Health inspection·September 12, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **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 Residents Affected - Some Page 1 of 3 145527 145527 09/12/2025 Brandel Health and Rehab 2155 Pfingsten Road Northbrook, IL 60062

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 145527 Page 2 of 3 145527 09/12/2025 Brandel Health and Rehab 2155 Pfingsten Road Northbrook, IL 60062

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 145527 Page 3 of 3