to my cane for my life. I knew if R2 got my cane she was going to bust my head open. I was so afraid, upset and in pain, my body was hurting. It took three staff members to pull R2 off me. My body was hurting all over very sore for a week. I do not know why she jumped on my like she did. I was crying every night, afraid to sleep. I felt so bad about myself and embarrassed, because I did not do anything to R2.On 12/31/25 at 12:00PM V7 [Certified Nurse Assistant] stated, I worked on 12/25/25 night shift. I saw R1 and R2 arguing. I went into the room. I told them to stop arguing. That was it, I did not report the arguing. I don't know nothing else. I received abuse training a while ago, the abuse coordinator is the administrator. R1 and R2 was just nip picking each other, no cursing it was not verbal abuse.On 12/30/25 at 2:00 PM V5 [Agency-Certified Nurse Assistant] stated, I worked on 12/25/25 night shift rolling over to 12/26/25. I heard yelling from R1's room. I saw R2 hitting R1. It took V6 [Licensed Practical Nurse], V7 [Certified Nurse Assistant] and myself to pull R2 off R1. Once we separated R2 from R1, R2 kept charging at R1 and all of us then started throwing items at us. R2 broke loose from V6 and R2 started hitting R1 again. We separated them and removed R1 from the room. During the attack, R2 was throwing a jar of petroleum jelly, lotion, deodorant like personal items. The items were hitting all of us. R1 called the police and told them R2 attacked her, which was the truth. R2 was sent out to the hospital.Surveyor read V5 her written witness statement:[Read: To whom it may concern; I V5, heard arguing coming from resident room. I [V5] and other staff immediately went to see what happened. Residents [R1, R2] were having a verbal disagreement, staff separated residents to calm them down.]V5 stated, I never wrote or gave any one my statement. That statement is not the truth. No one asked me what happened or what I witness.On 12/30/25 at 3:30 PM, V2 [Director of Nursing] stated, On 12/26/25 early morning I received a phone call from V6 [Licensed Practical Nurse], told me R1 and R2 had a verbal argument and R2 was throwing items in the room. R2 refused to take medication to help calm her down, so R2 was petitioned out to the hospital. Later that day 12/26/25 I spoke to R1, and she did not tell me R2 hit her or any of the items that was thrown around hit her. I did not ask R1 if she was hit by R2 or any items hit R1. R2 was transferred back to the facility after the emergency room visit. R2 was moved to another room.On 12/30/25 at 4:00 PM, V1 [Administrator] stated, The incident occurred on 12/26/25. I was made aware R1 and R2 had an argument on 12/26/25. R2 was still agitated after the incident, offered medication to help calm down R2, but she refused the medication. R2 psychiatrist gave an order to send R2 to the hospital for psych evaluation. R2 was petition to the hospital. I was notified R1 phoned 911. I did not know what she told the police. I do not know why R1 phoned 911. I do not have a copy of the police report. I spoke with R1 on 12/26/25, R1 did not tell me she was struck by R2. I was not aware of the severity of the argument until 12/29/25 during morning meeting. I learn the argument was serious and I tried to report to IDPH. R2 returned back to the facility on [DATE] and was moved into a different room. Policy document in part:Abuse Policy [9/2025]All reports of resident abuse are reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigation are documented and reported.Resident abuse is suspected, the suspicion must be reported immediately to the administrator and other officials.Immediately defined as within two hours of an allegation involving abuseAbuse, is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, 483.12 Freedom from Abuse, Neglect, and ExploitationThe resident has the right to be free from abuse, neglect, misappropriation of residentproperty, and exploitation as defined in this subpart. This includes but is not limited tofreedom from corporal punishment, involuntary seclusion and any physical or chemicalrestraint not required to treat the resident's medical symptoms. or punishment with resulting physical harm, pain orResident Rights:All residents have the right to be free from abuse

Based on interview and record review the facility failed to follow their Abuse Reporting Policy and report allegations of abuse within two hours of the incident for one [R1] out of three residents reviewed for abuse.Findings Include: Reviewed facility's IDPH Initial Report for incident 12/26/25 [R1and R2].Dated: 12/30/25Time: 10:33 [NAME] 12/30/25 at 11:40 AM, R1 stated, On Christmas night, I was sleeping when my roommate [R2] hit me all in my back, everywhere on my body. Then R2 started throwing items at me, and some of the items hit me on my arm. R2 was cursing at me and yelling, she called me names I never been called before. I finally was able to get out of bed, and then I was yelling and screaming for help. I got out of bed and grabbed my walking cane to help me walk so I could get out of the room. R2 then tried to grab my cane out of my hands as she was pushing the cane towards my face trying to hit me with my own cane. I was holding on to my cane for my life. I knew if R2 got my cane she was going to bust my head open. I was so afraid, upset and in pain, my body was hurting. It took three staff members to pull R2 off me. My body was hurting all over very sore for a week. I do not know why she jumped on my like she did. I was crying every night, afraid to sleep. I felt so bad about myself and embarrassed, because I did not do anything to R2.On 12/31/25 at 12:00PM V7 [Certified Nurse Assistant] stated, I worked on 12/25/25 night shift. I saw R1 and R2 arguing. I went into the room. I told them to stop arguing. That was it, I did not report the arguing. I don't know nothing else. I received abuse training a while ago, the abuse coordinator is the administrator. R1 and R2 was just nip picking each other, no cursing it was not verbal abuse.On 12/30/25 at 2:00 PM V5 [Agency-Certified Nurse Assistant] stated, I worked on 12/25/25 night shift rolling over to 12/26/25. I heard yelling from R1's room. I saw R2 hitting R1. It took V6 [Licensed Practical Nurse], V7 [Certified Nurse Assistant] and myself to pull R2 off R1. Once we separated R2 from R1, R2 kept charging at R1 and all of us then started throwing items at us. R2 broke loose from V6 and R2 started hitting R1 again. We separated them and removed R1 from the room. During the attack, R2 was throwing a jar of petroleum jelly, lotion, deodorant like personal items. The items were hitting all of us. R1 called the police and told them R2 attacked her, which was the truth. R2 was sent out to the hospital.On 12/30/25 at 3:30 PM, V2 [Director of Nursing] stated, On 12/26/25 early morning I received a phone call from V6 [Licensed Practical Nurse], told me R1 and R2 had a verbal argument and R2 was throwing items in the room. R2 refused to take medication to help calm her down, so R2 was petitioned out to the hospital. Later that day 12/26/25 I spoke to R1, and she did not tell me R2 hit her or any of the items