**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse and mental anguish by staff and also failed to appropriately identify incident(s) of abuse. This failure affected one resident (R2) whose wrists were tied to their bed side rails using pillowcases by a facility nurse as an attempt to confine R2 in bed for the nurse's convenience. As a result, R2 experienced feelings of humiliation and despair as evidenced by being tearful as well as physical pain and discomfort in both wrists. Any reasonable person in this situation would feel humiliated and ashamed. This was identified as an immediate jeopardy which begin on 10/12/24 at 3:00pm when V6 RN (Registered Nurse) tied R2 with pillowcase to the bed side rails. V1 (Administrator) was informed of the immediate jeopardy and template was presented 11/25/24 at 2:17 pm. The immediate jeopardy was removed on 11/28/24 at 3:36 pm. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings include: R2 is a [AGE] year-old, cognitively impaired resident with diagnosis that includes but not limited to restlessness and agitation, tracheostomy, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia, muscle wasting and atrophy and repeated falls. On 11/14/24 at 2:43 pm, V6 RN (Registered Nurse) stated that the shortage (referring to facility staffing) started at the beginning of the shift (referring to CNA shift 3:00 pm to 11:00 pm). V6 stated normally the second-floor staffing is to have three CNAs (Certified Nurse's Aide) but only two were working. V6 stated because R2 is known for climbing out of bed and falling and the RN (V6) was busy passing medication, V6 decided to tie R2's wrists to the bedrail with a pillowcase. V6 stated R2 had become agitated when the family member who came to visit R2 left. V6 stated that they (V6) knew what they did was wrong, but it was done so R2 would not fall when there was not enough staff (referring to CNAs). V6 stated that there was no other staff involved in tying R2 down. When the surveyor asked if R2 was willing to be tied down V6 stated that R2 was not cooperative with the tying down, but V6 was busy and could not stay with R2 and supervise them. V6 acknowledge that there was no physician order in R2s chart to restraint R2 with a pillowcase or any other restraint. When asked if that is a form of abuse V6 stated Yes, it can be abuse. The surveyor asked V6 if R2 is able to easily remove a pillowcase tied to their wrist and V6 stated No, because both hands were tied. On 11/14/25 at 2:51 pm, V20 CNA (Certified Nurse's Aide) stated On 10/12/24 I (V20) was not in the building, but V21 (CNA) called me at home very upset and told me how she found R2 tied down like a dog with a pillowcase in the bed. So, I called V2 (Director of Nursing). On 11/14/24 at 2:58 pm, V21 (CNA) stated that she witnessed R2's wrists tied to the bed side rails by use of pillowcases on 10/12/24. V21 stated she called V8 (Registered Nurse) working on the floor to see what was going on. V21 then stated that tying a resident to the bedrail with a pillowcase was a form of abuse. V21 confirmed that when she found R2, they were tearful, showing gestures for help and when she released R2's wrists from the pillowcase, R2 began rubbing their wrists and gesturing to pain and discomfort by use of mouth gestures. V21 also stated that R2 was grateful for V21's help and began blowing kisses and mouthing thank you. V21 acknowledged that a reasonable person would not want to be tied down like R2 was. V21 said, I could not believe what I saw so I walked out and called the other nurse V8 (RN) and V25 (CNA). I also called a union representative because this traumatized me, and I was not allowed to go home because we (facility) were short of working CNAs. I had to go off the floor for a short period in the staffing lounge. V21 confirmed that she called V20 at home to talk about what happened and at that time, V20 called V2 (Director of Nursing) to report what had happened. On 11/14/24 at 3:28 pm, V1 (Administrator) stated that the incident was marked as abuse but it was not founded to be abuse an applying the pillowcase was for safety of R2 and no injury was discovered. V1 attributed V6's action to V6 being busy with another resident and did not have other staff available to assist them (V6) in making sure R2 was supervised. Present during the interview with V1 was V22 (Nurse Consultant) who stated, it is a form of abuse, and it should absolutely be reported to IDPH (Illinois Department of Public Health). On 11/18/24 at 10:42 am, V19 (Restorative Director) stated that it is