**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident's (R4) right to be free from sexual abuse by a facility staff member. This failure resulted in R4 experiencing psycho-social harm from V13's (Certified Nursing Assistant/CNA) inappropriate sexual touching. The facility also failed to protect a resident's (R2) right to be free from physical abuse by another resident (R1). This applies to 2 of 6 residents (R2 and R4) reviewed for abuse. The findings include: 1. On 6/03/2025 at 10:00 AM, R4 said V13 (CNA) had sexually touched her private vaginal area with his gloved hand and fingers when rendering incontinence care on the early morning of 6/01/2025. R4 said she told V13 to stop touching her because he was causing her pain in her private area. R4 said V13 would take approximately thirty minutes when providing her incontinence care, which was unusual for her. R4 said V13 had done this to her three times prior when rendering incontinence care. R4 said the prior incidents had occurred in the past months after she no longer had a roommate. R4 said she had not reported the prior incidents because she was afraid but after the last incident on 6/01/2025, she decided to report it to her family because it was painful. R4 said she also did not want this to occur to other residents. R4 said she then decided on 6/02/2025 to be transferred to the hospital for a sexual assault exam. R4 said she was told her exam showed trauma and has decided to pursue criminal charges. On 6/04/2025 at 11:00 AM, R4 said V13's inappropriate sexual contact to her vaginal area made her feel sexually violated. R4 said she had been fearful that V13 would continue to care for her after the incidents. R4 said she now felt safe that V13 was no longer at the facility. On 6/02/2025 at 1:55 PM, V14 (R4's Family Member) said R4 called her on the evening of 6/01/2025 and reported V13 had touched her private area inappropriately when providing incontinence care on four different occasions including on 6/01/2025. V14 said she notified V1 (Administrator) immediately. On 6/02/2025 at 12:40 PM, V17 (Social Worker) said she conducted a well-being check on R4 after being informed of R4's reported incident. V17 said R4 was alert and reviewed her care plan. V17 said R4 had no behaviors or history of reporting abuse. On 6/04/2025 at 10:15 AM, V15 (Hospital Sexual Assault Nurse Examiner/SANE) said she interviewed, recorded a physical assessment, and collected samples from R4 after she went to the hospital for sexual assault treatment. V15 said R4 reported V13 had assaulted her on 6/01/2025 at 3 AM when changing her incontinence brief and had done this three times prior in the past months. V15 said R4 reported V13 touched her vaginal and rectal areas with his gloved fingers causing her discomfort and one time he spit saliva in his hand for lubrication. V15 said R4's vaginal exam showed positive uptake of specialized dye which indicates trauma of abrasions or tears. V15 said she also collected swab samples as part of R4's kit. On 6/04/2025 at 10:50 AM, V16 (Local Police Detective) said he had formally interviewed R4 on 6/02/2025. V16 said R4 wanted to proceed with criminal charges. V16 said the criminal investigation was active and could not provide additional information. On 6/04/2025 at 3:30 PM, V11 (Physician) said on 6/04/2025 he interviewed R4 about her reported incident. V11 said R4 was alert and coherent. V11 said R4's statement about being sexually touched inappropriately by a CNA during incontinence care was consistent. On 6/02/2025 at 5:00 PM, V13 (CNA) was interviewed over the phone. V13 denied R4's allegation. V13 said he on 6/01/2025 he had provided R4 incontinence care at 3 AM and 6 AM. V13 said he had provided care to R4 in the past and believed the last time was weeks prior to 6/01/2025 when she had a roommate. On 6/02/2025 at 11:30 AM, V1 (Administrator) said V14 (R4's Family Member) notified him of R4's sexual abuse allegation involving V13 (CNA) on 6/01/2025. V1 said the facility had initiated an investigation and notified all responsible parties including the local police and V11 (Physician). V1 said V13 was immediately suspended from the building. V1 said R4 had refused to be transferred to the hospital on 6/01/2025 but after talking to V12 (Nurse Practitioner/NP) on 6/02/2025 she agreed. V1 said the facility was reviewing R4's hospital records from 6/01/2025 and communicating with the local police. R4's care plan dated 6/04/2025 had a focus problem initiated on 9/24/2024 for being at risk for abuse and trauma. The care plan said R4 should be observed and monitored to mitigate potential abuse. R4's MDS (Minimal Data Sheet) assessment dated [DATE] showed R4 was cognitively intact. The assessment also said R4 was frequently incontinent of bowel and bladder needing partial to moderate assistance with her toileting hygiene. R4's progress note dated 6/02/2025 said Primary MD by phone about resident reported incident on Saturday night. MD ordered to send resident to hospital ER for evaluation of trauma. V12's (NP) progress note dated 6/02/2025 said RN requested patient be seen for alleged sexual abuse. Pt states that CNA touched her inappropriately Saturday night .Appears to be anxious about events .Provided emotional support. R4's hospital records dated 6/02/2025 said R4 was evaluated and treated for sexual assault. The records said R4 reported V13 touched her inappropriately in her private area with his finger on 6/01/2025 at approximately 3 AM during incontinence care. The record said R4 reported V13 had done this three times prior. The record said R4's vaginal physical exam showed there was positive uptake of toluidine blue dye in five areas. Census List report dated 6/03/2025 showed R4 last had a roommate on 4/21/2025. The facility's untitled document showing V13's (CNA) residents assignments showed after 4/21/2025 V13 was assigned R4 on 4/28/2025, 5/01/2025, 5/15/2025, 5/21/2025, 5/22/2025, and 5/31/2025 on the overnight shift (10:30 PM-6:30 AM). 2. On 5/31/2025 at 9:55 AM, R1 was being assisted with his care by V4 (CNA). R1 was not able to engage in the interview. V4 said R1 was confused and had aggressive behaviors towards others. V4 said R1 had been aggressive towards R2 on 2/19/2025 and 5/14/2025 in the dining room. V4 said R2 no longer resided in the memory care unit. On 5/31/2025 at 9:45 AM, R2 was in her room. V5 (Registered Nurse/RN) asked R2 about her incident involving R1 in her preferred language. V5 said R2 was confused and unable to recall the incident because of her dementia. On 5/31/2025 at 12:05 PM, V7 (Agency CNA) said on 2/19/2025 she was supervising the memory care unit's dining room. V7 said R2 was trying to leave the area when R1 stood and started hitting R2 on the face and head. V7 said she intervened and then R1 launched and swung at her but did not hit her. V7 said R1 was redirected to his room and placed on 1-on-1 supervision till he was transferred to the hospital. On 5/31/2025 at 11:40 AM, V9 (Licensed Practical Nurse/LPN) said on 5/14/2025 he heard arguing coming from the memory care unit's dining room. V9 said R2 was on the floor and R1 was over her swinging his hands at her. V9 said R1 hit the back of R2's head. V9 said he had difficulty redirecting R1 but was able to separate them. V9 said R1 was transferred to the hospital for his aggressive behavior. V9 said R2 quickly forgot about the incident because of her dementia. On 5/31/2025 at 12:10 PM, V1 (Administrator) said he investigated R1 and R2's incidents on 2/19/2025 and 5/14/2025. V1 said his abuse investigation process included obtaining witness statements from those present to identify the root cause of the incident. V1 said R1 was petitioned out and admitted for aggressive behavior after both incidents. V1 said both R1 and R2 had dementia and believed R2's loud noises triggered R1 to flare his arms. R2's care plan dated 5/31/2025 said she had impaired cognition and was confused related to her dementia. The care plan also said R2 was at risk for abuse and trauma. R2's progress note dated 2/19/2025 said At approximately 1215 pm, a physical altercation occurred between [R2] and [R1] in the dining room. Witnesses reported that the incident started when [R2] became upset because [R1] was in the way when attempting to leave the dining room. She began to yell at [R1] in her native language. This evoked a response from [R1], where he struck [R2] in the head. V7's Statement form dated 2/19/2025 said she observed R1 approaching R2 when she was trying to leave the dining room. The statement continued to say R1 then hit R2 in the head with an open hand approximately twice. R2's progress note dated 5/14/2025 said Resident was found on the floor in the dining area following an altercation with another resident, who was observed hovering over her. V9's Statement form dated 5/14/2025 said he observed R1 hovering over R2 while she was on the floor. The statement continued to say V9 attempted to move R1 but was resistive and started to slap R2 in the head. R1's care plan dated 5/31/2025 said he had impaired cognition and was confused related to his dementia and schizoaffective diagnosis. The care plan said I am confused and disoriented and may misinterpret interactions/situations I experience. Consequently, I may present with aggression when agitated or frustrated. R1's Petition for Involuntary Judicial admission dated 2/19/2025 said R1 required an emergency inpatient hospital admission because he presented physically aggressive with another resident. The resident is nonredirectable at this time. R1's Petition for Involuntary Judicial admission dated 5/14/2025 said R1 again required an emergency inpatient hospital admission because he presented physically aggressive with another resident. The resident is nonredirectable at this time. The facility's final investigation report for R1 and R2's incident on 2/19/2025 said After review of the incident, contact between residents appears to be an accident R1 was startled by R2 speaking and is best suited in a calm atmosphere away from startling moments. CNAs and nurses educated on techniques of de-escalation and signs to monitor for R1 to encourage a calm atmosphere for him in this setting. The facility's final investigation report for R1 and R2's incident on 5/14/2025 said At this time, it appears that the contact between R1 and R2 was accidental and unintentional. R1 is best suited in a different setting. The facility's policy titled Behavior Management Policy and Procedure dated 12/18/2024 said Purpose- To ensure a safe, respectful, and therapeutic environment by providing consistent guidelines for identifying, preventing, and managing challenging or disruptive behaviors in residents while preserving their dignity and rights. The facility's policy titled Abuse Prevention Training Program undated said The objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention .I. PREVENTION & SCREENING .II. IDENTIFICATION AND INTERNAL REPORTING .III. PROTECTION .IV. INVESTIGATION .V. REPORTNG & RESPONSE .Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Willful, as used in this definition of abuse, means the individual must have acted deliberately .Physical Abuse includes hitting, slapping, pinching, kicking .Sexual Abuse is non-consensual sexual contact of any type with a resident Mental Abuse is also the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. This includes, but is not limited to, harassing a resident; mocking, insulting, or ridiculing; yelling or hovering over a resident, with the intent to intimate .Abuse is most likely to happen in situations that result in frustration, annoyance, and anger .To prevent these situations from turning into a possibly abusive situation, you must know the causes of why a resident gets agitated or aggressive .Some of those causes could be .Dementia .Sudden movements, startling noises .