Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect residents' right to be free from physical abuse of R3 by R2 and R4. This failure affects three (R2,R3,R4) of five residents reviewed for abuse on the sample list of eight. Findings include: 1.) R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status (BIMS) score of two out of a possible 15 indicating, severe cognitive impairment R2's Brief Interview of Mental Status (BIMS) assessment dated [DATE] documents R2 has a score of 15 out of a possible 15, which indicates no cognitive impairment. The facility Illinois Department of Public Health (IDPH) Final Report Incident Date: 2/23/2025 signed by V1, Administrator/Abuse Prevention Coordinator, documents the following: Summary; Received report that (R2) resident, struck (R3) resident. They were immediately separated without any apparent injuries (right cheek injury documented below) . R2's Nursing Progress Note dated 02/23/2025 at 12:30 pm, and signed by V6, Licensed Practical Nurse (LPN), documents the following: Note Text : Resident has been up to the nursing desk several times calling (V20, Family Member) and (V22, Family Member). No one answered the phone. Resident (R2) is becoming angry. Another resident sitting buy (by) the assignment board (R3), and he (R2) became physically aggressive with her (R3). Separated the two (R2 and R3). Assessed resident (R3) for any injuries, she has a red mark on her right upper cheek. Took v/s (vital signs) and assisted her to bed to relax. The DON (Director of Nursing) and the Administrator (V1, Abuse Prevention Coordinator) was (were) notified. R3's Nursing Progress Note dated 02/23/2025 at 5:24 pm documents: Note Text: Resident remains resting in bed. Awakens easily. Right upper cheek remains red. Denies any tenderness to the area at this time (four hours and 54 minutes after the above physical abuse was documented). On 3/26/25 at 12:50 pm , R2 propelled his wheelchair into his room, over to the side of his bed, and transferred himself. R2 laid semi-Fowler back onto his bed. R2 stated I sure can tell you what the hell went on. (R3) was touching my arm in the dining room earlier that day. I was in a pissed off mood after getting off the phone. I saw her sitting across from the nurse's station. I remembered earlier in the dining room she was tapping on my arm. I went over to her. I (R2) hauled off and busted her (R3) in the eye, just like this (R2 raised his elbow up to his shoulder level, tightened his fist, and punched into the air). It is the law. If someone hits you first, you can hit them back. She (R3) tapped my arm several times earlier in the day. I (expletive, f***ing) hit her (R3), once with my fist. Staff took her away somewhere and that ended that. R2 then stated She (R3) wanders in the dining room and does the same thing, to other residents too. She (R3) is tapping peoples arms all the time. I was sick of it, she is annoying. That one punch is how I let her know. I have had no problems with her since. On 3/26/25 at 1:34 pm V6, LPN stated I witnessed (R2) getting mad. He wants to go home. He had been asking to use the portable phone repeatedly that day. His family (unidentified) will not answer the phone. He was getting frustrated, that escalated to real angry because he couldn't reach his family. Then everybody (residents and staff) went to the dining room, residents to eat lunch and staff to serve it. I was passing medication on halls A and B (unit's divided by a nurses station). I had just finished med pass (medication administration) and he (R2) came up to use the phone again. His family still did not answer. He was really upset again. Very angry. (R3) was seated in her wheelchair across from the nurse's station, 12 to 15 feet away from (R2). (R2) wheeled his wheelchair over to (R3's) wheelchair. His room is right down B hall. I thought he (R2) was just going to pass in front of her (R3). (R3) had her hands in her lap. I was looking right over at them, He raised his arm, to his shoulder level. His hand was fisted. He hit her on her upper right cheek. Her whole cheek was red. It happened really fast. He (R2) knew what he was doing, and (R3) was not doing anything. Me (V6, LPN) and (V10, Certified Nursing Assistant) (sic) separated them. She took him (R2) to his room and educated him, that he could not hit anyone. That is abuse. We took (R3's) vital signs. She was upset. She is not a talker but put both her hands on her face. I did a skin assessment and laid her in bed. I checked on her again and again. I gave her roommate (R8) medication and checked on (R3) again then too. (R3) was sleeping by then, about a half hour later. (R3's) right upper cheek was still red. On 3/26/25 at 2:05 pm V10, CNA stated It was a rough day. I was here. He (R2) was having a bad day trying to call his family. He called repeatedly. Then ate a meal. He tried again to reach his family. (V6, LPN) helped him with the phone down there (points to the opposite end of the nurses station). (R3) was seated in her wheelchair across from the nurses station right here (V10, points approximately 12 feet away from where she said R2 had used the phone). (R3) had her hands in her lap. She (R3) was looking around and I was standing up here (three feet away) talking to her. He (R2) was really upset not reaching his family on the phone. I could hear his (R2) raised voice but could not make out what he said. He (R2) wheeled his wheelchair in the direction of his room. I thought he was going to pass (R3) up. He (R2) suddenly drew up his fist and hit (R3) in the right check. When I realized what had happened, I took him immediately away to his room, and (V6, LPN) was taking care of (R3). I saw (R3) put her hands up over her face and made a loud sound. She (R3) then said 'he (R2) hit me'. When (V6, LPN) and I (V10, CNA) put her to bed, She was scared. I sat with her in her room for a while. I (V10) kept telling her (R3) I would keep her safe. She was clingy and very nervous. It just broke my heart. (V6, LPN) reported to the (V1, Abuse Prevention Coordinator)Administrator. The DON (V2, Director of Nursing) and (V13, CNA) were here and notified (V1) too, as soon as we made sure the resident was safe. On 3/28/25 at 12:00 pm V13, CNA stated confirmed she was present when R2 hit R3 in the eye. V13 stated the physical abuse of R3 by R2 happened on a Sunday 2/23/25, V13 did not work on Monday 2/24/25. V13, CNA also stated I worked Tuesday (2/25/25) or Wednesday (2/26/25) after that happened. (R3's) eye and cheek were still dark red with a purple tint. (two and three days after R2 hit R3). 2.) R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status (BIMS) score of two out of a possible 15 indicating, severe cognitive impairment. R4's MDS dated [DATE] documents R4's BIMS score of 15 out of a possible 15, indicating no cognitive impairment. R5's MDS dated 103/25 documents R5's BIMS score of 14 out of a possible 15, indicating no cognitive impairment. The facility Illinois Department of Public Health (IDPH) Final Report Incident Date: 2/24/2025 signed by V1, Administrator/Abuse Prevention Coordinator, documents the following: On February 24th, 2025, it was reported by resident (R5) that resident (R4) struck resident (R3) on the arm. The residents were in the dining room for dinner when (R3) approached (R4) multiple times. (R3) enjoys greeting all of the residents. patting them on the hand, leg and arm as if to greet them. (R4) had eventually gently steered (R3) wheelchair away from him. (R3) did not make any indications at the time of experiencing any pain. The same report documents: There were not any employees present at the time of this interaction. On 3/26/25 at 12:20 pm, R4 stated (R3) when she comes into the dining room, she comes and reaches for other people's food. When I interrupt her, I started batting at her. I don't think I made contact with her, though. If I did hit her, it didn't hurt her. I had to push her wheelchair away from me twice, before she would stay away from me. That is all I did on that day you're referring to (2/24/25). R4 also stated I am not the only one that has a problem with her. We (unidentified) even ask her is a nice way. I'd just try to turn around and go on with what I'm doing. Sometimes I have to swat at her to get her to leave me alone. I can't think of any of the other resident name, off the top of my head, but there are several she gets on their nerves too. I don't remember names very well, but others can tell you the same thing about her (R3). Yes, I (R4) have raised my voice telling her to get the hell away from me. If staff are around, they take her (R3) to the far table, and lock her wheelchair brakes. There are times she still scoots her wheelchair over to people. Even with the brakes locked. There are staff around that see it all the time. There are other times when there aren't any staff in the dining room at all, until it's time to serve food. They come in and out bringing people in the dining room for meals. There have been many times going down the hall she (R3) starts slapping at me. Staff see it, I tell them too. They (unidentified staff) say she doesn't know what she is doing ( R3 has severe cognitive impairment). They say just ignore her. I don't feel I have ever been abusive to her. She (R3) is just annoying to have to deal with this every day. On 3/27/25 at 10:25 am V2, Director of Nursing (DON) stated V1 Administrator / Abuse Prevention Coordinator told V2, DON about the allegation that R4 hit R3, but she was not working the day it happened. V2, DON then stated R4 'is educated constantly' that R3 has Dementia and does not know what she is doing. He is alert and oriented, he needs to leave the situation and find a staff member. On 3/28/25 at 1:00 R5 stated I witnessed (R4) getting mad at (R3), raising his (R4) fist up and acting like he was going to follow threw and hit (R3) in the head. She (R3) was about two feet from him (R4). That (hit her in the head) didn't happen. He (R4) hadn't hit her (R3) yet. (R3) wheeled her wheelchair up closer to where (R4) was sitting. (R4) turned around and pushed (R3's) wheelchair backwards. He pushed it hard. He is a lot bigger than she is. I bet she doesn't weigh one hundred pounds. He is a bigger guy, even when seated in a wheelchair. She (R3) flew in her wheelchair backwards, about eight feet. There were no staff anywhere around. I looked (for staff) for a minute or two. Then, I watched (R4) as (R3) approached (R4) table. (R3) gave him (R4) a little pat on the arm to get his attention. She (R3) barely touched him (R4). (R3) was not being aggressive in any way. She is very sweet and was being kind to him. (R4) purposely struck (R3) on the upper arm. I (R5) saw it all. You could hear he (R4), slapped her (R3) hard. He then, forcefully pushed R3's wheelchair again, but not as far (eight feet prior in this interview) as he had. He (R4) yelled 'get the hell out of here'. (R3) looked stunned as she propelled herself away to the other end of the dining room. It was definitely, abuse. There is no way around that. I went immediately out to find a staff member (unidentified). I can't remember who it was I told. Several staff came into the dining room right away. The staff are few and far between at mealtimes. They are all getting people out of their rooms, and bringing them to the dining room. I was eating about eight feet away from (R4), facing him (R4). I saw every bit. He (R4) hates her with a passion, and I don't know why. Her little hand, was a tender tap. She is very loving. Nothing he (R4) should be so upset about. He knows exactly what he is doing. She has Dementia, and doesn't understand what she is doing. The facility (facility name) RESIDENTS RIGHT TO FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION POLICY AND PROCEDURE policy dated 2025, documents the following: PURPOSE To ensure that all of (Facility name) residents are free from abuse, neglect, misappropriation of their property, and exploitation. POLICY The facility's residents have the right to be free from abuse, neglect, misappropriation of their property and exploitation as defined in this policy. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the residents medical symptoms. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the Facility (''Associates). PROCEDURE III. The Facility shall review altercations from resident to resident as a potential situation of abuse. A. Staff shall monitor for any behavior that may provoke a reaction by residents or others, which include, but are not limited to: a. Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; b. Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to remove R2, the perpetrator of physical abuse, from direct access with R2's vulnerable, dependent, non-verbal roommate R6. This failure affects two (R2,R6) of five residents reviewed for abuse on the sample list of eight. Findings include: R2's Brief Interview of Mental Status (BIMS) assessment dated [DATE] documents R2 has a score of 15 out of a possible 15, which indicates no cognitive impairment. R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status (BIMS) score of two out of a possible 15 indicating, severe cognitive impairment R6, MDS dated [DATE] documents R6 has severe cognitive impairment and is totally dependent of staff for all activities of daily living and does not ambulate R6's Diagnoses List last updated 01/16/25 documents the following: Cerebral Palsy, Quadriplegia, Unspecified, Metabolic Encephalopathy, Adjustment Disorder With Anxiety, Major Depressive Disorder Recurrent, Unspecified, and Adjustment Insomnia R2's Nursing Progress Note dated 02/23/2025 at 12:30 pm, and signed by V6, Licensed Practical Nurse (LPN), documents the following: Note Text : Resident has been up to the nursing desk several times calling his (V20, Family Member) and his son. No one answered the phone, Resident (R2) is becoming angry. Another resident sitting buy (by) the assignment board (R3) and he (R2) became physically aggressive with her. Separated the two (R2 and R3). Assessed resident (R3) for any injuries she has a red mark on her right upper cheek. Took v/s (vital signs) and assisted her to bed to relax. The DON (Director of Nursing) and the Administrator (V1, Abuse Prevention Coordinator) was (were) notified. On 3/26/25 at 12:48 pm , R6, (R2's roommate) was in a reclined geriatric type wheeled chair parked next to R6's bed. R6's gestured with spastic movements and made inaudible sounds. R6 did attempt to converse and shook his head back and forth, yes, he feels safe and no one has hurt him. R2 then closed his eyes as if to sleep. On 3/26/25 at 12:50 pm, R2 wheeled his wheel chair into his room and transferred himself to bed. R2 confirmed he was anger and hit R3 in the eye on 2/23/25. On 3/26/25 at 1:34 pm V6, Licensed Practical Nurse (LPN) stated V6 LPN witnessed R2 hit R3 on the right cheeks leaving a red mark. V6 also stated she had talked to V1, Administrator/ Abuse Prevention Coordinator and wanted to move R2 to a different room, because R6, R2's roommate was still in their shared room. V1, Administrator /Abuse Prevention Coordinator told V6, LPN that if (R2) had any more aggressive behaviors, staff could send him to the hospital. On 3/26/25 at 2:05 pm V10, Certified Nursing Assistant stated I worried about (R6), (R2's) roommate. (R6) couldn't defend himself. He is totally dependent on staff for everything. (V1, Administrator/Abuse Prevention Coordinator) gave the direction for us not to move them to a different rooms. (V6, LPN) the nurse and I would really worried. Actually everybody here was really worried. I have never seen (R2) do anything to another resident. He has been mad and yelling at staff. We had just witnessed the outburst with (R3), and felt he needed to be moved to a different room, away from (R6) . He (R2) stayed in his room the rest of the shift watching tv (television). He did come out for supper, but we watched him extra close. When he went back to his room, I looked in there several times just to make sure he wasn't doing anything toward (R6) He didn't. He knew he had to have staff with him to come out of his room. On 3/27/25 at 9:40 am V1, Administrator / Abuse Prevention Coordinator confirmed R6, R2's roommate remained in their shared room overnight, on the night R2 hit R3 on 2/23/25. The facility (facility name) RESIDENTS RIGHT TO FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION POLICY AND PROCEDURE policy dated 2025, documents the following: : B. IV. When the Facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: A. Taking steps to prevent further potential abuse .