not appropriate to use a pillowcase as a restraint device because it can cause psychological and emotional anguish. V19 stated, This can cause the resident to be sad and feel isolated .a pillowcase can block flow of blood circulation due to it not being designed for use as a restraint device. The surveyor asked V19 that in his own professional opinion can this be a form of abuse and V19 stated Yes, it can be a form of abuse that should be reported. On 11/18/24 the facility staffing schedule dated 10/12/24, showed documentation that V21 was pulled from the 3rd floor to work on the 2nd floor because there was only one CNA present with two nurses at 3:00 pm. On 11/25/24 at 2:04 pm, V1 stated that V6's action did not constitute a form of abuse because it was not unreasonable confinement. V2 (DON) who was present at the time of V1 interview stated that it was a form of abuse because the effect can be psychological/ mental anguish. Record review of R2's medical record showed that the only way R2 can communicate with facility staff is by using R2's hands, either by writing or using hand gestures. R2's MDS (Minimum Data Set) dated 10/18/2024 section C-cognitive patterns did not score R2's BIMS (Brief Interview for Mental Status) indicating that R2 was unable to complete the interview. R2's medical record did not show any Plan of Care stating R2 was susceptible to abuse. On 11/18/24 at 1:30 pm, R2 was observed in the room sitting in a recliner chair using the right hand to wipe saliva from the mouth. R2's left hand was noted with weakness; R2 was using their right hand to lift their left hand onto their lap. When asked about the incident on 10/12/24, R2 answered with thumbs down while shaking their head back and forth in a No gesture. The surveyor asked R2 whether R2 wanted to be tied down R2 shook the head back and forth in a No gesture and mouthed NO. When asked if R2 experienced pain, R2 shook their head Yes. On 11/18/24 at 3:21 pm, V23 (Physician) stated that he has never heard of staff tying down a resident and will never give an order to do so. V23 stated How can anyone do that? In 28 years of being in medicine, I know that it is not professional, and it is not right. On 11/18/24 at 3:46 pm, V24 (Psychiatrist) stated, I will never give such order. The nurse (V6) acted on their own. V24 stated Use of mitten may be used, not a use of pillowcase. It is not good, and it should not be done, and no physician should give that kind of order. That kind of abuse it is unheard of. When asked about what can happen to a resident who is inappropriately restrained, V24 stated that it can compromise their breathing. On the 11/25/24 facility census report for 10/12/24 presented for the 2nd floor showed that 41-residents were residing on the 2nd floor and 110 total residents residing in the facility. On 12/04/24 at 10:14 am, V29 (PRSD/Psychiatrist Rehabilitation Services Director) stated that she is new to the facility and was not sure what happened for the nurse to tie down R2. When the surveyor asked about the 10/12/24 incident in which V6 restrained R2 with a pillowcase when the facility was short-staffed and if that can be a form of abuse, V29 stated In my own professional opinion, yes, it will be considered abuse, and it should have been reported. On 12/05/24 at 1:12 pm V6's time sheet presented showed that on 10 /12/24 V6 clocked in at 7:11 am and clocked out at 7:26 pm, showing that V6 worked the whole shift. The facility Abuse Prevention Program policy presented with revised date 04 January 2018 documented that definition of abuse includes but not limited to willful infliction of injury, unreasonable confinement, pain and mental anguish. Willful as used in the definition of abuse means the individual must have deliberately, or that the individual must have intended to inflict injury or harm. The policy under external reporting documented that initial reporting of allegations documented that when an allegation of abuse occurred the department of Public Health's regional office shall be informed by telephone or fax. The facility policy presented titled Abuse Prevention Program Facility Policy and Procedure with revised date January 4, 2018, documented that abuse is defined as the willful infliction of injury that includes but not limited to unreasonable confinement, or punishment that is resulting in pain or mental anguish. The policy documented that Willful as used in this definition of abuse, means the individual must acted deliberately not that the individual must have intended to inflict injury or harm. The surveyor confirmed on 12/04/24 and 12/05/24 through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: the facility completed all measures on the abatement plan. Therefore, the abatement plan could be approved on 11/18/24. 