Aliya on 87th

Inspectors wroteBased on interview and record review the facility a.) failed to provide a proper transfer for a dependent resident that required a two person assist with a mechanical lift, b.) failed to communicate a resident's mode of transfer to a new employee and c.) failed to educate a staff of how to properly transfer a resident. This failure resulted in one (R4) resident sustaining an impacted transverse fracture of the right humeral neck and the greater tuberosity during the resident transfer from the wheelchair to the bed. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a safe environment for one [R3] of five [R7, R9, R10, R11] residents reviewed for falls. This failure resulted in R1 falling from the bed, sustaining an open area to back of head, bleeding, sent to emergency department via 911 and was admitted to the hospital diagnosed with a blunt head trauma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its skin care prevention policies and procedures and failed to implement the resident's comprehensive care plan to prevent skin breakdown and wound development. This failure affected one (R1) of two residents reviewed for wound management and prevention, in a total sample of 35 residents. As a result of the facility's failure to provide timely and appropriate preventive skin care and incontinence management, R1 experienced a decline in skin integrity, evidenced by the development of a new Stage 2 pressure ulcer/injury and moisture-associated skin damage (MASD). Findings Include:On 2/4/26 at 11:09 a.m., R149 stated her roommate (R1) has not been changed since 4:00 a.m. R149 said, [R1's] been lying on that soiled diaper for hours. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to have sufficient staffing to provide adequate care and assistance for residents. This has the potential to affect all the residents residing in the facility. Findings Include:On 2/4/26 at 10:58 AM, R101 stated he's been in the facility for a year and a couple of months. R101 said facility is always short on staff. R101 said sometimes he does not get his medications on time and is mostly short on weekends. On 2/4/26 at 11:07 AM, V6 (Certified Nursing Assistant) started working in the facility full time for two years. V6 said she works morning shifts and every other weekend. V6 said sometimes facility is short on CNAs (Certified Nursing Assistants). V6 said morning shift needs five CNAs but sometimes there are only 4 CNAs working the floor. On 2/4/26 at 11:09 AM, R149 stated she's been in the facility for two years. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) ensure food items were properly labeled and dated, b.) store food items according to manufacturer recommendations, c.) discard expired food based on use by date and guidelines, d.) store food at least six inches off the floor. These failures have the potential to affect all 185 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was no trash on the ground surrounding the dumpster. This deficient sanitation practice has the potential to affect all 191 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to (a) ensure staff cleaned and disinfected shared equipment between 3 (R29, R128, R181) residents use; (b) perform hand hygiene prior and place on a pair of gloves while obtaining one (R181) resident's blood glucose; (c) ensure proper Personal Protective Equipment (PPE) was worn by staff upon entry to resident's (R150) room on contact precautions; and (d) post an Enhance Barrier Precautions (EBP) sign for a resident (R135) with an indwelling medical device. The facility also failed to ensure proper Personal Protective Equipment (PPE) was worn by staff when providing high contact resident care activities to a resident (R1) on Enhanced Barrier Precaution (EBP). This failure has the potential to affect all 74 residents residing on the third-floor unit.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to develop a comprehensive person-centered care plan for each resident. This failure affected 2 (R104 and R178) residents on anticoagulant medication use in a sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely incontinence care was provided to one (R1) out of two residents reviewed for activities of daily living (ADL) care in a final sample of 35. Findings Include:On 2/4/26 at 11:09 a.m., R149 stated her roommate (R1) has not been changed since 4:00 a.m. R149 said, [R1's] been lying on that soiled diaper for hours. I've been awake since four in the morning and that was the last time the CNA [Certified Nursing Assistant] came in here to change her [R1]. They should know that she [R1] needs to be changed frequently because she has that tube feeding going and she [R1] soils herself a lot. On 2/4/26 at 11:16 a.m., R1's lying in bed alert and able to verbalize needs. R1 stated she's wet and needs to be changed. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow physician's orders for R129's IV (intravenous) dressing, failed to ensure that R129's IV dressing was secure and intact, failed to perform hand hygiene while handling R129's IV dressing, and failed to address R129's IV site in the comprehensive care plan for 1 out of 1 resident reviewed for IVs out of a total sample of 35 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide one-to-one (1:1) feeding assistance for two residents (R84 and R192) with aspiration and swallowing precautions and failed to include the aspiration and swallowing precautions in their comprehensive care plan for two out of a total sample of 35 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to place oxygen cannula tubing in a bag when not in use for one (R78) of two residents reviewed for respiratory care in a sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care planned, fall risk interventions for a high fall risk resident (R2); failed to provide 2 person assist during activities of daily living (ADL) care for a dependent resident in bed (R2); and failed to notify the practitioner of the nurse's assessment of a resident's pain post fall incident for one resident (R2) in the total sample of 8. These failures affected R2 who suffered a fall in the facility on 1/4/2026 from the bed to the floor sustaining a 3 centimeter left head laceration and exhibiting pain signs immediately post fall with the nurse's palpation of R2's left leg which was not communicated to the practitioner; and after increased pain signs, R2's left hip X-ray was performed on 1/6/2026 showing a proximal left femur fracture.

