**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement policies and procedures to prohibit and prevent Abuse. This deficiency affects all five (R1, R3, R4, R5 and R6) residents reviewed for Abuse Prevention Program.Findings include: R1On 9/9/25 at 9:51AM, Observed R1 lying in bed with low air loss mattress. She has oxygen via nasal cannula. She is lethargic but arousable and weak. She needs total care with ADLs (Activity of Daily Living) and transfers. Both V6 RN (Registered Nurse) and V7RN said R1 has declined in mental status and ADLs. She is re-admitted yesterday from hospital with pneumonia. R1 is initially admitted on [DATE] and re-admitted on [DATE] with diagnosis listed I part but not limited to Atherosclerotic heart disease, Hypertension, Stage 3 Kidney disease, Stage 4 sacral pressure ulcer, Dysphagia, Cognitive and communication deficit, Gait and mobility abnormalities, Severe protein calorie malnutrition, Chronic embolism, and thrombosis of femoral vein. Comprehensive care plan indicated: She has history of Stage 4 sacral pressure ulcer and at risk for developing. She has ADLs and mobility deficit. She is at risk for falls related injury. She has history of depression with insomnia managed with medication. Trauma screening assessment was not upon initial admission. Trauma screening was only completed when R1 was re-admitted on [DATE]. R1 has reported mental abuse allegation on 6/3/25. No trauma assessment was done after the abuse allegation. No Abuse prevention care plan was developed.R3On 9/9/25 at 10:05AM, Observed R3 up on high back wheelchair in front of her room. V7 RN said, R3 has bilateral shin protector due for skin tear prevention. R3 need total assist with ADLs and uses mechanical lift for transfer. She is awake but confused. R3 is admitted on [DATE] with diagnosis listed in part but not limited to Cerebral infarction due to embolism, Hemiplegia affecting left non dominant side, Dysphagia, Type 2 Diabetes Mellitus, Atrial fibrillation, Hypertension, Gait and mobility abnormalities, Lack of coordination, Metabolic encephalopathy. Comprehensive care plan indicated: She is at risk for falls related injury. She has ADLs and mobility deficit. She has cognitive and communication impairment due to CVA. She is at risk for inadequate oral/fluid intake. She is on hospice care 8/13/25. She is on psychotropic medications for antipsychotic and anti-anxiety. R3 refused admission Trauma screening/assessment as indicated in assessment dated [DATE]. R3 is a vulnerable resident with cognitive impairment and behavioral issues. No Abuse prevention care plan was initiated upon admission. R3 has reported sexual abuse allegation on 8/25/25. No trauma assessment was done after the abuse allegation. No Abuse prevention care plan was developed.R4On 9/9/25 at 10:58AM, Observed R4 up in wheelchair in the activity/dining room. She has hard of hearing. She is alert and confused, responsive to simple questions. She needs assistance with ADLs and transfers. R4 is admitted on [DATE] with diagnosis listed in part but not limited to Age-related osteoporosis, Alzheimer's disease, Dementia, Type 2 Diabetes Mellitus, Depression, Lack of coordination, Gait and mobility abnormalities, Repeated falls. R4 refused trauma assessment upon admission as indicated in assessment. Comprehensive care plan indicated: She is at risk for falls related injury. She has depression managed by medication. She has ADLs and mobility deficit. She is at risk for inadequate oral/fluid intake. She has cognitive deficits due to Alzheimer's and Dementia. She refused Trauma assessment as indicated in assessment. She has physical abuse allegation report on 9/1/25. No trauma assessment was done after the abuse allegation. No Abuse prevention care plan was developed.R5On 9/10/25 at 10:17AM, Observed R5 up in recliner chair. She is alert and responsive with period of confusion. She needs maximum assistance with ADLs and transfers. R5 is admitted on [DATE] with diagnosis listed in part but not limited to Cerebral infarction, hemiplegia affecting right dominant side, Dementia with mood disturbance, Anxiety disorder, Depression, Gait and mobility abnormalities, Dysphagia. Comprehensive care plan indicated she is prone to skin tear or bruising related to fragile skin. She has history of depression and anxiety managed by medications. She has ADLs and mobility deficit. She has presented with rapid significant health declined. Family wishes comfort measures only. She is on hospice care on 2/11/25. No Trauma assessment done upon admission. R5 is a vulnerable resident with cognitive impairment and behavioral issues. No abuse prevention care plan was initiated upon admission. R5 has physical abuse allegation (employee to resident) report on 3/26/25. No trauma assessment was done after the abuse allegation. No Abuse prevention care plan was developed.R6 was admitted on [DATE] with diagnosis listed in part but not limited to Urinary Tract Infection, Congestive heart failure, Atrial fibrillation, Parkinson's disease with dyskinesia, Type 2 Diabetes mellitus, gait and mobility abnormalities, lack of coordination, Dementia, Cognitive deficit. Comprehensive care plan indicated he is at risk for falls related injury. ADLs (Activity of daily living) and mobility deficits. He has short term memory deficit and moderately impaired decision making. He has shortness of breath on exertion and when lying in bed. He is at risk for inadequate oral/fluid intakes. No care plan for abuse prevention. No trauma screening assessment was done upon admission. R6 was sent out to the hospital on 5/23/25 for