Based on interview and record review the facility failed to maintain complete and accurate medical records for two (R3,R4) of five residents reviewed for abuse on the sample list of eight. Findings include: 1.) R2's Nursing Progress Note dated 02/23/2025 at 12:30 pm, and signed by V6, Licensed Practical Nurse (LPN), documents the following: Note Text : Resident has been up to the nursing desk several times calling (V20, Family Member) and (V22, Family Member). No one answered the phone. Resident (R2) is becoming angry. Another resident sitting buy (by) the assignment board (R3), and he (R2) became physically aggressive with her (R3). Separated the two (R2 and R3). Assessed resident (R3) for any injuries, she has a red mark on her right upper cheek. Took v/s (vital signs) and assisted her to bed to relax. The DON (Director of Nursing) and the Administrator (V1, Abuse Prevention Coordinator) was (were) notified. R3's Nursing Progress Note dated 02/23/2025 at 5:24 pm is the only documentation in R3's chart that refers to R3's reddened facial area and does not mention the physical abuse noted above. R3's Progress note documents: Note Text : Resident remains resting in bed. Awakens easily. Right upper cheek remains red. Denies any tenderness to the area at this time (four hours and 54 minutes after the above physical abuse was documented). R3's complete electronic medical records does not documents the above physical abuse occurred, measurements of the red mark on R3's face, family or physician notification, and there is no ongoing assessments alert charting' or monitoring of R3 response to the physical abuse by R2. On 3/26/25 at 1:34 pm V6, Licensed practical Nurse (LPN) confirmed she did not measure R3's reddened face, therefor did not document the skin impairment measurement, when R3 was hit in the face by R2. V6 also confirmed she did not document the physical abuse by R2 in R3's chart. V6 also confirmed she did not document that V1, Administrator/Abuse Prevention Coordinator was notifying the physician and families V6, LPN also acknowledged V6, LPN should have initiated 72 hour assessments post the abuse on 2/23/25. On 3/28/25 at 1:50 pm V3, Assistant Director of Nursing/Wound Nurse stated I complete assessments and document the measurement on a spread sheet and on the resident assessment in pcc (electronic medical record) in resident chart. (R3) has had bruises in the past. I did not know she had a red area on her face that needed measured. I did not look at her skin the day of the incident with (R2), but I don't remember seeing anything the next day, so I did not document an assessment, because I saw nothing. Our floor nurses are supposed to initiate 72 hour documentation after skin issues. I don't see that happened. 2). The facility Illinois Department of Public Health (IDPH) Final Report Incident Date: 2/24/2025 signed by V1, Administrator/Abuse Prevention Coordinator, documents the following: On February 24th, 2025, it was reported by resident (R5) that resident (R4) struck resident (R3) on the arm. The residents were in the dining room for dinner when (R3) approached (R4) multiple times. (R3) enjoys greeting all of the residents, patting them on the hand, leg and arm, as if to greet them. (R4) had eventually gently steered (R3) wheelchair away from him. (R3) did not make any indications at the time of experiencing any pain. R3's complete electronic medical records does not documents the above physical abuse by R4, family or physician notification, and there is no ongoing assessments alert charting' or monitoring of R3 response to the physical abuse by R4. R4's complete electronic medical records does not documents the above physical abuse of R3, family or physician notification, and there is no ongoing assessments alert charting' or monitoring of R4. On 4/1/25 at 1:00 pm V2, Director of Nursing stated When you (surveyor) entered the building to investigate the allegations of abuse (R2 hit R3 and R4 hit R3), I reviewed their charts. I talk to (V6, Licensed Practical Nurse) and asked her why she did not document (R3) was hit by (R2), in (R3's) chart. She acknowledged she should have documented in both charts. I also saw (R4) had nothing in his chart about the incident between him and (R3), nor did (R3). Documentation is expected to be complete including notifications of family and physician. Though both situations were reported to the (V1, Administrator/Abuse Prevention Coordinator) and she called the families and physician, the nurse should have documented that (V1) was doing the notifications. Ongoing behavior tracking was completed for (R2 and R4's) behaviors. On (R3) there needed to be follow-up for signs and symptoms of fearfulness and her red bruise measurements and tracking. I saw one follow up note with (R3) redness documented, the next day I believe. There should have been 72 hour follow-up charting as I mentions to you before. Documentation is not a new issue but will still be addressed in the next staff meeting. The facility policy Policy and Procedure, Charting and Documentation dated 11/05/2019 documents the following: Purpose To maintain a medical record to serve a legal document that details the services provided to the resident, or any changes in the resident's medical or mental condition, through charting and documentation. Each resident will have an active medical record that contains accurately documented information, systematically organized and readily accessible to authorized persons. The same policy documents: 10. Documentation will include information on assessment, notifications, interventions and evaluation including but not limited to: a. Incidents/Accidents per facility policy b. Change in condition per facility policy c. Physician notification d. DPOA/Responsible Party notification e. Refusal of medications/treatment or recommendations The same policy documents: 11. Additional documentation requirements will be followed: d. Alert Charting - documentation on incident/accident or change in condition for 72 hours or until stable.