Inspectors wroteBased on interviews and record reviews, facility failed to follow their policy and did not notify resident's legal representative/guardian about a fall incident for one resident (R1) in the final sample of 8 residents reviewed for quality care/treatment. On 1/20/2026 during complaint investigation for allegation of quality care, record review, and interviews showed in part, that R1's legal guardian was not notified of R1's fall incident on 4/8/2025, and instead, R1's second emergency contact was left a phone message, and no other notification was documented. On 1/20/2025 at 10:05 AM, confirmed that R1 no longer resides in the facility. R1 was discharged [DATE]. [...]

Inspectors wroteBased on interviews and record reviews, facility failed to follow their policy to ensure residents are free from accidents and hazards by planning for preventative strategies and facilitate as safe as an environment as possible for one (R4) out of three residents reviewed accidents and hazards in a sample of four. This failure resulted in R1 sustaining an acute subdural hematoma to the left frontotemporal region of her head.

Inspectors wroteBased on interview and record review, facility failed to follow their policy to ensure residents are free from physical and verbal abuse by not providing necessary care, resulting in a staff worker being physically rough during activities of daily living (ADL) care and being verbally abusive to one resident (R1) out of three residents reviewed for abuse in a sample of four.

Inspectors wroteBased on observations, interviews, and record reviews, facility failed to ensure activities of daily living (ADL) are provided for dependent residents by getting them out of bed for one (R1) out of three residents reviewed for ADL care in a sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the fall prevention interventions for cognitively impaired residents who are also at risk for falls. This failure has the potential to affect 5 residents, R3, R4, R5, R6, and R7 out of 7 reviewed for proper footwear as a fall prevention intervention.

Inspectors wroteBased on record review and interview the facility failed to follow their abuse policy for two residents (R1,R2,) out of four residents reviewed for abuse. This failure resulted in staff members not immediately intervening in a situation where residents became abusive to each other. Staff did not intervene in time resulting in R1 and R2 engaging in a physical altercation that lead to them both putting scratches/abrasions on each other's faces. Finding Include: R1's wound assessment sheet dated 4/25/25 reads upon assessment writer noted skin alteration to face. Classification abrasion. Doctor made aware , staff to continue to monitor. R1s Nursing Note 4/25/2025 08:35 reads: was notified of the situation that occurred and will notify the rest of her family. MD has also been notified. MD wants wound care to evaluate and treat. Resident does not need to go out to the hospital at this time. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to notify a resident's responsible party about a room change prior to being moved to a new room on a different unit within the facility. This affected one (R1) of one resident reviewed for resident rights.