shortness of breathing and was admitted with diagnosis of hypoxia and ribs fracture. Facility completed and reported injury of unknown origin on 5/24/25. On 9/9/25 at 10:40Am, V3 SSD (Social Service Director) said that she completes trauma screening assessment of resident upon admission. They used trauma screening instead of abuse screening/assessment. She was told trauma assessment was only done upon admission. She said, she did not do trauma assessment after resident has reported abuse allegation. She did not develop abuse prevention care plan for vulnerable resident with cognitive impairment and behavioral issues nor develop abuse prevention care plan for resident who reported abuse allegation.On 9/9/25 at 11:47AM, V1 Administrator said that she is the abuse coordinator. She initiates reported abuse allegation investigation. They screen employees and residents as part of the abuse prevention program. The admission coordinator screens the resident prior to admission by checking criminal background checks. Upon admission, the social service does the trauma screening instead of abuse screening. V1 is not aware how often the trauma screening/assessment is done in the facility. She said that resident should be assessed after allegation of abuse has been reported. Trauma assessment should be completed. Reviewed Facility's policy on abuse prevention program revised 7/12/23 with V1 Administrator. Informed V1 that their policy did not have resident screening to prohibit and prevent both abuse and neglect. She said it should indicate screening for both resident and employees to prohibit and prevent abuse. She said that she will inform their corporate and consultant. On 9/9/25 at 12:19PM, Reviewed R1, R3, R4, R5 and R6 medical records with V2 DON and V3 SSD. Informed V2 DON and V3 SSD of concerns identified from the following residents: R1 is initially admitted on [DATE]. Trauma screening was not done upon admission. It was done completed when R1 was re-admitted on [DATE]. R1 has abuse allegation report on 6/3/25. No trauma screening was done. No abuse prevention care plan was developed. V3 said that she was on vacation when the abuse allegation incident occurred. V14 Memory Care coordinator was in charged in her absence. R3 is admitted on [DATE]. R3 refused trauma screening as indicated in R3's assessment. R3 is a vulnerable resident with cognitive impairment and behavioral issues. No Abuse prevention care plan was initiated upon admission. R3 has abuse allegation report on 8/25/25. No Trauma screening was done. No Abuse prevention care plan was developed. V3 said that she was on vacation when the abuse allegation incident occurred. V14 Memory Care coordinator was in charged in her absence. R4 is admitted on [DATE]. Trauma screening was not done. R4 has abuse allegation report on 9/1/25. No Trauma screening was done. No Abuse prevention care plan was developed. V3 said that she was on vacation when the abuse allegation incident occurred. V14 Memory Care coordinator was in charged in her absence. R5 is admitted on [DATE]. Trauma screening was not done upon admission. R5 is a vulnerable resident with cognitive impairment and behavioral issues. No abuse prevention care plan was initiated upon admission. R5 has abuse allegation report on 3/26/25. No trauma screening was done. No abuse prevention care plan was developed. R6 was admitted on [DATE]. No care plan for abuse prevention. No trauma screening assessment was done upon admission. R6 was sent out to the hospital on 5/23/25 for shortness of breathing and was admitted with diagnosis of hypoxia and ribs fracture. Facility completed and reported injury of unknown origin on 5/24/25. On 9/9/25 at 12:30PM, Both V2 DON and V3 SSD said that Trauma screening assessment should be done upon admission. Trauma assessment should be done to the resident after allegation of resident abuse. Abuse prevention care plan should be formulated after abuse allegation made. Abuse prevention care plan should also be developed for those vulnerable residents who has cognitively impaired with behavioral issues. On 9/10/25 at 10:37AM V15MDS Coordinator/Care Plan Coordinator said that Trauma screening assessment should be done upon admission. If resident has reported allegation of abuse, the social service should complete resident trauma assessment and develop abuse prevention care plan. Vulnerable resident who are cognitively impaired, with behavioral issues should be care planned for abuse prevention because resident can react negatively to other resident and the other way around. On 9/10/25 at 12:33PM, V14 Memory Care Coordinator said that she covers for V3 SSD in her absence. She said that upon admission, they completed resident's trauma screening /assessment. They use trauma assessment instead of abuse screening. She was told only do the trauma assessment once upon admission. She does not update resident's trauma assessment after allegation of abuse.On 9/10/25 at 2:30PM, Informed V1 Administrator and V2 DON of above concerns regarding implementation of abuse prevention program. Facility's policy on Abuse Prevention Program revised 7/12/23 did not indicated screening of residents as indicated in State Operating Manual. Facility's policy on Trauma-informed and culturally competent care revised August 2022 indicated: Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and or re-traumatization. Resident screening: 1. Performed universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events.Resident Care Planning:1. Develop individualized care plans that address past trauma in collaboration with the resident and family.