1. R2 screened, reassessed for risk for abuse with care plan interventions. 2. All staff in-serviced training completed on 11/26/24 by V1, V2 and V29. 3. Documentation showed that all residents were re-educated on abuse with completion date of 11/26/24. 4. R2, R14, R15, R16, R17, R18, R19 and R20 were screened for potential abuse with care plan reviewed and initiated. 5. All staff will be responsible for monitoring residents for behavior that can make them vulnerable for abuse. 6. All residents determined to be vulnerable or those that will be affected by this deficiency citation R2, R14, R15, R16, R17, R18, R19 and R20 were identified, and plan of care initiated, with ongoing, on admission, quarterly and annually. 7. Review Quality Assurance audit tool started on 11/27/24 weekly ongoing to ensure compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure that residents are free of unnecessary physical restraint(s), failed to identify the specific medical symptoms warranting the use of physical restraint(s) and failed to obtain physician orders with medical justification for physical restraint(s). This failure affected R2 whose wrists were tied to the bed side by a pillowcase by a nurse with no physician order, no consent or resident permission, and no medical justification. Any reasonable person in this situation would feel humiliated and ashamed. This was identified as an immediate jeopardy which begin on 10/12/24 at 3:00pm when V6 (Registered Nurse) tied R2 to their bedside rails with a pillowcase. V1 (Administrator) was informed of the immediate jeopardy and template was presented 11/25/24 at 2:17pm. The immediate jeopardy was removed on 12/3/24 at 3:29 pm. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings include: R2's medical record admission Record showed documented that R2 was admitted originally to the facility on [DATE] with latest admission on [DATE]. Listed diagnosis includes but not limited to Tracheotomy status, restlessness and agitation, hematemesis, Type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, acute and chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, and repeated falls. R2's MDS (Minimum Data Set) dated 10/18/2024 section C-cognitive patterns did not score R2's BIMS (Brief Interview for Mental Status) indicating that R2 was unable to complete the interview. R2's medical record did not show any documentation of medical symptoms or behavior that would justify the use of restraint, no physician order for restraint usage, no restraint assessment, no consent, and no plan of care for restraint usage. On 11/14/24 at 2:43pm, V6 (Registered Nurse) stated that there was staffing shortage for CNAs that started at the beginning of the shift (referring to 3:00pm to 11:00pm shift on 10/12/24). V6 stated that normally the second-floor staffing is to have three CNAs, but only two were working. V6 stated Because R2 is known for climbing out of bed and falling and I (V6) was busy passing medication and taking care of other residents that were screaming and yelling, I (V6) decided to tie R2's hands with a pillowcase to prevent R2 from falling. I know what I've done is wrong, but it was done so R2 will not fall when there was not enough staff . When asked about the daily staffing for 2nd floor, V6 stated there should be two nurses and three CNAs (3pm to 11pm shift). When the surveyor asked for any medical justification like R2 trying to remove the tracheostomy tube or the oxygen, V6 stated that R2 was not trying to remove the tracheostomy tube or the oxygen, but was just trying to climb out of bed. V6 stated, R2 became restless and agitated because the family (V41) came to visit R2, and V41 (family member) had just left. V6 confirmed that R2 did not have any physician order(s) for restraint and that R2 was tied at the beginning of the shift. V6 also confirmed that before V6 could return to check on R2, V21 (CNA) discovered that R2 has been tied down. When the surveyor asked whether R2 was willing to be tied down V6 stated that R2 was not cooperative with the tying down, but V6 was busy and could not stay and supervise R2. V6 stated, I know that is not a restraint device but tying R2 down is a form of restraint that was not ordered. V6 stated, I did not want R2 to fall. The surveyor then asked whether restraints is a part facility intervention