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor for behaviors and report the side effects of a resident's anti-psychotic medication. This failure resulted in R4 continuing to receive Seroquel and experiencing a hospitalization, increased falls, and inability to participate in his rehab care. This applies to 1 out of 3 (R4) residents reviewed for psychotropics. The findings include: R4's EMR (Electronic Medical Record) showed R4 was admitted to the facility on [DATE] with multiple diagnoses including a history of falls, metabolic encephalopathy, vascular dementia, depression, epilepsy, convulsions, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, urinary tract infections, and left femur fracture. R4's MDS (Minimum Data Set) dated 10/18/2024 showed he was severely cognitively impaired and receiving high-risk medications including antipsychotics, antidepressants, and anticonvulsants. R4's EMR showed he was transferred to the hospital on [DATE] and did not return to the facility. On 12/31/2024 at 8:50 AM, V8 (R4's Wife) said she would visit R4 frequently at the facility and became worried because he started to become overly sedated as if drugged and having multiple falls. On 1/2/2025 at 9:00 AM, V14 (Registered Nurse/RN) said she had been R4's routine morning nurse during his stay at the facility. V14 said R4 was nice but would become agitated when his wife was not present. V14 said R4 was a high risk for falls and had to be redirected frequently. V14 said R4 was hospitalized because he was noted to be too sleepy. V14 said R4 was non-decisional and V8 (R4's Wife) was his representative and decision-maker. On 1/2/2025 at 10:20 AM, V12 (Geriatric Nurse Practitioner/NP) said she had assisted in managing R4's primary care at the facility. V12 said she did not prescribe R4's Seroquel medication but had decreased, held, and discontinued it because she was informed he was too sedated. V12 said R4's behavior was difficult to manage and difficult to find the right balance of treatment. V12 said ultimately V13 (R4's Psychiatric NP) should have been notified as the ordering prescriber for Seroquel. On 1/2/2025 at 11:00 AM, V13 (Psychiatric NP) said she was consulted to treat R4 for behavior of agitation related to his dementia and managing his Seroquel. V13 said she last saw R4 on 11/7/2024 and decreased his Seroquel after she was informed of his fall. V13 said the facility should have called her first to inform her of R4's side effects as practice for managing residents receiving psychotropics. V13 said R4 had a lot of adjustments in a short period of time, which made it harder to identify the right dose for him. V13 said this could have contributed to R4 becoming more unstable and lethargic. V13 said it was always better to be cautious when using antipsychotics and that's why she started to taper his Seroquel in November. V13 said she did not contact R4's wife but discussed her recommendations with the facility's nurses. V13 said R4 was showing signs of sundowning (increased confusion in the evening hours) and would have also benefited from nonpharmacological approaches such as sleep hygiene promotion practices, activities, and family visits in the evenings. R4's comprehensive care plan showed R4 had a focus problem for the use of Seroquel (antipsychotic) medication for Alzheimer's disease initiated and last updated on 6/6/2024. The focus problem included a goal for R4 to reduce the use of psychotropic medications and included the interventions of Monitor for side effects and effectiveness [every] SHIFT. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. R4's care plan did not show any resident-centered target behaviors or non-pharmacological approaches for the use of Seroquel. R4's Order Summary Report dated 1/2/2025 showed R4 was started on SEROquel Oral Tablet 25 MG [milligrams] Give 1 tablet by mouth two times a day for depression on 6/6/2024. R4's EMAR (Electronic Medication Administration Record) showed R4 received Seroquel 25 mg twice a day until 9/10/2024. The Report showed R4 was started on an additional dose of SEROquel Oral Tablet 25 MG Give 1 tablet by mouth at bedtime related to UNSPECIFIED DEMENTIA on 6/13/2024. R4's EMAR showed R4 received Seroquel 25 mg at bedtime as well until 8/14/2024. R4's Order Summary Report showed R4 was started on an additional as needed dose of SEROquel Oral Tablet 25 MG by mouth every 24 hours as needed for Behavioral disturbances on 7/29/2024. R4's EMAR showed R4 had the order active for Seroquel PRN (as needed) until 10/15/2024 (79 days). The EMAR showed R4 received Seroquel PRN on 8/1/2024, 8/14/2024, and 8/23/2024. R4's Order Summary Report then showed R4's Seroquel at bedtime was increased to 75 mg on 8/15/2024 with the order SEROquel Oral Tablet 25 MG give 3 tablet by mouth at bedtime related to UNSPECIFIED DEMENTIA. R4's Progress Note dated 9/11/2024 said, Informed [V12 (Geriatric Nurse Practitioner/NP)] patient is sleeping most of the time in the morning after breakfast fall asleep again .D/C Seroquel during the day and leave Seroquel at bedtime, hold if sedated. V13's Psychiatric Periodic Evaluation note dated 9/12/2024 said, Nursing staff reported that dosage of Seroquel during the day was discontinued due to excessive daytime sedation. The evaluation said R4 was to continue with Seroquel 25 mg every 24hrs PRN, Seroquel 75 mg at bedtime for agitation/Psychosis, and to monitor for changes in mood and behaviors. R4's Pharmacy Recommendation dated 9/16/2024 said there were recommendations for a GDR (gradual dose reduction) for SEROQUEL 75MG QHS and a need for stop date of 14 days for PRN order for Seroquel. The recommendation was declined by V13 (Psychiatric NP) because the Patient has had good response to treatment and requires this dose for condition stability. R4's EMAR showed R4 received Seroquel 75 mg at bedtime until 9/17/2024. R4's Progress Note dated 9/18/2024 said, Informed [V12 (Geriatric NP)] that patient during the day there are times that patient is just sleeping, doesn't want to participate in the therapy .order reduce seroquel 50mg at bedtime. V13's Psychiatric Periodic Evaluation note dated 9/19/2024 said, The patient was referred to us today due to worsening depression and a lack of motivation. According to nursing staff, the patient has displayed little motivation lately, dragging himself around and showing a disinterest in participating in any activities, indicating worsening depression. The patient was seen sitting around the nursing station, confused at baseline, and was unresponsive during our interaction. Nursing staff recently discontinued his daytime dose of Seroquel, and while the patient is now more alert, he suntil does not engage much which is unusual for him. The evaluation said R4 was started on another psychotropic medication of Bupropion 100mg daily (antidepressant). R4's NP Progress Note from V12 (Geriatric NP) dated 9/20/2024 said, Pt seen for somnolence HPI Pt has been more sleepy. Seroquel reduced. V13's Psychiatric Periodic Evaluation note dated 10/3/2024 said Declined GDR recommendation for Seroquel at bedtime due to risk for decompensation. R4's Progress Note dated 10/14/2024 said, Resident slipped and fell from wheelchair hitting his head on the floor. Resident sustained a cut on his right forehead .Dr on file was reached and ordered resident to be sent out to ER. R4's Progress Note dated 10/15/2024 said, Pt is admitted for altered mental status. R4's Order Summary Report showed R4 was restarted on 50 mg at bedtime on 10/17/2024 with the order SEROquel Oral Tablet 25 MG Give 2 tablet by mouth at bedtime for bipolar disorder. The Report then showed on 10/26/2024, R4 was started on SEROquel Oral Tablet 25 MG Give 1 tablet by mouth two times a day for behavioral disturbances. R4's Progress Note dated 10/17/2024 said, Upon admission, res appeared very sleepy not verbally responsive even with much verbal cuing from staff and paramedics. His eyelids were quivering and throat had visible swallowing reflex. After about 10 minutes with verbal prodding from staff to say something res said hello and opened his eyes. R4's Progress Note dated 10/26/2024 said, Called [V13 (Psychiatric NP)] for patient being restless and keep on standing. Patient is very unsteady to stand up. NP ordered for Seroquel 25mg bid. Informed wife. R4's Progress Note dated 10/27/2024 said, Change in Condition/s reported this CIC Evaluation are/were: Altered mental status .Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Functional Status Evaluation: General weakness .Primary Care Provider responded with the following feedback .Monitor him closely. R4's Progress Note dated 11/2/2024 said SEROquel Oral Tablet 25 MG Give 1 tablet by mouth two times a day for behavioral disturbances patient appears calm and relaxed poa stated not to give. R4's Progress Note dated 11/7/2024 said, Seen by [V13 (Psychiatric NP)] due to sleepy during the day. D/C seroquel on 9am dose. R4's EMAR showed R4 received Seroquel 25 mg twice a day until 11/7/2024, and received Seroquel 50 mg at bedtime until 11/9/2024. R4's Progress Note dated 11/10/2024 said R4 fell and was transferred to the hospital for an evaluation. R4's EMARs from August through November 2024 showed an order for monitoring the use of Anti-Psychotic Medication Use: Observe closely for significant side effects, sedation, drowsiness, dry mouth, constipation, blurred vision, extra pyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention. Enter the number of times side effect noted. (Requires progress note of physician notification for each occurrence) every shift for Monitoring. R4's EMARs showed no side effects were documented for R4. R4's EMARs from August through November 2024 showed an order for Monitor/Record if targeted behavior of Agitation occurs every shift for Monitoring indicate if behavior occurred by indication the number of times observed. R4's EMARs showed R4 had the behavior documented on 11/8/2024 and 11/9/2024. R4's Incidents By Incident Type fall report dated 1/2/2025 said R4 had a total of 20 fall incidents during his stay at the facility. The report showed R4's initial fall was on 6/9/2024 (after starting Seroquel). The report showed R4 also fell on 6/11/2024, 6/14/2024, 6/28/2024, 7/2/2024, 7/6/2024, 7/23/2024, 8/2/2024, 8/19/2024, 8/26/2024, 8/31/2024, 10/5/2024, 10/7/2024, 10/10/2024, 10/11/2024, 10/14/2024, 10/27/2024, 11/2/2024, 11/5/2024, 11/8/2024, and 11/10/2024. V16's (R4's Neurologist) Progress Notes dated 8/29/2024, 9/24/2023, and 10/31/2024 said [reccommend] limit seroquel. The facility's policy titled Psychotropic Drug Use dated 6/11/2024 said, The purpose is to promote the safe and effective use of psychotropic medications that are used in lowest possible dose and time frame and have indication for the use that enhances the resident's quality of life .Initiating the Use of Psychotropic Medications .4. Every attempt will be made to utilize the lowest possible dose of the medication .7. If an order is obtained for a Psychotropic Medication, the resident, family or POA must be informed of the risks and benefits of the medication The care plan will be developed with input from the resident, family, legal representative and include participation from the IDT (Interdisciplinary Team). 3. The care plan will be developed initially upon the start of the medication and be reviewed at least quarterly or more often as the resident's condition dictates .Monitoring and Gradual Dose Reduction .The Psychiatrist/PCP will review the continued need for the medication and monitor for side effects .The Psychiatrist or ANP will also be notified and review changes in the resident's condition and behavior or any side of the medications. The facility's policy titled Behavior and Psychoactive Management Program dated 10/22/2024 said, It is the policy of the facility to provide care and services to promote our resident's quality of life. It is the philosophy of the facility that all resident behavior has meaning. Our facility will work diligently to minimize the use of psychoactive medications in its resident population .a. Program will ensure that staff are monitoring residents' behavior to establish patterns, determine intensity and frequency behavior is exhibited, and identify specific targeted behavior/s that can be distressing to the resident. b. The program will assess the need for psychoactive medication use. Care plans with residents and or resident's representatives will be scheduled as necessary via phone or in person to discuss behaviors, psychoactive drug order/s and treatment, and recommended plan of care .e. Evaluating the effectiveness of pharmacological and non-pharmacological interventions will be performed. f. Monitoring for any adverse side effects of medications .g. Care plan on focus problem will be developed with approaches to address and manage identified behaviors .Tapering and Gradual Dose Reduction a. Facility will attempt to achieve the lowest effective dose, to discontinue the medications that no longer benefit the resident, and to minimize exposer to increased risk of adverse consequences .iii. Daily behavior monitoring. iv. May schedule resident and family meetings as necessary.