Inspectors wroteBased on observation, interviews, and review of records the facility failed to ensure proper supervision and monitoring was provided to 1 (R1) out of 3 residents reviewed for risk of elopement. Facility also failed to establish preventive measures for recurrent of elopement to the same resident (R1). These failures are not in accordance with elopement and out on pass policies of facility. Failures affected 1 resident (R1) who was able to leave premises of facility without authorization or awareness of facility staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the posted nursing staffing information was accurate and failed to ensure the posted staffing information included all required data. This failure affects all 190 residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide snacks to the facility's residents when the duration between meals (dinner and breakfast) exceeded 14 hours. This failure affects all 190 residents that reside within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the environment was free from hazards. This failure has the potential to affect all 46 residents on the first-floor unit.

Inspectors wroteBased on observation, interview and record review the facility failed to properly label, date and store prepared food items and store unthawed meats, to complete daily temperature logs to prevent the spread of foodborne illnesses. This failure has the potential to affect all residents receiving oral nutrition.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure staff don appropriate PPE (personal protective equipment) prior to performing ADL (activities of daily living) care to 3 (R100, R139, and R189) residents; and failed to ensure an EBP (enhanced barrier precaution) sign was posted for 2 (R53 and R189) residents on EBP. These failures affected 4 residents (R53, R100, R139, and R189) reviewed for infection control and has the potential to affect all the residents on 2nd floor and 3rd floor.

Inspectors wroteBased on observation, interview, and record interview, the facility failed to follow their own policy of getting a physician' order and completing a care plan when initiating resident self-administration of medication. This failure affected 1 (R53) resident reviewed for self-administration of medication and has the potential to affect all residents on the 3rd floor.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse prevention policy and failed to report abuse to the state survey agency within required time parameters. This failure affects 1 resident (R45) in a sample of 74 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRR) was completed prior to resident's admission for one resident R137. This failure affects 1 (R137) resident in a sample of 74.

Inspectors wroteBased on interview and record review, the facility failed to review the baseline care plan with the resident/resident's representative and failed to provide a copy of the baseline care plan to the resident/resident's representative. This failure affects 1 resident (R398) in a sample of 74.

Inspectors wroteBased on interview and record review the facility failed to provide a person center care plan focus PASRR (Pre-admission Screening and Resident Reviews) for one resident (R137).

Inspectors wroteBased on observation, interview and record review the facility failed to provide ADL care (Activities of Daily Living) to two dependent residents (R137, R176) to maintain grooming and personal hygiene. This failure affected two residents (R137, R176) in a sample of 74 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Low Air Loss Mattress were set based on the resident's weight. This failure affected 1 resident (R100) reviewed for pressure ulcer/injury prevention and treatment in a sample of 74 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide foot care for one resident (R64) who is dependent on staff for Activities of Daily Living (ADL) care (foot care). This failure affected one resident reviewed for foot care in the total sample of 74 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date oxygen equipment (nebulizer mask); failed to change oxygen tubing (nasal cannula tubing) per facility policy; and failed to properly contain oxygen equipment (nebulizer mask). These failures affected two residents (R132 and R349) reviewed for oxygen equipment, in a total sample of 74 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy of reconciling controlled substances at the end of the shift. This failure has a potential to affect all 3 residents (R116, R144, and R172) receiving controlled substances on the 2nd floor.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that prescribed medications are available for two of three residents (R1, R3) reviewed for pharmacy services, failed to ensure that the location of medication in the convenience box is accurate, and failed to ensure that staff utilize the convenience box when medications are unavailable in the medication cart or not received from pharmacy. These failures have the potential to affect 191 residents.

Inspectors wroteBased upon observation, interview, and record review the facility failed to ensure that five of thirteen residents (R1, R3, R8, R9, R10) in the sample remained free of significant medication errors.