for falls and can R2 free self from the restraints without injury. V6 stated I should not have tied R2 down, and it is not part of intervention for fall prevention. On 11/14/24 at 3:28pm, when this was brought to V1 (Administrator) attention, V1 stated that applying the pillowcase was for safety of R2 and no injury was founded. V1 attributed V6's action to V6 being busy with another resident and did not have other staff available to assist him (V6) in making sure R2 is stabilized not fall. On 11/25/24 at 2:26 pm, V2 DON (Director Of Nursing) stated that the nurse (V6) should not have used a restraint on R2 and if this was left to her she would have terminated V6 but V1 (Administrator) prefers for this situation to go through them first. V2 confirmed that the situation with R2 was an unnecessary use of restraint. R2's medical record showed no recorded documentation that R2 had prior to 10/12/24, or after, any physical restraint assessment performed by the facility. There also was not any consent obtained from R2 or a resident representative, either written or verbal for the use of physical restraints. There was also no medical justification for physical restraints documented in R2's medical record. R2's care plan for communication initiated 07/15/2024 and revised on 08/05/2024 showed that R2 is non-verbal and can only communicate with staff using a writing pad and pen as well as using hand or mouth gestures. When the surveyor asked R2 about how R2 feels about being tied with pillowcase. R2 responded with hand gestures showing a thumbs down and shaking the head to gesture No. R2's medical record, Risk for Falls Assessment dated 11/21/2024 showed that R2 scored 18 and under category deemed to be at a moderate risk for falls. Facility in-house investigation report on 10/12/24 documents in part: Staff witnessed R2 tied up to the bed side rails with a pillowcase by V6 (Registered Nurse). As a result, R2 experienced psychosocial impact that was described as crying for help and tearful. V6 stated R2 was agitated and restless and because there was not enough staff working at the time of the incident he tied R2 with the pillowcase. V6 stated that he was busy with other residents and could not supervise R2. V42 (Director of Rehabilitation services) statement dated 10/16/24 with no date of incident and interview. V42 wrote I (V42) was not present at the time of incident but R2 was in therapy due to having multiple falls out of bed. V42 documented in part in the statement that whenever R2 is trying to get out of bed he can usually redirect R2 and that R2 can usually tell of the needs through on-verbal communication. V42 further stated that R2 likes to have a towel to clean up saliva the mouth/trach (Tracheostomy) and R2 can become anxious if (R2) does not have one. V8's statement documentation dated 10/12/24 documented that on 10/12/24 at 6:10 pm when (V21 CNA) called her (V8 RN) to R2's room the room was dark and when the light was turned on, she (V8) observed R2's left, and right wrist tied with pillowcase. On 11/18/24 at 10:40 am, V19 (Restorative Director) stated that the facility is a restraint free facility therefore no physical restraint should be used on any of the resident and if there is justification for emergency usage for the restraint there must be a physician order immediately after or within eight hours of use. V19 stated that the resident must be placed on 1:1 staff supervision for safety reasons and it is not appropriate to use a pillowcase as a restraint devise because it can cause psychological/ psychological emotional anguish. V19 stated that this can cause the resident to be sad and isolated. And a pillowcase can cause flow of blood circulation due to it not designed to be used as a restraint device. R2's medical record did not show any documentation of medical symptoms or behavior that justify use of restraint, no physician order for restraint usage, no restraint assessment, no consent, and no plan of care for restraint usage. R2's medical record review showed that the only way of R2 communicating with facility staff is by using writing or using mouth and hand gestures. R2's medical record showed no recorded documentation that R2 before 10/12/24 and after had any physical restraint assessment done. There was no consent obtained either written or verbal. R2 was not informed. No physician order, no psych-evaluation and no medical justification for the use of restraints. On 11/18/24 at 1:30 pm, R2 was observed in the room sitting in a recliner chair using the right hand to wipe saliva