Based on interview and record review, the facility failed to conduct a Health Care Worker Registry background verification for an employee before working and caring for residents in the long term care facility. This failure has the potential to affect all 66 residents currently residing in the facility. Findings include: On 4/21/25 at 9:30 AM, V1, Administrator presented the survey team with the facility matrix showing 66 current residents. On 4/22/25 at 11:07 AM, V6, Human Resource Director was inquired of completing background screening checks for staff. V6 said, Yes, we check them upon hire. The health care worker background check was completed for random Certified Nurse Assistants (CNAs) and other direct care access staff members with V6. V3, CNA was hired in August of 2000. Upon review of V3 CNA's background check it was identified that the facility did not complete a UCIA (Uniform Conviction Information Act) check upon hire. The facility was also unable to provide V3's fingerprint based background check upon hire. On 4/22/25 at 12:42 PM, V6 said, We don't have any other background checks for V3 until 2006. On 4/23/25 at 10:25 AM, V6 provided this surveyor with a IDPH Health Care Worker Registry background check for V3 CNA completed on 4/23/25 at 8:03 AM. The September 2018 Illinois Department of Public Health Employer Health Care Worker Registry states in part: FINGERPRINTS/BACKGROUND CHECKS WHICH EMPLOYEES NEED TO BE FINGERPRINTED FOR A BACKGROUND CHECK? Health care employers must ensure that a fingerprint-based background check, initiated as a Fee Applicant Inquiry to the Illinois State Police, has been conducted for each employee who falls under the jurisdiction of the Health Care Worker Registry (HCWR). The HCWR is governed by the Health Care Worker Background Check Act [225 ILCS 46] and the Health Care Worker Background Check Code [77 Ill. Adm. Code 955]. The Act and the Code mandate which employees fall under the jurisdiction of the HCWR. The following types of employees fall under the HCWR's jurisdiction: o For all health care employers, an unlicensed individual employed as a home health care aide, a nurse aide, a personal care assistant, a private duty nurse aide, a day training personnel, or an individual working in any similar health-related occupation where he/she provides direct care. o Additionally, for long-term care facilities ONLY, an unlicensed individual who has or may have contact with long-term care residents or access to the living quarters or financial, medical, or personal records of long-term care residents (access workers). Therefore, the only employees who fall under the HCWR's jurisdiction are unlicensed staff providing direct care or unlicensed staff in long-term care facilities who have access to resident's living quarters or records. Licensed staff (such as nurses) do not fall under the HCWR jurisdiction and should not be added to the HCWR or sent for a fingerprint-based background check through the HCWR. Likewise, staff who do not provide direct care (except for access workers in long-term care facilities) also do not fall under the HCWR jurisdiction; those staff should not be added to the HCWR or sent for a fingerprint-based background check through the HCWR. Employers may have policies that require fingerprint-based background checks to be completed on all employees. For staff that do not fall under the jurisdiction of the HCWR, however, employers must have an alternative way to conduct those background checks. Background checks for those employees cannot be initiated through the HCWR. If a background check for an employee who does not fall under the jurisdiction of the HCWR discloses disqualifying convictions, the HCWR cannot process a waiver application for that employee, since that employee is not under our jurisdiction. WHAT IS A UCIA BACKGROUND CHECK? UCIA, which stands for the Uniform Conviction Information Act, is the type of background checks used by the HCWR prior to the implementation of the fingerprint-based background checks (prior to October 2007). A UCIA background check is no longer valid for use with the HCWR. If someone on the HCWR has a UCIA background check, that person's Work Eligibility will show Not Yet Determined. A new or potential employer must initiate a Livescan request to conduct a fingerprint-based background check for that individual. The March 2019 Personnel and Staffing Background Screening Investigation policy states in part: Policy Statement Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents (direct access employees). Policy Interpretation and Implementation 1. For purposes of this policy direct access employee means any individual who has access to a resident or patient of a long term care (LTC) facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the state for purposes of the national background check program. 2. The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment. 3. For any individual applying for a position as a certified nursing assistant, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file.