Based on record review and interview the facility failed to recognize and report reasonable suspicion of a crime to a law enforcement agency, related to physical abuse of R3 by R2 and R4, and failed to recognize and report suspicion of a crime to a law enforcement agency of an allegation of sexual abuse of R1 by V4, R1's Visitor. These failure affects four (R1,R2,R3,R4) of five residents reviewed for abuse on the sample list of eight. Findings include: The facility facsimile Incident Report Form - IDPH ( Illinois Department of Public Health) Notification) dated 2/23/25 signed by V1, Administrator/Abuse Prevention Coordinator documents: The facility received an allegation of physical abuse that R2 struck R3. The same form documents the police were not notified. As part of this investigation V6, Licensed Practical Nurse witness statement documents V6 observed R2 hit R3 in the face leaving a red mark on R3's cheek. The facility facsimile Incident Report Form - IDPH ( Illinois Department of Public Health) Notification) dated 2/24/25 signed by V1, Administrator/Abuse Prevention Coordinator documents: The facility received an allegation of physical abuse that R4 struck R3. The same form documents the police were not notified. As part of the same investigation, R5's witness statement documents R5 observed R4 hit R3 on the upper arm, and R5 heard a pop. The facility facsimile Incident Report Form - IDPH (Illinois Department of Public Health) Notification) initial report dated 3/25/25 signed by V1, Administrator/Abuse Prevention Coordinator documents: The facility received an allegation of sexual assault that (R1) was sexually assaulted on 3/17/2025 by an employee (with the same first name as a family friend of R1's). The same form documents the police were not notified. On 3/27/25 at 9:40 am V1, Administrator / Abuse Prevention Coordinator stated I did not call the police on any of the three allegation (V4 to R1, R2 to R3 and R4 to R3). I did not know I was supposed to. I thought I just reported to IDPH right away, and then I finished my investigation within five days. It makes sense to report all three, since one was a sexual abuse (R1) allegation and two (R3 by R2, and R3 by R4) could be considered allegations of battery. The facility Resident Right To Freedom From Abuse, Neglect, And Exploitation Policy And Procedure dated 2025 documents: The facility will ensure compliance with the Elder Justice Act pursuant to the Facility's Elder Justice Act Policy and Procedure. The facility The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure protocol dated 2025 documents: PURPOSE; To facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation.: The same policy documents: Reasonable suspicion of a crime must be reported to the State Survey Agency and at least one local law enforcement agency. Procedure: I. Definitions A. Alleged violation is defined as a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. a. An alleged violation can be observed or reported by staff, resident, relative, visitor, another health care provider, or others. b. An individual (e.g., a resident, visitor, facility staff) who reports an alleged violation to the Facility staff does not have to explicitly characterize the situation as abuse, neglect, mistreatment, or exploitation in order to trigger reporting requirements. Rather, if the Facility staff could reasonably conclude that the potential exists for noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property, then it would be considered reportable. The same policy documents: C.Abuse a. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. b. The deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. c. Instances of abuse of all residents, irrespective of any mental or physical condition, that cause physical harm, pain or mental anguish. This includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. i. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. ii. Sexual abuse is non-consensual sexual contact of any type with a resident. e. Abuse includes resident to resident altercations, including, but not limited to any willful action that results in physical injury, mental anguish, or pain. f. Willful actions include, but are not limited to the following: i. Hitting; ii. Slapping; iii. Punching; iv. Choking; v. Pinching; vi. Biting; vii. Kicking; vii. Throwing objects; ix. Grabbing; x. Shoving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R10's undated Face Sheet documents medical diagnoses of Paraplegia, Retention of Urine, Need for Assistance with Personal Care, Right Heel Stage 4 Pressure Ulcer, Right Ischium Stage 4 Pressure Ulcer and Muscle Weakness. R10's Minimum Data Set (MDS) dated [DATE] documents R10 as cognitively intact. This same MDS documents R10 as requiring maximum assistance for personal dressing, bathing and is dependent on staff for bed mobility. R10's Physician Order Sheet (POS) dated April 2024 documents physician orders to complete urinary catheter care every shift and as needed. R10's Care Plan intervention dated 10/12/22 documents R10 is total dependent on staff for all Activities of Daily Living (ADL). On 4/11/24 at 2:05 PM V19 and V21 Certified Nurse Aides (CNA) completed urinary catheter care for R10. V19 CNA applied Zinc Oxide paste containing 20.6% Zinc to R10's buttocks and perineal area after completing urinary catheter care. On 4/11/24 at 2:30 PM V19 Certified Nurse Aide (CNA) stated V19 applied Zinc Oxide paste to R10's perineal area because that is all we (facility) have. That is what we (staff) always use. I didn't know we (CNA) could not use Zinc. On 4/11/24 at 3:30 PM V2 Director of Nurses (DON) stated only nurses are to apply medicated creams. V2 stated The CNA's are not supposed to apply Zinc. That should only be applied by the licensed nurses since it is considered a medication. I will educate the staff on this. We (facility) do not have a policy on this but it is considered standard of care. Based on observation, interview and record review the facility failed to follow-up with physician regarding laboratory results for R40, and failed to ensure only licensed personnel administer medications for R10. R10 and R40 are two of 22 residents reviewed for the provision of skilled care/services on the sample list of 35. Findings include: 1.) R40's Current (multiple dates) Diagnoses Sheet documents the following diagnoses: Unspecified Dementia , Unspecified Severity With Psychotic Disturbance, and Unspecified Dementia, Moderate With Anxiety. R40's Minimum Data Set, dated [DATE] documents R40 has severe cognitive impairment. R40's Nursing Progress Note dated 03/20/2024 at 3:12 pm documents the following: Note Text: Called and spoke with (V25, Physician's) nurse about aggressive behavior on (of) resident (R40) toward staff, (V25) ordered (laboratory blood test) CBC (Complete Blood Count) and Ferritin (protein that helps the body store iron) level, (and) continue same meds (medications) (,) if (R40) continues to be aggressive (R40) needs sent to psych (Psychiatry). On 4/12/24 at 11:05 am V2 Director of Nursing (DON) reviewed R40 abnormal CBC and low Ferritin laboratory (lab) blood test results dated as drawn 3/20/24. V2, DON confirmed the lab values were abnormal and facsimile (handwritten date of 3/21/24 documented labs faxed at the bottom of R40's lab result sheet) sent to V25, Physician. V2, DON stated her expectation is that the nurses follow-up with a phone call to the doctor if no call back from the Physician in 24 to 48 hours. V2 confirmed the follow-up did not occur until 4/10/24 (after surveyor asked about the labs). V25, Physician ordered and signed the physician order on R40's original 3/20/24 laboratory result sheet. The physician order was dated 4/10/24 and documents Ferrous Sulfate (type of iron to treat anemia) 325 mg, BID (twice a day), repeat (labs) CBC and Ferritin iron studies, in one month. On 4/12/24 at 12:35 pm V25, Physician (R40's) CBC and Ferritin labs were ordered 3/20/24, results were faxed to me 3/21/24. I responded with a return fax to the facility on 3/22/24. I requested the current dose of Ferrous Sulfate (R40) was on. I did not receive that information until I was notified by the facility 4/10/24. I should have had a call or return fax with the information identifying (R40's) current Ferrous Sulfate dose, that I requested. I would have addressed this immediately. I do not feel this caused harm or even a potential for harm. I do feel this delay (19 days) should have never occurred. It prevented the start of the Ferrous Sulfate increase.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide timely incontinence care for a resident. This failure affects one resident (R15) reviewed for incontinence care on the sample list of 35. Findings include R15's Minimum Data Set (MDS) dated [DATE] documents R15's Brief Interview of Mental Status (BIMs)score as 12 out of a possible 15, indicating moderate cognitive impairment, on the day of assessment. (interviews of staff documented below indicate R15 is cognitively intact and reliable). The same MDS documents R15 has limited range of motion of bilateral upper and lower extremities, and is occasionally incontinent of bowel and bladder. R15's Physician Orders Sheet documents R15 is taking Furosemide (medication to help reduce the build-up of fluid in the body, and increases the production of urine) 40 milligrams daily, for the diagnoses of Shortness of Breath and Edema. R15's Care Plan dated 04/09/24 documents the following: R15 currently has an alteration to her ability to care for herself and need assistance due to Activity intolerance, Pain, Weakness.The same care plan documents: R15 requires extensive assistance of two staff for toileting, and peri-care will be completed anytime R15 is toileted and as needed. On 4/10/24, during resident council group, between 10:00 am -10:55 am, R31 (R15's roommate) stated (R15) puts her call light on to be transferred to the bedside commode. It takes two people. Often it will take an hour to an hour and a half. I have heard in the hall, staff (unidentified) say '(R15's) on the call light again'. Then, I hear the response, 'that is just (R15)'. This woman (R15) has had to wait so long she goes (incontinence) in her pants. The other day she (R15) asked me (R31) to help. I can't help her get up on the toilet. (R15) would never complain. I think staff know this, and don't get into a hurry for (to help) her. R31's MDS dated [DATE] documents R31's BIMS score as 15 out of a possible 15, indicating R31 has no cognitive impairment On 4/11/24 at 9:20 am R15 confirmed she turns on her call light and has to wait long period of time for staff to respond. R15 also stated I don't want to get anyone in trouble. I can't say I have waited a full hour or more. It may just seem like it to me, because I can't hold my bladder and bowel. When I need to go (void bowel or bladder), I need to go sooner then the staff can get (help) to me at times. I have a diaper (incontinence brief) on, and have learned to accept the fact that I may not make it to the commode. I don't like it, but I have accepted it. I know staff are busy. They provide good skin care, when they get to me. There are a lot of people here for them to care for. (V17's Family Member) brings in (brand name pericare barrier) cream and the CNA's (Certified Nursing Assistants) put it on when I have had my accidents (incontinence episodes). I have had a really sore bottom from setting in my wet diaper. The (brand name pericare barrier) is a great comfort. I am not sore now, but I have been many times. The CNA put the (brand name pericare barrier) on at least once per shift. It is a good barrier to prevent the irritation to my skin. I used it on all six of my babies. I still believe it it the best. I can't get up on my own to sit on the commode. If I could, I would not ever be sitting in my own (slang for urine and feces). On 4/12/24 at 10:25 am V16, CNA stated Yes, there have been times when I found (R15) really wet, and redness on her peri-area (Moisture Associated Skin Damage/MASD). We use a (brand name pericare barrier) to her peri-areas. There have been times, where she has had to have prescription cream. The nurse gets the order for it. Sometimes she (R15) gets UTI's (Urinary Tract Infections) and she gets sore down there (pericare), then. There have been times where she says she had her call lights on for a long time. There are times where the call light isn't on and she thinks it was. I always check to make sure the call light is working. On 4/12/24 at 10:52 V12, Registered Nurse (RN) confirmed R15 has a history of UTI's and Moisture Associated Skin Damage (MASD). V12 RN also stated R15 is alert and oriented and if R15 said she had her call light on, V12, RN would say R15 knows what she is talking about. On 4/12/24 at 11:20 am V3, Assistant Director of Nursing/ Registered Nurse acknowledged It is a dignity issue for any resident to have to wait long periods of time to be toileted. V3 stated R15 's does have a history of MASD, V3 also stated I do expect call lights to be answered within five minutes, and bathroom call lights within a minute.' On 4/12/24 at 12:12 pm V11, Licensed Practical Nurse (LPN) stated R15 and R15's roommate R31 are both alert and oriented. V11, LPN stated if R15 and R31 said the call light was on for a long time and it caused R15 to void incontinent, 'it must have happened'. V11, LPN stated I have put (R15) on the bedside commode myself, recently. She had wet (urinated) in her brief by the time I took her to the bathroom, but I wouldn't say she was very red, maybe slightly. I guess being wet for any length of time, when she is continent most of the time, would be a dignity issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow a physician ordered pressure ulcer treatment and implement pressure ulcer interventions for one (R10) of two residents reviewed for Pressure Ulcers on the sample list of 35. Findings Include: R10's undated Electronic Medical Record (EMR) documents medical diagnoses of Paraplegia, Retention of Urine, Need for Assistance with Personal Care, Left Ischium Stage 4 Pressure Ulcer, Right Gluteal Stage 4 Pressure Ulcer, Right Heel Stage 4 Pressure Ulcer and Muscle Weakness. R10's Minimum Data Set (MDS) dated [DATE] documents R10 as cognitively intact. This same MDS documents R10 as requiring maximum assistance for personal dressing, bathing and is dependent on staff for bed mobility. R10's Physician Order Sheet (POS) dated April 2024 documents physician orders to cleanse R10's Left Ischium with wound cleanser, apply thin layer of Hydrogel then cover with bordered gauze dressing daily and as needed. This same POS documents a physician order to cleanse Right Gluteal, cleanse area with wound cleanser, loosely pack tunnel and wound bed with Calcium Alginate rope, then cover with silicone foam dressing daily and as needed. *may use plain packing if Calcium Alginate rope not available. R10's Care Plan intervention dated 10/12/22 documents R10 requires total dependence on staff for all Activities of Daily Living (ADL). This same careplan documents an intervention dated 1/5/23 to turn and position (R10) every two hours/(R10) to only be on back when eating. This same careplan documents an intervention dated 1/5/23 to apply treatment as ordered by Physician. R10's Wound Assessment and Plan dated 4/10/24 documents R10's Left Ischium Stage 4 Pressure Ulcer as Declined due to development of slough and unstable eschar. On 4/10/24 at 9:35 AM R10 was laying on his back in reclined wheelchair in room. R10 stated My butt hurts. I want to lay down. On 4/10/24 at 1:40 PM R10 was laying on his back in reclined wheelchair in room. R10 stated I have been up all morning. My butt hurts. On 4/11/24 at 9:00 AM R10 was laying on his back in reclined wheelchair eating breakfast in the dining room. R10 stated I hope I don't have to stay up all day again. That really hurts my butt. On 4/11/24 at 2:00 PM R10 was being assisted to bed per staff. R10 stated I have been up all day again. Sometimes I like to stay up but my butt hurts a lot lately and I want to lay down more. On 4/10/24 at 10:00 AM V19 Certified Nurse Aide (CNA) stated (R10) does not lay down after breakfast. (R10) stays up until after lunch. V19 stated it is difficult to reposition someone while laying in a reclining wheelchair. On 4/11/24 at 2:50 PM V20 Licensed Practical Nurse (LPN) completed R10's Pressure Ulcer dressing changes. V20 LPN did not cleanse R10's Left Ischium prior to cleansing pressure ulcer. V20 LPN applied Calcium Alginate with Silver to R10's Right Ischium Pressure Ulcer. On 4/11/24 at 3:15 PM V20 LPN stated V20 did not review R10's physician orders prior to completing dressing change. V20 LPN stated V2 DON wrote the physician orders on a piece of paper and V2 had written the orders down wrong. V20 LPN stated the packages for the Calcium Alginate and Calcium Alginate with Silver are very similar looking. V20 LPN stated I just picked up the wrong dressing. I should have used the regular Calcium Alginate. I forgot to cleanse (R10's) Left Ischium. That could cause an infection. On 4/11/24 at 3:45 PM V2 Director of Nurses (DON) stated nurses should always cleanse a resident's wounds prior to applying new dressing. V2 DON stated not cleansing an open wound as the physician orders could cause a wound to get infected. V2 DON stated the physician orders were not followed for R10's Right Gluteal Stage 4 Pressure Ulcer wound. V2 DON stated We (facility) do not have a policy for a clean dressing change. I consider that standard of care. All nurses should have been taught that in nursing school and would be expected to follow that same teaching at our facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to check the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube prior to administration of medication and enteral feeding for one (R37) out of one resident reviewed for PEG tubes in a sample list of 35 residents. Findings include: R37's undated Face Sheet documents medical diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Aphasia, Cerebrovascular Disease and Dystonia. R37's Minimum Data Set (MDS) dated [DATE] documents R37 as severely cognitively impaired. R37's Care Plan intervention dated 2/12/24 instructs staff to check for Percutaneous Endoscopic Gastrostomy (PEG) tube placement and gastric contents/residual volume per facility protocol and record. R37's Physician Order Sheet (POS) dated April 2024 documents a physician order starting 3/7/24 to administer Jevity 1.5 calorie at (55 milliliter/hour). Check for placement and residual amount prior to administration. This same POS documents physician orders for Glycopyrrolate Oral Tablet (Glycopyrrolate) one milligram (mg) via PEG-Tube three times a day for ulcers and Metronidazole 500 milligrams (mg) per PEG tube three times a day for infection for 6 Weeks for infection. On 4/10/24 at 12:09 PM R37 V13 Registered Nurse (RN) administered R37's Metronidazole 500 milligrams (mg) and Glycopyrrolate 1 mg per R37's Peg Tube without checking for residual prior to medication and water flush administration. V13 RN then resumed R37's Jevity 1.5 enteral feeding after medication administration without checking for residual. On 4/10/24 at 12:20 PM V13 Registered Nurse (RN) stated R37 has an order to check R37's Peg tube placement daily. V13 RN stated I am not sure what the policy says but we (staff) do not check the residual before each medication administration or starting or stopping (R37's) feeding. We only check it once a day. On 4/10/24 at 4:20 PM V2 Director of Nurses (DON) stated the nursing staff should always check the placement of R37's PEG tube prior to administering any medications, water flushes and/or enteral feedings. V2 DON stated it is important to check the placement to ensure the medications, water and feeding is 'going to the right place'. The facility policy titled 'Tube Feeding' initiated November 28, 2023 documents the staff providing medication administration should verify the Physician's order, gather equipment, identify resident, provide privacy, explain procedure to resident, assist resident to semi-or high Fowler's position (30 degrees to 45 degrees) unless contraindicated, perform hand hygiene and apply gloves, prepare medication, unclamp tube, attach a 60 cc syringe into the tube, verify tube placement check for residual gastric contents by aspirating the syringe, return gastric contents removed during residual check back into stomach, insert syringe (without plunger) and flush tube with 30 cc water; do not use cold water which may induce abdominal cramping,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide, change, date and maintain respiratory equipment according to physician orders and facility policy. This failure affected three of three residents (R8, R22. and R31) on the sample list of 35. Findings include: 1.) R8's Physician Order Sheet (POS) dated 4/9/24 documents the following: O2 (Oxygen) at (administer) 4L (four liters per minute) PRN (as needed), if sat (blood oxygen saturation) below 85 '(Notify Physician)', every 15 minutes as needed for SOB (Shortness of Breath). The respiratory administration device is not documented. R8's same POS documents: Change Humidifier Bottle (with) date and time on bottle of (sic) change every night shift every 7 day (s) for Oxygen (sic) use refillable humidifier bottle change date and time on bottle of change (sic). R8's same POS documents R8 is on Hospice end of life care. On 4/9/24 at 12:00 pm, V28, R8's Family Member was seated at R8's bedside. R8 was asleep with an oxygen nasal cannula present in her nares. R8's oxygen concentrator was actively dispersing four liters of oxygen per minute. R8's oxygen tubing with the nasal cannula were not dated or timed as to when they had last been changed. R8 did not have a humidifier bottle attached to the (valve) of the oxygen concentrator. V28 stated V28 is not sure if the oxygen tubing has been changed and is not sure if R8 has had a humidifier bottle of water on her oxygen concentrator. V28 stated It seems it would be more comfortable if she did. comfortable. On 4/9/24 at 12:05 pm ,V11, Licensed Practical Nurse stated R8 is on Hospice. Hospice was suppose to bring in their own supplies for R8. V11 confirmed R8 does not have a humidifier bottle on her concentrator and the tubing and nasal cannula are not dated to indicate when they were last changed. 2.) R22's POS dated 4/10/24 documents the following: Oxygen at 2 L/min (liters per minute) via Nasal Cannula, Humidification as needed. Change Humidifier Bottle, date and time on bottle of (when) change (d) every night shift, every 7 day(s) for Oxygen use Refillable (sic). On 04/09/24 at 12:25 pm R22 was not in R22's room. R22's oxygen concentrator was dispensing oxygen at 2 liters per minute via a nasal cannula. The nasal cannula tubing was draped on top of and around an oxygen concentrator machine. There were no date or time documented on R22's oxygen tubing, nasal cannula or humidifier water bottle to indicate when the respiratory equipment had last been changed. On 4/9/24 at 12:30 pm V11, LPN confirmed the observation of R22's oxygen tubing being draped around R22's concentrator, undated tubing and cannula, and actively dispensing oxygen when R22 was not using the oxygen. V11 stated the respiratory equipment should have been changed. 3.) R31's Physician Order Sheets dated 4/11/24 documents the following orders: Oxygen at 3L/min via Nasal Cannula with humidification to maintain oxygen saturation above 90% and to promote resident comfort. O2 Tubing: Change Tubing On Sunday & PRN as needed for Infection Control Change every Sunday when in use and as needed. R31's Minimum Data Set, dated [DATE] documents R31's Brief Interview of Mental Status score as 15 out of a possible 15, indicating R31 has no cognitive impairment. On 4/9/24 at 12:50 pm R31 was seated in a wheelchair bedside with a nasal cannula actively dispensing oxygen at three liters per minute via a bedside oxygen concentrator. R31's Oxygen humidifier bottle was attached to R31's oxygen concentrator and was empty. R31's oxygen tubing and humidifier bottle were dated 3/31/24 (9 days). R31 stated I don't know how often they change my oxygen bottle or tubing. I think it only gets changed when the bottle runs dry. It is dry now, as you can see. At 12:55 pm V11, Licensed Practical Nurse stated R31's tubing and humidifier were outdated (3/31/24) and should have been changed last Sunday 4/7/24. The humidifier bottle should have never run dry, that gets changed prn as well. On 4/9/24 at 2:47 pm V3, Assistant Director of Nursing reviewed resident records and stated the facility policy should be followed. V3 also stated Nebulizer equipment and oxygen equipment are to be changed weekly and as needed. A plastic bag should be changed too. The humidifier bottles, tubing and Nebulizer (treatment) equipment should be dated when they (nurses) change them, and when not in use placed in clean bag. V3 also stated V3 is aware that some nurses have been signing resident electronic medication administration record for the oxygen equipment changes though the oxygen equipment changes had not been completed. I will be addressing oxygen administration record) documentation right away. The facility policy Oxygen Administration and Storage dated as revised 03/08/22 documents the following General Guidelines: 4. The nasal cannula or mask should be changed weekly or when soiled. 5. The extension tubing (the tube used to lengthen the cannula, but is not connected directly to the resident) should be changed monthly or when soiled. 6. Nasal cannula and/ or mask should be stored in a manner to prevent from touching the floor when not in use. If the mask or nasal cannula touches the floor, it should be changed to prevent pathogens from entering the respiratory system. 7. The humidifier bottle is to be labeled with the date of application and changed weekly if refillable. If it is disposable (single use) humidification, bottle is to be changed at least weekly and more frequently as it is near empty to maintain humidification. 8. Filters should be removed and cleaned by rinsing with clear, cool water weekly to maximize flow rate of clean air.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R16's undated Face Sheet documents medical diagnoses of Traumatic Brain Injury, Dysphagia, Hallucinations, Alzheimer's Disease, Need for Assistance with Personal Care, and Cognitive Communication Deficit. R16's Minimum Data Set (MDS) dated [DATE] documents R16 is severely cognitively impaired. This same MDS documents R16 requires maximum assistance for dressing, bathing, toileting and personal hygiene. R16's Care Plan intervention dated 3/8/24 documents R16 is independent with eating. On 4/9/24 at 11:20 AM R16 was seated in a wheelchair, in the hallway. R16 was wearing a grey t-shirt with dried liquid spots down the front, and wet spot that extended from the left midsection of R16's shirt, to side of R16 wheelchair. R16 had fruit loops sitting beside him, on the seat of wheelchair that were touching R16's pants. On 4/9/24 at 2:45 PM R16 was seated in a wheelchair with same soiled clothing, with the same food debris and liquid spots on front of his shirt, as identified earlier in the day as documented above. On 4/10/24 at 10:15 AM R16 was seated in a wheelchair in hallway. R16 was wearing dark blue sweatpants, that had food debris and other circular spots of liquid spilled on R16's pants. On 4/10/24 at 1:30 PM R16 was seated in a wheelchair in hallway with the same clothing on soiled with food debris as observed earlier in day and documented above. On 4/9/24 at 3:00 PM V18, (R16's) Power of Attorney (POA) stated (R16) is partially blind and can't see if his clothes or clean or not. (R16) has Dementia and was never real picky about his clothes. I don't think he would care if (R16) was wearing matching clothes or not, but I know he would not want to wear dirty clothes. They (staff) should change that. On 4/11/24 at 9:15 AM V2 Director of Nurses (DON) stated the facility offers clothing protectors for residents during meal times. V2 DON stated if the resident declines to wear a clothing protector and spills food on themselves, then the staff should offer to assist that resident with changing clothes and 'getting cleaned up'. V2 DON stated Sometimes the resident refuses to change their clothes but the staff should reattempts to help provide hygiene cares. V2 DON confirmed the staff should ensure that dignity of all residents is maintained. The facility pamphlet titled 'The Illinois Long Term Care Ombudsman Program Residents' Rights for People in Long Term Care Facilities' revised 11/18 documents the facility must treat residents with dignity and respect and must care for you in a manner that promotes your quality of life. Based on observation, interview, and record review, the facility failed to ensure residents' rights to dignified activities of daily living. This failure affects six residents (R11, R14, R15, R16, R31, and R48) of six reviewed for dignity on the sample list of 35. Findings include: 1.) On 4/09/2024 at 12:30PM, five tables were pushed together in a row, at the center of the facility dining room with residents seated around the perimeter of the tables. Facility staff began serving lunch meals to the residents seated at the tables at 12:30PM, with residents seated at the same table receiving lunch meals within five minutes of each other. R11, R14, and R48 were all seated at the center table waiting for lunch to arrive while watching other residents eat lunch. R11, R14, and R48 did not receive a meal until 1:20PM, fifty minutes after the first meal was served to the adjoined tables. V10 (Activities Aide) was present and reported residents are supposed to eat lunch at 12:30PM. On 4/10/2024 at 12:45PM, no residents seated in the facility dining room had received a meal. On 4/11/2024 at 12:55PM, no residents seated in the facility dining room had received a meal. On 4/11/2024 at 1:20PM, R48 stated meals are late all the time. On 4/12/2024 at 11:46AM, R11 reported meals are late almost every day and usually don't arrive until 1-1:30PM. Resident Council meeting minutes (3/26/2024) document council members reported breakfast, lunch, and dinner meals are often served late. 2.) R15's Minimum Data Set (MDS) dated [DATE] documents R15's Brief Interview of Mental Status (BIMs)score as 12 out of a possible 15, indicating moderate cognitive impairment, on the day of assessment. (interviews of staff documented below indicate R15 is cognitively intact and reliable). The same MDS documents R15 has limited range of motion of bilateral upper and lower extremities, and is occasionally incontinent of bowel and bladder. R15's Care Plan dated 04/09/24 documents the following: R15 currently has an alteration to her ability to care for herself and need assistance due to Activity intolerance, Pain, Weakness.The same care plan documents: R15 requires extensive assistance of two staff for toileting, and peri-care will be completed anytime R15 is toileted and as needed. On 4/10/24, during resident council group, between 10:00 am -10:55 am, R31 (R15's roommate) stated (R15) puts her call light on to be transferred to the bedside commode. It takes two people. Often it will take an hour to an hour and a half. I have heard in the hall, staff (unidentified) say '(R15's) on the call light again'. Then, I hear the response, 'that is just (R15)'. This woman (R15) has had to wait so long she goes (incontinence) in her pants. The other day she (R15) asked me (R31) to help. I can't help her get up on the toilet. (R15) would never complain. I think staff know this, and don't get into a hurry for (to help) her. R31's MDS dated [DATE] documents R31's BIMS score as 15 out of a possible 15, indicating R31 has no cognitive impairment. On 4/11/24 at 9:20 am R15 confirmed she turns on her call light and has to wait long period of time for staff to respond. R15 also stated I don't want to get anyone in trouble. I can't say I have waited a full hour or more. It may just seem like it to me, because I can't hold my bladder and bowel. When I need to go (void bowel or bladder), I need to go sooner then the staff can get (help) to me at times. I have a diaper (incontinence brief) on, and have learned to accept the fact that I may not make it to the commode. I don't like it, but I have accepted it. I know staff are busy. They provide good skin care, when they get to me. There are a lot of people here for them to care for. R15 also stated,I can't get up on my own to sit on the commode. If I could, I would not ever be sitting in my own (slang for urine and feces). On 4/12/24 at 10:25 am V16, CNA stated Yes, there have been times when I found (R15) really wet, and redness on her peri-area (Moisture Associated Skin Damage/MASD). V16 stated, There have been times where she says she had her call lights on for a long time. There are times where the call light isn't on and she thinks it was. I always check to make sure the call light is working. On 4/12/24 at 10:52 V12, Registered Nurse (RN) confirmed R15 has a history of UTI's and Moisture Associated Skin Damage (MASD). V12 RN also stated R15 is alert and oriented and if R15 said she had her call light on, V12, RN would say R15 knows what she is talking about. On 4/12/24 at 11:20 am V3, Assistant Director of Nursing/ Registered Nurse acknowledged It is a dignity issue for any resident to have to wait long periods of time to be toileted. V3 stated R15 's does have a history of MASD, V3 also stated I do expect call lights to be answered within five minutes, and bathroom call lights within a minute.' On 4/12/24 at 12:12 pm V11, Licensed Practical Nurse (LPN) stated R15 and R15's roommate R31 are both alert and oriented. V11, LPN stated if R15 and R31 said the call light was on for a long time and it caused R15 to void incontinent, 'it must have happened. The facility pamphlet titled 'The Illinois Long Term Care Ombudsman Program Residents' Rights for People in Long Term Care Facilities' revised 11/18 documents the facility must treat residents with dignity and respect and must care for you in a manner that promotes your quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) The facility Fall Reduction Policy dated 6/17/22 documents all falls should be documented in the residents electronic medical record and the risk management report and fall risk assessment should be completed after each fall. If the fall is not witnessed neurological checks should be initiated. Nursing staff should update the 24 hour report. The resident's care plan should be reviewed after every fall and updated with a new intervention. R159's Medical Diagnoses List dated April 2024 documents R159 is diagnosed with Repeated Falls, Psychotic Disorder, Mild Cognitive Impairment, Dementia, Motor and Sensory Neuropathy, and Muscle Weakness. R159's Minimum Data Set, dated [DATE] documents R159 is severely cognitively impaired, uses a wheelchair, and requires substantial assistance for chair/bed transfer and toilet transfers. R159's Fall Risk assessment dated [DATE] documents R159 is high risk for falls due to dementia diagnoses, he has three or more falls in past three months, he is ambulatory and incontinent, has balance problems while standing and walking, requires assistive devices, and has at risk medications and at risk diagnoses. R159's Nurses Progress Note dated 4/3/24 documents R159 continues to be on fall follow-up protocol (from a fall on 3/31/24) and had another fall at 10:00 PM (on 4/2/24) when he was attempting to self-transfer to his wheelchair to use the bathroom. There is no other documentation concerning this fall on 4/2/24. Neurological checks were not initiated. A fall investigation was not completed. A root cause was not determined and a new, root cause specific intervention was not implemented. R159 fell again on 4/9/24. On 4/12/24 at 11:15 AM V2 Director of Nurses confirmed R159 had an unwitnessed fall on 4/2/24 at approximately 10:00 PM which was not entered into the risk management system, neurological checks were not initiated, a fall investigation and root cause was not determined, and no new fall interventions were implemented to aid in future fall prevention. Based on observation, interview and record review the facility failed repeatedly to adequately supervise a resident (R40) at risk for self harm, and failed to document a resident (R159) fall into the facility's risk management system, initiate neurological checks, conduct a fall investigation, determine a root cause, and implement a specific fall intervention to aid in future fall prevention. These failures affect two of five residents (R40, and R159) reviewed for accidents/supervision on the sample list of 35. Findings include: 1.) R40's Current (multiple dates) Diagnoses Sheet documents the following diagnoses: Unspecified Dementia , Unspecified Severity With Psychotic Disturbance, and Unspecified Dementia, Moderate With Anxiety R40's Minimum Data Set, dated [DATE] documents R40 has severe cognitive impairment and uses a wheelchair for mobility. R40's Care Plan dated 04/04/24 documents the following: I currently have an alteration in my behavior status r/t (related to) Anxiety, Depression, Res (resident) preference to not follow medical recommendations '(noncompliance)', Aggressive Behavior '(Physical or Verbal)', Agitation, Crying/Tearful, Restlessness, (and) Yelling out. Interventions include: Intervene as necessary to protect rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. I currently have an alteration to my Mood status d/t (due to) Restlessness, anxiousness, and exit seeking. Cognition wise, I am not able to understand some commands or questions. I am known for coming out of my room looking for food therefore, I take any food I find, even if it's others and I take objects that aren't food and put in my mouth to try and eat. I am known for verbal aggression and repetitive statements. R40's same Care Plan documents: Behavior- Agitation/ Restlessness/ Anxious. Behavior- eating/ licking inappropriate items. Behavior- taking items that are not mine.' My current risk for Wandering / Elopement is High Risk 7 ( score of seven) or higher and my safety will be monitored every shift by all staff. R40's Behavior Note dated 3/3/2024 at 2:10 pm documents the following: Note Text: Resident was in the front lobby and grabbed a bottle of lotion off of the desk it was taken from the resident as he wouldn't give it back he then picked up a wooden out going mail box and threw it across the floor towards the copy room and was cursing at staff. Resident removed from front lobby and taken to his room. R40's Nursing Progress Note dated 03/06/2024 at 12:15 pm documents the following: Note Text: CNA came to this nurse with the fact that resident had put some calazime cream in his mouth called poison control spoke with (proper first name only) to see what we needed to do since it was a keep out of reach of children warning label was told to give him a drink of water milk or juice, water was given and he drank without issues V/S T 97.9 P 76 R 18 B/P 116/56 O2 sat at 98% on room air. He might experience some GI upset vomiting or diarrhea if excessive call back but to just watch resident. R40's Behavior Note dated 03/10/2024 at 3:12 pm documents the following:Note Text: Resident had been in and out of his room numerous times, attempting to take stuff off the carts, trash bags and going to the dinning room to eat off other residents used trays, then going to the nurses carts shaking the drawers to attempt to get in them, resident has been redirected several times given snacks, talking with him ,watching his tv (television). Continues to come behind the nurses desk looking for food. Has took (taken)decorations from the desk and then he places them under his blanket to hide them. Goes to the dinning room and gets into the condiments and licks the packages. Became verbally aggressive with the cna (unidentified, Certified Nursing Assistant) when the cna asked for the trash bags back give those back u (you) son of a (expletive). R40's Nursing Progress dated 3/11/2024 at 2:10 pm documents the following: Note Text: Reported to ( proper first name only) at ( V25, Physician) office about resident attempting to eat things that are non edible, items such as kleenex, oxygen tubing, lancets, paper clips and getting into staffs purses and bags behind the nurses station. Not currently on anything for anxiety. R40's Behavior Note dated 3/17/2024 at 10:43 am documents the following: Note Text: Resident grabbed a bottle on hand sanitizer and took the lid off and this nurse took bottle from resident and he took the top of the bottle and threw it at the wall behind B hall med cart. Screaming at this nurse to go to my room. Attempts to redirect resident met with resistance. R40's Behavior Note dated 3/17/2024 at 11:25 am (37 minutes after the last incident documented above) documents the following: Note Text: Resident was in the front lobby and picked up a small bottle of hand sanitizer and took a drink and stated 'that killed me honey it burns it burns' (.) Called poison control and was asked by (proper first name only) what the ingredients were and told her ethyl alcohol 80% she told this nurse to give him something to eat to help absorb the alcohol it was like drinking a shot of scotch he didn't need to go to the hospital. R40's Behavior Note dated 3/20/2024 at 10:11am documents the following: Note Text: Resident has been very agitated this AM taking Easter decorations off the table and trying to eat the Styrofoam egg had 2 (two) eggs in his mouth and staff had to place fingers on his cheeks to get the eggs from resident's mouth to prevent him from sucking the eggs down his throat (,) he was then taken to his room and given a snack and some water (.) he then went across the hall and opened a bottle of lotion and tried to drink it, staff removed the lotion and he threw the lid across the room and cursed at staff, before breakfast trays were picked up he was eating off multiple trays this nurse removed him from the dining room and was cursed at he also drew back his fist as if to hit this nurse. R40's Nursing Progress Note dated 3/20/2024 at 3:12 pm documents the following: Note Text: Called and spoke with (proper first name only) (V25's) nurse about aggressive behavior on resident toward staff ordered CBC (Complete Blood Count) and Ferritin level continue same meds if continues to be aggressive needs sent to psych (Psychiatry). R40's Behavior Note dated 4/3/2024 at 10:25 am documents the following: Note Text: Resident was waiting outside the shower room when he went into a female residents room and got in her bedside table and was trying to eat lotion before staff took the lotion and removed resident from the females room and was taken to the dining room until time for his shower. On 4/10/24 at 10:00 am, during a resident group meeting R31 stated R31 saw R40 in the dining room doorway. R40 had approached an unlocked medication cart, while V11, Licensed Practical Nurse (LPN) was passing medications. V11's back was turned. When V11 turned back around she saw R40 had removed a large bag from the drawer of the medication cart. 'The bag was full of something, I think it was medication and blood test vials.' R31 also stated V11 knew if R40 got away with those medications it could really hurt him. R40 started swinging at V11. R40 was arguing with V11. (V11) and (R40) were in a tug of war for a minute. V11 got the bag away from R40. R40 was taken back to his table to eat. During the same group meeting R18 stated he saw the same event occur between R40 and V11, exactly as R31 had described. R18's Minimum Data Set (MDS) dated [DATE] documents R18's Brief Interview of Mental Status (BIMS) score as 15 out of a possible 15, indicating no cognitive impairment. R31's MDS dated [DATE] documents R31's BIMS score of 15 out of a possible 15, indicating no cognitive impairment. On 4/11/24 at 11:55 am R40 was seated in a recliner in his room. R40 had a throw blanket over his head and hummed loudly when surveyor knocked on R40's door. R40 removed the blanket from his head and said over and over I love you. When asked any question, R40 hummed or would say I love you. R40 was unable to answer any questions. R40 had three empty plastic glasses and an empty snack bowl on his bedside table. On 4/11/24 at 12:05 pm V15, Certified Nursing Assistant stated she works with R40 all the time. V15, CNA stated He (R40) is always into to something. We try to watch him close. I was off the day he got stuff out of the medicine cart and hit (V11, Licensed Practical Nurse). I heard about it the next day. That was a couple weeks ago. I was not surprised. He can be easily re-directed but is consistently taking stuff off the medicine carts. Staff intervene daily. We all know to watch him every minute. He has dementia and doesn't know better. It is up to us to give him something to do. He is a good eater. We give him snacks a lot. He will try to eat other things he should not be eating. He just doesn't understand. He can get agitated with us. He has never been agitated with another resident, that I know about. On 4/12/24 at 10:10 am V16, CNA stated R40 grabbed a potted plant on the nurses station and another time he had taken another residents a gift set of shampoo, body wash and lotion set. V16 said she assumed he was going to eat it and got V26, LPN. V16, CNA also stated R40 has taken the water pitcher off of the med cart and V16 has seen him shake the drawers of the med cart. V16 also stated an unidentified CNA saw R40 drink pericare liquid wash. On 4/12/24 at 12:12 pm V11, LPN confirmed she provided care to R40 (3/17/24) when R40 consumed a good size swallow of hand sanitizer in the lobby, and had tried earlier the same day to drink the hand sanitizer at the nurses station. V11 had to call poison control and was directed by V25, Physician to follow poison control recommendations. V11 also stated she was R40's nurse when he had gotten medicated Calazime cream in his mouth (3/6/24). V11 stated R40 had gone into the shower room that day and had already got the medicated cream when an unidentified CNA saw R40 and reported. V11 stated she had to call V25, Physician and Poison Control. V11 stated R40 needs constant supervision sometimes because he puts thing in his mouth that are not food. V11 also stated On the weekend we do not have ancillary staff. Those days are very hard to keep constant eye on him (R40) if he is having one of those days where he is busy and trying to put stuff in his mouth. We intervene a lot those days. When ancillary staff are here, they see him and redirect too. Those extra eyes make a difference when he is really active. On 4/12/24 at 12:35 pm V25, Physician stated she has observed staff fail to supervise R40 as closely as they should, on the weekend. V25 also stated it is expected, knowing R40 history, that staff stay diligent in supervising him.