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure two staff assisted a dependent resident while providing incontinent care. This failure resulted in R2 falling from the bed to the floor, sustaining a left eye laceration along her hairline. This applies to 1 of 4 residents (R2) reviewed for falls and accidents in a sample of 9. Findings include: V3's (Registered Nurse) witness statement dated 06/23/2024 showed R2 falling on the floor while V4 (Certified Nursing Assistant) was providing incontinent care. R1's Minimum Data Set, dated [DATE] showed R2 was dependent on most of the activities of daily living, including toileting, hygiene, and rolling left to right, and required two or more assistance to provide incontinent care. The hospital emergency physician progress notes on 06/23/2024 showed R2 fell out of bed with multiple lacerations to the head; CT (Computed Tomography) of the head revealed subdural hematoma, and R2 was admitted for further management to ICU (Intensive Care Unit) V4's incident witness statement dated 06/23/2024 showed he was changing R2 and rolling her to her side. V4 thought R2 attempted to grab the tray or table for stability, which slid away, and R2 lost her balance and fell. A review of the post-fall huddle worksheet showed one Certified Nursing Assistant (V4) was changing R2, and R2 was on her side and left the left side of her bed; the resident appeared to have hit her head on the table and had two lacerations, one on the hair line and other one was on the left eyebrow. On 07/10/2024 at 11:05 AM, V4 (Certified Nursing Assistant) said that on the day of the incident, R2 was soiled, and everyone was busy. V4 said she thought she could help R2 by herself; however, dependent residents need two staff members' assistance, and if she had taken the help of another staff member, she could have probably prevented the fall. On 07/09/2024 at 3:00 PM, V12 (Physical Therapist) said dependent residents should always have at least two staff members assist with bed mobility and incontinent care to prevent falls and injuries. On 07/09/2024 at 12/12/2023 at 11:22 AM, R2 was in bed and was not interviewable. A review of the face sheet showed that R1 was a [AGE] year-old initially admitted on [DATE] with diagnoses including polyarthritis, fall, long-term use of blood thinner, contusion (discoloration) of the left upper arm, heart diseases with a pacemaker, type 2 diabetes, and chronic kidney disease. On 07/09/2024 between 2:38 PM and 3:00 PM, V5 and V6 (Registered Nurses) and V11 (Certified Nursing Assistant) said dependent or bedbound residents' care should be provided with two assists. V11 said R2 always required two assists for incontinent care and mobility. V11 said when he came to work on the morning of the R2's incident and transferred to the hospital, some staff told him that R2 had a fall while changing with one assist while R2 was holding the bedside table, which slid, and R2 lost her balance and rolled down to floor from the bed. On 07/09/2024 at 2:00 PM, V1 (Administrator) said she thought R2 was with one assist for incontinent care and bed mobility but realized R2 was with two assists after reviewing R2's MDS (Minimum Data Set) documents. She said a dependent resident should have two assistants for activities of daily living care to prevent accidents. V1 said the facility follows universal fall prevention precautions. V1 said R2's fall incidents with injuries were reported to IDPH. A review of the facility's fall prevention and management policy, dated October 2021, showed, in part, that all residents and patients considered at risk for falling regardless of fall risk score. Universal fall precaution (Facility protocol) interventions will be implemented to all. High-risk residents for falls will receive individualized intervention as appropriate to risk factors.

Based on observation, interview, and record review the facility failed to monitor a resident's weight, assess the resident's nutritional status, and assist the resident with eating to prevent significant weight loss. This failure resulted in R1 experiencing a weight loss of 11.5% in one month. This applies to 1 out of 3 residents (R11) reviewed for nutrition. The finding includes: R11's EMR (Electronic Medical Record) showed an admission date of 3/15/2024 with multiple diagnoses including metabolic encephalopathy, facial weakness, pneumonia, acute kidney failure, dysphagia, vitamin B12 deficiency anemia, assistance with personal care, pressure ulcer, delirium, dementia, and depression. R11's MDS (Minimum Data Set) dated 5/15/2024 showed R11 was cognitively impaired and required moderate assistance with eating. On 6/12/2024 at 12:34 PM, R11 was in bed sleeping, he appeared thin with dry skin. Then at 1:40 PM R11 was awake and said he was hungry. R11 started to fidget and lean on his right side trying to reach for a cup of water on his bedside table. V27 (Registered Nurse/RN) was alerted and came to assess R11. R11 yelled, I need food, I did not eat. Then V28 (Certified Nurse Assistant/CNA) said R11 had refused breakfast and lunch, and he had been pocketing and spitting his food earlier in the week. Then at 1:50 PM V28 brought R11 two cups of nutritional supplement drinks and proceeded to assist R11. R11 was shaky and sipped one entire cup and did not want to let go of the cup; then V28 continued to assist R11 with the second cup. V27 (RN) said R11 appeared hungry, and staff should have gotten R11 something else if he had refused his meal. On 6/13/2024 at 9:08 AM, V28 (CNA) said she was familiar with R11 and for approximately a week he had been taking a few bites and then spitting them out and his oral intake would vary every meal. V28 said she had been offering R11 different foods and giving nutritional supplement drinks. R11's nutrition care plan was reviewed on 6/12/2024 and showed R11 was overweight. The care plan was updated on 4/29/2024 and showed Current weight shows 3 lb increase in 1 month. The care plan included an intervention to assist at meals as needed/tolerated and obtain weights on [R11], as per orders and monitor per protocol. Notify of any sign weight changes. R11's rehospitalization discharge documents dated 4/29/2024 showed R11 should have received a high calorie and high protein diet, be offered 2 liters of water orally daily, and continue with an oral nutritional frozen supplement dessert twice daily. R11's Medication Review Report dated 6/12/2024 showed a diet order for general diet mechanical soft texture with regular thin consistency and liquid protein for wound healing. The report did not show R11's discharge hospitalization dietary recommendations or weight monitoring orders. R11's EMR showed the following weights: 2/18/2024-202.8 lbs. (Pounds) at the hospital 3/15/2024-203 lbs. at admission 3/16/2024-203 lbs. 4/03/2024-204.5 lbs. 4/24/2024-165.2 lbs. at the hospital 4/29/2024-205.6 lbs. at readmission 4/30/2024-206 lbs. 5/14/2024-167.8 lbs. 6/12/2024-148.4 lbs. On 6/12/2024 at 2:48 PM, V2 (Director of Nursing/DON) said resident weights are monitored weekly for four weeks during admissions and readmissions and then monthly or as ordered. V2 said weight discrepancies should be assessed and residents should be reweighed. V2 said identified weight loss should be referred to the dietician for evaluation. V2 said residents who need assistance with feeding should be fed to meet their nutritional needs. On 6/13/2024 at 10:06 AM, V19 (Registered Dietician Consultant) said R11's readmission nutritional assessment was done based on his weight on 4/30/2024. V19 said she was not notified of R11's identified significant weight loss on 5/14/2024. V19 said R11's medical condition had changed from his admission, and she had reassessed his nutritional needs. V19 said R11 was now started on a high-calorie drink of 120 ml (milliliters) three times a day, gelato frozen supplement dessert with lunch, and pudding with dinner for additional calories. V19 continued to say part of R11's significant weight loss could have been avoided if his weight had been monitored and communicated correctly. On 6/14/2024 at 11:42 AM, V31 (Physician) said she was notified on 6/12/2024 of R11's weights and believed R11's weight from 3/15/2024 was a discrepancy. V31 continued to say R11's significant weight loss from 5/14/2024 to present could have been intervened if caught earlier. V31 said she expected the facility to follow its weight policy protocol to assess residents' nutrition. The facility's policy titled Weight with the reviewed date of 7/14/2023 showed General: To establish a policy for the consistent, timely monitoring and reporting of resident weights Guideline: 1. All residents will be weighed on admission, readmission, weekly for the first 4 weeks and then at least monthly. 2. Weekly weights will also be done with a significant change of condition, food intake decline that has persisted for more than one week, or with a physician order .4. The DON or designee to determine a list of reweighs will review all weights upon completion. 5. Once the reweighs have occurred any resident with an unexplained significant or insidious weight loss will have a weight loss investigation . The facility's policy titled Medication Pass Supplementation Program with the reviewed date of 10/30/2023 showed Guideline: 1. Based on the nutritional assessment the Registered Dietician, Health Care Provider or staff nurse may recommend a calorie dense supplement at med pass. 2. The nurse .will ask for an order. The order will include the amount and frequency of the supplement .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility consistently failed to serve food items on their facility planned and approved menu to ensure adequate nutritional intake. This failure resulted in weight loss for R3 and R20 due to insufficient calories, prolonged feelings of sadness, anger, frustration, and low self-worth for R1, R2, R4, R13, and R18, and financial hardship to the residents and families of R1, R3, R13, and R21 who brought in food to supplement their food intake. This applies to 19 of 19 residents (R1-R4, R6-R14, R16-R21) reviewed for menus served as planned in a sample of 22. The findings include: Facility Week At A Glance menu, dated 6/2/24 to 6/8/24 and distributed to facility residents, shows the following menu items were planned to be served at the facility: Sunday, 6/2/24 Breakfast: Juice of choice, milk of choice, coffee/tea, hot/cold cereal, pancakes with margarine/syrup, scrambled eggs Lunch: Hot dog on a bun, onion rings, potato salad, lemon cake, milk, beverage Dinner: Tomato Basil Soup, Grilled Cheese and tomato, coleslaw, brownie, milk, beverage Monday 6/3/24 Lunch: Savory ribs, baked sweet potato, scalloped corn, fruit ambrosia, wheat bread, beverage of choice, milk of choice Tuesday 6/4/24 Breakfast: Juice of choice, milk of choice, coffee/tea, hot/cold cereal, waffles, bacon. 