that was thrown around hit her. I did not ask R1 if she was hit by R2 or any items hit R1. R2 was transferred back to the facility after the emergency room visit. R2 was moved to another room.On 12/30/25 at 4:00 PM, V1 [Administrator] stated, The incident occurred on 12/26/25. I was made aware R1 and R2 had an argument on 12/26/25. R2 was still agitated after the incident, offered medication to help calm down R2, but she refused the medication. R2 psychiatrist gave an order to send R2 to the hospital for psych evaluation. R2 was petition to the hospital. I was notified R1 phoned 911. I did not know what she told the police. I do not know why R1 phoned 911. I do not have a copy of the police report. I spoke with R1 on 12/26/25, R1 did not tell me she was struck by R2. I was not aware of the severity of the argument until 12/29/25 during morning meeting. I learn the argument was serious and I tried to report to IDPH. R2 returned back to the facility on [DATE] and was moved into a different room. I sent in the IDPH reportable on 12/29/25, but I would not go through. No, I don't have an email or any documentation stating I make attempts to send in the IDPH reportable. I just tried to send in the IDPH reportable today and somehow it went through today. Any abuse allegations including verbal must be reported within two hours.Policy document in part:Abuse Policy [9/2025]All reports of resident abuse are reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigation are documented and reported.Resident abuse is suspected, the suspicion must be reported immediately to the administrator and other officials.Immediately defined as within two hours of an allegation involving abuse

Based on observations, interviews, and record review, the facility failed to provide a homelike environment for two (R3 and R4) out of three residents reviewed for homelike environment in a total sample of 4 residents.The findings include:On 08/26/2025 at 11:21 AM, surveyor observed a hole on the ceiling and paint chip in R3's room. There was a musty smell, and a blue blanket placed on the floor. R3 stated, the water leaks when it rains, and a bin must be placed to help collect the water. R3 stated he has told V4 (Maintenance Director) to fix it, but nothing has been done. On 08/26/2025 at 12:07 PM, V4 was first made aware of the water leak in R3's room approximately 1 1/2 months ago. V4 told V5 (Regional Maintenance Director) about the leaking from the walls in R3's room. He let him know that there was a hole in the wall in room [ROOM NUMBER]. V4 stated he has not seen any vendors come to the facility to address these issues. V4 stated no residents should be in the room under these conditions and will require a room change.On 08/26/2025 at 12:10 PM, surveyor observed there was a large hole on the wall, with a rusty metal object exposed, paint chipping surrounding the hole and throughout the ceiling. R4 stated the hole was much bigger and someone came to fix it but never came back to finish the job.On 08/26/2025 at 12:12 PM, V4 stated the painter had to scrape off the paint, clean the walls, and repaint the affected area in R4 room. V4 stated the painter was let go on August 12, 2025, and no one has come to finish the job. V5 is made aware that there is still a hole in the wall. V4 stated there should not be any residents living under these conditions and should be removed.On 08/26/2025 at 12:21 PM, V5 stated he is aware of the water leak in R3 and R4 room. V5 stated he tried to go up in the roof to patch it one week ago with no success. V5 stated he put in a work order for room [ROOM NUMBER] and 236 last week. Someone will be coming in 2 days to make necessary repairs. V5 confirmed it is not safe for residents to stay in the room, until the affected area is repaired.Policy titled Homelike Environment with review date of February 2021 documents Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Staff provides person- centered care that emphasizes the residents' comfort, independence and personal needs and preference. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike settings. These characteristics include: clean, sanitary and orderly environment.

Based upon interviews and record review the facility failed to: conduct head counts (every two hours); failed to provide supervision for one resident (R7) in the sample; failed to follow Doctor's pass order for one resident (R5); and failed to implement the elopement and pass policies for three residents in a sample of 15 (R5, R6 and R7). These failures resulted in an immediate jeopardy and has the potential to affect 123 residents that reside in the facility.An immediate jeopardy began on 8/9/25 at 9:00 am, when R6 left the facility unauthorized and continued with subsequent failures that led to R5 and R7 also being away unauthorized.On 8/14/25 at 3: 47.pm, V1 (Administrator) and V20 (Regional Consultant) were notified of the Immediate Jeopardy and the IJ template was presented.On 8/19/25 an acceptable removal plan was accepted after revisions to other removal plans that were submitted on 8/18/2025.The immediacy was removed on 8/19/25, however deficiency remains at a level two because more time is needed to evaluate the implementation and effectiveness of staff training. Findings include:R7 is a [AGE] year-old with diagnoses including but not limited to: Suicidal Ideations, Major Depressive disorder, Bipolar disorder and Generalized Anxiety disorder.R7's admission Record documents an admission date of 8/11/25.On 8/12/2025 at 11:15 am, V1 (Administrator) stated the following, R5 left the facility alone on yesterday (8/11/2025) at 1:30 pm and has not returned to the facility. R7 eloped during a smoke break on yesterday (8/11/2025). R6 left out on pass on 8/9/2025 and has not returned yet. I have been in contact with the police department and there is no new information regarding their whereabouts.On 8/13/25 at 3:37 pm, V6 (Smoking Monitor) stated the following, On Tuesday (8/11/25) during the 2:00 pm smoke break, a new resident (R7) was outside smoking and began walking off. Another smoking monitor was following him (R7) and he crossed the street. I came in the building and announced a code 99 (elopement code) because he (R7) was away from the smoking area. At that time, staff members ran out to try and get him but couldn't find him. I have not seen him since.On 8/13/25 at 4:30 pm, V12 (Social Service Director) stated the following, R7 had just been admitted to the facility. Usually, a smoking and elopement assessment is done within 24 hours of admission. In certain cases, I will allow the resident to smoke with supervision prior to the assessments (smoking and elopement). Residents who are elopement risks and new admits are scheduled a specific time to smoke (apart from the other smokers) to have special supervision. I had allowed R7 to smoke with the regular smokers and smoking monitor because he was agitated and stated that he had not smoked in days.On 8/18/25 at 4:55 pm, V26 (Medical Doctor) stated the following, When a patient is admitted to the facility, the patient should have an evaluation prior to being allowed to go out and smoke or to go out on