Based on interview and record review, the facility failed to provide residents food at an appetizing temperature for four of four resident ( R11, R12, R18, and R31) reviewed for palatable meals on the sample list of 35. Finding include: R11, R12, R18 and R31's Current, Minimum Data Sets document R11, R12 R18 and R31 all have Brief Interview of Mental Status scores of 15 out of a possible 15, indicating they have no cognitive impairment. On 4/10/24 at 10:00 am during a resident group meeting, R11, R12, R18 and R31 their meals were often served late, up to one and a half hours past the scheduled meal time, resulting in hot food being served cold. All residents stated there has not been cold food served since state surveyors arrived in the building 4/9/24. On 4/10/24 at 11:30 am V8, Dietary Manager (DM) stated V8 DM Inherited a lot of kitchen problems when he started as DM two weeks ago. V8, DM stated All the hall trays are delivered to the halls first. We use a disc at the bottom and a cover over the top of the plate to keep the food hot. There have been a lot of complaints. The food comes out of the kitchen at safe hot temperatures, then they set on the hall for 30 to 45 minutes before the aides (Certified Nursing Assistants) get the trays delivered to the resident. I have discussed this with nursing staff. What I hear is, they are busy getting people up and out to the dining room, so they can't deliver the trays yet. The problem happens in the dining room as well. The food is at a safe temperature and brought out to the dining room. I watched a cart, with food set for 30 minutes with the dining room full of residents waiting to eat. There is no problem with the kitchen re-heating the food to a safe temperature. The CNA's just need to let us know. I said something to nursing when I saw the cart of food had not been delivered. That is when the Aides got the trays out to the residents in the dining room. There were a couple residents that asked for their food to be reheated that day. I think it was Monday. The facility Resident Council (meeting notes) Tuesday, January 30, 2024 documents Old Business-Last Month. Some members had several dietary concerns. Food Temps (Temperatures) are documented as one of the concerns Resident Council follow-up. document. The facility Resident Council (meeting notes) Tuesday, February 27, 2024 documents December and January (unidentified council) Members expressed some meals are not warm enough when received. The facility Resident Council (meeting notes) Tuesday, March 26, 2024 document council members reported breakfast, lunch, and dinner meals are often served late, lately.

Based on interview and record review the facility failed to provide bedtime snacks for four of five of four residents (R11, R12, R18 and R31) reviewed for bedtime snacks on the sample of 35. Findings include: R11, R12, R18 and R31's Current, Minimum Data Sets document the following: R11, R12 R18 and R31 all have Brief Interview of Mental Status scores of 15 out of a possible 15, indicating they have no cognitive impairment. On 4/9/24 at 10:00 during a resident group meeting, R11, R12, R18 and R31 stated snacks are not stocked daily or offered at bedtime. The facility sometimes puts the snack cart in the linen room and not at the nurses station, so the resident can't get snacks on their own. R12 and R31 both added they have Diabetics Mellitus and need to have a snack available so their blood sugar level doesn't drop. On 4/10/24 at 11:30 am V8, Dietary Manager stated There should be no problem with snacks at bedtime or between meals. The snack carts are taken to the nurses station, filled on each unit, each shift. I don't know if the snack carts are being put in the linen room. I had not heard that before. On 4/11/24 at 9:00 am V3, Assistant Director of Nursing (ADON) and V2 Director of Nursing (DON) together discussed resident council group meeting concerns with this surveyor. V2, DON stated she was not aware that snacks were not being provided at bedtime. V3, ADON stated The snack cart is put in the linen room because a wandering resident (R40) gets into the snack cart and tries to eat everything, and he (R40) is a diabetic and can't have all the stuff on the cart. V2, DON then stated she will look into a better solution, so all resident have access to the snacks on A, and B halls.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 53 in the facility. Findings include: On 4/9/2024 at 10:58AM, V8 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V8 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V8 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V8 reported the facility dietician does not work full-time in the facility. V8 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. On 4/9/2024, the facility dietary staff failed to prevent direct cross-contamination of food and failed to maintain sanitary food storage areas. On 4/12/2024 at 11:50AM, V8 reported the food prepared in the facility kitchen is available for all residents to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (3/9/2024) documents 53 residents reside in the facility.