1. Face sheet, dated 6/5/24, shows R3's diagnoses included end stage renal disease, dependence on renal dialysis, type 1 diabetes, deficiency of Vitamin K, and depression. POS (Physician Order Sheet), dated 6/5/24, shows R3's diet order included carbohydrate controlled, renal, low concentrated sweets, low potassium. Nutrition progress note, dated 1/22/24, shows R3's weight after dialysis was 174 pounds and R3's appetite varies but is usually good. The note shows R3's weight appeared to be stabilizing after previous weight loss due to fluid being removed in the hospital. Nutrition progress note, dated 4/27/24 shows R3 experienced a significant weight loss of 19.3 pounds in three months. The note shows R3's appetite varies but is usually good. Nutrition progress note, dated 5/29/24, shows R3's post dialysis weight was 153 pounds. The progress note shows R3 had a weight decrease of 9.1 pounds in three months. The note shows R3's appetite varies but is usually good. MDS(Minimum Data Set) Assessment, dated 3/25/24, shows R3 was cognitively intact. On 6/4/24 at 8:35 AM, R3's breakfast ticket showed she was to be served cold cereal, 2 eggs over easy, fresh fruit as available, apple juice, 2 hard boiled eggs, 1 slice of toast, 2 slices of bacon, and milk of choice. R3's tray ticket notes showed, No scrambled eggs. On R3's breakfast tray she received scrambled eggs, 1 sausage link, cereal, 4 ounces of apple juice and 8 ounces of milk. R3 received no eggs over easy or hard boiled eggs and no fresh fruit. On 6/5/24 at 10:33 AM, R3 stated I write on my menu, turn it in, and they give me what they want! This has gone on two years! It makes me feel like they don't care! Pepper hurts my tongue and it makes me made I take the time to fill out the menu and they ignore me! Then they send foods that hurt my tongue! R3 stated she orders food from outside when she can afford to do so approximately twice a month. R3 stated It's a financial hardship because I can't buy shoes or clothes or mouthwash! I get the smaller sizes because I can't afford the economy sizes when I spend money on ordering food! I also buy snacks with my money. I use my social security - that's all I get! So I order twice a month and get stuck with what they give me other meals. I lost weight because I can't stand it! It's nasty! We would rather have something else. And when they send sandwiches, it is no meat and all bread! You're eating a bread sandwich! On 6/3/24 at 12:55 PM during lunch service, R3 received a deli sandwich with 2 slices of thin deli meat and no cheese on 2 slices of bread for lunch. R3 also received tomato, 2 pickles, ice cream, bag of potato chips, and an unsweetened lemon beverage. R3's tray ticket, dated 6/3/24, shows R3 was to be served scalloped corn, and a choice of milk which she did not receive. Grievance, dated 5/29/24, shows R3 complained a nurse refused to bring R3 a snack requested by R3 around 3:00 AM on 5/28/24 The form shows R3 stated she was hungry and could not sleep. On 6/5/24 at 12:37 PM, V14 (Dietitian) stated R3 weighed 172 pounds in January 2024 and R3 lost 18 pounds in 5 months. V14 stated R3 received dialysis and some weight fluctuation could be fluid but not eating enough at meals could contribute to R3's weight loss. V14 stated R3 was not on a planned weight loss program and R3's weights were trending down since December 2023. V14 stated R3 orders food from outside the facility because she does not like the food the facility served. V14 stated R3 did not want to remain on a renal diet because R3 was requesting more food choices. V14 stated R3's appetite may be good, but did not mean she was eating what was served from the facility. V14 stated it was her expectation that the facility followed the planned menu and should not be making changes to the menu unless products did not come in or there was a diet holiday. V14 stated if the facility was not consistently serving 100% fruit juice she was concerned residents may not be meeting their daily Vitamin C and calorie requirements as the fruit juice at breakfast of the planned menu met the requirement for a high quality Vitamin C product. V14 also stated daily 100% fruit juice provided approximately 90 calories each day. V14 stated if the facility was not consistently serving milk as planned, V14 was concerned residents were not meeting their daily protein, calories, Vitamin D, and calcium requirements as the milk helped meet resident daily requirements for the nutrients and provided approximately 240 calories each day as planned. 2. Face sheet, dated 6/5/24, shows R20's diagnoses included low back pain, hypertension, personality disorder, mild cognitive impairment, delusional disorders, and nonspecific abnormal finding of lung field. MDS, dated [DATE], shows R20's cognitive status was moderately impaired. Dietitian note, dated 1/30/24, shows R20 weighed 129 pounds and experienced unintended weight loss R/T (related to) inadequate energy intake AEB (as evidenced by) weight loss and documented intake of 26-100%. The note shows R20 had a significant weight lost of 16.2 pounds in six months, her appetite varied and R20 was being provided a high calorie drink, yogurt at breakfast, and ice cream at lunch and dinner to supplement her intake. Monthly weight report, dated 1/2024 to 6/2024, shows R20's weight was 123.6 May 2024 representing further weight loss of 5.4 pounds. POS, dated 6/5/24, shows R20 received a no added salt diet and received a high calorie drink 120 milliliters twice a day since 9/14/23. On 6/5/24 at 1:40 PM, R20 stated I was surprised I lost so much weight! I'm not eating! R20 stated she loved milk but never receives it on her meal trays. R20 stated once in a while she gets fruit juice, but mainly only receives the unsweetened lemon drink. R20 stated she is provided yogurt at breakfast and ice cream lunch/dinner for calories but is not fond of yogurt and can only eat ice cream once in a while. R20 stated she is able to eat the breakfast most days at the facility but often can not eat the lunches or dinner because the food has no seasoning or taste. R20 stated the facility used to provide seasoning packets that she loved and would put on the food to be able to eat the food but they stopped providing them on her meal trays. R20 stated she did not eat lunch that day because it had no flavor. On 6/5/24 at 12:37 PM, V14 (Dietitian) stated R20's weight loss was due to a lack of calories and was not on a planned weight loss program. V14 stated she had not spoken to R20 about her weight loss and was unsure if she was eating the meals at the facility or taking the supplemental nutritional items she was given. V14 stated she added the high calorie supplement, yogurt at breakfast, and ice cream at lunch and dinner to provide more calories because R20 was losing weight. V14 stated she writes that R20's appetite varied, but meant her intake varied. V14 stated R20 was not mentioned in weight meetings for not eating. V14 stated she was told by the facility diet tech that milk was not being served on trays at dinner approximately a month prior. V14 stated she spoke with a corporate food service representative and V14 stated she was told milk was always available. V14 could not confirm that milk was being consistently served at the facility at meals by food service. 3. On 6/4/24 at 7:48 AM with R13, R4 (Resident Council [NAME] President) stated she lived at the facility 10 years and the food has never been as bad as it was currently. R4 stated the dinners were the worst meal at the facility. R4 and R13 provided a copy of the facility menu of the week, dated 6/2/24 to 6/8/24, and R4 stated, If you look at the menu you get you would say, 'WOW! They are eating well!' But it doesn't come that way! R4 stated the menu is rarely served as it is written and the foods that are served are very small portions. R4 stated most dinners served are only a sandwich and chips and are served at approximately 5:15 PM. R4 stated the sandwich she received a couple nights prior only had one paper thin slice of turkey, no cheese, and no mayonnaise or mustard. R4 stated the sandwich may only come with potato chips and an unsweetened lemon beverage. R4 stated, That's not a real meal! R4 stated she begged for a different sandwich to be served as a night snack but only gets a few cookies or a peanut butter and jelly sandwich. R4 stated she was diabetic and becomes concerned about her blood sugars. R4 stated recently for dinner they were served a grilled cheese and tomato sandwich but residents did not receive the coleslaw that was planned on the menu. R4 stated her son comes to visit and brings food for R4 to supplement the facility food served. At 8:18 AM, R4's breakfast tray was served and R4 agreed to allow her tray to be used as a test tray. R4's tray ticket showed she was to be served orange juice, cold cereal, low-fat milk, 2 fried eggs over easy, a juice of choice, hot or cold cereal, toast, 2 slices of bacon, milk of choice and coffee/tea. R4 was served scrambled eggs, one sausage link, one slice of bacon, toast in a baggie, unsweetened lemon beverage, and skim milk. R4 stated she does not like skim milk and prefers 2% milk. No waffle was served as planned on the menus distributed to residents. R4 failed to receive her orange juice, cold cereal, and 2 fried eggs. R4 stated this was the first time they received toast in a long time. R4 received no butter for her toast. R4 stated the residents had not been served butter in a long time. R4 stated she complained in a resident meeting they were not receiving butter and the food service manager responded, If I give it to you, I can't give you something else. R4 stated the residents are served juice only once in a great while. R4 stated the residents are consistently served the unsweetened lemon beverages and not real fruit juice. R4 stated last week the resident council meeting was canceled because R2 (Resident Council President) came to the meeting a stated, 'I'm going to cancel the meeting because it does no good! Every month the write it down on the paper and nothing is done!' I agreed with him and told the staff I wouldn't do the meeting either! R4 stated she fully supported R2's frustration with the facility not responding to any of the ongoing resident concerns such as menus not served. R4 stated the residents complained but none of the staff were listening. On 6/5/24 at 8:59 AM, R4 received a replacement tray and this time received 2 eggs over easy, 2 sausage, orange juice, cereal and toast. On 6/5/24 at 9:33 AM, R4 stated she lives on food brought from outside by her sons and friends because of the poor food quality and the menus not served properly. R4 stated she has food brought in at least 4 times a week which she pays for. R4 stated she also pays for friends to bring in snacks to eat so she had food when she could not eat the facility food. R4 stated she spends no less than $40 to $50 a week on food to supplement the facility meals. R4 stated she was very upset the facility food quality declined drastically in the last year and stated, What am I, chopped liver!? Everything they have taken away like the food and not resolved! I feel like they don't care about us as human beings. We are just a number. It's not human! R4 stated at resident council some residents say the food is all they have to look forward to every day. R4 stated, It makes me worry about how people in the facility are struggling. That's all they have! That's scary! And we don't ever get a choice about the food! Take it or leave it! If you don't eat your meal, they just pick it up because the staff know there are no options! R4 stated since IDPH (Illinois Department of Public Health) has been in the building watching food service on 6/3/24 and 6/4/24, she began receiving juice and milk as instructed on her tray tickets. R4 stated, In the last 2 months I have received juice only 4 to 5 times! How do you think it makes us feel that they can serve us juice all of a sudden when the state is here!? 4. On 6/5/24 at 9:32 AM, R18 stated she has complained about the food quality and menus for two years. R18 stated It's hard and I am sick and tired of not being able to eat! My sister brings food once a week. There is nothing to eat and it makes me sick! I cry once a day because it's so bad and not enough food! R18 stated she was angry, sad, frustrated daily for months regarding the food served at the facility. 