Inspectors wroteBased upon record review and interview the facility failed to ensure that a baseline care plan includes required ADL (Activities of Daily Living) care assistance for one of three residents (R1) reviewed for quality of care.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that care requirements are documented in the plan of care, failed to implement care plan interventions, and failed to provide timely ADL (Activities of Daily Living Care) to one of three dependent residents (R1) reviewed for quality of care.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed monitor blood glucose levels, failed to ensure that medication administration records include actual times for administration, failed to follow physician orders, and/or failed to ensure that medications/supplements were administered and documented within regulatory requirements for nine of thirteen residents (R1, R3, R5, R6, R7, R8, R9, R10) in the sample. The facility also failed to ensure that (R2's) Humalog was ordered and administered before meals, this failure resulted in R2's frequent blood glucose levels above 200. On 9/2/24, R2's blood glucose level was 399 (critical high).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents who are dependent on staff assistance for toileting receive the care needed. This failure applies to 1 (R2) of 3 residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly log refrigerator temperatures; failed to label food items with a date; and failed to discard food items placed in the dining room refrigerator for residents personal use. This failure has the potential to affect all 49 residents on the first-floor unit.

Inspectors wroteBased on interviews and record reviews the facility (A) failed keep one resident [R1] head of the bed elevated, and failed to provide one to one feeding assistance, (B) failed to follow their code blue policy to call 911, R1 was unresponsive and having difficulty breathing, (C) failed to notify the physician in a timely manner of an acute change in condition, and failed provide an accurate report to the physician, (D) failed to relay STAT (immediate) laboratory and diagnostic test results to the physician. These failures resulted in R1 higher level of care being delayed, R1 experiencing an acute change in condition and subsequently expiring on 3/3/24 in the facility. This was identified as an Immediate Jeopardy which began on 3/2/24. On 4/11/24 at 9:14 AM, the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on 04/16/2024 at 12:24 PM. [...]

Inspectors wroteBased on interview and record review the facility staff failed to provide necessary treatment and services to promote healing and prevent infection of an existing pressure ulcer for 1 (R2) of 4 (R4, R7, R8) residents. R2 was admitted to the facility on [DATE] with a pre-existing pressure ulcer, however the facility was unable to provide consistent documentation that the physician ordered treatments for R2's sacral pressure ulcer was documented on from 03/06/24 through 03/11/24 and 03/12/24 through 03/17/24. The deficient practice resulted in R2 sacral wound becoming infected. Findings Include: During record review R2's sacral wound initial assessment documentation dated 03/05/24 with the second assessment dated [DATE] during which time R2 sacral wound evolved with no further wound documentation. [...]

Inspectors wroteBased on interviews and record reviews the facility staff [A] failed to have the necessary skills and competencies to meet one [R1] resident health care needs [B] failed to keep the head of bed elevated, and [C] failed to provide 1:1 feeding assistance. These failures resulted in R1 experiencing an acute change of condition and subsequently expiring on 3/3/24 in the facility. Findings Include: R1's clinical record indicated in part; [...]

Inspectors wroteBased on interviews and review of pertinent facility documentation on 3/26/24 and 3/27/24, it was determined the facility failed to provide an accurate record of the actual experience for one [R1] of 6 sampled resident's vital signs. Findings Include: R1's clinical record indicated in part; R1 was admitted to the facility on [DATE] with medical diagnosis of pneumonitis due to inhalation of food and vomit, dysphagia, cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visuospatial deficit and spatial neglect, memory deficit, , protein-calorie malnutrition, muscle weakness, cognitive communication deficit, dysphagia, essential (primary) hypertension, attention-deficit hyperactivity disorder, weakness, gastrostomy, and generalized anxiety disorder. R1's physician order: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient Certified Nursing Assistant (CNA) on weekends to care for residents' needs based on the staffing scheduling and PBJ (Payroll Based Journal) staffing data report. This failure could potentially affect 189 residents residing in the facility as of census 3/5/24.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow sanitary standard and hand hygiene before handling clean side of the dishwashing machine to unload the sanitized dishes and utensils. This deficient practice has the potential to affect all 183 residents receiving food prepared in the facility kitchen. Findings Include: Facility diet type report provided by facility dated 3/7/24 documents that a total of six residents residing in the facility are NPO/nothing by mouth. On 03/05/24 at 10:11 AM, surveyor observed V17 (Food Handler) walked to the clean side of dish washing area. V17 did not perform hand washing before handling clean dishes. V17 stated V17 should wash hands and wear a pair of gloves before handling clean dishes. V17 stated handling clean dishes without hand washing could cause cross contamination. [...]