Based on observation and interview, the facility failed to prevent direct cross-contamination of stored food and failed to maintain sanitary food storage areas. This failure has the potential to affect all 53 residents residing in the facility. Findings include: 1. On 4/9/2024 at 11:05AM, three wire shelving sections located in the kitchen walk-in cooler were partially covered with a gray-colored, fuzzy biological growth resembling mold. Boxes of food items, pans of prepared food, and jugs of milk were stored directly on these shelving racks. 2. On 4/9/2024 at 11:21AM, the facility walk-in freezer evaporator/condenser supply lines were leaking accumulated condensation onto boxes of food stored below on shelving. The leak had dripped directly into a fully open box of frozen green beans, partially covering the product. At this time, V8 (Dietary Manager) was present and observed the box of green beans. When asked if the ice on the green beans was condensation that had leaked from the above evaporator/condenser supply lines, V8 replied yes. On 4/12/2024 at 11:50AM, V8 reported food in kitchen is available for all residents to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (4/9/2024) documents 53 residents reside in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to report an allegation verbal abuse of two (R5, R6) residents out of four residents reviewed for Abuse in a sample list of nine residents. Findings include: The facility policy dated 2022 titled 'The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure' documents individuals must report alleged violations, whether it was oral or in writing, to the Administrator or other designated facility representative and the facility must report the alleged violation to the State Survey Agency. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. This same MDS documents R6 as requiring moderate assistance for mobility and transfers. R6's Careplan initiated 11/27/2023 does not include a focus area, goal nor interventions for R1's risk of Abuse. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as moderately cognitively impaired. This same MDS documents R5 requires moderate assistance for mobility and transfers. R5's Careplan dated 10/4/2023 does not include a focus area, goal nor interventions for R1's risk of Abuse. The facility was unable to provide an Initial or Final Report to the State Agency of an allegation of verbal abuse towards R5 and R6 by V4 at the facility on 2/27/24 to the State Agency. On 3/3/24 at 10:20 AM V2 Director of Nurses (DON) stated V4 (R1's) family member was yelling and using the 'F' word. V2 stated (V4) said 'I can't believe this f******(expletive) place.' and using other profanities. V2 stated (R5, R6) were both sitting in their wheelchairs next to the nurses station 'about a few feet from (V4)'. A minute or so later (V1) walked up and escorted (V4) over to a private area where she could vent her concerns. I did not report this incident to (V1) because I thought he would have heard all the yelling. On 3/3/24 at 11:25 AM V19 Social Service Director (SSD) stated (V4) was pointing fingers, yelling and saying 'this f******(expletive) place' and this is 'b*******(expletive)' with (R5, R6) sitting a few feet from (V4). I thought (V1) overheard (V4's) yelling and using foul language in front of (R5, R6). I did not report (V4's) yelling and using profanity in front of (R5, R6). I probably should have reported this to (V1). On 3/3/24 at 11:40 AM V1 Administrator stated I was not aware that (V4) was yelling and using profanity in front of other residents (R5, R6). I knew (V4) was upset so I went to the area on E hall to talk to her. I did not realize (V4) had been acting that way in front of other residents (R5, R6). I only found that out today (3/3/24) during the interview with (V19) SSD. I will get this incident investigated and reported to the Illinois Department of Public Health (IDPH).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure the dignity of four (R1, R5, R6, R8) residents out of five residents reviewed for dignity in a sample list of nine residents. Findings include: 1.) R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. This same MDS documents R6 as requiring moderate assistance for mobility and transfers. R6's Careplan initiated 11/27/2023 does not include a focus area, goal nor interventions for R1's risk of Abuse. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as moderately cognitively impaired. This same MDS documents R5 requires moderate assistance for mobility and transfers. R5's Careplan dated 10/4/2023 does not include a focus area, goal nor interventions for R1's risk of Abuse. On 3/3/24 at 10:20 AM V2 Director of Nurses (DON) stated V4 (R1's) family member was yelling at V19 Social Service Director (SSD). V2 stated V19 SSD came to get V2 DON to help resolve V4's concerns. V2 stated V2 and V19 both walked back to the nurses station on E hall where V4 was waiting. V2 stated V4 (R1's) family member was yelling and using the 'F' word. V2 stated (V4) said 'I can't believe this F******(expletive) place.' and using other profanities. V2 stated (R5, R6) were both sitting in their wheelchairs next to the nurses station 'about a few feet from (V4)'. V2 stated (V4) had her finger out and pointing within an inch of (V19's) face and was yelling, screaming, using the 'f' word multiple times and was just hysterical. V2 stated V2 told V4 to calm down because [NAME] needed to be subjected to that kind of language. V2 stated I was trying to calm (V4) down but nothing was working. Then (V1) walked up and escorted (V4) over to a private area where she could vent her concerns. On 3/3/24 at 11:25 AM V19 Social Service Director (SSD) stated V4 (R1's) family member was screaming and yelling at staff. V19 stated V4 was upset that R1 had not gotten his recliner yet. V19 stated (V4) was pointing fingers, yelling and saying 'this f******(expletive) place' and this is 'b*******(expletive)' with (R5, R6) sitting a few feet from (V4). (V4) was out of control. (V2) Director of Nurses (DON) witnessed (V4's) behavior. On 3/3/24 at 12:05 PM R6 stated R6 has known V4 'all his life'. R6 stated (V4) has always cussed and ranted about everything. That is just the way (V4) is. Of course I heard everything (V4) said. I was sitting right next to (V4). The staff all thought (V4) was cussing, yelling and pointing her finger at me. I told them '(V4) is p***** (expletive) off at you not me'. That will be one for my journal. (R6 laughing). R6 denies concerns of being abused but stated I don't think it is right (V4) yell and carry on like that in front of other residents. That is no way to conduct yourself in public. 2.) R8's Minimum Data Set (MDS) dated [DATE] documents R8 as severely cognitively impaired. R8's Physician Order Sheet (POS) dated March 2024 documents R8's physician ordered diet as Low Concentrated Sweets (LCS), Mechanical soft, ground mechanical minced and moist texture with thin liquids. On 3/2/24 at 12:50 PM R8 sitting at dining room table eating lunch. R8 had poured cup of red juice over lunch meal which consisted of ham slices, mixed vegetables, boiled yams and chocolate pudding. R8 was using his spoon to try to eat the juice soaked vegetables while dripping liquid onto lap. Facility staff in dining room watching R8. No facility staff offered to help R8 or offer to get another plate of food for R8. On 3/2/24 at 12:51 PM V16 Certified Nurse Aide (CNA) stated (R8) always does that. (R8) always makes a mess. We (staff) just let him eat it like that. On 3/3/24 at 10:30 AM V2 Director of Nurses (DON) stated R8 has behaviors sometimes. V2 DON stated the staff should help R8 if R8 allows them to help. V2 stated The staff should have at least tried to help (R8). They could have gotten (R8) another plate. (R8) is very focused on food and he would not like the staff removing his food but if you had more food to replace it with, then I think (R8) would be ok with that. That is definitely a dignity issue. I will inservice the staff on making attempts and monitoring more closely. 3.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 as being dependent on staff and total body mechanical lift for transfers and maximum assistance for dressing, personal hygiene and eating. R1's Physician Order Sheet (POS) dated March 2024 documents a physician ordered diet of Low Concentrated Sweets (LCS), regular texture and thin liquids diet. This same POS documents medical diagnoses of Paraplegia, Urine Retention, Muscle Weakness, Anemia, Type II Diabetes Mellitus, Colostomy, Need for Assistance with Personal Care, Epilepsy and Epileptic Syndromes. R1's Careplan documents an intervention dated 2/26/24 which instructs staff R1 requires limited assistance of one person for eating. On 3/2/24 at 12:10 PM R1 sitting in recliner chair in room. R1's lunch tray was on food cart outside R1's room with mixed vegetables, yams and chocolate pudding sitting on tray. R1 was attempting to use both hands to feed himself a slice of dry looking ham in between two pieces of bread. R1's sandwich fell into R1's lap directly on R1's hospital gown due to R1's lack of coordination of fingers/hands. R1 attempted to pick up the three pieces of food to reassemble his sandwich and dropped it a second time. R1 stated Oh I give up. I am just going to throw this away. I can't eat it by myself and [NAME] will help me. They (staff) didn't even leave me a napkin. Sometimes they (staff) treat me like a toddler. On 3/3/24 at 10:45 AM V2 Director of Nurses (DON) stated facility staff should have stayed to help R1 until R1 was finished with his lunch meal. V2 DON stated (R1) has had a recent weight loss because of his refusals to eat and general decline in health. (R1) has been considering hospice lately due to his own decline in health. The staff should be doing everything we can to help him eat. We (facility) like to let the resident do as much as possible but then the staff should step in and help. It makes me sad that (R1) has to go through that. That is another dignity issue for certain. We (facility) will be re-training our staff to make sure they are assisting residents as needed with meals. The undated Illinois Long Term Care Ombudsman Program Residents' Rights Facility Handout documents the facility must treat residents with dignity and respect and must care for the resident in a manner that promotes the resident's quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to serve foods that are palatable to four (R1, R2, R4, R7) residents out of five residents reviewed for meal services in a sample list of nine residents. Findings include: 1.) R7's Minimum Data Set (MDS) dated [DATE] documents R7 as cognitively intact. On 3/2/24 at 12:15 PM R7 sitting in a wheelchair in room with lunch tray on bedside table in front of him. R7's lunch plate held two slices of dry ham, a small portion of mixed vegetables, a small portion of yams and a small portion of chocolate pudding. R7 stated The food is awful. This ham is so tough and dry. I can't even eat it. I tried to cut it with my fork but couldn't get through it. I guess I will just pick it up and see if I can rip it apart with my teeth. Wish me luck. It is like a hockey puck. This is what I guess prison food is like. 2.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. On 3/2/24 at 12:10 PM R1 sitting in recliner chair in room. R1's lunch tray was on food cart outside R1's room with mixed vegetables, yams and chocolate pudding sitting on tray. R1's mixed vegetables were very bland/dull looking and yams were small light brown pieces with no liquid present. R1 was sitting in room attempting to feed self a piece of very dry ham between two dry looking pieces of bread. R1 stated his sandwich was very hard to eat because the ham and bread were so dry and hard to chew. On 3/3/24 at 9:35 AM R1 stated The food isn't very good. That ham yesterday was so dry. Most days I cannot identify what the food is. There is no color to anything. Everything just looks grey. I know they (facility) can't do anything about the flavor because a lot of people can't stand any spice but it would be nice to have the flavor of the food itself. When I taste something, it should taste like whatever it is. If you blindfolded me, I would not be able to even say if I was eating a fruit, a vegetable or meat. The meat is always very dry and hard to chew. Most of time, I just don't eat it because it is too much work. 3.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. On 3/2/24 at 10:40 AM R4 stated I am the president of the resident meetings. The other residents say every month that the staff are really good here. The big problem is the food. The residents do complain about the food all the time. It is really bad. I mean really, really bad. There are days I don't eat because the food is so terrible. It is either burnt or cold or both. The meat is always very tough, especially the pork and chicken. 4.) R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. On 3/2/24 at 9:00 AM V8 Dietary Aide stated (R2) got a burned sausage patty today for breakfast. I put it on (R2's) plate to be served. I saw it and it was black and burned. It got thrown out because (R2) complained about it and couldn't eat it. (R2) complains a lot about the food. On 3/2/24 at 9:30 AM R2 stated The food is terrible. They (facility) served me burned sausage this morning. I got a sausage patty that looked like it just came from a house fire it was so black and hard. I couldn't even bite it. I don't know how you can call yourself a cook and serve that garbage. On 3/3/24 at 12:10 PM V13 Dietary Manager provided lunch meal which consisted of Swedish meatballs, butter noodles and cooked spinach. The Swedish meatballs were minimally covered in a thick brown/grey colored gravy that had a glue like consistency. The butter noodles were extremely soft, clumped together and difficult to separate. V13 Dietary Manager stated Our (facility) lunch doesn't look very appetizing today. We (facility) are struggling in my kitchen. Some of that is because the vendors change all the time or the staff is new and do not know how to cook yet and also because I don't have my Certified Dietary Manager (CDM) yet. Once I can get some staff trained and get my CDM then we will do much better. V13 Dietary Manager stated the residents should not be served burned foods. V13 stated the foods served should look appetizing and should taste palatable 'within reason'.

Deficiency Text Not Available

Based on interview and record review, the facility failed to report an allegation of employee to resident (R1) physical abuse to the State Agency. R1 is one of three residents reviewed for abuse in the sample of three. Findings include: R1's Diagnosis Sheet (current) includes the following diagnoses: Anxiety, Major Depression, Urinary Retention, Atrial Fibrillation and Atrial Flutter. R1's Physician Order Sheet dated February 2024 includes an order for Apixaban (anticoagulant) 2.5 milligrams twice a day. R1's Progress Notes document the following: 2/13/24 at 3:32 pm Created 2/14/24 at 3:56 pm - Late Entry: CNA (Certified Nursing Assistant) reported bruise to (R1's) right upper arm. I (V9 Registered Nurse) assessed bruise it was purple in color measuring 5 centimeters (cm) by 4 cm with scattered minimal brushing surrounding the large bruised area. (R1) reports that a CNA from previous day shift was rough when rolling (R1) for care. (R1) states (R1) doesn't feel like (R1) was in any harm from the CNA. (R1) states that it was just one CNA in room at time of incident. 2/15/24 at 11:48 am - CNA (Certified Nursing Assistant) reported bruise to (R1's) right upper arm. I (V9 Registered Nurse) assessed bruise it was purple in color measuring 5 centimeters (cm) by 4 cm with scattered minimal brushing surrounding the large bruised area. (R1) reports that a CNA from previous day shift was rough when rolling (R1) for care. (R1) states (R1) doesn't feel like (R1) was in any harm from the CNA. (R1) states that it was just one CNA in room at time of incident. On 2/22/24 at 10:00 am V1 Administrator confirmed the allegation of abuse between an employee and R1 had not been reported to the State Agency or to anyone. V1 also stated that V1 did not receive the information concerning the bruise at the time the bruise was noted on R1's arm. On 2/22/24 at 11:40 am R1 confirmed that one of the CNA's (doesn't know their name) was rough with R1 and believes that is how the bruise got on R1's arm. On 2/22/24 at 11:40 am R1's right lateral upper arm has a dark purple bruise measuring approximately 5 centimeters (cm) in length and approximately 4 cm in width. On 2/22/24 at 12:10 pm V2 Director of Nursing stated V2 had received the allegation of abuse made by R1 from Registered Nurse V9 on 2/13/24. V2 also stated V2 had immediately reported the allegation to V1. V2 stated V1 was very busy at that time and maybe V1 thought V2 was going to report the allegation to the State Agency, which V2 stated V2 did not report. On 2/22/24 at 12:20 pm V1 stated V1 does recollect receiving R1's allegation of abuse from V2. V1 also stated Corporate had instructed V1 not to report the allegation because V1 believed R1 had recanted the allegation. V1 could not provide documentation of an interview with R1 recanting R1's allegation of abuse. The facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation dated 2022, directs facility staff as follows: When the Facility has identified abuse, the facility will take all appropriate steps to remediate the non-compliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: A. Taking steps to prevent further potential abuse. B. Reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations. See CCG 00309 Elder Justice Act Policy and Procedure. The facility policy titled Elder Justice Act and Reporting Suspected Crimes Against Residents dated 2022, directs facility staff as follows: II. Duty to Report Reasonable Suspicion and or Alleged Violations. A. Covered individuals have a duty to report any reasonable suspicion of a crime (as defined by law of the applicable political subdivision) against any individual who is a resident of or is receiving care care from, the Facility pursuant to Section 1150B of the Social Security Act (the Elder Justice Act). B. The facility has a duty to report all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, as well as the results of all investigations of alleged violations pursuant to 42 CFR 482.12(c).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide a clean, homelike environment for two (R5, R7) of seven residents reviewed for the physical environment in a sample list of seven residents. Findings include: The undated Illinois Long-Term Care Residents' Rights for People in Long Term Care Facilities handout documents residents have the right to a facility that is safe, clean, comfortable and homelike. Resident Council Minutes dated November 28, 2023 documents New business: some residents expressed that soiled incontinence briefs are being left in trash cans in their rooms and bathrooms. Action taken: concern form given to (V2) Director of Nurses (DON). Resident Council Minutes dated December 26, 2023 documents Old business: last month (11/28/23) residents expressed soiled incontinence briefs are sometimes being left in trash cans in residents rooms. Action taken: concern form given to (V2) Director of Nurses (DO). (V2) response: staff will be inserviced about leaving soiled incontinence briefs in trash cans. Resident response: same residents expressed they are still finding soiled incontinence briefs in their trash cans. Action taken: concern from given to (V2) DON and (V4) Assistant Director of Nursing (ADON). Resident Council Minutes dated 1/30/2024 documents Old business: Last month (12/26/23) some residents expressed soiled incontinence briefs were being left in the trash cans. Action taken: concern form given to (V2) Director of Nurses (DON). (V2) DON response: new trash cans and dispensers for trash bag accessibility were ordered. New equipment came in and put into place last week. Resident response: residents expressed they understand new equipment has just been put out and into use and will readdress concern at next month's meeting. 1.) R5's undated Face sheet documents medical diagnoses of Osteoarthritis, chronic Pain Syndrome, Age Related Physical Disability, Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Kidney Disease Stage 4. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. This same MDS documents R5 as requiring supervision with toileting, transfers and personal hygiene. On 2/13/24 at 12:45 PM R5 was sitting in wheelchair in R5's room. R5's recliner chair was positioned so that R5's bathroom door would not fully open. R5 stated 'that chair makes it hard for me to get in and out of the bathroom. You can see what my wheelchair has done to the walls because there just isn't enough room.' Approximately 18 inches of the lower portion of the inside of R5's bathroom door was scuffed in multiple areas with brown areas showing through the white paint on door. All four walls in R5's bathroom had hundreds of small brown splattered areas. There was a half dollar sized area of brown dried feces on the floor next to R5's toilet. There were several small areas of thicker smudged feces on wall above toilet paper and grab bar. R5 stated Just look at that bathroom. It is awful. Who wants to sit in there? The housekeeper came in earlier and cleaned but didn't do a very good job. It looks like somebody threw p***(slang for feces) all over the walls. That is p***(slang for feces). It is just awful. On 2/13/24 at 12:00 PM V8 Certified Nurse Aide (CNA) stated the facility rooms stink because some of the other CNA's leave dirty incontinence briefs in the garbage cans. V8 CNA stated V8 removes garbage that contains soiled incontinence briefs from resident rooms 'several times per day'. On 2/13/24 at 1:30 PM V2 Director of Nurses (DON) stated R5's bathroom was not clean. V2 DON stated This is a mess. We (facility) need to get this bathroom clean right away. V2 DON confirmed that R5's bathroom walls were splattered with feces. On 2/14/24 at 11:20 AM R5's bathroom had not changed in appearance. R5 stated I thought they (facility) would get it cleaned up yesterday (2/13/24) but I guess I just am stuck with this filth. On 2/14/24 at 11:22 AM V2 Director of Nurses stated I just can't believe (R5's) bathroom hasn't been cleaned up yet. This was reported to the team yesterday and I was told it would be cleaned right away. (R5) should not have to use a bathroom that looks this bad. 2.) R7's undated Face Sheet documents medical diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Need for Assistance with Personal Care, Osteoarthritis and Depression. R7's Minimum Data Sheet (MDS) dated [DATE] documents R7 as cognitively intact. This same MDS documents R7 as requiring maximum assistance with dressing, bathing, toileting, set up assistance with oral hygiene and supervision with personal hygiene. On 2/13/4 at 1:20 PM R7's bathroom in R7's room had several white damp bath blankets piled loosely in the corner. The bath blankets had multiple black spots on them. R7's bathroom had a very strong musty/moldy odor. R7's wall hanging bathroom soap dispenser was laying on the floor. R7's bathroom door had a sign posted that read 'Do not use toilet'. On 2/13/24 at 1:15 PM R7 stated R7 was unable to use her toilet in her bathroom due to it was out of order. R7 stated R7 uses her bathroom to wash her hands and look in the mirror but does not use the toilet. R7 stated I use the toilet in the shower room down the hall. They (facility) are fixing my toilet today. It overflowed so I can't use it for awhile until they get it fixed. I am not worried about that. I just don't like the way my bathroom is kept. It is so dirty and smells awful. On 2/13/24 at 1:20 PM V11 Certified Nurse Aide (CNA) stated (R7) is very upset about her bathroom. I don't know what they are doing in there. I guess the toilet is broke. (R7) still uses the bathroom though just not the toilet. (R7) told me earlier that she wants it fixed so it doesn't smell so bad. It does smell pretty bad. On 2/13/24 at 2:15 PM V2 Director of Nurses (DON) stated R7's bathroom toilet was 'out of commission'. V2 stated was unaware that R7 had been continuing to use R7's bathroom to wash her hands. V2 DON stated the whole bathroom should have been 'out of commission.' V2 DON stated R7's bathroom was not safe or clean for resident use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an injury of unknown origin to the State Agency for one (R2) resident out of three residents reviewed for skin alterations in a sample list of seven residents. Findings include: R2's undated Medical Diagnosis List documents medical diagnoses of Alzheimer's Disease, Muscle Weakness, Need for Assistance with Personal Care, Cognitive Communication Deficit, Dysphagia and history of Focal Traumatic Brain Injury without Loss of Consciousness. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring maximum assistance with personal hygiene, bed mobility, toileting dressing, toileting and uses a wheelchair. R2's Weekly Skin assessment dated [DATE] does not document any abnormalities/bruises to R2's skin. R2's Risk Management dated 1/8/24 documents R2 has a bruise on Right mid back measuring 14.0 centimeters (cm) long x 12.0 cm wide and a bruise on Right Lower Back measuring 3.5 cm long x 3.0 cm wide. This same report documents R2's bruises were assessed and R2 was questioned about bruising. This same report documents (R2) not sure how bruises occurred. R2's Medical Record does not document staff being a witness to R2's Mid Right Back and Right Lower Back bruises. This same medical record documents R2's last fall prior to bruises being initially observed on 1/8/24 was 12/22/23. R2's Nurse Progress Note dated 1/8/24 at 3:11 PM documents Called to shower room due to bruise on (R2) back. Upon arrival noted bruise measuring 14.0 centimeter (cm) long x 12.0 cm wide to Right mid back and a bruise to Right Lower Back measuring 3.5 cm long x 3.0 cm wide. On 2/14/24 at 1:40 PM V14 Registered Nurse (RN) stated V14 was called to the shower room on 1/8/24 to look at R2's bruises on his back. V14 stated I measured both of them. Both of (R2's) bruises were dark purple. Some areas were lighter purple and other areas were darker purple but they were all purple. This appeared fresh within a couple of days. (R2) did not complain of any pain when I assessed the bruises. I do not know where (R2) would have gotten them. I just know that they were reported to me and I let (V2) Director of Nurses (DON) know about them. Both of (R2's) bruises were kind of square shaped. On 2/13/24 at 12:58 PM V2 Director of Nurses (DON) stated R2's bruise on Right mid back was not reported to the State Agency. V2 stated V1 Administrator and V2 discussed bruise and felt that R2 could have fallen into the side of the bathroom doorway. V2 stated We (facility) really aren't sure how (R2) got those bruises but that was a possibility. We (facility) can't rule out abuse if we don't know how (R2) got those bruises. (R2's) bruises appeared to be fresh. Probably happening within the two days prior to our staff noticing them. I don't think (R2) was abused but I can't determine an exact cause of the bruises and it was not reported and should have been. On 2/15/24 at 11:00 AM V1 Administrator stated the facility was unable to determine the origin of R2's Right Mid Back and Right Lower Back bruises. V1 confirmed R2's bruises were in an unusual location and should have been reported to the State Agency. V1 stated I didn't think we had to report bruises that didn't get treated outside the facility so it didn't get reported. I will look at things differently now going forward. The facility policy titled 'The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure dated 2022 documents an injury of an unknown source must be reported as a crime under State and Federal Law. It is the facility policy to empower and enable any and all owners, operators, employees, managers, agents or contractors of the facility to make reports to the relevant authorities pursuant to the provision for the Elder Justice Ace and Centers for Medicare and Medicaid Services (CMS) regulations. Alleged violation is defined as a situation or occurrence that is observed or reported by staff, residents, relative, visitor, another health care provider, or others but has not yet been investigation and if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source , and misappropriation of resident property. Injury of unknown source is defined as an injury when all of the following criteria are met: The source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.