pass. If no evaluation is done, there is a great risk taken when a resident is allowed out of the facility because we don't know that patient. If a patient elopes, especially a psych patient, we don't know what can happen because they are mentally unstable.Employee statement written by V6 (Smoking Monitor) on 8/11/25 documents, V27 (Smoking monitor) had lit R7's cigarette and sat down. I (V6) was bringing the wheelchair (residents) up (the ramp back into the facility) and as I was focusing on that, R7 started to get up and walking away from the smoking area. V27was following him and asking where he (R7) was going. The moment R7 passed the curb of the sidewalk. I had went up the ramp and yelled out to the receptionist to announce a code 99 over the intercom. A code 99 stands for a resident who is fleeing or running away. On 8/20/25 at 11:30 am, V1 (Administrator) stated that R7 had not returned to the facility.R7's Medical Chart excludes an elopement assessment, elopement care plan, smoking assessment/ agreement or smoking care plan.Facility Census report dated 8/11/25 excludes R7 as an active resident.R6 is [AGE] year-old with diagnoses including but not limited to: Suicidal Ideations, major depressive disorder, bipolar disorder and schizoaffective disorder.During investigation on 8/12/25 at 2:00 pm, V4 (LPN/ Licensed Practice Nurse) stated the following, when R6 went out on pass on 8/9/25 I gave him a pass. R6 came to the nursing station and said that he was leaving the facility and coming back at 4:00 pm. Once he takes the pass to the front desk, he is supposed to sign out and back in by 4:00 pm. My shift ended at 3:30 PM. When I was leaving that day (on 8/9/25), I (V4) informed V5 (LPN) that R6 had not returned yet since V5 was R6's night nurse. When I came in the next day (on 8/10/25), I also notified management once I realized that R6 still had not returned to the facility. I am not sure if management was notified prior to my notification.On 8/12/25 at 12:48 pm, V2 (Director of Nursing/ DON) stated the following, We (facility staff) are responsible for the residents, and it is important to recognize early if a resident is missing so that the resident can be searched for and reported to the police. Most residents take medication and have medical conditions and psychiatric issues. We want to make sure that they are safe. I am mainly concerned with their safety and them committing suicide. The receptionist is contacted between 4:30pm and 5:00 pm by the assigned nurse if a patient has not returned on a unit. At that point, the receptionist can verify whether or not the resident has signed back into the facility. If the patient has not signed back in, I (V2) or V1 (Administrator) are notified and a head count is done. V5 texted me at 8:18 pm (on 8/9/25) and notified me that R6 was missing. Everyone (staff) on each floor check for the missing resident. We notify the family in case the family may know where the resident may be, we call nearby hospitals and the physician is also notified at that time. It is imperative that we are notified of a missing resident as soon as possible. If a resident does not sign back in by curfew at 4:00 pm, management should be notified.On 8/13/25 at 3:00 pm, V7 (Receptionist) stated the following, I work 7:30 am- 3 pm. V10 (Receptionist) works from 3:00 pm - 11 pm. Any residents that come in and out has to sign in and out. The residents' curfew is 4:00 pm and the times that they stay out of the facility overnight is prearranged by family or friends. The family or a friend will have to sign the resident out and it will be documented in the system that the resident is out overnight and for a certain period. If a resident is not in the facility by 4:30 PM, the receptionist informs the nurse and also the social worker.On 8/13/25 at 3:45 pm, V10 (Receptionist) stated that if a resident is not back by 4:00 pm, that she notifies the nurse on duty at 4:00 pm so that the nurse can initiate the notification process. On 8/20/2025 at 2:35 pm, V5 (LPN) stated the following, Normally the curfew is 4:00 pm. If I don't see a resident after dinner at 4:30 pm, I am alarmed to look for the resident. During dinner, we are supposed to do head counts and the CNAs (Certified Nurse Assistants) do head counts every two hours. The CNAs have a piece of paper (roster) with resident's names (per floor) and they (CNAs) check off the residents' names. I realized that R6 was missing at 6:30 or 7 pm (on 8/9/25). I thought that his pass was extended or something, so I didn't worry too much about R6. I notified management around 8:30 pm but I don't know if I documented it or not. It is important to notify management immediately so that they can start the investigation process early to see if they (the residents) are hurt or in the hospital. Management should be notified immediately.On 8/18/25 at 4:55 pm, V26 (Medical Doctor) stated the following, mentally unstable residents are at risk for danger and their safety should be a priority. Routine head counts are important to recognize if a patient is not present in the facility.On 8/20/25 at 3:30 pm, V1 stated that he could not locate the resident rounding checklist (roster) for the third floor (R6's floor) for 8/9/25.R6s' Nurse's Note dated 8/10/2025 at 12:27 pm and authored by V4 (LPN) documents, writer called 911 of missing person since yesterday. R6 did not return to the facility by 4:00 pm. R6s' Nurse's Note dated 8/10/2025 at 10:34 pm documents, R6 has not returned back to the facility. Facility's Resident Sign-out Sheet dated 8/9/2025 documents exclude R6's signature.R6's Nursing Progress notes excludes any documentation on 8/9/25 of R6 signing out of the facility. Missing Persons Police Report dated 8/9/2025 documents R6 missing as of 8/9/2025 at 9:00 am.On 8/20/2025 at 3:30 pm, V1 stated that R6 returned to the facility on 8/17/25 (eight days later).R5 is a [AGE] year-old with diagnosis including but not limited to: Schizoaffective disorder, schizophrenia, essential hypertension and chronic obstructive pulmonary disorder.During investigation on 8/12/25 at 11:15 am, V1 (Administrator) stated the following, R5 left the facility alone on 8/11/25 at 9:00 am and has not returned to the facility. I have been in contact with the police department and there is no new information regarding R5's whereabouts. I was notified at 9:15 pm (on 8/11/25) that R5 was missing. On 8/12/2025 at 12:48 pm, V2 (DON) stated that all residents required a doctor's order to leave the facility independently and that she (V2) was not aware that R5 did not have a doctor's order for independent pass privileges. At that time, V2 also stated that she was new in her role and was not totally sure of whose responsibility it was to update pass orders. On 8/13/2025 at 3:00 pm, V7 (Receptionist) stated the following, R5's pass privileges are posted on the pass list at the front desk. His pass privileges are with supervision meaning that he may not leave the facility without supervision. He signed out on 8/11/25 without supervision.On 8/13/2025 at 4:30 pm, V12 (Social Service Director) stated the following, I update the pass list for the front desk according each