Austin Oasis, the

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive nutritionally adequate meals and follow recipes. These failures have the potential to affect all 172 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are receiving meals at scheduled times. These failures have the potential to affect all 172 residents receiving oral diets from the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to sanitize kitchen equipment based on facility policy. These failures have the potential to affect all 172 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to store and distribute food in accordance with professional standards for food service safety. This failure affected one resident (R5) and has the potential to affect all 182 residents that reside in the facility receiving oral diets.

Inspectors wroteBased on interview and record review the facility failed to ensure that one resident (R1) was discharged to a safe place back to the community. This failure affected 1 of 3 residents reviewed for discharges.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food at above 135 degrees F (for hot foods) on the steam table in accordance with professional standards for food service safety. This failure has the potential to affect all residents that eat food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received a blood pressure medication. The failure affects one (R1) of three residents reviewed for medication in a total sample of four residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were 6 inches above the floor in an effort to prevent foodborne illness. This failure has the potential to affect all 179 residents taking oral nutrition at the facility. The (01/14/2026) facility census was 180. The undated list of residents on NPO (nothing per mouth) include 1 resident. On 01/15/2026 at 10:28am with V6 (Dietary Manager) inside the Kitchen's walk-in refrigerator, there were stacks of boxes of food items with a box labeled pork/cerdo on the floor. V6 stated boxes of food items should be 6 inches above the floor to prevent food contamination. On 01/15/2026 at 1:24pm V6 stated all food items should be 6 inches above the floor to prevent food contamination and to prevent potential food borne illness. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a staff. This failure affected 1 (R2) resident reviewed for abuse and has the potential to affect all 34 residents on the 5th floor who smoke. The (undated) Patio/Smoking Schedule documented that there were 34 residents who smoke on the fifth floor. R2's (12/10/2025) Final Incident Investigation Report documented, in part (R2) alleged that a facility member called him a profane name. Calling residents kids when overseeing the cigarette line. Resident (R3) was interviewed him being there at the time of the incident. (R3) stated (V4-Former PRSC Psychiatric Rehabilitation Services Coordinator) was verbally aggressive towards residents. (R4) stated (V4) was rude and did not know how to talk to people. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident was administered a medication with a correct dosage. This failure affected 1 (R6) resident reviewed for medication administration in the total sample of 8 resident. On 01/15/2026 at 9:53am, during the medication administration observation with V11 (Licensed Practice Nurse), V11 dispensed R6's medications including Metoprolol 25mg/tab x 1 tablet. R6's container of Metoprolol has instruction written Metoprolol Tartrate 25mg. Take 0.75 tablet (18.75mg) by mouth every 12 hours. On 01/15/2026 at 9:56am, V11 administered R6 medications. ON 01/15/2026 at 10:01am, V11 stated she dispensed and gave Metoprolol 1 tablet to R6. V11 checked the container of R6's Metoprolol and stated he (R6) is supposed to get 18.75mg and she gave Metoprolol 25mg. V11 stated she did not follow the doctor's order. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's environment was free from hazardous material (razor). This failure affected 1 (R5) resident reviewed for supervision and hazard in the total sample of 8 residents. R5 sustained a wide linear abrasion on the left forearm beginning at the base of left thumb and extending to the mid forearm on radial side. The abrasion is approximately 1.5inch in width. R5's admission Record documented that R5's diagnoses (include but not limited to) cannabis dependence, alcohol dependence, alcoholic cirrhosis, and depression. R5's (01/03/20260 Petition for Involuntary/Judicial admission documented, in part a person subject to involuntary in-patient admission to a facility by reason of emergency inpatient admission by certificate. [...]