Based on observation, interview and record review the facility failed to protect the privacy of a resident by failing to obtain consent for in room videography for one (R48) of 24 residents reviewed for privacy from a total sample list of 24. Findings include: R48's undated face sheet documents that R48 is his own power of attorney for healthcare. On 5/30/23 at 11:23AM, on 5/31/23 at 2:00PM, and on 6/1/23 at 9:00 AM a video/audio monitor was on R48's bedside table in his resident room. On 5/30/23 at 11:30AM, on 5/31/23 at 2:10 PM and on 6/1/23 at 9:05 AM, the video/audio receiver for R48's video/audio monitor was at the C/D nurse's station. On 5/31/23 at 1:00PM, V9 CNA stated, They put a camera on (R48) to try to catch him before he falls. R48's fall care plan does not document R48 having a video/audio monitor for any purpose. On 6/01/23 8:45 AM at R48 was sitting in his room in a wheel chair. R48 stated that he didn't know that he had a camera in his room. R48 then asked what the camera was used for. The facility provided Resident's Rights for People in Long-term Care Facilities dated 3/2017 documents that residents have a right to privacy. On 6/01/23 at 11:29 AM, V19 Social Services Director stated that she obtained consent from R48 for the monitor today (6/1/23) and documented it in R48's medical record. On 6/1/23 at 11:43 AM, V1 Administrator stated, They should have gotten consent in writing from R48 before they put the camera in his room. I am instructing social services to do an in-service with the staff about this. On 6/1/23 at 1:01 PM, V1 Administrator stated, We would want to get consent before putting a camera on someone because they have a right to privacy.

Based on record review and interview, the facility failed to accurately encode a resident's minimum data set with regards to tobacco use. This failure affects one resident (R49) out of four reviewed for accident hazards on the sample list of 24. Findings include: On 5/30/23 at 11:42 am, the facility-provided list of resident smokers (undated) documents R49 as one of the resident smokers. On 5/30/23 at 2:04 pm, R49 stated, Yes, I smoke, regular cigarettes, not vaporizing. R49's Nurse Notes dated 1/30/23, 5/21/23, and 5/28/23 document (R49) off unit and outside to smoke. R49's care plan focus area dated 2/16/23 documents, (R49) is a smoker. R49's Minimum Data Sets dated 3/13/23, 3/13/23 modified, and 4/1/23 document under section J1300, for the question current tobacco use, the response is coded 0 for no. On 6/1/23 at 1:36 pm, V4, Minimum Data Set (MDS) and Care Plan Coordinator, stated, (R49) is a smoker, (R49's) care plan says she is a smoker, and all through (R49's) nurses notes it is documented she is a smoker. V4 then confirmed R49's MDSs documented R49 as no current tobacco use. At 2:05 pm, V4 stated, I started working here 4/14/23 and our corporate has been advising me to leave the MDS alone that were already completed before I started working here. Those MDS were just a mistake by the remote team that was completing our MDS before I started working here.

Deficiency Text Not Available

Deficiency Text Not Available

Based on observation, interview, and record review, the facility failed to ensure the dishwashing machine was operating as designed in a manner to sanitize dishes and wares, failed to properly thaw meats to protect ready to eat foods from meat juice dripping, failed to protect frozen foods from exposure to air and from leakage of foreign substances in the freezer, and failed to utilize clean utensils to access bulk food items. These failures have the potential to affect all 52 residents residing in the facility. Findings include: 1. On 5/30/23 at 10:10 am, V12, Dietary Aid, was actively operating the facility's dishwashing machine by placing soiled dishes, cups, glasses, utensils and cooking wares into one side of the machine, operating the machine through a wash and rinse cycle, then removing the same food service wares from the opposite side of the machine. The temperature gauge on the dishwashing machine was displaying an internal temperature of 120 degrees Fahrenheit (F). When asked if the dishwashing machine was a high temperature sanitizer or a chlorine sanitizer, V12 replied, I have no idea about this machine, I have only worked here a few days. V12 continued to operate the dishwashing machine in the manner previously described. When asked if (V12) uses any kind of strips to test the machine, V12 again replied, Really, I have no idea about this machine. On 5/30/23 at 10:25 am, V13, Dietary Manager, stated, The dishwasher is a high temp (temperature) machine. The temperature gauge displaying 120 degrees F (180 degrees F required to sanitize), and the opaque white tubes with a label sanitizer, were brought to V13's attention, and questioned if the staff use any kind of strips to test the machine, V13 replied, Yes, they test it every day. V13 did not provide any type of documentation to show the testing of the dishwasher by kitchen staff. V13 then obtained 2 different types of test strips, one multi-colored strip to test pH (potential hydrogen) (used to test the acidity, or base, properties of liquids), which tested approximately 8.4, and the other orange colored test strip (used to measure quaternary ammonium sanitizer) which tested with no color change, being interpreted as a zero reading. V13 was then asked if V13 had any chlorine test strips. V13 then obtained some white colored test strips to check the chlorine level of the dishwasher. This chlorine test also resulted in no color change, being interpreted as zero chlorine. V13 then located the chlorine (sodium hypochlorite) bucket under the dishwashing machine and stated, Oh, that's empty so that's why it is reading zero. V13 then stated, I worked Sunday (5/28/23) and the bucket was half-full, so I would have to say that bucket ran out last night. V13 then confirmed, All the dishes from breakfast this morning that have run through the machine today have not gotten sanitized. V13 further stated, I can get some bleach from laundry to use in the machine. On 5/30/23 at 12:20 pm, with the dishwashing machine again in operation washing dishes from the noon meal with the chlorine bucket now half-full of chlorine, V13 again tested the chlorine level of the machine. The chlorine test strip turned very lightly gray, almost no color change, which indicated a level of chlorine less than 10 ppm (parts per million). The facility policy Dish Machine Use dated 4/23/21 documents, Food service staff required to operate the dishwasher will be trained in all steps of the dish machine use. Dish machines that use bleach are to be tested prior to dishes entering the machine, the correct solution is 50 - 100 ppm with chlorine test strips. On 5/31/23 at 1:55 pm, V13, Dietary Manager, stated, With the dishwasher not sanitizing the dishes, and serving residents on the dishes, it could make people sick. 2. On 5/30/23 at 10:40 am, in the facility's reach-in refrigerator, was 4 packages of raw meat on the top shelf being thawed directly over top of ready-to-eat green chunky vegetable product. At this time, V13, Dietary Manager stated, The meat is pork and that is coleslaw. On 5/30/23 at 10:40 am, in the facility's reach-in refrigerator, was 2 whole turkeys being thawed on the top shelf directly over top of ready-to-eat food items including milk gallons and single serving yogurt containers. V13 confirmed that the turkeys were thawing. On 5/30/23 at 2:20 pm, V11, Regional Administrator, stated, Those (raw meats) should be on the bottom. On 5/31/23 at 1:55 pm, V13, Dietary Manager, stated and confirmed, The thawing pork and turkey should have been on the bottom shelf, not on the top shelf over other foods. I had a talk with my staff and told them 'we all have certificates hanging on the wall, we should know better.' 3. On 5/30/23 at 10:50 am, in the facility's walk-in freezer, was an open cardboard box containing pre-cooked ready to eat (heat and eat) biscuits. The plastic bag inside the cardboard box was wide open, exposing the biscuits to air. V13 then asked V17, Cook, to Close all the boxes in the freezer, but then V13 reached over and rolled the plastic bag closed around the biscuits. The facility's policy Food Storage Areas dated 11/15/21 did not address the failures of thawing raw meat above ready to eat items, not exposing stored food items to air. 4. On 5/30/23 at 10:50 am, on the top shelf of facility's walk-in freezer, was a box of vegetable products labeled as 'veggie blend.' Directly underneath this box were 2 boxes, one labeled as 'California blend,' and the second labeled as 'mixed veggies.' On the third and lowest shelf was a box of hash browns. Each of these four boxes were stored directly under the freezer condenser and fan unit, and each box was completely covered with a frozen, unidentified substance which was obviously a liquid coming from the condenser unit as there was no other possible source of liquid in the freezer. V13, Dietary Manager attempted to remove the top box of 'veggie blend,' but the box was entombed to the shelving unit with a minimum of 3 inches of the frozen substance on top of the box and over a half inch of the frozen substance along each side of the box, appearing like a frozen waterfall and stalactite formations. The remaining 3 boxes also had the frozen waterfall and stalactite formation appearance, causing each of the boxes to be firmly attached and adhered to the shelving unit. In addition, there were 2 frozen puddles on the floor of the freezer, the first was approximately 3 feet in diameter and approximately one half inch thick at the center. The second puddle was approximately 2 feet in diameter, and likewise approximately one half inch thick at the center. On 5/31/23 at 2:25 pm, V20, Maintenance Director, did not identify what the frozen substance was, but stated, I can only think that frozen ice was some kind of condensation from someone leaving the door open too long. 5. On 5/30/23 at 11:05 am, there were 4 storage buckets in the facility's kitchen containing powdered sugar, granulated white sugar, salt, and brown sugar. Inside each of these storage buckets was a plastic scoop or measuring cup in direct contact with the food items. V13, Dietary Manager, then removed each of the scoops from the buckets. On 5/31/23 at 1:55 pm, V13, Dietary Manager, stated, I was told we could keep the scoops in the foods as long as the handles were sticking up. The facility's Resident Census and Conditions of Residents dated 5/30/23 documents 52 residents reside in the facility.

Based on record review and interview, the facility failed to include the required infection preventionist in 2 of five quarterly meetings. This failure has the potential to affect all 52 residents residing in the facility. Findings include: The facility-provided sign-in sheets for their quarterly Quality Assurance (QA) meetings were dated 4/13/22, 7/13/22, 10/19/22, 1/20/23, and 4/21/23. The QA meetings dated 4/13/22 and 4/21/23 did not document the attendance of any Infection Preventionist identified by the facility as V18 (former) Assistant Director of Nursing, and V3 Regional Nurse Consultant. On 6/1/23 at 10:52 am, V1, Administrator, stated, This isn't a fun conversation to have but the meeting on 4/21/23 we did not have an Infection Preventionist at the meeting. The meeting from 4/13/22 was before my time here so I have to rely on those employees who were here at that time and they tell me they were in a transition period between (V18 and V3), but unfortunately I am not able to confirm that we had an Infection Preventionist at that meeting. On 6/2/23 at 10:20 am, when questioned about the employees involved in the transition period as stated on 6/1/23 at 10:52 am, V1, Administrator, stated, (V18) was in the building working on the floor (direct care) and we have some documents that (V18) had to share with (V21, Medical Director), so (V18) was at the meeting from 4/13/22. V1 continued, I have to call (V18) to confirm if she was at the meeting on 4/21/23, I can't remember, that was over a month ago. At 10:25, V1 further stated, The transition period was between (V18) who left the position as Infection Preventionist to go back to school so (V18) is just working the floor now, and (V2) Director of Nursing was in the process of training for the Infection Preventionist, and that occurred in April of 2023. The facility's Resident Census and Conditions of Residents dated 5/30/23 documents 52 residents reside in the facility.