Inspectors wroteBased on observations, interviews, and review of records the facility have the following failures related to infection control, procedures, practices, and prevention: Failed to follow policy on putting signage on a COVID-19 positive resident (R168). Failed to follow hand hygiene and Enhanced-Based Precaution policies by not performing hand hygiene during care and not using Personal Protective Equipment (gown and gloves) for a resident on Enhanced-Based Precaution (R336). Failed to ensure Enhanced Barrier Precaution signage was posted on the door of one resident (R152). Failed to dispose Personal Protective Equipment (gown) in a designated disposal equipment (large red bin with lid closure) for one resident (R21) Failed to ensure reusable medical equipment was cleaned and disinfected between four (4) residents (R19, R110, R111, R128) used to prevent cross contamination. [...]

Inspectors wroteBased on review of records and interview the facility failed to follow COVID-19 vaccination policy for resident in determining and documenting COVID-19 immunization status. And failed to follow COVID-19 vaccination for staff in tracking COVID-19 immunization status of staff. These failures have the potential to affect all 189 residents.

Inspectors wroteFindings include: R77 has medical diagnoses of chronic obstructive pulmonary disease, emphysema, acute and chronic respiratory failure, and asthma. R77's physician orders document in part orders for continuous oxygen (ordered 1/5/2024) and to change the oxygen tubing weekly (ordered 11/13/2023). R77's comprehensive care plan does not contain a focus for R77's oxygen use/needs. On 03/05/2024 at 11:08 AM, R77 was lying in bed receiving oxygen via nasal cannula. The nasal cannula and humidifier bottle were not dated. Facility's Oxygen Use, Storage and Labeling policy last revised on 1/2024 documents in part: Oxygen tubing, nasal cannula and masks are changed weekly and PRN [as needed]. Tubing and Humidifier bottle should be dated. Facility's Comprehensive CarePlan policy dated 1/2023 documents in part: The facility must develop a comprehensive person-centered care plan for each resident. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a.) medications were labeled when opened, b.) ensure medications were stored to present cross contamination and c.) ensure medications for discharged residents were removed from the medication cart in 3 of 3 medication carts reviewed for medication storage and labeling. Findings Include: On 03/05/24 at 01:04 PM the second-floor medication cart 1 was reviewed with V6 (Licensed Practical Nurse). R53 (Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (microgram/activated clotting time) 1 puff daily and Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligram/milliliter) 1 vial inhale orally Twice a day was observed opened in the medication cart and undated. V6 stated I think they are good for 30 days after opening. [...]

Inspectors wroteBased on review of records and interview the facility failed to follow immunization policies for both influenza and pneumococcal vaccination in determining and documenting influenza and pneumococcal status to record under immunization tab on electronic heath record (EHR) of 4 out of 5 residents (R57, R60, R336, R338) for a total sample of 5 residents reviewed for vaccination / immunization services. These failures have the potential to affect 4 residents (R57, R60, R336, R338) in receiving information of the benefits and risks of the vaccines.

Inspectors wroteBased on interview and record review, the facility failed to refer one resident (R21), out of thirty six residents in a total sample reviewed, for a Level II Preadmission Screening and Resident Review (PASARR) in alignment with facility policy.

Inspectors wroteBased on interviews and record reviews, the facility failed to include a resident's (R286) high-risk medications on the baseline care plan for one out of a total sample of 36 residents.

Inspectors wroteBased on review of records and interview the facility failed to provide a individualized care plan related to code status of 1 out of 36 resident (R57) reviewed for care plan. This failure has the potential to affect 1 resident (R57) right to choose code status.