Inspectors wroteBased on interviews and record review, the facility failed to prevent one resident (R4) from being physically attacked in an elevator. This failure has resulted in R4 sustaining a closed head injury, becoming emotional and stating that she is no longer comfortable in the facility. This failure has affected one (R4) of four residents reviewed for abuse.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure adequate running water and failed to provide adequate hot water. This failure has affected four residents (R1, R3, R9 and R10) and has the potential to affect all 181 residents that reside in the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the kitchen was free from pests. The facility also failed to ensure that the kitchen oven was clean and free from debris. This failure has the potential to affect 181 residents that reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents are free from abuse for two of four residents (R2, R4) reviewed for abuse in the sample of eight. This failure resulted in R2 requiring antibiotics for treatment of a bite to R2's hand.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect one (R40) resident's right to be free from physical abuse out of one sampled resident. R132 slapped R40 on the face that resulted in R40's falling on her back and sustained left elbow, back, and neck pain. R40 felt scared and shaken. Findings Include: The facility's incident investigation report dated 3/3/25 documents in part: On 3/3/25 [V1 Administrator] was notified by [R40] that [R132] pushed [R40] down. Both residents' representatives and the police were notified. R40's Minimum Data Set (MDS) dated [DATE] shows R40 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15 and requires supervision with walking. R40's functional assessment dated [DATE] shows R40 had no limitation with range of motion to upper extremities. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a.) kitchen staff wearing appropriate hair covering, b.) hand washing was being done in between handling dirty and clean dishes/equipment, c.) food items were properly labeled and dated. These failures have the potential to affect all 175 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their linen handling policy and procedure to ensure soiled linens are properly placed inside closed plastic bags with no loose items. This failure has the potential to affect all 175 residents residing in the facility reviewed for infection control. Findings Include: On 3/5/25 at 1:46 PM, Surveyor inspected the facility's laundry chute with V30 (Laundry Aide). When V30 opened the laundry chute, loose soiled and dirty incontinence pads, towels, and bed sheets were found that were not inside a plastic bag. V30 stated that staff should be bagging dirty soiled linens and clothing before dropping them in the laundry chute. V30 stated it's not sanitary to drop them in the chute without properly bagging them. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to display, in a public and accessible location, posters informing residents of their rights to explore or decline community transition under the [NAME] Consent Decree, and their right to be free from retaliation, regardless of their decision on transition. This has the potential to affect all [NAME] Class Members.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedure by not obtaining a physician's order for 4 residents' (R44, R63, R129, R332) code status and failed to develop a comprehensive person-centered care plan for 2 (R44, R63) out of 2 residents' code status in a final sample of 35 reviewed for advance directives. Findings Include: R44's face sheet shows an admission date of [DATE] and the advance directive section was blank. R44's minimum data set (MDS) dated [DATE] shows R44 is cognitively intact with BIMS (Brief Interview for Mental Status) of 14. R44's order summary report with active orders as of [DATE] shows no physician order for R44's code status. R44's comprehensive care plan does not address R44's advance directive/code status. R332's face sheet shows an admission date of [DATE] and the advance directive section was blank. [...]