residents current doctor's orders. I was not aware that R5 did not have a doctor's order to go out on pass. Any nurse in the facility has the authorization to update a resident's orders per Doctor. On 8/18/2025 at 4:55 pm, V26 (Medical Doctor) stated the following, All patients need a doctor's order to go out on pass and In order to go out overnight, the patient's family would have to sign the patient out of the facility. If a patient does not sign back into the facility after being out, the Doctor, family and facility administrator should be notified immediately. Anything could happen to the resident in a short period. I personally know of an incident involving a resident getting hit by a train after leaving a facility unauthorized.On 8/20/2025 at 2:50 pm V11 (Registered Nurse/ RN) stated the following, We (nurses) usually give the resident the pass to leave. I gave R5 a pass on the day that he left (8/9/25). I was not aware that R6 did not have a physician's order to leave the facility. Before we (nurses) were not checking the pass privileges before resident leaves but now we do. When a resident goes out on pass, they have be back at the facility by 4:00 pm. There is a two-hour rounding documented by the CNAs. If a resident is not here by 4:00 pm, we must notify the DON (Director of Nursing) immediately and investigate.On 8/20/25 at 3:30 pm, V1 stated that he could not locate the resident rounding checklist (roster) for the third floor (R5's floor) for 8/11/25.R5's Nurse's Note dated 8/11/25 at 10:19 pm documents, R5 left on pass and failed to return.R5 Physician Order sheet documents the following active order as of 7/22/25, may not go out on pass. Facility Front Door List dated 8/12/25 documents R5's pass privileges as ‘with supervision'.Facility's Resident Sign-out Sheet dated 811/25 documents, R5 signed out of the facility at 1:30 pm.Missing Persons Police Report dated 8/12/25 documents R6 missing as of 8/11/2025 at 1:30 pm.An IJ occurred when: R6 signed out at the receptionist and left the faciity on [DATE] at 9:00 am with temperatures over the weekend ranging in the 90s and did not return until eight days later; the facility failed to conduct resident checks (every two hours), therefore did not notice that R6 was not in the facility on 8/9/25 until around 8:00 pm; R6's assigned nurse (V5) did not notify management (Administrator or Director of Nursing) that R6 did not return to the facility until hours after 4 pm curfew (at 8:18 pm).R5 left the facility unsupervised and without a doctor's order on 08/11/25 at 1:30pm. R5's assigned nurse (V11) did not follow Doctor's order regarding R5's pass privileges; The facility failed to ensure R5's safety as he was allowed out of the facility (unauthorized); staff did not notice that R6 was not in the facility on 811/25 until around 9:00 pm; V5 (LPN) did not notify management that R5 did not return to the facility until hours after 4 pm curfew (at 9:15 pm); as of 8/21/25, R5's whereabouts still could not be confirmed.And when R7 eloped from the facility shortly after his admission on [DATE] during a smoke break around 2:00 pm; R7 was never assessed for smoking or elopement risk prior to being permitted outside to smoke; As of 8/21/25, R7's whereabouts still could not be confirmed.On 8/21/25, IDPH (Illinois Department of Public Health) was notified of R7's 8/11/25 elopement and R5's unauthorized leave on 8/11/25 (10 days after incidents occurred).On 8/21/25, IDPH (Illinois Department of Public Health) was notified of R6's unauthorized leave on 8/9/25 (12 days after occurrence). Facility Policy titled Wandering and Elopements documents, the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.Facility Smoking policy documents, the resident will be evaluated on admission to determine his/ her ability to smoke safely with or without supervision (per a completed smoking evaluation); The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the smoking evaluation. Facility Outside Pass Policy documents, residents may not be considered for community outside pass privileges without physician order. Facility policy titled Missing Resident documents, at the beginning of each shift, during med pass, and each meal the staff shall account for all at-risk residents under their perspective care. Facility Census dated 8/12/2025 documents a total of 123 active residents. On 8/19/25 and 8/20/25, surveyor confirmed through record review and interviews that the facility took the following actions to remove the Immediate Jeopardy: (However deficiency remains at a level two because more time is needed to evaluate the implementation and effectiveness of staff training). 1. The reception desk and each nurse station were provided with updated list of residents who can and cannot go out on pass. This was initiated on 8/15/25 and ongoing. 2. Pass Orders were initiated for all residents by the DON (director of nursing)/designee. Out on Pass Orders will be reviewed for all admissions, readmissions, or change in status by the DON (director of nursing), Administrator, Social Services/ Designee. This was initiated on 8/15/25 and ongoing. 3. The Front desk staff were up-dated on the following pass procedures: Front desk staff will monitor return times for those out on pass; Each resident is expected to sign back into facility by 4:00 pm (unless previous overnight arrangements were made and approved); Immediate investigation and notification of missing person is initiated if a resident does not return from being out on pass: Investigation begins with a facility-wide search of resident; Notification of missing person to Administrator, DON/ designee and family of suspected absence as soon as practical; local area hospitals are contacted. This training was conducted on 8/15/25 and ongoing. 4. On 8/14/2025, Resident head count of the facility was initiated and documented by the DON; headcounts are conducted during shift change as part of the nurse-to-nurse shift reporting and when the staff identifies that a resident is missing; On 8/18/2025, Resident 2-hour rounding was initiated by Nurses and CNAs (Certified Nurse Assistants) on duty to ensure residents are accounted for; On 8/18/2025, head counts during smoking breaks initiated by Smoking Monitors/PRSC's/Maintenance staff/Designated staff monitoring smoke breaks; Residents are signed in and out of facility during smoke breaks. 5. Social Services Director/ Designee updated the facility elopement binders with pictures of residents and care plans with interventions for those who are restricted from leaving by physician's orders; elopement binders were placed in all nursing stations, kitchen, front desk, and department head offices; the elopement binder is updated when a new resident is added to the binder; A resident is added to the binder when the resident is identified with exit- seeking behavior/risk for elopement. Initiated on 8/15/25. 6. The Social Services Director/ Designee developed care plans for all residents identified with wandering behavior/ elopement risk on 8/15/25. 7. On 8/21/2025, IDPH was notified of R7's 8/11/25 elopement, R5's unauthorized leave on 8/11/25 and R6's unauthorized leave on 8/9/25.