5. On 6/4/24 at 7:48 AM, R13 stated the residents receive scrambled eggs almost every day in spite of what is listed on the breakfast menu. R13 reviewed the weekly menu which showed a version of scrambled egg being served Sunday, Monday, Wednesday, Thursday and Saturday. R13 stated even the days scrambled eggs are not listed the residents are often served scrambled eggs and not the menued item. R13 stated waffles and bacon were planned for 6/4/24 breakfast, but stated there was a great chance they would receive scrambled eggs. R13 stated she gave up trying to select items on her menus or write in substitutions as it did no good because the kitchen served whatever they wished. R13 stated residents are told to call food service prior to 10:00 AM if they want a substitution for the lunch menu, but no staff answer the phone when residents call. On 6/5/24 at 8:20 AM during breakfast service, R13's tray ticket showed she was to be served juice of choice, hot or cold cereal, 2 hard boiled eggs, a donut, 2 slices of bacon, milk of choice and coffee or hot tea. R13 received only unsweetened lemonade beverage, hot cereal, 2 hard boiled eggs, and 1 slice of bacon on her breakfast tray. R13 stated her eggs felt and tasted cold. R13 stated I love milk! But they don't give it to me often. No waffles were served. R13 stated, They give this watered-down sugar free lemon crap! If I get real juice I am thrilled to death! On 6/5/24 at 9:33 AM, R13 stated I have to fight to get a proper meal and it makes me sad all day! Breakfast is important to me. Emotionally it just brings me down the whole day if breakfast is bad or not right. It happens here at least three days a week since December when I came! I get pissed off! Food is important to me! I am Italian! I get angry about the food. When it comes to the food, I don't feel taken care of since I have been here. R13 stated her day was ruined at lest 3-4 times a week because her breakfast is bad or not served correctly. R13 stated, If you have a decent breakfast, you can go on with your day - you have the energy and mindset and you feel satisfied and you can do well with your day! R13 stated she has friends/family bring in food from outside to supplement the meals at the facility. R13 pulled a chicken and tuna salad meal packages out of her dresser drawer. R13 stated she has to eat them 2-3 times a week because she can not eat the food served. R13 stated the only time in the last three months she received milk was if she received cold cereal for breakfast. Otherwise she was never served milk at breakfast, lunch or dinner. R13 stated, I know it's on the menu three times a day! But I never get it! 6. On 6/5/24 at 10:16 AM R21 stated, I used to indicate what I didn't like to eat on the menus and turn them in but I would still get the foods. It makes me mad they don't listen! This has gone on for 6-8 months! It causes me to be frustrated they keep giving me foods I don't eat! I don't like to cause trouble but I gotta eat! I only get $60 each month and it doesn't go very far. If I want to be happy and have something to eat, I have to use all of the $60! I don't feel I should have to pay for food when I give every cent to this place to stay here and already pay for the food served! I should be able to do something else with my $60 other than pay for food I am already paying for! I get anxiety about what they are going to send every day at every meal. I wait to see if they are going to give something I hate! Then they will serve the same thing every day for a week! They make out a menu and don't stick to it! I circle what I want, send it back, and then they send whatever they want! They run out of food on the weekends. I ask CNAs for something and they tell me food service is out of it when they call. It makes me angry and upset! This has gone on every day for at least 6-7 months but probably longer. They only give us a lemon drink at meals - I can't remember the last time I had real juice at breakfast! I like orange juice! But what is on the menu is not what is served! They just serve bug-juice! Koolaid! 7. On 6/3/24 during initial tour of the facility, R1 stated when he asks for a deli sandwich, he receives two pieces of bread and one thin slice of deli meat and one slice of cheese. R1 stated sometimes he is served only potato chips and a dessert with the deli sandwich as his meal. R1 stated there is not enough food at dinner to not be very hungry by breakfast. R1 stated he asked for salad at lunch and dinner several times during resident meetings. R1 stated he still does not get salads and stated he asked over and over again. They don't own the problem. R1 stated the staff only respond to residents with what they think residents want to hear and do not solve the problem. On 6/3/24 at 1:12 PM, R1 was eating one of his two hamburgers served at lunch. On his lunch plate, R1 had cooked corn, canned fruit and an unsweetened lemon beverage. R1's tray ticket showed he was to be served, Daily items: Tossed salad with cucumber if available . Savory ribs, baked sweet potato, scalloped corn, chilled fruit ambrosia, wheat bread, beverage of choice, and choice of milk which he did not receive. On 6/5/24 at 9:20 AM, R1 stated his sister brings in submarine sandwiches for a standby meal when he is unable to eat the food the facility serves. R1 stated he has been extremely disappointed because he and the residents complain at food and resident meetings and there is nothing done about their concerns. R1 stated he attended the food meetings and the facility tells you what they want you to hear and you feel let down! R1 stated, When the staff in the kitchen don't pick up the phone when you try to ask for a substitution, it doesn't make you feel good! My sister pays for the sandwiches because she wants me to have something to eat. I eat one of the sandwiches three to four times a week. I would like to have a decent meal! I don't expect a five star restaurant food but would like something I enjoy eating! It doesn't make me feel good at all and it has been going on for months! 8. On 6/3/24 at 2:00 PM, R2 stated he was the Resident Council President and he canceled the resident council meeting the week prior because he did not want to participate in another meeting listening to the same complaints from residents and the facility promising to address the problems and then doing nothing. R2 stated issues regarding residents not receiving what they ordered, the food service not serving the planned menus, and other food concerns came up frequently at resident council meetings and the facility decided to have a separate food council to discuss the concerns. R2 stated he was tired of discussing the concerns and describing the problems to administration and none of the issues being resolved by administration. R2 stated, They cut and cut and cut. They don't maintain the gardens on the patio, the food is terrible. Same s*** all of the time! We are on the fourth dietary manager! R2 stated he was tired of hearing ongoing concerns about the food with no resolutions from the facility. R2 stated he gave up arguing with the facility about the kitchen because he was tired of the B.S. On 6/4/24 at 8:52 AM, R2's breakfast tray ticket showed he was to be served cranberry juice, hard fried egg, fresh apple, extra toasted English muffin, juice of choice, donut, and coffee or tea. Review of R2's tray showed R2 failed to be served cranberry juice, hard fried egg, fresh apple, English muffin, juice of choice, donut and coffee/tea. R2 stated he never receives eggs any way but scrambled and never receives English muffins at the facility. On 6/5/24 at 9:10 AM, R2 stated he complained to the facility about the food service for two years since the new company took over at the facility. R2 stated, It makes me feel bad. It makes me feel horrible inside. We feel like second class citizens since the new food service took over! Resident council meeting minutes, dated 5/29/24, show the meeting was canceled by R2. Food Focus Group minutes, dated 2/21/24, show residents reported there was not enough coffee and juice available for meals. Food Focus Group minutes, dated 3/20/24, show residents asked for fresh fruits at meals, residents complained snacks were not available at night, that there was still not enough juices available at meals, and the food often did not match the daily menu tickets. Food Focus Group minutes, dated 4/3/24, show residents again asked for fresh fruits at meals, snacks were inconsistently available at night, there was still not enough juice served with meals, some residents asked for double portions, and food service would order English muffins to be available the next week. Food Focus Group minutes, dated 5/8/24, shows residents again asked for fresh fruits at all three meals, fruit juices served were watery and weak, an alternative menu was promised but was not available, food portions were served small, too many hot dogs were served on the menu, English muffins were not available, and cucumbers were requested in salad but residents were told cucumbers were very perishable and did not last long. 9. On 6/3/24 during initial tour of the facility, R6 stated she is usually served food items completely different from the facility weekly menu and different from her tray ticket for the meal. R6 stated the residents rarely receive the menu items listed on the facility menu passed to residents weekly. R6 stated she once received a breakfast sausage patty served on two slices of bread when she was supposed to receive a hamburger. R6 stated when she does receive a hamburger there is usually no onion, lettuce, tomato or other condiments. R6 showed a picture of a meal from her phone which showed a hamburger on a bun with a scoop of mashed potatoes on the plate. The picture showed a mustard packet, a yellow beverage and a piece of unfrosted cake in a plastic baggie. R6 showed a picture of her tray ticket for that meal which showed, No substitute found for deli sandwich with cheese on a bun, lettuce, tomato, onion, macaroni salad, no substitute for carrot cake, choice of milk, unsweetened beverage of choice. R6's tray failed to include macaroni salad, lettuce, tomato, onion, ketchup and milk. R6 also stated the residents received scrambled eggs almost every day in spite of what is listed on the weekly menu they are provided. R6 stated they often did not receive waffles if they were planned on the menu. R6 stated the last milk she was served was a while ago. R6 stated, They don't give a decent meal. R6 stated the residents complained at resident council and food council with no resolutions. R6 stated, We just want a decent meal. 10. On 6/4/24, observations during the breakfast service included: - At 8:22 AM, the beverage cart in the 100 hall had coffee, hot water, and unsweetened lemon beverage on the cart. No 100% fruit juices were present on the cart. - At 8:25 AM, R7's tray ticket showed she was to be served a donut, juice of choice. R7's tray had no donut but was served a small croissant. R7 stated she often did not receive juice and the last time she received 100% fruit juice was a week ago. - At 8:30 AM, R14 had her breakfast tray in her room and was waiting for the nurse to bring milk which she was not served on her meal tray. R14's tray ticket showed she was to to be served orange juice, low-fat milk, donut, and fresh fruit as available. R14's received a small croissant in a baggie that was very hard on the bottom but no orange juice, donut, milk or fresh fruit were served. - At 8:40 AM, R10 stated she only received a little amount of food for breakfast. R10's tray card showed she was to receive orange juice, hot coffee, and milk of choice. Review of R10's tray showed R10 did not receive any juice, milk, or coffee which R10 stated she enjoyed if she receives them. - At 8:43 AM, R11's breakfast tray ticket showed she was to receive orange juice, donut, milk, and coffee. Review of R11's tray showed R11 did not receive juice, coffee, milk or the donut. R11 stated she preferred to receive all of the items. - At 8:45 AM, R16's breakfast tray ticket showed he was to receive juice and a donut. Review of R16's tray showed R16 failed to receive either. - At 8:48 AM, R17's breakfast tray ticket showed she was to receive a toasted English muffin, donut, and juice. None of the items were served to R17 for breakfast on her tray. - At 8:50 AM, when asked if she ever received fruit juice at breakfast, R18 stated, Never! R18's breakfast tray ticket showed she was to be served 2% milk, juice, donut, and coffee or tea. None of the items were served to R18 for breakfast. R18 received skim milk and only one slice of bacon instead of two listed on the tray ticket. R18 stated she liked tea and preferred 2% milk and not skim but did not receive either. - At 8:56 AM, R19's ticket showed he was to receive eggs over easy, bacon, toasted English muffin when available and juice. Review of R19's tray showed R19 received scrambled eggs, no bacon, no juice, and no toast or English muffins. R19 received skim milk and stated he only liked whole milk. - At 9:29 AM, V11 (Activities) had a weekly menu on her activity cart and confirmed the waffles were on the weekly menu for 6/4/24 breakfast. 