from the mouth. R2's left hand was noted with weakness while R2 was using the right hand to lift the left hand unto the lap. When asked about the incident on (10/12/24). R2 answered with thumbs down and shaking the head that it was bad. The surveyor asked R2 whether R2 wanted to be tied down R2 shook the head and with lip movement to gesture NO. R2 indicate with yes that it was painful. R2's medical record risk for Falls assessment dated [DATE] record that R2 scored 18 and under category deemed to be at a moderate risk for falls. On 11/18/24 at 3:21 pm, V23 (Physician) stated that he has never heard of staff tying down a resident with a pillowcase and will never give an order to do so. On 11/18/24 at 3:46 pm, V24 (Psychiatrist) stated, I will never give such order, V6 acted on their own. V24 stated that use of mitten may be used in a hospital but not a use of pillowcase. V23 stated it is not good and it should not be done, and no physician should give that kind of order, it is a kind of abuse it is un-heard off. When asked about what can happen to the resident. V24 stated that it can compromise R2's breathing. V24 stated, No, I did not give that order because there is no such thing in physician book for a staff to tie up a resident with a pillowcase. On 12/04/24 at 10:36 am, interview conducted with V8 (Registered Nurse) regarding the incident of 10/12/24 where R2 was tied down to the bedside rails with pillowcase. The surveyor asked if R2 was able to remove the pillowcase if R2 wanted to and if it was easily removable. V8 stated No, R2 would not be able to remove the pillowcase. I reported it to V2 (Director of Nursing). Surveyor asked why did V8 report the incident, V8 said that they did because it was wrong and it was abuse. Surveyor asked if V8 ever tied any of the resident up like that, V8 said No, that will be abusive. With any restraint use, we must get a doctor's order and monitor the resident. The restraint is not necessary and the purpose of pillowcases is to be used for pillows, it should not be used as a restraint. The incident happened around 5:30 pm and R2 was happy to be released. This is restraint free facility. When asked what was R2's reaction to what happened. V8 stated that R2 was using hand gestures to thank us. V8 also said that a reasonable person would not have liked to be tied down and it is wrong to do that and no one would like to be tied down. On 12/04/24 at 1:00pm, V19 (Restorative Director) stated that I V19 returned to work 12/02/24 and is still auditing the residents records. V19 stated that the facility is a restraint free facility and that safety belt, medical recliners, side rails and mittens are forms of restraint devices, but the facility does not use restraints. V19 stated that medical recliners are used for positioning and comfort for poor trunk control All those things listed that V6 (RN) did not follow with R2. On 12/04/24 at 2:06 pm, V25 CNA (Certified Nurse Aide) stated that she worked 3pm to 11pm on 10/12/24. V25 stated, at the beginning of the shift when making rounds, R2 kept trying to get out of bed and the V6 (Registered Nurse) came in R2's room and stated he will stay in the room with R2. V25 stated, I (V25) was doing my rounds. Dinner trays came and the other CNA (V21) was passing the dinner trays when she saw R2's arm restrained to the bed rails. V21 told me to come and look and I saw R2's hands tied with pillowcases to the bed rails. R2 was just lying there on the bed. When V25 was asked about what a reasonable person would like and if would R2 liked to be tied down to the bed rails, V25 stated No. On 12/05/24 at 1:12 pm V6 time sheet presented showed that on 10 /12/24 V6 clocked in at 7:11 am and clocked out at 7:26 pm, showing that V6 worked the whole shift. The facility procedure for the use of Physical Restraint:Exception for emergency Situations documented that after less restrictive interventions to prevent the resident from serious harm have proven ineffective, determined the need for an emergency physical restrain. This determination may be made by the nurse. Under emergency authorization documentation documented that approval for the use of emergency physical restraints must be made by attending physician , the medical director or a supervisory nurse.if approval is given by a nurse , a physician's order must be received within eight (8) hours, validating the supervisory nurse's decision. Physician orders regarding emergency physical restraint placement may be taken by telephone or fax machine. The facility Fall Prevention policy