Based on interviews and record review, the facility failed to report that one newly admitted resident (R7) eloped from the facility; and failed to report that two residents (R5 and R6) left the facility unauthorized and did not return to the facility. This failure has affected three of fifteen residents in the sample and has the potential to affect all 123 residents that reside in the facility.R5 is a [AGE] year-old male with diagnoses of Schizophrenia, schizoaffective disorder, essential hypertension, tachycardia, and chronic obstructive pulmonary disease.R6 is a [AGE] year-old male with diagnoses of schizoaffective disorder, suicidal ideations, acute embolism, and thrombosis of unspecified deep veins of bilateral lower extremity, Gastro-esophageal reflux disease.R7 is a [AGE] year-old male with diagnoses of bipolar disorder, major depressive disorder, generalized anxiety, tachycardia, insomnia, and suicidal ideations.During investigation on 8/12/2025 at 11:15 AM, V1 (Administrator) stated the following, R5 left the facility alone on yesterday (8/11/2025) at 1:30 pm and has not returned to the facility. R7 eloped during a smoke break on yesterday (8/11/2025). R6 left the facility out on pass on 8/9/2025 and has not returned yet. I (V1) have been in contact with the police department and there is no new information regarding their whereabouts.On 8/12/25 at 12:21pm, V2 Director of Nursing (DON) stated that a Physician order is needed for any resident to leave the facility and that if a resident does not return by 4:00 pm, administration should be notified immediately for further instructions to be carried out. On 8/12/25 at 2:00 pm, V4 (LPN/ Licensed Practice Nurse) stated the following, when R6 went out on pass on 8/9/25 I gave him a pass at 1:30 pm. My shift ended at 3:30 PM. When I was leaving that day (8/9/25), I informed V5 (LPN) that R6 had not returned yet since V5 was R6's night nurse. When I came in the next day (8/10/25), I also notified management once I realized that R6 still had not returned to the facility.On 8/13/25 at 12:23pm, V1 stated that he had been in contact with the police department and that there was no information regarding the whereabouts of R5 and R6. At that time V1 also stated that he was not aware that he had to report missing residents to the State Agency.Employee statement written by V6 (Smoking Monitor) on 8/11/25 documents, V27 (Smoking monitor) had lit R7's cigarette and sat down. I (V6) was bringing the wheelchair (residents) up (the ramp back into the facility) and as I was focusing on that, R7 started to get up and began walking away from the smoking area. V27 was following him and asked where he (R7) was going. The moment R7 passed the curb of the sidewalk. I (V6) had went up the ramp and yelled out to the receptionist to announce a code 99 over the intercom. A code 99 stands for a resident who is fleeing or running away from the facility. R7's Medical Chart excludes an elopement assessment, elopement care plan, smoking assessment/ agreement or smoking care plan.R5's Nurse's Note dated 8/11/25 at 10:19 pm documents, R5 left on pass and failed to return.R5 Physician Order sheet documents the following active order as of 7/22/25, may not go out on pass. Facility Front Door List dated 8/12/25 documents R5's pass privileges as ‘with supervision'.Facility's Resident Sign-out Sheet dated 811/25 documents, R5 signed out of the facility at 1:30 pm.Missing Persons Police Report dated 8/12/25 documents R6 missing as of 8/11/2025 at 1:30 pm.R6s' Nurse's Note dated 8/10/2025 at 12:27 pm and authored by V4 (LPN) documents, writer called 911 of missing person since yesterday. R6 did not return to the facility by 4:00 pm. R6s' Nurse's Note dated 8/10/2025 at 10:34 pm documents, R6 has not returned back to the facility. Facility's Resident Sign-out Sheet dated 8/9/2025 documents excludes R6's signature.R6's Nursing Progress notes excludes any documentation on 8/9/25 of R6 signing out of the facility. Facility Census report dated 8/11/25 excludes R5, R6 and R7 as active residents.Facility reportable binder excludes reported incidents regarding R5, R6 or R7.Facility's undated policy titled Accidents and Incidents-Investigating and Reporting documents in part: All accidents or incidents involving residents, employees,visitors,vendors,etc.,occurring on our premises shall be investigated and reported to the administrator; Policy Interpretation and Implementation:2.(a)The date and time the accident or incident took place;(b) The nature of the injury/illness;(g) The time the injured person's physician was notified, as well as the time the physician responded and his or her instructions;(h)The date/time the injured person's family was notified and by whom;(n)The signature and title of the person completing the report;(4)The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Incident report and submit the original to the director of nursing services within 24 hours of the incident or accident.