Inspectors wroteBased on interview and record review, the facility failed to refer 9 (R1, R22, R35, R55, R59 R70, R83, R99, R136) residents to the appropriate state designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation out of 9 residents reviewed for PASARR in a total sample of 35. Findings Include: 1. R22 was admitted to the facility on [DATE] with diagnosis not limited to Multiple Sclerosis, Muscle Spasm, Personal History of Suicidal Behavior, Bipolar Disorder, Schizoaffective Disorder, Bipolar Type and Major Depressive Disorder, Recurrent. R22's Document titled Notice of PASRR Level II Outcome dated 09/26/24 document in part: PASRR Determination: Approved without Specialized Services. This Level II evaluation is good within 90 calendar days of the Notice date listed on the Notice of PASRR Level II Outcome that came with this letter. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to complete a quarterly smoking assessment for one resident (R1) and have individualized smoking care plans for independent smokers. This has the potential to affect R1 and all the independent smokers in the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to label open insulins for 4 [R36, R282, R283, R284] residents on 2 of 8 medication carts reviewed for medication storage in a sample of 35. Findings Include, On 3/4/25 at 9:12 AM, V7 [Licensed Practical Nurse] and surveyor conducted inventory of the second-floor south medication cart observed the following: A plastic open cup with [28] dark green pills. R36's open vail of Basaglar Kwik Pen, inject 12 units at bedtime. R283's Lantus (Glargine Insulin) Pen, inject 20 units one time per day. A label on the pen Refrigerate. [Pen was in top drawer of med cart] R284 's Humalog, inject per sliding scale, before meals and at bedtime. R282's Insulin NPH Isophane and Regular Subcutaneous 70/30, inject 12 units in the morning. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare food items listed on menu for pureed diets and prepare adequate food portions as documented on the recipe. This failure has the potential to affect 165 residents receiving pureed and regular diets prepared in the facility's kitchen based on the diet order list dated 03/04/25. Findings Include: On 03/04/25 at 12:00 PM, observed lunch tray line. Regular diets were receiving Sweet and Sour Chicken, Steamed Rice, and Oriental Vegetables. Pureed diets were receiving Pureed Sweet and Sour Chicken, Mashed Potatoes, and Pureed Spinach. V19 (Cook) stated she did not make pureed rice and the pureed diets were receiving mashed potatoes in place of pureed rice. On 03/04/25 at 12:54 PM, surveyor tasted pureed vegetable which was spinach. There was no spinach in the Oriental vegetables. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare ground/mechanical soft and pureed food in appropriate diet consistency form. This failure has the potential to affect 10 residents on mechanical soft/ground diets (R15, R19, R26, R36, R39, R60, R79, R81, R82, R95) and 8 residents on pureed diets (R68, R71, R84, R94, R106, R114, R115, R116) prepared in the facility kitchen based on list of residents receiving mechanical soft with ground meat and pureed diets dated 03/04/25. Findings Include: Facility had 10 residents on mechanical soft/ground diets and 8 residents on pureed diets. On 03/04/25 at 12:16 PM, observed V19 (Cook) portioning out food on the tray line. Observed large pan of Sweet and Sour Chicken and smaller container of pureed Sweet and Sour Chicken. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide double portions as part of the therapeutic diet as prescribed by the physician for 19 (R9, R17, R18, R23, R47, R78, R97, R98, R100, R107, R134, R136, R155, R164, R165, R174, R176, R232, R433) residents reviewed for dining services in a total sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to: (1) provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations; (2) assess eligibility and offer pneumococcal vaccinations to five (R61, R85, R156, R44, R332) of five residents reviewed for pneumococcal vaccinations; (3) update the facility's Pneumococcal Screening and Immunization policy to reflect the recent Centers for Disease Control and Prevention (CDC) Adult Vaccination Schedule and guidance. This had the potential to affect any residents eligible to receive the Pneumococcal vaccinations.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the same time. These failures affected 3 residents (R27, R43, R125) reviewed during dining in a total sample of 35 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure (A) The five administration rights were followed for one [R151] of three [R108, R139] residents reviewed for medication administration in a sample of 35 residents. Findings Include, R151's Physician orders: 6/25/24 Insulin Glargine 100unit/ml, inject 30units daily. On 3/4/25 at 9:40 AM, observed V5 [Licensed Practical Nurse] prepare R151's insulin: V5 administered R151's insulin in the upper left arm. Surveyor observed the open half-filled insulin Glargine vail was labeled with R59's name, no open or expiration date on the vail. On 3/4/25 at 9:46AM, V5 stated, I was aware that I obtained R151's insulin dose from R59's multi use insulin vial, R151 did not have any more insulin. I re-ordered R151's insulin and should be delivered sometime tonight. The facility has an emergency Insulin Box. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) ensure oxygen tubing and nebulizer mask were labeled and dated, b.) ensure nebulizer supplies were properly stored when not in use to prevent contamination for and c.) ensure oxygen signage was posted for residents receiving oxygen therapy. This failure has the potential to affect 3 (R10, R63, R104) residents reviewed for oxygen therapy in a sample of 35. R10 has diagnosis not limited to Generalized Anxiety Disorder, Heart Failure and Chronic Obstructive Pulmonary Disease. R10's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R10's Physician Orders document in part: Oxygen via NC (Nasal Cannula) at 3L (Liters) continuous every shift. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to document the information on the resident's (R332) COVID-19 vaccine and failed to document if education was provided regarding the benefits and potential risks associated with the COVID-19 vaccine to 3 (R61, R156, R332) out of 5 residents reviewed for COVID-19 immunizations in a final sample of 35.