presented with revised date 12/20/22 documented that based on the result of the falls assessment, the Inter disciplinary team will determine the best approach to implement for fall prevention, adjust the care plan, inform the family and resident and implement comprehensive fall prevention management approach. The facility titled Restraints Policy presented with revised date 9/17 documented under policy statement that in accordance with federal and state laws has a stringent policy regarding the use of physical and chemical restraints on resident. Our philosophy (Facility) of providing residents with the highest possible quality of care and life is reflective of our belief that is essential for our residents to maintain their dignity and independence by being permitted to take the normal risks of everyday life. For these reasons and in accordance with federal and state laws, restraint use in our facility will only be considered to treat a medical symptom/condition that endangers the physical safety of the resident. Listed procedures includes but not limited to with a physician order, with consent of the resident (or legal representative); when the benefits of the restraint outweigh the identified risks. If the restraint use is deemed necessary, the goal will be to use the least restrictive type of restraint for the shortest period possible. On 12/04/24 and 12 /05/24, the surveyor made observations, conducted interviews, and received documentation to confirm the following removal plan was initiated. 1. All staff were trained on what constitute proper training, unnecessary use of restraint, with ongoing training scheduled Quarterly by V29 and completed on 11/28/24. 2. All residents have been assessed to ensure that none are restrained improperly or unnecessarily by V19. 3. Assessment will be ongoing and conducted at admission, quarterly and annually 4. Outside consultant and V2 and V29 conducted in-service training on behavior management. On 11/27/24 and 12/05/24. 5. Documentation showed all the facility residents were in-service on abuse and restraints by V29. 6. R2, R14, R15, R16, R17, R18, R19 and R20 were care planned/interventions with potential for abuse and proper restraints related to their diagnoses. 7. A system put in place for audit to be done weekly to ensure compliance with unnecessary use of restraint to be monitored by V1, V2 and V29.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to keep R6 free from abuse. This failure resulted in R6 being sprayed in the face with a chemical agent by a staff member (V26). R6 experienced eye irritation and pain which required irrigation at the emergency department. The facility further failed to keep V26 away from R6 after the incident by allowing V26 to continue to work with R6 and allowed V26 to remain on the same unit. This situation was identified as an immediate jeopardy. The Administrator, Assistant Administrator-in-training, and the Director of Nursing were presented with the immediate jeopardy template on 1/5/2024 at 9:55 AM. The immediate jeopardy began on 11/15/2023 and removed on 1/12/2024. The facility presented an acceptable removal plan on 1/12/2024. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan. Findings include: R6's face sheet documents in part medical diagnoses of psychosis, restlessness, and agitation. R6's comprehensive care plan does not contain a focus for R6's risk for abuse. Facility's final reportable to the Illinois Department of Public Health reads: an incident occurred between R6 and V26 (former Restorative Aide) on 11/15/2023. It documents in part: Based on the known fact's resident appeared aggressive towards staff. Staff was fearful of resident and sprayed pepper spray at the resident and not on the resident. Surveyor reviewed the written witness statements and interviewed staff regarding the incident. During interview regarding 11/15/2023 incident on 1/2/2024 at 12:19 PM, V18 (Nurse) stated, There was something in the air when I got to the floor. I started coughing because it was something in the air. It was clear. Not cloudy or hazy or smoky but it made my eyes burn and caused me to cough that I had to turn right around. I couldn't respond properly to the code. V18's written witness statement dated 11/15/2023 documents in part that V18 could not properly respond to the code because V18 started coughing bad and eyes were burning. On 1/2/2024 at 1:46 PM, V20 (Certified Nurse Aide) stated around 7:20 AM on 11/15/23, R6 was at the desk asking V39 (Nurse) about coffee and breakfast. V39 told R6 that breakfast