Based on interview and document review the facility failed assure the resident right to be free of physical abuse in 1 of 3 (R1) residents in a total sample of 8 residents. This failure resulted in R1 having bleeding lips, bump to right temporal area and feelings of fearing for his life. Findings include: The following incident took place on 4/28/25, around dinner time in the facility dining area. R1 is a [AGE] year-old male with diagnoses including Schizophrenia, Seizures, Depression, Scoliosis and Post-Traumatic Stress Disorder. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview of Mental Status) score of 15/15. R1 is care planned for including alteration in mental health function due to Schizophrenia and Depression. On 4/28/25, R1 was involved in a physical and verbal altercation with another resident R2. The altercation resulted in R1 having bleeding on lips and bump to right temporal area. R2 is a [AGE] year-old male resident with diagnoses including Schizoaffective Disorder, Bipolar Type, Diabetes 2, Anxiety and Epilepsy. R2 has a BIMS (Brief Interview of Mental Status) score of 15/15. R2 was first admitted to the facility on [DATE]. R2 is care planned for alteration in mental health function. Per nurse notes on 4/25/25, R2 was hospitalized due to aggressive behavior. On 4/28/25, R2 had a physical altercation with R1. On 5/12/25, at 11:43 AM, R1 stated I was at the table. I walked past R2's table. He got up and knocked me to the floor. R2 started punching me in the face at least 10 to 12 times. I got a bloody lip and a swollen face. My leg and arm hurt. There was kitchen staff standing in the doorway, but they didn't do anything. R4, my roommate, was there and stopped R2 from hitting me. I went to the DON (Director of Nursing) and told her what happened. The nurse took care of my lip. The police came and said they couldn't do anything since this is a mental institution. They took me to the hospital, but I didn't want to wait and came back to the facility. I was very traumatized and feared for my life when the incident happened. Facility document titled IDPH Incident/Accident Report Notification dated 5/2/25, includes statement R2 did have a physical altercation with resident R1. Both residents were separated immediately. R2 was transferred to the hospital due to aggressive behaviors and was admitted to inpatient psychiatric unit. R1 is currently a resident of the facility and feels safe in the building. He does not have any concerns during investigation or at the conclusion. Resident care plan has been updated accordingly. R2 is currently at hospital on inpatient psychiatric unit. Upon readmission resident will be reassessed and care plan will be updated accordingly. R1's progress note dated 4/28/2025, notes this writer was called in the office to assist resident and to take his vital signs Blood Pressure/BP: 141/88 Resting Respirations/RR: 18 Heart Rate/HR:88 temp:97.6 Oxygen Saturation/spo2: 98%. R1 noted bleeding on his lip. R1 stated he got hit in the dining room by another resident. Staff assessed R1. R1 was observed with no bruising. Staff noted bump on his right temporal area and applied ice. R1 was given tylenol 650mg for his pain until police came to interview and escort him in the hospital. R1 refused to call family regarding incident. Medical doctor was notified. R1 was escorted to the hospital by the police department. Progress note dated 4/28/2025, notes R1 came back in the facility. He left the hospital because he is waiting in the waiting room for a long time. He cannot wait for a long time. This nurse notified the physician with new orders for x-rays of his leg and right arm. Vitals are stable and R1 took his meds for the night. As stated above in progress note, R1 left the hospital before being assessed. No hospital record is available. Progress note dated 4/28/2025, notes writer notified physician regarding resident leaving hospital AMA (Against Medical Advice) in the emergency department due to trauma incident. Per the medical doctor, may order x-rays of the spine, right hand, and right leg to rule out fracture. Writer called medical diagnostic for x-ray. Progress note dated 04/30/2025, notes x-ray result came back normal. (no fractures). On 5/12/25, at 1:13 PM, V6 (Dietary Aid) stated on 4/28/25, we heard a commotion in the dining area. I was in the kitchen. When I looked in the dietary area R1 and R2 were not fighting but other staff were in there. On 5/12/25, at 1:20 PM, V7 (Dietary Aid) stated I was washing dishes when I heard a tray hit the floor in the dining area. I did not see what happened. V6 (Dietary Aid) looked and said he didn't see any altercation at the time, but staff were in there talking to R1 and R2. On 5/12/25, V8 (Registered Nurse/RN) stated I saw him (R1) in office. I gave him ice and did vital signs. He sat with me at the nurses' station to keep an eye on him. He complained of injury on head, right leg, right hand, and right hip. I put a splint on the right hand. The physician was notified and ordered R1 to the hospital emergency room. R1 went to hospital but he refused to wait for brain scan and came back to facility. I told the physician, and he just ordered x-rays at the facility. The x-rays turned up negative. On 5/12/25, at 11:31 AM, V5 (PRSD) stated R1 and R2 were in a physical altercation. R1 went to pick up R2's tray at lunch as he was trying to help the kitchen staff. R2 got up and knocked R1 to the floor. R2 punched him in the face multiple times. R1 reported the incident to staff. R1 sustained a bloody lip. R1 went to the hospital but left the waiting room. R1 came back to facility. R2 was sent out to the hospital for evaluation and has not returned. R2 has never physically assaulted anyone in the facility before. This is the first time he has ever hit anyone. On 5/13/25, at 12:48 PM, V12 (Physician) stated the nurse notified me of the altercation between R1 and R2. R1 was struck in the head and also was put on the floor. R1 complained of pain to head, right arm, right leg, and back. I ordered R1 to the hospital for evaluation. R1 refused and left the hospital after being brought to the hospital. R1 returned to facility. I ordered x-rays at the facility. The x-rays came back negative for any injury. R1 was monitored for any more serious head injury. R1 did get a bloody lip and that was treated at the facility. That is all I could do. When someone gets hit in the head there is potential for serious injury. Facility policy titled Abuse Prevention Program, Policy Statement shows 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 from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat resident symptoms.