Based on interview and record review, the facility failed to notify the physician when a resident's (R1) prescribed dosage was not available. R1 was one of three residents reviewed for medications in the sample of four. Findings include: R1's Physician Order Sheet (POS) dated December 2022 includes the following diagnoses: Osteomyelitis, Peripheral Vascular Disease and Diabetes Mellitus. The above same POS dated December 2022 documents an order dated 12/29/22 for Vancomycin Hydrochloride Sodium Reconstituted, Use 1500 milligrams (1.5 grams) intravenously every 24 hours for Osteomyelitis. Start date 12/29/22. R1's Nursing Notes dated 12/28/22 at 4:41 pm documents the following by V8, Reregistered Nurse: Spoke with Pharmacy about trough levels (therapeutic levels of Vancomycin in the blood) and Vanco (Vancomycin) was increased to 1.5 G (grams) Q 24 H (every 24 hours). A repeat Vanco through and creatinine level scheduled for 1/2/23. R1's Nursing Notes dated 12/29/22 at 11:52 am V8 documents the following: Spoke with Pharmacy IV (Intravenous) dept (department) about new orders for 1.5 G vanco and rec'd (received) in overnight run still the 1.25 G. They will deliver the correct dose tonight. The 1.25 G dose ran this day. Still to have the trough (level) on Monday 1/2/23. On 2/10/23 at 11:30 am, V7 Assistant Director of Nursing confirmed the following: V8 called the pharmacy on 12/28/22 in the allotted time for R1's Vancomycin dosage change to be delivered in the midnight delivery. V7 confirmed that the incorrect dose of 1.25 G of Vancomycin was sent by pharmacy in the delivery at midnight on 12/28/22 and V8 went ahead and gave R1 the 1.25 grams of Vancomycin on 12/29/22. V7 stated that V8 should have called the pharmacy and got the correct dosage of medication in the facility or notified the physician of the unavailability of the 1.5 G of Vancomycin and if the 1.25.G was alright to administer until the therapeutic dose of 1.5 G of Vancomycin came in.

Based on interview and record review, the facility failed to follow physician orders when administering a resident's (R1) medication dosage based on therapeutic drug levels. R1 is one of three residents reviewed for medication administration in the sample of four. Findings include: R1's Physician Order Sheet (POS) dated December 2022 includes the following diagnoses: Osteomyelitis, Peripheral Vascular Disease and Diabetes Mellitus. The above same POS documents the following orders: 12/24/22 - Vancomycin Hydrochloride Sodium Reconstituted 1250 milligrams (1.25 Grams) to be given I.V. (Intravenously) every 24 hours for Osteomyelitis. End date 12/27/22. 12/29/22 - Vancomycin Hydrochloride Sodium Reconstituted 1500 milligrams (1.50 Grams) to be given IV every 24 hours for Osteomyelitis. End date 1/3/23. R1's Nursing Notes dated 12/27/22 at 11:05 am document blood drawn via PICC (Peripheral Intravenous Central Catheter) line. Res (Resident) tolerated well. Good blood return noted. Flushes with ease. Will await creatinine and vanc (Vancomycin) trough levels for Vanc dosing. Signed by V8, Registered Nurse. (There are no laboratory reports in the Medical Record of R1's trough levels). R1's Nursing Notes dated 12/28/22 at 4:41 pm document Spoke with (facility) pharmacy about vanc trough levels and vanc was increased to 1.5G (Grams) Q24H (every 24 hours) a repeat vanc trough and creatinine level scheduled for 1/2/23. Signed by V8, Registered Nurse. R1's Nursing Notes dated 12/29/22 at 11:52 am document the following by V8: Spoke with Pharmacy IV (Intravenous) dept (department) about new orders for 1.5 G vanc and rec'd (received) in overnight run still the 1.25 G. They will deliver the correct dose tonight. The 1.25 G dose ran this day. Still to have the trough (level) on Monday 1/2/23. On 2/10/23 at 11:30 am, V7 Assistant Director of Nursing confirmed the following: V8 called the pharmacy on 12/28/22 concerning the increase of R1's Vancomycin medication and for it's delivery that night of 12/28/22 for 12/29/22 administration. V7 confirmed that the incorrect dose of 1.25 grams of Vancomycin was sent by pharmacy in the night delivery of 12/28/22 and V8 administered that incorrect dose to R1 on 12/29/22. V7 stated the facility's Pharmacist decides the dosage of the Vancomycin to be administered based on what the medication therapeutic blood levels are. The physician signs off on these dosages and any changes that occur and they are to be carried out as any physician order should. V7 confirmed that V8 did not follow physician's orders when administering the incorrect dose of Vancomycin 1.25 grams on 12/29/22. V7 confirmed that R1 should have received 1.5 grams of Vancomycin I.V. on 12/29/22.

Based on observation, interview and record review, the facility failed to ensure that residents (R2,R4) receive physician ordered supplements as part of their therapeutic diets with their meals. R2 and R4 are two of four residents reviewed for therapeutic diets in the sample of four. Findings include: 1. R2's Physician Order Sheet (POS) dated February 2023 documents the following therapeutic diet and/or supplements: Regular diet, Mechanical Soft with Thin liquids. House supplement tid (three times a day) with meals. This same POS includes the diagnoses of Anemia, Pressure Ulcer and Weakness. R2's Care Plan (current) documents R2 is to have (high protein frozen supplement) with meals. On 2/9/23 at 12:45 pm, R2 received a luncheon tray containing mechanically softened turkey, mashed potatoes with gravy, a green vegetable, bread and thin liquids of tea and lemonade. There was no house supplement of high protein included on the tray per physician orders and as documented on R2's dietary slip lying beside R2's plate of food. On 2/9/23 at the same time as above, V5 Certified Nursing Assistant (serving the tray) verified that R2 should have gotten a high protein frozen supplement per the dietary slip. On 2/9/23 at 1:20 pm, V4 Dietary Manager confirmed that R2 should have received the high protein supplement with R2's noon meal and could not say why it was omitted. 2. R4's POS dated February 2023 documents the following therapeutic diet and or supplements: Regular Mechanical Soft with Nectar thickened liquids, Protein Powder each meal. Aspiration Precautions. This same POS documents the diagnoses of Chronic Buttock Ulcer, Dysphagia and Anxiety. On 2/9/23 at 12:55 pm, R4 received a luncheon tray containing mechanically softened turkey, mashed potatoes with gravy, a green vegetable, bread and thickened liquids of punch and lemonade. R4's dietary slip lying next to R4's plate documented that R4 was to have protein powder with meals. V5 Certified Nursing Assistant (serving the tray) stated R4's protein powder is put in R4's pudding at each meal and confirmed that there was no pudding on R4's tray. On 2/9/23 at 1:20 pm, V4 confirmed that R4 was not served a food item with protein powder added at R4's noon meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure R145 was not subjected to physical abuse and mental abuse by R36. R145 is one of four residents reviewed for abuse on the sample list of 29. Findings Include: R36's assessment sheet Brief Interview of Mental Status (BIMS) dated 3/22/22 documents R36's BIMS score as 14 out of possible 15, which reflects no cognitive impairment. R145's Minimum Data Set, dated [DATE] documents R145 BIMS score as 11 out of possible 15, which reflects moderate cognitive impairment. The facility Incident Investigation Report dated 3/16/22 documents the following: Administrator (V1, Administrator/ Abuse Prevention Coordinator) received report that a resident (R36) 'dumped' a bowl of salad on the lap of another resident (R145) and walked out of the dining room. The staff (unidentified) stated that it appeared like he (R36) was walking over to talk to the other resident (R145). R36's Nurse Progress Note dated 3/16/2022 at 1:43 pm, written by V5, Registered Nurse (RN) documents the following: Res (resident, R36) told this nurse (V5, RN), this day, 'They won't make me leave, they want my money.' Also, 'I won't kill him, but I will hurt him.' about another resident (R145) that he (R36) shares an (adjoining) room with. (R36) Threw a bowl of food on said resident (R145) in the dining area as well. Resident (R36) walked over with (R36's) walker to the other said resident (R145) and dumped the bowl of food on the other said resident's (R145) lap. Administrator (V1, Administrator/Abuse Prevention Coordinator) aware. Administrator (V1, Administrator/Abuse Prevention Coordinator) also aware of resident's (R36) being outside on (the) bench this morning with staff (unidentified). On 3/25/22 at 10:30 am. V5, Registered Nurse (RN) confirmed she was the nurse that worked 3/16/22, the day of the alleged physical abuse of R145 by R36. V5, RN stated I was at the med (medication) cart, parked in the dining room, passing (administering) meds. I had my back towards them (R36 and R145). I saw (R36) walking in the direction of (R145's) table. I didn't think anything of it. Then, I (V5, RN) heard (R36) say to (R145) 'Are you mister (R145's last name).' I (V5, RN) couldn't hear what (R145) responded. A CNA (Certified Nursing Assistant) did. I can't remember which one (CNA) it was. (R36) and (R145) have been snippy at a distance before, but nothing like this. (R36) is alert and oriented, he knows exactly what he is doing and saying. (R145) is confused most of the time, some days worse than others. I didn't have to see (R36) throw the food on (R145). I heard (R145) hollering and I saw (R145) had food on his lap. (R36) was walking back to his (R36's) table with an empty bowl in his (R36) hand. I (V5, RN) can put two and two together. It was physically abusive. I reported this situation immediately to the Administrator (V1, Administrator/Abuse Prevention Coordinator) as abuse and gave her the same details. I went and talked to (R36) and told him the behavior was unacceptable. I went to talk to (R145) and calmed him down. There were no further episodes of physical abuse since. On 3/23/22 at 4:35 pm R36 stated the following: As far as the incident with my roommate (adjoining room), (R145), he (R145) is annoying. He (R145) is constantly cussing at the women and treating them terrible. I (R36) am sick of it. The Aides (unidentified Certified Nursing Assistants) are sick of him (R145) too. That day (3/16/22) just before lunch, he (R145) was talking to the Aides like dirt. I (R36) walked over and dumped my plate of meat and vegetable in his (R145) lap, to shut him up. At first the staff (unidentified) didn't say anything. Then he (R145) started going ballistic. I (R36) was not going to hurt him (R145). I (R36) was just letting him (R145) know the way he (R145) talks to staff is horrible and it needs to stop. Most of the CNA's (unidentified) understood, but when he (R145) went ballistic, I (R36) left the dining room. I know it was childish for me to act like that, but hearing him argue and cuss with the Nurses (unidentified) isn't okay either. On 3/24/22 at 12:00 pm V1, Administrator/Abuse Prevention Coordinator stated V1, Administrator / Abuse Prevention Coordinator was informed by staff, immediately that R36 had thrown a bowl of food on R145. On 3/24/22 at 1:30 pm V21, Licensed Practical Nurse (LPN) stated (R36) was coming around the corner and up to (R145's) wheelchair. (R36) stated to (R145) 'how did you like that food in your lap yesterday (3/16/22).' (R145) got really anxious and tearful. I (V21, LPN) stayed with him (R145), to calm him down. I did not have to separate them. (R36) propelled (wheelchair) himself out of the area, and down the hall. I (V21, LPN) went to the DON (V2, Director of Nursing) and reported this to her (V2, DON) as abuse. It was just before breakfast and the Administrator (V1, Administrator/Abuse Prevention Coordinator) was not in (the facility) yet. (R36) is very aware of what he (R36) says. He (R36) was intentionally being mean to (R145). On 3/24/22 at 11:40 am, V2, Director of Nursing (DON) stated V2, DON was in the facility the morning staff reported the mental abuse to her. V2, DON then reported this as mental abuse to the administrator (V1, Administrator/ Abuse Prevention Coordinator). The statements (R36) made to (R145) the morning (3/17/22) after (R36) poured food on (R145) the day before (3/16/22), was mental abuse. The facility Finalabuse investigation report to Illinois Department of Public Health facsimile time stamped 3/29/22 at 10:48 am, documents the following conclusion: It is the conclusion of this thorough investigation that we suspect (R36) intentionally got food on (R145). (R36's) remarks indicate it may have been done intentionally. (R36) has since been avoiding (R145) and has been moved to another room to minimize the interactions between them. (R36) has been educated that it was inappropriate to 'dump' food or any other substance on anyone. No other inappropriate interactions have occurred. And (R36) has properly discharge from the facility.