Inspectors wroteBased on observation, interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R1) of 4 residents reviewed for physical abuse. This failure resulted in R2 physically attacking R1, resulting in R1 bleeding from an abrasion R1 sustained under the left eye and R1 being transferred to the hospital for evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (R1) out of 9 from physical abuse. This failure affected R1 who was pushed in the elevator by R8. As a result, R1 had an unwitnessed fall, R1 was sent to a local hospital. R1 sustained a left lateral tibial plateau fracture approximately 1mm (One millimeter) depression and small joint effusion.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer right dosage of a prescribed medication as per physician order for one resident (R3,) out of three residents reviewed. This failure affected R3 who has a physician order to receive Ibuprofen oral tablet 800mg (milligrams) as needed every eight (8) hours for pain but was administered 600 mg instead with potential that R3's pain may not be controlled.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper sanitation in the kitchen to prevent food-borne illnesses; and failed to ensure that staff store their food and personal items out of the facility kitchen used for residents. These failures have the potential to affect all 177 residents receiving an oral diet in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the dumpster was closed and fee from overflowing trash. These failures have the potential to affect all 178 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure that the facility's kitchen is free of insects. This failure has the potential to affect all 178 residents in the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff on 4 of 5 resident floors (2nd, 3rd, 4th, and 5th floors) of the facility.

Inspectors wroteBased on observation, interview and document review the facility fails to maintain an effective pest control program so that the facility is free of insects and rodents on 5 of 6 floors of the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food in the refrigerator and freezer was labeled with a date indicating when the item was placed into the refrigerator/freezer, a thermometer was inside of the freezer, and expired food was discarded on or before the expiration date. These failures have the potential to affect 163 residents in the facility who are receiving an oral diet.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the outside dumpster lid was closed and garbage bags were placed into the dumpster to prevent pests and rodents from entry into the garbage bin. This failure has the potential to affect all 163 residents residing in the facility.

Inspectors wroteFindings include: R76's Brief Interview for Mental Status (BIMS) dated shows that R76 has a BIMS score of 15 which indicates that R76 is cognitively intact. R76 has a diagnosis which includes but not limited to: Obesity, major depressive disorder, generalized anxiety, paranoid schizophrenia and essential hypertension. On 05/13/24 at 11:05 am, Surveyor observed R76's room with the window open about six inches and without a window screen. Surveyor observed five flies flying in R76's room. R76 stated that R76 did not know how long R76's window has been without a window screen. On 05/14/24 at 1:27 pm, Surveyor observed R76's room remain with the window open about six inches and without a window screen. Surveyor observed five flies still flying in R76's room. On 05/15/24 at 9:35 am, V17 (Maintenance Director) stated that all residents windows should have a window screen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the laundry chute in the hallway of the second floor and the fourth floor, are locked to prevent residents from falling through the chute to the ground floor. This failure has the potential to affect all 40 residents on the second floor, and all 44 residents on the fourth floor, reviewed for safety from environmental hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient Psychiatric Rehabilitation Services Coordinators/PRSC to meet the individualized psychosocial and mental health needs of residents. This failure has the potential to affect all 49 residents with diagnoses of Severe Mental Illness and other residents in the facility who require psychosocial support.