Inspectors wroteBased on observations, interviews and record reviews, the facility [A] failed to provide incontinence care timely, [B] failed to provide scheduled showers for 1 resident [R36] who requires assistance with activities of daily living and [C] failed to provide eating assistance per MDS [Minimum Data Set] assessment for one resident (R21) out of thirty-six residents in the total sample reviewed. Findings Include: On 3/5/24 at 10:45 AM, during the initial tour, surveyor entered R36's room and smelled a strong odor of urine. Surveyor and V29 [Certified Nurse Assistant] with the permission of R36, allowed surveyor to observed ADL care. Surveyor and V29 observed R36 with an under brief in place, and she was laying on a bed pad. The bed pad was wet with dark color rings extending off the bed on to the bed linen. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and a physician's order for weights for one (R74) out of a total sample of 36 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 2 residents with limited range of motion receives appropriate treatment and services to prevent further decrease in range of motion by not applying / maintaining left hand splint and right-hand roll. The facility also failed to obtain orders for splint / device use. These failures could potentially affect 2 (R48 and R87) of 6 residents reviewed for limited range of motion in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain order, comprehensively assess, and develop care plan for indwelling urinary catheter use. These failures could potentially affect 1 (R87) resident reviewed for urinary catheter in a sample of 36.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow a resident's (R286) food preferences for one out of a total sample of 36 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure accurate documentation and reconciliation of narcotic medications for 2 (R179, R286) of 2 residents reviewed in 1 of 3 medication carts. Findings Include: On 03/05/24 at 02:28 PM the first-floor medication cart 1 narcotic count was reviewed with V16 (Agency Registered Nurse). Review of document titled Shift Change Accountability Record Sheet for Controlled Substances dated March 2024 was reviewed with missed nurse's initials for the date of 03/04/24 11-7 and 7-3. Surveyor asked V16 was the change of shift narcotic count done by the oncoming and off going nurse, V16 responded yes. R179 Controlled Drug Receipt/Record/Disposition Form document in part: Hydrocodone/APAP (Acetaminophen) tab 5-325 mg (milligrams) take 1 tablet by mouth every 6 hours as needed. Quantity received 24, amount remaining 15. [...]

Inspectors wroteBased on review of records and interview the facility failed to follow antibiotic stewardship policy in monitoring and maintaining record for 2 out of 5 residents (R88 and R21) on antibiotic therapy per physician orders. These failures have the potential to affect 2 residents (R88 and R21) proper use of antibiotic therapy.

Inspectors wrote1. Based on observation, interview, and record review, the facility failed to supervise ten residents (R2, R9, R10, R11, R12, R13, R14, R15, R16, R17) in the sample. This failure also affected R2 who had an unwitnessed fall which resulted in R2 sustaining a fractured nose. This failure has the potential to affect all residents on the first and second floor of the facility. The facility failed to ensure that the emergency cart on the 3rd floor was safely locked when not in use and failed to ensure that a full oxygen tank for the emergency cart was stored securely in the oxygen rack. These failures have the potential to affect all the resident on the 3rd floor.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents call light was within reach for 5 residents (R1, R5, R6, R7, and R8) reviewed for call light.

Inspectors wroteBased on interview and record review the facility failed to report to IDPH (Illinois Department of Public Health) within the required regulation time, an allegation of abuse for two residents (R3 and R4) reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to immediately initiate an investigation into alleged physical abuse and misappropriation of resident property for two residents (R3 and R4) reviewed for abuse. This failure affected R3 who alleged staff mistreatment and being physically aggressive during care and R4 who alleged theft and misappropriation of property. This failure has the potential to affect all 190 resident residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of two residents (R6) reviewed for ADL care.

Inspectors wroteBased on interview and record review the facility failed to safely transfer a resident to prevent a fall for one of three residents (R1) reviewed for falls. Staff failed to utilize a gait belt during transfer from toilet to wheelchair. This failure resulted in R1 sustaining a subarachnoid hemorrhage (bleeding in the space that surrounds the brain) and a left zygomaticomaxillary complex fracture (fracture involving the cheekbone and the surrounding bones).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of two residents (R6) reviewed for ADL care.