Based on observation, interview, and record review, the facility failed to prevent involuntary seclusion by preventing a cognitively intact resident's free movement to the outside of the facility. This failure affects one resident (R36) of three reviewed for resident rights in the sample of 29 residents. Findings include: R36's Brief Interview of Mental Status (BIMS) dated 3/22/22 documents R36's BIMS score as 14 out of possible 15, reflecting no cognitive impairment. The facility Policy and Procedure, Signing Out for LOA (Leave of Absence) dated revised November 5, 2019 documents the following: Purpose To ensure staff have knowledge of residents that are out of the facility. Procedure 1. Each resident leaving the premises (excluding transfers/discharges) must be signed out. The facility Sign Out Sheet-When Taking a Resident Off Grounds or Going For a Walk documents R36 signed himself out of the facility on 3/19/22 at 6:45 pm. R36's Nursing Progress Note dated 3/19/2022 at 8:00 PM documents the following: Note Text: Resident this evening was upset he could not smoke a cigarette. He (R36) said he wanted to leave this place if he could not smoke. He stated if staff can smoke then he can too. Resident then went outside without staff knowing it and left the property. (The facility) Received a phone call from a concerned citizen (unidentified) asking if we (the facility) had a resident leave the nursing home. CNAs (unidentified, Certified Nursing Assistants)) went and got him brought him back to facility without any problems. Administrator (V1, Administrator/ Abuse Prevention Coordinator) and ADON (V3, Assistant Director of Nursing) notified of incident. Asked to have resident sign an AMA (Against Medical Advice) paper if he wants to leave facility. Explained to resident what he was signing and that someone needs to pick him up, family or call a cab. He understood. Resident decided to stay tonight and will decide what he wants to do in the morning. Will notify MD (V23, Physician). Will monitor. R36's Nursing Progress Note dated 3/19/2022 at 10:00 PM documents: Note Text: (V23, Physician) Resident had an elopement this evening. Decided he wanted to leave because he could not smoke a cigarette. No injuries noted. CNA's (unidentified) brought him back into facility without difficulty. R36's Wandering/Elopement Risk Assessment dated 3/19/22 and signed 3/22/22 at 10:37 am documents the following: A. Cognition: Is the patient cognitively impaired with poor decision-making skills? No B. Diagnosis: Does the patient have a pertinent diagnosis (i.e. dementia substance abuse use disorder) that may increase his/her risk of elopement? No C. History of Wandering: Does the patient have a history of escape or elopement? No D. Verbal Intent: Does the patient persistently state in a hostile or aggressive (manner) that he/she wants to leave the unit and/or will find a way to leave? Yes E. Wandering: Does the patient wander aimlessly? If yes does the patients wandering include risky behaviors such as open doors, monitoring or standing at exits? No F. Predisposing Factors: Are there any other factors (for example, recent loss or personal tragedy, anger) which may contribute to patient's risk for elopement. Yes If so explain: Anger due to nicotine withdrawal. On 3/22/22 at 5:15 pm, V1, Administrator/ Abuse Prevention Coordinator stated (R36) just signed himself out and was going to the gas station. I assumed he was mentally capable of making his own decisions. He seems fine when I have talked to him. He was on his way to the gas station and staff went to get him and brought him back here to the facility. On 3/23/22 11:30 am, V1, Administrator/Abuse Prevention Coordinator stated V1 started working in the facility November of 2019. V1 also stated We are a no smoking facility. We have been since I started working here. Yes the employees do smoke but the residents are not allowed to. V1 also acknowledged that there is no documentation in the admission packet that says a resident can not smoke. V1 also stated she will have to find out if there is an actual policy. On 3/23/22 at 1:05 pm, V3, Licensed Practical Nurse / Assistant Director of Nursing (LPN/ADON) stated (R36) signed himself out and we (the facility) thought he was just out on the patio. We did not know he left the facility until and unknown citizen called to ask if we had a resident in a wheelchair missing. (R36) is alert and oriented. I did his BIM's, yesterday. He signed himself out, but he did not tell us he was leaving the premises. V3, LPN/ ADON then verified the sign out sheet and stated the sheet does say to 'Sign out when taking a resident off the grounds or going for a walk. No one knew where he went. That is why we went to get him and brought him back to the facility. We thought he was on the patio. On 3/23/22 at 4:35 pm, R36 was propelling himself in his wheelchair, without difficulty, down the hall and into an empty resident alcove sitting area. R36 stated the following: The other night when I was heading to the gas station to get cigarettes, one of the Aides (unidentified) came to get me. At first I (R36) told the Aide I was going to get cigarettes. I (R36) wasn't going to get in the car. The Aide said to get in the car or she would call the police. Hell, I (R36) just waved at the cops as they went by me. I didn't do anything wrong. I was a cop for twenty years and did not want to cause any problem. I got in the car and even offered to help put my wheelchair in the car. I was going to get cigarettes. The Aide told me I am not allowed out of the facility. I feel like a prisoner, and they all know it. It gets me upset when they stop me at the door and don't let me leave. I am moving on Friday or Saturday. I am going to (another facility) assisted living. I haven't had a seizure in several months. I can transfer myself fine to the toilet, when I need to. I can walk with a walker or holding onto to something to keep myself stable. I am safe to leave this facility on my own. I don't see any reason for them to restrict me or make me wait to go outside, even on the patio till (until) an Aide can go with me. That is ridiculous. On 3/23/22 at 5:50, V20, LPN stated (R36) is alert and oriented and has behaviors every time we re-direct him. He (R36) can't go outside without staff. He (R36) gets mad when we tell him he can't smoke. I (V20, LPN) worked the night he went off the property. I thought (R36) was on the patio. I did not know he went to get cigarettes until somebody in the community called here. I sent a CNA (unidentified) to get him and bring him back. He cooperated with her and seemed fine when he got back. My job is to keep my residents safe. It was my understanding that he was aloud to go out of the building with staff or visitors (not own his own). He does make all of his other decisions, and he has been out on the patio while staff smoke. I can see why he gets upset. This is a non-smoking facility for the residents. I don't smoke but there are staff that do. On 3/24/22 at 2:45 pm, V13, Social Service Director stated (R36) is his own person, makes all his own decisions. On occasion he is forgetful. I (V13, Social Service Director) find him (R36) reliable and very aware of his actions and behaviors. I worry about all residents that go outside on their own. We are a non-smoking facility and we re-direct (R36) when he tries to go outside. He (R36) does get agitated when we re-direct him, its to keep him safe. This is his (R36) home and he likes to go outside without staff and sit on the patio. (R36) leaving to go to the gas station was the first time he has done that. Staff usually go out on the patio with him, or he leaves with a responsible party. Since he is alert and oriented, it doesn't make sense that he can't go outside on his own. Smoking is his goal but he can't do that on the facility property. On 3/25/22 at 10:00 am V1, Administrator/Abuse Prevention Coordinator stated I can see how (R36) had a right to leave the facility after signing out. He (R36) is alert and oriented, makes all his own decisions and we stopped him from going outside. We should not have done that. That is involuntary seclusion and against our policy (Abuse Prevention). I think myself and my staff just wanted to keep him safe, but we went about it the wrong way. V1 also stated V1, Administrator/Abuse Prevention Coordinator is not sure which CNA told him R36 they would call the police on him for leaving the property without staff, but V1, Administrator/ Abuse Prevention Coordinator had heard something about that. It should have never been said to R36. V1, Administrator/Abuse Prevention Coordinator also stated (R36) is also safe to smoke, if he goes off the property to do so. I will be informing my staff, as long as (R36) signs out he ( R36) can go about his business independently. On 3/25/22 at 10:55 am R301 stated the following: I (R301) come and go as I please. Staff have never told me I (R301) can't leave. I know they have stopped another resident, (R36), constantly and won't let him (R36) go on his own. They even went in his (R36's) room and took his cigarettes so he wouldn't go out to smoke. I (R301) had staff help me go outside to smoke the first week I was here. I wanted to smoke but didn't feel well enough to be outside on my own. The last couple weeks, I (R301) just sign myself out and smoke whenever I feel the need. I don't know why they stop him (R36) all the time, and not me (R301). I have never been told this is a non-smoking facility. I (R301) have smoked with staff (unidentified) out on the patio. (R36) has been out there at the same time, with staff watching him (R36). He is not allowed to smoke, but I am not sure why I (R301) can and he (R36) can't. I just figured he had some medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to operationalize their abuse prevention policy by failing to recognize involuntary seclusion, and physical/mental abuse. This failure affects two of four residents (R36 and R145) reviewed for abuse on the sample list of 29. Findings include: The Residents Right To Freedom from Abuse, Neglect, and Exploitation Policy and Procedure dated 2020 states PURPOSE To ensure that all of (facility) residents are free from abuse, neglect, misappropriation of their property, and exploitation. POLICY The Facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the Facility (Associates). PROCEDURE I. Associates must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion against any resident. The same policy documents: VII. The Facility will ensure that all Associates are properly trained pursuant to the Facility's Associate Training policies The V1, Administrator/Abuse Prevention Coordinator submitted an additional policy on 3/25/22 at 1:37 pm. V1, Administrator/Abuse Prevention Coordinator stated the additional policy is part of the facility's abuse prevention program. The Policy and Procedure, Abuse Prevention and Reporting dated revised November 5, 2019 documents the following: Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. This same policy documents: The facility will investigate all incidents and complaints and report all occurrences promptly to the Department of Health when there is reasonable cause to believe abuse, neglect or mistreatment 'hereinafter abuse' has occurred. In order to prevent occurrences of abuse, this facility will screen potential employees, train all staff, proactively attempt to prevent abuse, identify the potential for abuse, investigate any allegation of abuse, and report instances of abuse to DOH (Department of Health) as required, The facility will implement programs and interventions individualized to the residents, and ensure that the individual reporting an allegation of abuse is protected from retribution. R36's independent assessment, Brief Interview of Mental Status (BIMS) dated 3/22/22 documents R36's BIMS score as 14 out of possible 15, which reflects no cognitive impairment. R145's Minimum Data Set, dated [DATE] documents R145 BIMS score as 11 out of possible 15, which reflects moderate cognitive impairment. The facility Incident Report Form-IDPH (Illinois Department of Public Health) Notification form documents an interaction occurred 3/16/22 between R36 and R145. This facility incident report is dated 3/24/22. An Addendum facsimile cover sheet dated 3/25/22 at 10:33 am, to the Incident Report Form-IDPH Notification form documents Addendum to Initial Report, Incident Date 3/16/22. To clarify the interaction between residents (R36) and (R145). It was alleged that (R36) approached (R145) and dumped a bowl of food from a bowl onto him (R145). He (R36) also made a statement the following day,How did you like that food on you yesterday?. Investigation continues. On 3/23/22 at 4:35 pm, R36 stated R36 was going to the gas station 3/19/22 to get cigarettes when a facility Certified Nursing Assistant (unidentified CNA) drove up and told R36 to get in the car or the CNA (unidentified) would call the police. R36 also stated the facility staff stop R36 at the facility door and do not let R36 leave to go outside to the patio. R36 stated I feel like a prisoner in the facility. On 3/25/22 10:00 am V1, Administrator/Abuse Prevention Coordinator acknowledged V1, Administrator/Abuse Prevention Coordinator did not recognize the interaction on 3/16/22 between R36 and R145, as a physical and mental abuse allegation as the facility abuse policy directs in order to initiate a thorough investigation. V1. Administrator Abuse Prevention Coordinator also stated I can see how (R36) had a right to leave the facility after signing out. He (R36) is alert and oriented, makes all his own decisions and we stopped him from going outside. We should not have done that. That is involuntary seclusion and against our policy (Abuse Prevention). I think myself and my staff just wanted to keep him safe, but we went about it the wrong way.

Based on record review and interview the facility failed to report allegations of physical and mental abuse to the State Survey Agency (Illinois Department of Public Health) in a timely manner, within the two hour required time frame. This failure affects one of four residents (R145) reviewed for abuse on the sample list of 29. Findings include: The facility Incident Report Form-IDPH (Illinois Department of Public Health) Notification form documents an interaction occurred 3/16/22 between R36 and R145. This facility incident report is dated 3/24/22. An Addendum facsimile cover sheet dated 3/25/22 at 10:33 am, to the Incident Report Form-IDPH Notification form documents Addendum to Initial Report, Incident Date 3/16/22. To clarify the interaction between residents (R36) and (R145). It was alleged that (R36) approached (R145) and dumped a bowl of food from a bowl onto him (R145). He (R36) also made a statement the following day,How did you like that food on you yesterday?. Investigation continues. On 3/23/22 at 4:35 pm R36 confirmed he intentionally threw food on R145. R36 stated he dumped food in R145's lap to shut R145 up, because R145 was annoying. R36 also stated R145 went ballistic. On 3/24/22 at 11:40 am, V2, Director of Nursing (DON) stated V2, DON reported this as mental abuse to the V1, Administrator/ Abuse Prevention Coordinator. V2, DON stated R36 made a statement to R145 'How did you like that food in your lap yesterday (3/16/22)?' V2, DON stated R36 made the statement to R145 the day after R36 poured food on (R145). On 3/24/22 at 12:00 pm V1, Administrator/Abuse Prevention Coordinator stated V1, Administrator/Abuse Prevention Coordinator did not consider the incidents above, as alleged abuse because the alleged perpetrator (R36) told V1, Administrator/Abuse Prevention Coordinator the incident was an accident. V1, Administrator/ Abuse Prevention Coordinator confirmed V1, Abuse Prevention Coordinator did not report the allegation to Illinois Department of Public Health, until this survey was in progress (3/24/22). On 3/24/22 at 1:30 pm V21, Licensed Practical Nurse (LPN) stated on 3/17/21 V21, LPN witnessed R36 was coming around the corner and up to R145's wheelchair. V21, LPN heard R36 say to R145 'how did you like that food in your lap yesterday (3/16/22)?'. On 3/25/22 at 10:30 am. V5, Registered Nurse (RN) stated V5, RN was present and witnessed R36 approach R145 in the dining room. V5 stated as she turned around R36 was walking back to R36's table with an empty bowl in R36's hand. V5, RN also stated V5, RN didn't have to see R36 throw the food on R145. V5, RN stated V5, RN put two and two together. V5, RN I heard (R145) hollering and I saw (R145) had food on his lap. V5, RN stated V5, RN reported to V1, Administrator that R36 physically abused R145.

Based on record review, observation and interview, the facility failed to complete a thorough abuse investigation related to physical and mental abuse of R145 by R36. This failure resulted in R36 having full access to R145 who resided in an adjoining room. R145 is one of four residents reviewed for abuse on the sample list of 29. Findings include: On 3/22/22 at 3:45 pm R36 was seated in a wheel chair next to R36's bed. An eight foot wide corridor extended from the foot of R36's bed, 15 feet. The eight foot wide, 15 foot length corridor lead into R145's bedroom. On 3/25/22 at 10:30 am, V5, Registered Nurse stated V5 was in the dining room (on 3/16/22) when R36 physically abused R145 by pouring food in R145's lap. V5 stated she watched R36 walk back from R145's table with an empty bowl in his hands, while R145 was upset and had food in his lap. V5 stated V5 immediately reported the incident to V1 Administrator. V5 reviewed V5's incident (physical abuse allegation) witness statement, written by V1, Administrator. V5 stated The witness statement is correct but important details I (V5) gave the Administrator are not documented on my (V5) witness statement. On 3/24/22 at 1:30 pm V21, Licensed Practical Nurse (LPN) stated on 3/17/21, V21 witnessed R36 was coming around the corner and up to R145's wheelchair. V21 heard R36 say to R145 How did you like that food in your lap yesterday (3/16/22)?. V21 stated V21 reported the incident as abuse to V2 Director of Nursing. The facility Incident Investigation Report dated 3/16/22 documents the following: Administrator (V1, Administrator/ Abuse Prevention Coordinator) received report that a resident (R36) 'dumped' a bowl of salad on the lap of another resident (R145) and walked out of the dining room. The staff (unidentified) stated that it appeared like he (R36) was walking over to talk to the other resident (R145). The resident (R36) came into the Admin (V1) office and was asked what happened. He (R36) was adamant that he had stumbled and it (food) fell out of his hands. He (R36) stated 'I'm not going to hurt anyone, (I) wouldn't do that.' We (V1 and R36) talked for quite sometime. He (R36) sat outside the front door and was calm. V24, Certified Nursing Assistant's statement documents Observed food on floor and lap and (R145) upset (R145) stated 'he threw food on me'. (R145) was upset, said 'that (expletive) just threw food on me'. I didn't hear anything (R36) said. V5's statement documents I heard him (R36) say are you Mister (R145's last name). I saw there was food in his (R145) lap and (R36) walked back to his seat. My (V5, RN) back was to him. The Incident Investigation Report does not contain documentation that V21 was interviewed concerning the statement V21 overheard R36 make to R145 on 3/17/21 or statements from employees other than V24 and V5. The Incident Investigation Report does not include interviews with residents other than R36. There was also no documented statement concerning the investigation of mental abuse of R145 by R36 that occurred on 3/17/22. On 3/24/22 at 12:00 pm V1, stated V1, did not consider the incidents above as alleged abuse because the alleged perpetrator (R36) told V1, the incident was an accident. V1, stated V1, did not continue an the investigation because R36 said the incident was an accident and there were no staff that actually saw what happened. On 3/25/21 at 10:00 am V1, Administrator/Abuses Prevention Coordinator confirmed the facility did not move R36 to a separate room to prevent further abuse of R145 until 3/24/22.

Based on interview and observation, the facility failed to maintain a resident bathroom in a repaired and functional condition. This failure affects one resident (R20) reviewed for bathrooms in the sample of 29. Findings include: On 3/22/2022 at 1:58 PM, R20 reported having a bathroom in poor condition. R20's bathroom had extensive wallboard damage in the lower portions of the wall around the toilet, with about six feet of the flexible baseboard missing at the wall and floor junction. Another portion of baseboard was curling free from wall and directly in the way of toilet use. The walls around the toilet were damaged severely and crumbling with the wall missing portions. The toilet paper dispenser was missing the roller bar which was located in a pile of accumulated debris located behind the toilet basin. R20 reported the bathroom condition has been the same for a year.

Based on observation, interview, and record review, the facility failed to effectively sanitize dishes, failed to maintain sanitary food cooler areas, failed to prevent the potential for cross-contamination of food from physical contaminants, and failed to properly store bulk food items. These failures have the potential to affect all 49 residents in the facility. Findings include: 1. On 3/22/2022 at 10:45AM, the kitchen mechanical dishwasher sanitizer bucket was completely empty. At 12:38PM, V7 (cook) was washing dishes at the dishwasher and the chemical sanitizer bucket remained empty. The dishwashing water was tested by Illinois Department of Public Health test strip after the sanitizing portion of the wash cycle was complete and measured zero sanitizer was present. The manufacturer dishwashing requirements were posted on the side of the machine and documented a sanitizer concentration of 50 parts per million was required, at a minimum, to achieve effective dish sanitation. V9 (cook) was present with V7 and both were unaware if the kitchen mechanical dishwasher required chemical sanitizer or hot water to effectively sanitize dishes. 2. On 3/22/2022 at 10:45AM, the kitchen walk-in-cooler interior walls were covered throughout with flat, circular growths of a gray substance resembling mildew. Wire food storage racks located in the front of the cooler were also covered with the same substance. A four foot wide wire rack in the back compartment of the cooler was heavily soiled with a gray fuzzy substance resembling mold growth. These fuzzy growths on the surface of the rack were equivalent in thickness to to the wire itself. Fifteen gallons of milk were resting directly on the racks and the growths. The cooler floor was littered with debris including food particles, paper, plastic, single use butter containers, yogurt cups, and cardboard. On 3/23/2022 at 2:07PM, V8 (cook) looked at the heavy mold growth on the wire storage racks in the walk-in-cooler and stated Oh my God. V8 reported the growth on the racks and throughout the cooler was mold and mildew. V8 reported the cooler door was not sealing correctly and reported the interior light in the cooler could still bee seen around the edges of the door when the door was closed. The cooler door appeared loose to the cooler body with a half-inch gap between the cooler and the door. The cooler floor remained littered with the same debris from above. 3. On 3/22/2022 at 10:45AM, the kitchen can opener was excessively soiled with accumulated metal shavings. V7 was present and reported The shavings, I've tried to clean it so many times. 4. On 3/22/2022 at 10:50AM, a 35 gallon food storage barrel was located in the the kitchen pantry room and was one third full of dry oatmeal. Partially buried into the oatmeal was a plastic drinking glass used to scoop the oatmeal. The oatmeal storage barrel did not have a lid to protect the contents and was open to the environment. Adjacent barrels of bulk dry foods also contained drinking cups used as scoops and partially buried in the food items On 3/23/2022 at 2:07PM, the cups being used as food scoops in the bulk food containers remained from above. The Resident Census and Conditions of Residents report dated 3/23/22 documents 49 residents reside in the facility.