11. On 6/3/24 all residents were distributed a piece of paper which stated, Date: 6/3/24 Instead of BBQ Ribs for lunch on 6/3/24, we will be serving Salmon Filets and Breaded Fish. Management Observations during the lunch meal included: - At 12:55 R7 stated, I don't want this s***! R7's lunch tray included salmon, a roll, and mashed sweat potato. R7's tray ticket showed R7 was to be served savory ribs (3 ounces), baked sweet potato (1 each), scalloped corn (4 ounces), chilled fruit ambrosia (4 ounces), and wheat bread (1 slice). - At 1:00 PM, R8 received salmon on her lunch tray. R8 stated she wanted the ribs on the planned menu distributed to residents. R8's tray ticket showed she was to be served savory ribs, baked sweet potato, scalloped corn, fruit ambrosia, wheat bread and choice of milk which she did not receive. - At 1:05 PM, R9 stated the facility fails to serve the planned menu more than you would like. R9 stated the food served at the facility was terrible on a normal day. R9 stated the residents were not served cole slaw or macaroni salad when on the menu, and the facility rarely served milk. R9 stated,We don't get a choice. We just have to accept the regular menu. We have no choices on what we eat here at all. R9 was eating a lunch of salmon, cooked plain corn, mashed sweet potato, canned fruit cocktail, and two unsweetened lemon beverages. R9's tray ticket showed she was to receive savory ribs, baked sweet potato, scalloped corn, drained fruit, wheat bread which she did not receive. -At 1:09 PM, R10 and R11 were both eating their lunch which included a piece of breaded fish, corn, fruit cocktail, mashed sweet potato and unsweetened lemon beverage. R10's and R11's tray tickets both showed they were to be served the savory ribs, baked sweet potato, scalloped corn, chilled fruit ambrosia, wheat bread, unsweetened beverage, and choice of milk which they did not receive. - At 1:13 PM, R12's lunch tray ticket showed R12 was to be served ribs, baked sweet potato, diced carrots, fruit ambrosia, buttered wheat bread, unsweetened beverage, and milk. R12 did not receive any of the food items on his meal ticket. On 6/5/24 at 11:56 AM, V15 (Food Service Manager) stated she worked at the facility for three weeks and she witnessed the food service staff were not cooking and/or serving items on the planned menu. V15 stated she was not aware ribs were not available for lunch until the morning they were to be served, was not aware the staff did not prepare the ambrosia salad, and was not sure why the whole baked sweet potatoes were not served. V15 stated she observed the food service staff serving unsweetened lemon beverages on breakfast trays instead of providing the 100% juice and milk as planned on the facility menu. V15 reviewed the menu passed out to the residents and stated the menu they were following in the kitchen was different than the menu which was circulated to the residents. V15 stated there were waffles in house, but the menu she was following the kitchen did not have waffles on the planned menu as written on the menus the residents received. On 6/3/24 at 4:04 PM, V13 (Corporate Food Service Manager) stated the facility orders frozen bread for the residents and the facility had no ribs on hand for lunch. V13 stated there was no cream corn to make the corn casserole and V13 was not sure why the ambrosia salad was not sure. V13 also stated she was unsure why milk was not served during the lunch. Grievances, dated 1/1/24 to 6/2/24, show three grievances (3/11/24, 3/16/24, and 3/25/24) regarding residents not receiving correct menu items from dining services. Review of the menus show juice of choice milk of choice, and coffee/tea were to be served every breakfast. The menus show choice of milk was to be served at every lunch and dinner except Friday. The menus show a variation of scrambled eggs was served on Sunday, Monday, Wednesday, Thursday, and Saturday. Menu extensions, dated 6/3/24 and 6/4/24, show all diets, other than those with physician orders for clear and full liquids, were to be served milk at all three meals. The extensions showed all diets were to be served a choice of juice at breakfast. Policy and Procedure Menu Portion Sizes, revised 3/17/23, shows, Follow 'Serving Instructions' on the Daily Production Sheet versus the Extensions Sheets for portion size and plating instructions for each diet Policy and Procedure Menu Planning, revised 4/1/23, shows Menus will be written to provide nourishing, well-balanced diets . 2. Menus are reviewed by menu committee meetings with input from dietary managers and regional/facility dietitians. 3. M[TRUNCATED]

Based on observation, interview and record review, the facility consistently failed to provide palatable, appetizing meals to residents. This failure resulted in weight loss for R3 and R20 due to insufficient calories, prolonged feelings of sadness, anger, frustration, and low self-worth for R1, R2, R4, R13, and R18, and financial hardship to the residents and families of R1, R3, R13, and R21 who bought food to supplement their food intake. This applies to 12 of 12 residents (R1-R4, R6, R9, R13, R14-R15, R18, R20 and R21) reviewed for food palatability a sample of 22. The findings include: 1. Face sheet, dated 6/5/24, shows R3's diagnoses included end stage renal disease, dependence on renal dialysis, type 1 diabetes, deficiency of Vitamin K, and depression. POS (Physician Order Sheet), dated 6/5/24, shows R3's diet order included carbohydrate controlled, renal, low concentrated sweets, low potassium. MDS (Minimum Data Set), dated 3/25/24, shows R3 was cognitively intact. Nutrition progress note, dated 1/22/24, shows R3's weight after dialysis was 174 pounds and R3's appetite varies but is usually good. The note shows R3's weight appeared to be stabilizing after previous weight loss due to fluid being removed in the hospital. Nutrition progress note, dated 4/27/24 shows R3 experienced a significant weight loss of 19.3 pounds in three months. The note shows R3's appetite varies but is usually good. Nutrition progress note, dated 5/29/24, shows R3's post dialysis weight was 153 pounds. The progress note shows R3 had a weight decrease of 9.1 pounds in three months. The note shows R3's appetite varies but is usually good. On 6/4/24 at 8:35 AM, R3's breakfast ticket showed she was to be served cold cereal, 2 eggs over easy, fresh fruit as available, apple juice, 2 hard boiled eggs, 1 slice of toast, 2 slices of bacon, and milk of choice. R3's tray ticket notes showed, No scrambled eggs and R3 received scrambled eggs, 1 sausage link, cereal, 4 ounces of apple juice and 8 ounces of milk. R4 stated her toast was burnt on both sides but soggy on one side. R3's toast was very dark brown. R3 took a bite and stated the toast was chewy. On 6/3/24 at 12:55 PM during lunch service, R3 complained she received a deli sandwich with 2 slices of thin deli meat and no cheese on 2 slices of bread for lunch. On 6/5/24 at 10:33 AM, R3 stated I write on my menu, turn it in, and they give me what they want! This has gone on two years! It makes me feel like they don't care! Pepper hurts my tongue and it makes me made I take the time to fill out the menu and they ignore me! Then they send foods that hurt my tongue! R3 stated she orders food from outside when she can afford to do so approximately twice a month. R3 stated It's a financial hardship because I can't buy shoes or clothes or mouthwash! I get the smaller sizes because I can't afford the economy sizes when I spend money on ordering food! I also buy snacks with my money. I use my social security - that's all I get! So I order twice a month and get stuck with what they give me other meals. I lost weight because I can't stand it! It's nasty! We would rather have something else. And when they send sandwiches, it is no meat and all bread! You're eating a bread sandwich! On 6/5/24 at 12:37 PM, V14 (Dietitian) stated R3 weighed 172 pounds in January 2024 and R3 lost 18 pounds in 5 months. V14 stated R3 received dialysis and some weight fluctuation could be fluid but not eating enough at meals could contribute to R3's weight loss. V14 stated R3 was not on a planned weight loss program and R3's weights were trending down since December 2023. V14 stated R3 orders food from outside the facility because she does not like the food the facility served. V14 stated R3 did not want to remain on a renal diet because R3 was requesting more food choices. V14 stated R3's appetite may be good, but did not mean she was eating what was served from the facility. 2. Face sheet, dated 6/5/24, shows R20's diagnoses included low back pain, hypertension, personality disorder, mild cognitive impairment, delusional disorders, and nonspecific abnormal finding of lung field. The MDS Assessment, dated 3/27/24, shows R20's cognitive status was moderately impaired. Dietitian note, dated 1/30/24, shows R20 weighed 129 pounds and experienced unintended weight loss R/T (related to) inadequate energy intake AEB (as evidenced by) weight loss and documented intake of 26-100%. The note shows R20 had a significant weight lost of 16.2 pounds in six months, her appetite varied and R20 was being provided a high calorie drink, yogurt at breakfast, and ice cream at lunch and dinner to supplement her intake. Monthly weight report, dated 1/2024 to 6/2024, shows R20's weight was 123.6 May 2024 representing further weight loss of 5.4 pounds. POS, dated 6/5/24, shows R20 received a no added salt diet and received a high calorie drink 120 milliliters twice a day since 9/14/23. On 6/5/24 at 1:40 PM, R20 stated I was surprised I lost so much weight! I'm not eating! R20 stated she loved milk but never receives it on her meal trays. R20 stated once in a while she gets fruit juice, but mainly only receives the unsweetened lemon drink. R20 stated she is provided yogurt at breakfast and ice cream lunch/dinner for calories but is not fond of yogurt and can only eat ice cream once in a while. R20 stated she is able to eat the breakfast most days at the facility but often can not eat the lunches or dinner because the food has no seasoning or taste. R20 stated the facility used to provide seasoning packets that she loved and would put on the food to be able to eat the food but they stopped providing them on her meal trays. R20 stated she did not eat lunch that day because it had no flavor. On 6/5/24 at 12:37 PM, V14 (Dietitian) R20's weight loss was due to a lack of calories and was not on a planned weight loss program. V14 stated she had not spoken to R20 about her weight loss and was unsure if she was eating the meals at the facility or taking the supplemental nutritional items she was given. V14 stated she added the high calorie supplement, yogurt at breakfast, and ice cream at lunch and dinner to provide more calories because R20 was losing weight. V14 stated she writes that R20's appetite varied, but meant her intake varied. V14 stated R20 was not mentioned in weight meetings for not eating. 2. On 6/4/24 at 7:48 AM with R13, R4 (Resident Council [NAME] President) stated she lived at the facility 10 years and the food has never been as bad as it was currently. R4 stated the dinners were the worst meal at the facility. R4 and R13 provided a copy of the facility menu of the week, dated 6/2/24 to 6/8/24, and R4 stated, If you look at the menu you get you would say, 'WOW! They are eating well!' But it doesn't come that way! R4 stated the hot food served at the facility was ice cold by the time she received it. R4 stated the sandwich she received a couple nights prior only had one paper thin slice of turkey, no cheese, and no mayonnaise or mustard. R4 constantly has a cheeseburger or grilled cheese substitute for meals because of the poor food quality of food served. R4 stated the dinners were the worst meal at the facility. R4 stated the bread is served tasting stale and the staff respond that the bread is toasted when she complains. R4 stated the facility had not had a working toaster for months and was not sure what the facility was doing to the bread, but she typically had to take the crusts off because they were so hard. R4 stated the facility used to serve a nicer meal on Sundays lunch. R4 stated the prior Sunday, the facility served a hot dog and onion rings with no catchup or other condiments. They were served a small amount of potato salad and small piece of cake. R4 stated the residents preferred to eat in the main dining room because the food was served right from the kitchen to their tables and food is served hotter, but they are no longer able to eat in the dining room and they put the residents in the small dining room away from the kitchen R4 stated her son comes to visit and brings food for R4. On 6/4/24 at 8:18 AM, R4's breakfast tray was served and R4 agreed to allow her tray to be used as a test tray. The eggs tasted grainy and luke warm, the sausage tasted luke warm, and the bacon was dark reddish-brown and looked well cooked but