Inspectors wroteBased on observation, interview and record review, the facility failed to label an opened multi dose vial and discard an expired opened multi dose vial. These failures have the potential to affect all 44 residents on the 4th floor and all 42 residents on the 5th floor, potentially affecting a total of 86 residents at the facility reviewed for labeling and storage of drugs and biologicals.

Inspectors wroteBased on observation, interview and record review the facility failed to you provide appropriate Personal Protective Equipment (PPE) supplies for two residents (R22 and R86) with Enhance Barrier Precautions; and failed to display Enhance Barrier Precaution sign for one resident (R8). This failure affected all 37 residents on the third floor and all 42 residents on the fifth floor reviewed for infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the community shower room on the fourth-floor is maintained in a sanitary manner and in good repair, and failed to ensure that the fifth-floor bathroom and day room are kept in good repair. These failures have the potential to affect all 44 residents on the fourth floor and all 42 residents on the fifth floor.

Inspectors wroteBased on Observation, interview and record review the facility failed to administer scheduled medications in the schedule time frame. This failure affected 4 residents (R1, R2, R3, and R4) reviewed for medication administration. This failure has the potential to cause negative outcome to a resident's physical, mental, psychosocial health, or well-being. Findings Include: On 4/30/24 at 12:00 pm, surveyor observed V3 LPN (License Practical Nurse) passing medications to residents. Surveyor inquired to V3 if afternoon medications were being passed. V3 stated, No I'm passing 9:00 morning meds. I was call in to work and didn't get here until 9:00 this morning. I normally work second shift 3 to 11p. Surveyor inquired to V3 how many residents V3 is taking care of. V3 stated, I have 23 residents. V3's timecard preview report for 4/30/24 clock in time is 9:02 am. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was free from physical abuse. This failure affected R3 who was physically punched and pushed by R8, causing R3 to fall and sustained a left hip fracture and right finger fracture that required emergency transfer to the trauma hospital with surgical repair of the left hip fracture and right finger fracture when reviewed for physical abuse in the sample of 4 residents (R3, R6, R7 and R9).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that adequate supervision was provided for five of five residents (R15, R16, R17, R18, and R19) reviewed for supervision in the sample. This failure affected R15 who had a fall with injury laceration to the right side of the head and was sent to hospital emergency room where R15 received seven staples for laceration closure. This also affected R16 who was noted in the shower room without any supervision and R17, R18 and R19 who were observed in the dining room during lunch time without supervision. This has potential to affect all the resident on the 2nd and 4th floor of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that call light is within the reach for four residents (R1, R4, R15 and R16) reviewed for call lights.

Inspectors wroteBased on observation, interview, record review the facility failed to ensure that the call light system was in a working condition for residents to call for staff assistance. This failure has the potential to affect all the resident residing on the 2nd and 4th floor of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe and functional environment in regard call light for resident's staff assistance. This failure affected all the residents in Rooms 202, 204, 207, 209, 210, 211, 212, 214, 215, 216, 220, 406, 407, 408, 409, 410, 420, 42 and has the potential to affect all the residents on the 2nd and 4th floor of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy during glucose monitoring and insulin administration for one resident (R23) reviewed for resident rights in the sample. This failure affected R23 whose glucose monitoring, and insulin administration was done in the hallway at the nursing station while peers are present and watching. And has the potential to affect nine residents identified as needing glucose monitoring and insulin administration.