Based on interview and record review, the facility failed to prevent and protect residents from physical abuse. This failure affected 2 (R1 and R2) out of 7 residents reviewed for abuse. R1 and R2 had a brawling incident on 3/28/25 that resulted in R2 having a nosebleed. The findings include: R1's admission record showed admitted on 2/24/2025 with diagnoses not limited to Schizophrenia, Insomnia, Anorexia, Attention-deficit hyperactivity disorder, predominantly inattentive type. MDS (Minimum Data Set, dated dated dated [DATE] showed R1's cognition was intact. R2's admission record showed admitted on 1/13/2025 with diagnoses not limited to Schizophrenia, Bipolar disorder, Depression, Essential (primary) hypertension, Insomnia. MDS dated [DATE] showed R2's cognition was intact. On 4/20/25 at 9:22AM R2 sitting on the side of the bed, alert and oriented x/times 3, verbally responsive. R2 stated R2 has been residing in the facility since mid-January 2025. He (R2) is ambulatory with steady gait, no assistive device. He (R2) said on 3/28/25, there was a fight/physical contact incident between him (R2) and R1. R2 said he (R2) was in the lobby when he (R2) was looking in R1's direction. R2 stated R1 looked back at him (R2) and said, what the F*** are you looking at? R2 then stated who are you talking to? R2 said R1 went to him and started attacking him. R2 said R1 purposely/deliberately hit him with his fist on his chin and nose. R2 said R1's fist touched his nose and chin. R2 said he (R2) did not fight or hit back R1. He (R2) said V9 (Escort), V11 (Activity Aide), V16 (Maintenance Director) were present during the fight/brawling incident and were able to separate them right away. R2 said he had a bloody nose and was assisted by V16 to the 4th floor nurse's station to be checked. R2 said there was mild pain to his nose and chin after the fighting incident. R2 stated after he was checked by the nurse on the floor, he requested V16 to bring him down to the lobby to speak with DON/Director of Nursing to file a grievance regarding the incident between him and R1. R2 said as he was at tin lobby on the 1st floor and R1 was on other side of the lobby by the 1st floor dining room, R1 attacked him again. R2 said R1 keep charging, swinging his arm and hitting him with his fist. R2 said he hit R1back with his fist and landed on R1's chin, chest and arm. R2 said he grabbed R1's leg and took him down to the ground. R2 said staff was having a hard time separating them. R2 stated Police and paramedics came. R2 stated he and R1 were sent to the hospital. On 4/20/25 at 9:55AM R6 sitting on the side of the bed, alert and oriented x 3, verbally responsive. R6 said R1 is his roommate and has been out on pass. R6 said he witnessed the fight between R1 and R2 on 3/28/25. R6 stated he was in the lobby waiting for trust fund and he saw R1 moving towards R2. R6 said he saw R1strike/punch/hit R2. R6 stated R2's fist landed / hit R1's chest, chin a couple of times. R6 stated he saw R1 on the ground, bleeding a little bit. R6 said the fight happened so fast and staff were trying to separate them. R6 stated police and paramedics came to the facility. R6 said it looks like R1 was hurt because he was transferred to the hospital. On 4/20/25 at 10:02AM R7 by the dining room (1st floor), ambulatory with steady gait, alert and oriented x 3, verbally responsive. R7 said on 3/28/25, there were 2 physical fight incidents between R1 and R2 in the lobby. R7 stated R1 and R2 exchanged punches/hit each other. R7 said R1 and R2's fist landed or touched each other's face. R7 stated he saw R1 on the floor by the lobby. On 4/20/25 at 10:06am V6 (Activity Director) stated on 3/28/25 there was an incident between R1 and R2. V6 stated V6 was in a meeting and heard the commotion. V6 stated V6 went out and saw staff separating R1 and R2. V6 said, about 30 - 45 minutes later, he heard a commotion again in the lobby and saw R1 and R2 were on the floor. V6 stated he did not see the actual fight, but police came to the facility and intervene. On 4/20/25 at 10:34am V9 (Escort) said on 3/28/25, there were 2 separate fights between R1 and R2 in the lobby. V9 said R1 and R2 physically hit each other, throwing punches and staff were able to separate them right away. V9 said the 2nd fight happened in the lobby again. V9 stated R1 and R2 coming out of the dining room by the lobby going towards each other. V9 said it's hard to break up 2 men fighting. V9 stated staff called for help. V9 said she saw R1 on the floor / pinned down to the ground. V9 stated the fight happened so fast, police and paramedics came to the facility. On 4/20/25 at 10:57am V11 (Activity Aide) stated on 3/28/25 there was a physical fight that happened in the lobby (1st floor) between R1 and R2. V11 said, R2 was coming from the activity room (1st floor) and R1 was waiting for the elevator (1st floor). R2 was telling R1 what B**** Ass you're looking at. V11 said R1 told R2 that he was tired of picking at him. V11 said R1 and R2 exchanged words, started charging at one another. V11 said R1 and R2 started fighting/exchanging punches. V11 said R1 and R2 physically hit each other on the face and chest. V11 said it was willful and deliberate physical fight between R1 and R2 and staff was able to separate R1 and R2. V11 stated V16 (Maintenance Director) kept R2 by the dining room and R1 by the door in the lobby. V11 said both R1 and R2 were kept on the first floor. V11 stated the 2nd fight happened about an hour later between R1 and R2. V11 said R1 and R2 exchanged blows, they hit each other. V11 said R1 and R2's fists landed on each other's face, arm, chest whatever was open to be hit. V11 said both R1 and R2 were on the ground / floor in the lobby. V11 stated R1 was pinned down on the ground and was crying. V11 stated she heard R1 complaining of back pain. V11 said staff called police to the facility. V11 said R1 was handcuffed. V11 said the 2nd fight could have been prevented if R1 and R2 were not seeing each other or were not placed in the same location (1st floor). On 4/20/25 at 11:17AM V13 (RN/Registered Nurse nursing supervisor) stated she been working in the facility for [AGE] years. She said had witnessed the physical fight between R1 and R2 on 3/28/25 at the lobby. She said she was inside V2's (DON/Director of Nursing) office when she heard a commotion. V13 stated she went to the lobby and saw R1 and R2 physically punching / hitting each other on the face. V13 stated police were called. V13 said both R1 and R2 were on the ground/floor in the lobby. V13 said police and paramedics came to the facility and R1 and R2 were transferred to the hospital. On 4/20/25 at 12:19PM V16 (Maintenance Director) stated there were 2 physical fight incidents between R1 and R2 on 3/28/25 in the lobby (1st floor). V16 said they were in a meeting and heard a commotion. V16 said they went to the lobby, R1 and R2 were separated by staff already. V16 said R1 was moved to the door by the lobby. V16 stated he saw R2 with blood on his right-hand finger. V16 said, R2 appeared to have been assaulted, he was breathing heavy and was escorted to the 4th floor for the nurse to see him. V16 Stated R2 was checked by the nurse on the 4th floor. V16 said R2 wanted to press charges against R1 and requested to be brought back down to the 1st floor lobby. V16 said R1 was by lobby door and when R2 was coming out of the elevator, words were exchanged between R1 and R2 who were yelling and screaming at each other. V16 said R2 was by DON's office in the lobby and R1 was by the door in the lobby. V16 said it happened so fast, when R1 ran towards R2, R1 swung and hit R2 on the side of the head. V16 said R1 and R2 were hitting each other's face. V16 stated R1 put R2 on a head lock and choking him. V16 said he tried to go in between to separate R1 and R2. He said on the process of separating both residents, the 3 of them ended on the ground / floor at the lobby. V16 said he was able to remove R1's arm from R2's neck to release the pressure from a head lock. Ambulance came, R1 and R2 taken to the hospital. V16 said there was willful and deliberate physical contact between R1 and R2. V16 stated if he was trained better regarding abuse, then then the 2nd fight could have been prevented. V16 said he should not bring R2 back in the same location where R1 was. V16 stated he did not receive a specific procedure on how to deal abuse. On 4/20/25 at 12:44PM V2 (DON/Director of Nursing) said on 