was limp when picked up and left a puddle of grease on the plate. The toast was served in a plastic baggie, appeared brown, and tasted very chewy. R4's tray ticket showed she was to be served orange juice, cold cereal, low-fat milk, 2 fried eggs over easy, a juice of choice, hot or cold cereal, toast, 2 slices of bacon, milk of choice and coffee/tea. R4 was served scrambled eggs, one sausage link, one slice of bacon, toast in a baggie, unsweetened lemon beverage, and skim milk. R4 stated she does not like skim milk and prefers 2% milk. R4 received no butter for her toast and R4 stated the residents had not been served butter in a long time. R4 stated she complained in a resident meeting they were not receiving butter and the food service manager responded, If I give it to you, I can't give you something else. R4 stated the residents are consistently served the unsweetened lemon beverages and not real fruit juice. R4 stated, They give this watered-down sugar free lemon crap! If I get real juice I am thrilled to death! R4 stated last week the resident council meeting was canceled because R2 (Resident Council President) came to the meeting a stated, 'I'm going to cancel the meeting because it does no good! Every month the write it down on the paper and nothing is done!' I agreed with him and told the staff I wouldn't do the meeting either! R4 stated she fully supported R2's frustration with the facility not responding to any of the ongoing resident concerns such as food palatability. R4 stated the residents complained but none of the staff were listening. On 6/5/24 at 8:59 AM, R4 received a replacement tray and this time received 2 eggs over easy, 2 sausage, orange juice, cereal and toast. On 6/5/24 at 9:33 AM, R4 stated she lives on food brought from outside by her sons and friends because of the poor food quality and the menus not served properly. R4 stated she has food brought in at least 4 times a week which she pays for. R4 stated she also pays for friends to bring in snacks to eat so she had food when she could not eat the facility food. R4 stated she spends no less than $40 to $50 a week on food to supplement the facility meals. R4 stated she was very upset the facility food quality declined drastically in the last year and stated, What am I, chopped liver!? Everything they have taken away like the food and not resolved! I feel like they don't care about us as human beings. We are just a number. It's not human! R4 stated at resident council some residents say the food is all they have to look forward to every day. R4 stated, It makes me worry about how people in the facility are struggling. That's all they have! That's scary! And we don't ever get a choice about the food! Take it or leave it! If you don't eat your meal, they just pick it up because the staff know there are no options! R4 stated since IDPH (Illinois Department of Public Health) has been in the building watching food service on 6/3/24 and 6/4/24, she began receiving fried eggs, juice and milk as instructed on her tray tickets. R4 stated, In the last 2 months I have received juice only 4 to 5 times! How do you think it makes us feel that they can serve us juice all of a sudden when the state is here!? 3. On 6/5/24 at 9:32 AM, R18 stated she has complained about the food quality and menus for two years. R18 stated It's hard and I am sick and tired of not being able to eat! My sister brings food once a week. There is nothing to eat and it makes me sick! I cry once a day because it's so bad and not enough food! R18 stated she was angry, sad, frustrated daily for months regarding the food served at the facility. 4. On 6/5/24 at 8:20 AM, R13's tray ticket showed she was to be served juice of choice, hot or cold cereal, 2 hard boiled eggs, a donut, 2 slices of bacon, milk of choice and coffee or hot tea. R13 received only unsweetened lemonade beverage, hot cereal, 2 hard boiled eggs, and 1 slice of bacon on her breakfast tray. R13 stated her eggs felt and tasted cold. R13 stated I love milk! But they don't give it to me often. No waffles were served. R4 stated, They give this watered-down sugar free lemon crap! If I get real juice I am thrilled to death! On 6/5/24 at 9:33 AM, R13 stated I have to fight to get a proper meal and it makes me sad all day! Breakfast is important to me. Emotionally it just brings me down the whole day if breakfast is bad or not right. It happens here at least three days a week since December when I came! I get pissed off! Food is important to me! I am Italian! I get angry about the food. When it comes to the food, I don't feel taken care of since I have been here. R13 stated her day was ruined at lest 3-4 times a week because her breakfast is bad or not served correctly. R13 stated, If you have a decent breakfast, you can go on with your day - you have the energy and mindset and you feel satisfied and you can do well with your day! R13 stated she has friends/family bring in food from outside to supplement the meals at the facility. R13 pulled a chicken and tuna salad meal packages out of her dresser drawer. R13 stated she has to eat them 2-3 times a week because she can not eat the food served. 5. On 6/5/24 at 10:16 AM R21 stated she did not like the taste of most foods at the facility and made attempts to adjust her menus to avoid the unpalatable foods. R21 stated, I used to indicate what I didn't like to eat on the menus and turn them in but I would still get the foods. It makes me mad they don't listen! This has gone on for 6-8 months! It causes me to be frustrated they keep giving me foods I don't eat! I don't like to cause trouble but I gotta eat! I only get $60 each month and it doesn't go very far. If I want to be happy and have something to eat, I have to use all of the $60! I don't feel I should have to pay for food when I give every cent to this place to stay here and already pay for the food served! I should be able to do something else with my $60 other than pay for food I am already paying for! I get anxiety about what they are going to send every day at every meal. I wait to see if they are going to give something I hate! Then they will serve the same thing every day for a week! They make out a menu and don't stick to it! I circle what I want, send it back, and then they send whatever they want! They run out of food on the weekends. I ask CNAs (Certified Nursing Assistants) for something and they tell me food service is out of it when they call. It makes me angry and upset! This has gone on every day for at least 6-7 months but probably longer. They only give us a lemon drink at meals - I can't remember the last time I had real juice at breakfast! I like orange juice! .They just serve bug-juice! Koolaid! 6. On 6/3/24 during initial tour of the facility, R1 stated when he asks for a deli sandwich, he receives two pieces of bread and one thin slice of deli meat and one slice of cheese. R1 stated sometimes he is served only potato chips and a dessert with the deli sandwich as his meal. R1 stated he received a hot dog and did not think the temperature reached 100 degrees Fahrenheit and tasted cold and uncooked. R1 stated , over and over again. They don't own the problem. R1 stated the staff only respond to residents with what they think residents want to hear and do not solve the problem. On 6/5/24 at 9:20 AM, R1 stated his sister brings in submarine sandwiches for a standby meal when he is unable to eat the food the facility serves. R1 stated he has been extremely disappointed because he and the residents complain at food and resident meetings and there is nothing done about their concerns. R1 stated he attended the food meetings and the facility tells you what they want you to hear and you feel let down! R1 stated, When the staff in the kitchen don't pick up the phone when you try to ask for a substitution, it doesn't make you feel good! My sister pays for the sandwiches because she wants me to have something to eat. I eat one of the sandwiches three to four times a week. I would like to have a decent meal! I don't expect a five star restaurant food but would like something I enjoy eating! It doesn't make me feel good at all and it has been going on for months! 7. On 6/3/24 at 2:00 PM, R2 stated he was the Resident Council President and he canceled the resident council meeting the week prior because he did not want to participate in another meeting listening to the same complaints from residents and the facility promising to address the problems and then doing nothing. R2 stated issues regarding the poor food quality, hot foods being served cold, food palatability, and other food issues came up frequently at resident council meetings and the facility decided to have a separate food council to discuss the concerns. R2 stated he was tired of discussing the concerns and describing the problems to administration and none of the issues being resolved by administration. R2 stated, They cut and cut and cut. They don't maintain the gardens on the patio, the food is terrible. Same s*** all of the time! We are on the fourth dietary manager! R2 stated he was tired of hearing ongoing concerns about the food with no resolutions from the facility. R2 stated he gave up arguing with the facility about the kitchen because he was tired of the B.S. R2 stated when residents open up their meal trays, the food is not appetizing. R2 stated on 6/3/24 they received breaded fish and it looked horrible. R2 stated the toaster was broken for months and residents have complained with no resolution. R2 stated he was supposed to receive toast that morning for breakfast but received plain bread instead. On 6/5/24 at 9:10 AM, R2 stated he complained to the facility about the food quality for two years since the new company took over at the facility. R2 stated, It makes me feel bad. It makes me feel horrible inside. We feel like second class citizens since the new food service took over! Resident council meeting minutes, dated 5/29/24, show the meeting was canceled by R2. Food Focus Group minutes, dated 3/20/24, show residents complained hot foods were served cold to residents and the presentation of the meals should be improved. Food Focus Group minutes, dated 4/3/24, show residents complained hot food was served cold to residents. Food Focus Group minutes, dated 5/8/24, show residents complained fruit juices served were watery and weak, food presentation was poor, an alternative menu was promised but was not available,, too many hot dogs were served on the menu, and the pizza was served cold. 7. On 6/3/24 during initial tour of the facility, R6 stated the toaster was broken for at least three months and it seemed like staff were putting bread in the microwave to toast it. R6 stated she once received a sausage patty served on two slices of bread when she was supposed to receive a hamburger. R6 stated when she does receive a hamburger there is usually no onion, lettuce, tomato or other condiments. R6 showed a picture of a meal from her phone which showed a hamburger on a bun with a scoop of mashed potatoes on the place. The picture showed a mustard packet, a yellow beverage and a piece of unfrosted cake in a plastic baggie. R6 showed a picture of her tray ticket for that meal which showed, No substitute found for deli sandwich with cheese on a bun, lettuce, tomato, onion, macaroni salad, no substitute for carrot cake, choice of milk, unsweetened beverage of choice. R6's tray failed to include macaroni salad, lettuce, tomato, onion, ketchup and milk. R6 stated the waffles the facility serve were delivered cold and slimy as if they were just taken out of the freezer and left to thaw on the plate. R6 stated the pancakes were served the same way. R6 stated on 6/2/24 she was served onion rings that were so hard they could cut walls. R6 stated the residents complained at resident council and food council with no resolutions. R6 stated the last milk she was served was a while ago. R6 stated, They don't give a decent meal. R6 stated the residents complained at resident council and food council with no resolutions. R6 stated, We just want a decent meal. 8. On 6/4/24, observations during the breakfast service included: - At 8:30 AM, R14 had her breakfast tray in her room and stated, The bacon looks awful! R14's received a small croissant in a baggie that was very hard on the bottom. -At 8:38 AM, R15 received toast on her tray but stated she could not eat the facility toast because the crusts were too hard. 9. On 6/3/24 all residents were distributed a piece of paper which stated, Date: 6/3/24 Instead of BBQ Ribs for lunch on 6/3/24, we will be serving Salmon Filets and Breaded Fish. Management Observations during the lunch meal included: - At 1:05 PM, R9 stated the food served at the facility was terrible on a normal day. R9 stated the chicken and other meat was served dry, the residents were not served cole slaw/macaroni salad when on the menu, the hot food is served cold, and the facility rarely served milk. R9 stated, We don't get a choice. We just have to accept the regular menu. We have no choices on what we eat here at all. On 6/5/24 at 11:56 AM, V15 (Food Service Manager) stated the toaster was not broken and she was working with the food service staff to improve the palatability of the food served. V15 stated she she had only worked at the facility three weeks and observed the food service staff serving unsweetened lemon beverages for 100% fruit juice and was working to correct the staff. On 6/3/24 at 4:04 PM, V13 (Corporate Food Service Manager) stated the facility orders frozen bread for the residents and the toaster was not broken at the facility. Facility policy and procedure Palatability and Nutritive Value, revised 3/9/23, shows, Food will be prepared, held, and served in a manner that preserves nutritive value and palatability . 