Inspectors wroteBased on interview and record review the facility failed to report to IDPH (Illinois Department of Public Health) within the required regulation time, unwitnessed fall with injury for one resident (R15) in the sample reviewed for fall with injury. This failure affected R15 who had an un-witness fall and was bleeding from laceration to the right side of the head. R15 was sent to the hospital where R15 received seven staples application to laceration site, this has the potential to affect all 158 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that physician order on medication administrations was followed, failed to document insulin administration and blood glucose monitoring as late. This failure affected R23 whose glucose monitoring (accu-check) was done late, and insulin medication was administered. This also have the potential to affect eight other residents identified as dependent on licensed staff to monitor their blood sugar on the 5th floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that privacy was afforded to one of four residents (R14) with urine collection bag in the sample reviewed for privacy. This failure affected R14 whose urine bag was visibly exposed to the hallway and with no privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (R2) remained free from verbal abuse. This failure affected one resident (R2) out of three residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident (R1) who depend on staff's assistance for their ADL (Activities of Daily Living) care received showers, nail care and grooming. This failure affected one out of three residents reviewed for ADL care and showers.

Inspectors wroteBased on observation and document review the facility failed to provide a clean homelike environment, this failure has the potential to affect all residents

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents remain free from staff to resident physical abuse (R2) and staff to resident theft (R3) for two of two residents reviewed for abuse and theft.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident to resident abuse and resident to employee. This failure affected two (R2, R1) residents in a sample of three residents reviewed for abuse. This failure resulted in (R4) with known aggressions striking (R2) in the face causing inury. This failure resulted in R1 being verbally and mentally abused by V3(former cook).

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by other residents for two (R1 and R4) out of four residents reviewed for abuse. This incident resulted in one (R4) resident having a swollen forehead and bruised eye.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their recipes and give adequate portion sizes. This failure has the potential to affect all 163 residents receiving food prepared in the facility's kitchen. Findings Include: On 04/05/23 at 10:08 AM, V13 (Cook) stated that 1 portion of ham is equal to four slices of ham to yield a 3-ounce portion. V13 stated that she has 8 residents on a pureed diet. Observed V13 count off the number of slices of ham as V13 put them into the blender. V13 stated, I put 16 slices into the blender. Observed V13 add 8 - 3 ounce ladles of ham broth to the sliced ham in the blender and then press the on button. Observed the mixture to be very watery. V13 stated that because the consistency was so thin, V13 needed to add thickener to the mixture to make it thicker. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to a.) ensure food items were properly labeled and dated; b.) the facility failed to clean ice machine; c.) the facility failed to ensure that cook-service ware were air dried after being sanitized; d.) facility failed to reheat prepared pureed food to 165 degrees. These deficient practices have the potential to affect all 163 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage and refuse were disposed of properly by not closing the lids of the dumpsters outside the facility. This deficient sanitation practice has the potential to affect all 164 residents who reside in the facility.

Inspectors wroteBased on observations, interviews and records review, the facility failed to ensure a safe system of narcotic storage/disposition for four (R26, R50, R22, R57) residents, failed to accurately reconcile controlled medications for one (R147) resident reviewed for narcotic storage and labelling in two of four medication carts reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide wheelchair arm rest for 1 (R4) and arm rest pads for 2 (R12, R15) of seven residents reviewed for accommodation of needs.

Inspectors wroteBased on Interviews and records review, the facility failed to address advance directives with residents and ensure documentation of advance directives status for two residents (R140, R132) reviewed for Advance Directives. This failure has the potential to effect 32 residents reviewed.

Inspectors wroteBased on interview and record review, facility failed to follow their policy to ensure residents are free from physical abuse by providing necessary care in services thus resulting in a female resident having injuries of unknown origin for 1 (R24) out of 32 in the sample residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment free from accident hazards by a.) having an exposed light bulb without a cover and no ability for one resident (R102) to turn the light on and off, b.) not providing supervision or monitoring for one resident (R147) while shaving. These failures affected two (R102, R147) of seven residents reviewed for potential accidental hazards in the survey sample of 32 residents.

Inspectors wroteBased on observations, interviews, and record reviews. The facility failed to A) follow their infection prevention and control policy when staff entered a room of one [R61] resident on transmission-based precautions without the appropriate personal protective equipment [PPE], and B) staff failed to perform hand hygiene after touching high touched areas in the isolation room for one [R61] of 32 residents in the sample reviewed of transmission-base precautions.