3/282/25, they were in a meeting when she heard a commotion. V2 stated we went to the lobby and saw R1 and R2 being separated by staff. V2 said V2 did not witness the physical fight incident between R1 and R2. V2 said R2 sustained a bloody nose after a fight incident as reported to her by nurse on duty V17 (Agency LPN/Licensed Practical Nurse). V2 said she was not sure if there was a complaint of pain. V2 said, 2nd fight happened early afternoon about an hour later from the 1st fight. V2 said R1 and R2 get to each other again. V2 said that it was reported to her that R1 and R2 had a physical fight, punch / hit each other on the face. Stated she saw R1 on the ground / floor at the lobby with police and R2 was in the dining room [ROOM NUMBER]st floor. V2 said the 2nd fight could have been prevented if R1 and R2 were not placed/kept in the same location (1st floor) after the first incident. On 4/21/25 At 1:41PM V1 (Administrator) was interviewed via phone and stated he has been an administrator in the facility for 3 weeks and he is the Abuse coordinator. He said he was not in the building on 3/28/25, when R1 and R2 had a physical altercation. V1 stated it was reported to him and staff were able to separate both residents (R1 and R2). He said one of the residents had a bloody nose. He said he is aware of the 1st and 2nd fight as it was reported to him. V1 said if R1 and R2 were not in the same location (lobby), the 2nd fight could have been prevented. On 4/20/25 and 4/21/25, R1 was out on pass, surveyor attempted to call R1 multiple times to no avail. Care plan dated 3/17/25 showed in part: R1 has a history of aggressive/inappropriate behavior. Has exhibited problems with self-management and self-regulation and displays socially inappropriate maladaptive behavior. R1's Nurse's Note dated 3/28/2025 showed in part: Resident had an altercation with another resident and another resident highly agitated verbally and physically aggressive. 911, police came and took over and was transferred to the hospital. R1 was admitted in the hospital with diagnosis of bipolar disorder. R2's Nurse Note dated 3/28/2025 showed in part: R2 had an altercation with another resident and another resident highly agitated verbally and physically aggressive. 911, police came and took over and R2 was transferred to hospital with petition. R2 admitted in the hospital with diagnosis of bipolar disorder. R2's care plan dated 1/13/25 showed in part: R2 has an alteration in mental health function related to diagnosis of Schizophrenia., Bipolar Disorder. On 3/7/25, R2 was highly agitated and verbally aggressive, with paranoid behavior, sent out to hospital. Facility's final incident report submitted to IDPH dated 4/1/25 showed in part: R1 was interviewed and stated this morning 3/28/25, at approximately 7am, he pressed elevator button and R2 made inappropriate remarks towards him. Later, when R1 encountered in the facility's office, R2 act in a disrespectful manner, making disparaging comments saying, Boy watch where you are pressing the button and continued staring at him throughout the day. R1 confronted R2's behavior, he physically pushed R1, leading to a confrontation in which R1 had to defend himself. Later in the day, R2 once again targeted R1 with his actions, provoking and taunting R1. When R1 approached R2 to address the situation, R2 attempted to physically lift R1 off the ground by grabbing his legs, prompting R1 to defend himself by restraining R2. R2 was interviewed and stated, he had to defend himself. An investigation was completed and concluded there was a physical altercation between two residents. Both residents were discharged to the hospital for evaluation on 3/28/25 and were admitted with diagnosis of bipolar disorder. R1's hospital records dated 3/28/25 showed in part: R1 came to hospital ED (Emergency Department) for aggression. R1 was cooperative but very anxious about being in the hospital. Per report, R1 was noted to be verbally and physically aggressive towards peers at the nursing home and was threatening other peers and staff. R2's hospital records dated 3/29/25 showed in part: R2 was sent to the ER (emergency room ) from the nursing home with a petition due to aggressive behavior. R2 reportedly had a physical and verbal altercation with another resident and was hit on the nose. Facility's policy on resident rights dated 11/2020 showed in part: To be free from verbal, sexual, physical and mental abuse. Facility's abuse prevention program policy and procedure dated 1/4/18 showed in part: This facility desires to prevent abuse.

Based on interview and record review, the facility failed to supervise and monitor a resident, who was previously hospitalized for [REDACTED]. This failure affected one resident (R2) of two residents reviewed for resident injury. R2 choked on a peanut butter sandwich, resulting in R2 becoming unresponsive and later intubated in the hospital due to [MEDICAL CONDITION]. Findings include: On 10/13/20, V2 presented the following records of R2: 1. R2's Hospital Records Discharge Summary, dated 9/29/20 written by V10, Hospital Physician, states, Patient was unresponsive, tachypneic, and oxygen saturation was 50-60 percent (%) on ambient air. Patient was immediately intubated in the ED (Emergency Department) by the ED MD (Medical Doctor) and Peanut Butter in the airway was suctioned out. The hospital record also states that R2's [DIAGNOSES REDACTED]. Plan states: Secondary to hypoxemia, [MEDICAL CONDITION], and the patient required intubation essentially on arrival. I used a glide scope video-assisted device with success. He did require large amount of suctioning secondary to the large amount of peanut butter in his airway. V10 also referred to the prior choking episode approximately one year ago on 9/13/2019, when R2 was hospitalized from [DATE] to 9/16/2019, for Aspiration Pneumonia. 2. R2's Care Plan, dated 9/29/2019, states that R2 has a swallowing problem related to Dysphagia and needs extensive assistance when eating; 3. R2's Nutritional Risk Review, dated 2/27/2020, states that R2 is on Aspiration Precaution, and needs extensive assistance in eating to ensure adequate PO (oral) intake; 4. R2's Incident Report, dated 9/12/20, that was sent to the State Agency on 9/13/20 and the investigation by the facility; 5. R2's progress notes which showed R2 was sent to the hospital for Aspiration Pneumonia about a year ago, specifically on 9/13/2019, and now, had this choking incident, for which R2 was intubated. On 10/13/20 at 1:40 PM, V2 (Director of Nursing) stated R2 was in the hospital for over two weeks and is back at the facility. On 10/13/20 at 1:45 PM, V2 stated that R2 had a behavior of grabbing food from another resident and might have grabbed another sandwich, however, no such behavior was documented on R2's care plan either before or after the choking incident. On 10/14/20 at 3:43 PM, V11 (Licensed Practical nurse, LPN) was interviewed regarding R2's choking incident of 9/12/20. V11 stated that during his rounds, he saw R2 holding his neck and coming towards him. He realized that R2 was choking and he did the [MEDICATION NAME] maneuver, and there was no pulse, and 911 was called. V11 stated that V12 (CNA, Certified Nurse Assistant) had given R2 the evening snack which was a sandwich. Facility's policy on Aspiration Precautions, dated 1/1/2020, states in #3: Residents that have been assessed to be a risk for aspiration will be monitored on a regular basis. Any further identified aspiration will be relayed to the MD for additional and treatment.