3. Best efforts will be made to present hot food hot and cold foods cold at the point of service by using thermal lids and bases, heated or chilled plates and thermal pellets as necessary. 5. Food service staff will monitor palatability of food at point of service by periodic test tray evaluations and review of resident council concerns. Facility policy and procedure Food Temperatures at Point of Service, revised 6/27/23, shows, Food will be prepared, held and served in a manner that preserves nutritive value and palatability .3. Best efforts will be made to maintain nutritional value and hot foods hot and cold foods cold such as batch cooking and keeping foods refrigerated and taking out of refrigeration in small batches. 4. Best efforts will be made to present hot food hot and cold foods cold at point of service by using thermal lids and bases, heated or chilled plates and thermal pellets as necessary. 5. Food service staff will monitor palatability of food at point of service by periodic test tray evaluation and review of resident council concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse. This resulted in R1's left pinky finger being pulled backwards during care and x-ray showed a non-displaced fracture of the left finger. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of The findings include: R1's face sheet shows she is a [AGE] year-old female with diagnoses including type 2 diabetes, osteoarthritis, macular degeneration, atrial fibrillation and non-displaced fracture of distal phalanx of left little finger. R1's Minimum Data Set assessment dated [DATE] show she is cognitively intact, has no behaviors, rejections of care, or delusions. She requires partial moderate assist with showers/bathing. The facility's Initial Report dated 3/19/24 documents R1 verbalized today, on Saturday March 16, 2024, that CNA (Certified Nursing Assistant) provided her a shower and was not gentle to her. R1's statement dated 3/19/24 documented by V3 states, On Saturday 3/16/24 PM shift, I was scheduled to get my shower. V6 was my CNA. She was not very nice, refused to clean the shower chair as somebody used it before me. She washed me with towel that was on the floor. She did not do a good job with my shower. She grabbed my left arm when I was transferred to a shower chair. She even hurt my left pinky finger while she was getting the towel I was holding. My pinky finger was bent backward . R1's Diagnostic Imaging Results dated 3/20/24 shows a transverse non-displaced fracture at the base of the distal phalanx of the left little finger. On 3/25/24 at 9:05 AM, R1 was observed in her room sitting in her wheelchair. Her left pinky finger was wrapped with elastic bandage. R1 said on 3/16/24 around 8:00 PM, V6 (Agency CNA) said I need to give you a shower. She wheeled me to the shower room. I asked her if she could clean the shower chair because it was used by someone else before me. She said I already cleaned it. I asked her again if she could clean the shower chair and she told me I already told you I cleaned it. She then grabbed me by my upper left arm and transferred me to the shower chair. She set the washcloth on the grab bar and the washcloth fell on the floor. She picked them up, I said I don't want to use them they are dirty. She did not listen to my request and used the dirty washcloth. She washed my face roughly, she then started washing my body. I was trying to get the towel from her, and she grabbed my left pinky and pulled it backwards. She was laughing, I said that hurt me. V6 was a rough lady. I'm not happy. On 3/25/24 at 10:11 AM, V4 (RN) said he was R1's nurse on 3/19/24 when she was complaining of pain to her left pinky finger. Her left pinky finger was red and swollen, I asked if anything happened. She told me on 3/16/24 she received a shower from V6(Agency CNA), and her pinky got pulled. R1 is alert and oriented, I asked her if it was done intentional and she did not answer me. On3/25/24 at 12:18 PM, V9 (Social Services) said I was asked to check on R1 to see how she was doing after an incident with V6 (CNA). R1 told me she was receiving a shower from V6, and it sounded like it was not a good experience. Something about their being a tussle with the washcloth. R1 was visibly upset and said she does not want agency staff to care for her. R1 has not made any complaints about staff in the past. On 3/25/24 at 2:35 PM, V5 (LPN) said on 3/16/24, R1 approached me after V6 gave her a shower. R1 told me she did not like the way V6 gave her a shower. She complained about the washcloth being dropped on the floor and she used the dirty washcloth to clean her. I was not R1's nurse that day, I reported to her nurse that R1 was not happy with the shower and that V6 should not take care of her anymore. Both the nurse and V6 were agency staff. On 3/25/24 at 2:39 PM, V3 (RN Supervisor) said she was notified on 3/19/24, R1 was complaining of pain to her pinky finger. I asked her did any body hurt you, and she said a CNA (V6) was not nice to her during a shower. When I asked her about her finger, she told me it was bent backward. V6 was trying to get the towel from her and R1 got hurt. R1 sustained a fracture to her left finger caused by some trauma. On 3/25/24 at 2:53 PM, V1 (Administrator) said V6 is placed on the DNR (Do Not Return) list for this facility. V1 confirmed R1 sustained a finger fracture, and R1 will be following up with the orthopedic physician. R1's nurses note dated 3/19/24 documents by V2 (DON) per R1 during shower on Saturday 3/16/24, while CNA (V6) was providing care and washing her body, she reported her finger was pulled back. R1's nurses note dated 3/20/24 documents (R1) returned back from a physician appointment. Left hand x-ray shows left hand digit fracture. R1 has swelling, redness and pain 3 out 10. R1's current care plan dated through May 2024 shows my comprehensive assessment reveals factor that may increase my susceptibility to abuse/neglect. I deny any history of abuse or neglect or mistreatment and no indicators of past recipient or a perpetrator of mistreatment .I am considered a vulnerable adult. The facility's undated Abuse Policy states, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint .Abuse is the willful infliction of injury .willful, as used in this definition of abuse, means the individual must have acted deliberately .physical abuse if the infliction of injury on a resident that occurs other than by accidental means .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure bed heights were at the lowest level and failed to provide two staff assist to prevent injuries. As a result, R1 and R3 sustained left and right hip fractures, respectively, and were admitted to the hospital. This applies to 2 of 5 residents (R1 and R3) reviewed for falls in a sample of 14. Findings include: 1. R1's progress notes showed R1 had two falls on 03/23/2023 and one on 03/24/2023 and 03/30/2023. R1's Minimum Data Set, dated [DATE] showed R1 was dependent on her daily living activities and required two or more assistance for daily living care activities. The universal fall precaution in part showed Place the hospital bed in a low position when a patient (Resident) is resting in bed. On 12/14/2023 at 09:32, V9 (R1's Physician) said he had known R1 for a long time and her health conditions were deteriorating. V9 said R1 was bedbound and required two assists. On 12/14/2023 at 09:55 AM, V19 (Director of Rehab Therapy) said R1 was a total assist and was confused and has a history of high fall risk. V19 said R1 required two staff assistants for all her daily care activities, and her bed should be as low as possible to minimize the impact of falls. On 12/13/2023, V10 (Certified Nursing Assistant) said on 11/23/2023 at night, he changed R1's colostomy bag, and R1's linen was soiled. V10 said when he leaned to reach for clean linen to change her, R1 rolled over the left side of the bed and fell on the floor. V10 said he thought he needed to use two assistances only for mobility/transfer and said, Now I know. On 12/12/2023 at 01:22 PM, R1 was in bed and was not interviewable. R1's bed height was not at a lowest level,writer showed V4 (Registered Nurse) the level of R1's bed, and V4 said R1's bed should have been at a lower level. The Hospital Physician's history and physical report dated 11/23/2023 at 9:28 AM showed R1's colostomy bag was being changed around midnight when she sustained a witnessed fall as she rolled over from her bed to the floor. R1 was admitted to the intensive care unit (ICU), and R1's X-ray of her left femur was positive for hip fracture (intertrochanteric hip fracture), which was acutely displaced. R1 had a surgery on 11/28/2023. A review of the face sheet showed that R1 was a [AGE] year-old initially admitted on [DATE] and readmitted to the facility multiple times, including on 03/10/2022 with diagnoses including colostomy status, diabetes mellitus, hypertension, schizophrenia, anemia with chronic kidney disease, and retention of urine. A review of V18's (Registered Nurse) progress notes on 11/23/2023 at 01:15 AM showed that V18 heard a noise coming from the room; upon entering the room, the resident on her left side and she noted a small amount of blood from the left outer lining of the ear and paramedics were called. Progress noted further showed that when paramedics transferred R1 from the floor to the gurney, R1 said her left leg and back were hurting. On 12/12/2023, V2 (Director of Nursing) at 3:00 PM, and on 12/13/2024 at 9:37 PM, V18(Registered Nurse) said V18 and V10 (Certified Nursing Assistant) were assigned for R1 and V10 should have called for help. V2 said the facility follows universal fall prevention precautions. V18 said bedbound and fall-risk residents' beds should be as low as possible while in bed and use two staff assistance for activities of daily living care. V2 said R1 and R3's fall incidents with injuries were reported to IDPH. 2. R3's hospital Physician progress notes dated 11/24/2023 showed R3 presented to the hospital on [DATE] after a fall, was diagnosed with a right hip displaced femoral neck fracture, and had had surgery. On 12/12/2023 at 01:12 PM, R3 was in bed and was interviewable. V12 (R3's POA, Power of Attorney) was by R3's bedside. R3's bed height was not in the lowest level. R3 and V12 said R3 had a fall a few weeks ago and had a fracture. V12 said he visits R3 frequently and does not see his bed in the lowest level. R3 said during the fire alarm check, he got scared, tried to get up, and fell from the bed to the floor. R3 said he did not think his bed was at a lower level. At 1:12 PM, V3 (Registered Nurse) witnessed the bed height at a higher level and said R3 is a high fall-risk resident, and the bed should be at a lower level while he is in bed. On 12/14/2023 at 09:55 AM. The facility's fall prevention and management policy, dated October 2021, showed in part, All residents and patients considered at risk for falling regardless of fall risk score. Universal fall precaution (Facility protocol) interventions will be implemented to all.