will be up shortly and directed R6 back to the bedroom. The elevator opened and V26 (former Restorative Aide) was there. V26 told R6 to go to the bedroom. R6 stated [R6] did not want to go back to the bedroom and started yelling. V20 stated, [R6] started coming towards [V26] a little aggressive so [V26] sprayed [R6] with something towards [R6's] face. R6 grabbed R6's head with R6's hands and put R6's head down. V20 stated V26 later took R6 to the bedroom. On 1/3/2024 at 2:13 PM, V35 (Nurse) stated, I got off the elevator that day and it was something in the air that caused my eyes and nose running. I had to go someplace to get some air. I was coughing and had a headache for two days. I never experienced it before. I didn't know what it was. I had to drink cold water to get me through that day. I had to flush my eyes out and I wear glasses. Never felt that way while at work. V35 written witness statement dated 11/15/2023 documents in part: When I came off the floor, something was in the air. My eyes were running. I started coughing and throwing up. V13's (Nurse) written witness statement dated 11/15/2023 documents in part: Elevator opened smell of pepper spray. I couldn't get off the elevator because the smell was so strong. On 1/3/2024 at 2:27 PM, V24 (Psychiatric Rehabilitative Services Director) stated, If a resident is agitated and aggressive towards someone, you try to separate them. Try to get them to calm them down by talking to them calmly. Ask what's going on and see what brought them to that level of agitation. We have to see what we can do to help them. When asked about R6's incident, V24 stated they should have calmed [R6] down and talked to [R6] calmly and not be aggressive with it. You don't spray. No spraying. If it was that bad, you always call for help. Call for more assistance. If [R6] was escalating bad and showing more agitation, I'd call for help and step back and see what they can do. You're not supposed to have something on you in here to spray. I will walk away and get more assistance and let them know how [R6] is reacting. Find my exit and let them know this is what's going on so we can get more people to help. On 1/4/2024 at 8:46 AM, V34 (Certified Nurse Aide) stated, Me and [V18], the nurse, came out the stairwell and before I even reached the nurses' station, I had to turn around. I probably only got half-way through the hallway because the smell was so strong. It smelled like pepper spray. I had to turn around. It was affecting my eyes and getting into my nose. I just remember [R6] standing there by the nurses' station rubbing [R6's] eyes. V34's written witness statement dated 11/15/2023 documents in part that when V34 arrived on scene, it smelled like bear spray. V34 had to turn around because V34's eyes were burning. During interviews on 1/4/2024 at 9:22 AM and 11:35 AM, V26 stated R6 came towards V26 aggressively but [V26] did not spray anything at R6. V26 stated someone was spraying an air freshener in the hall. V26 stated afterwards that V26 brought R6 coffee and breakfast. V26 stated [V26] did not leave the facility until around 9:30 AM on 11/15/23. V26 acknowledged the facility provided an in-service about how to handle residents with behaviors at the beginning of the year but felt it wasn't specific to psychiatric behaviors or offered frequently enough throughout the year. On 1/4/2024 at 11:58 AM, V37 (Director of Nursing at the time of the incident) stated staff are not to carry pepper spray or anything that is caustic or that's an eye irritant while working with residents. V37 stated if a resident is displaying aggressive behaviors, the first line is to separate the individuals and try to talk and see what's going on or find root cause. On 1/5/2024 at 12:08 PM, V42 (R6's Physician) stated, Staff should not be using pepper spray in the facility. They shouldn't be carrying it. The purpose of pepper spray is to keep a person away from you. If it is sprayed and it goes into your eyes, it will have irritating effects because it is a chemical. You have to wash out your eyes. On 1/9/2024 at 9:24 AM, V1 (Administrator/Vice President of Quality Assurance) stated a substance got into R6's eyes and the resident was sent to the emergency room for evaluation. V1 stated when facility reviewed the surveillance video of the incident, it was not an air freshener. V1 stated it was clear what the employee had on hand in the video. On 1/9/2024 at 11:57 AM, V47 (Manager on Duty at time of incident) stated when [V47] arrived at the unit, R6 was frustrated, loud and upset. V47 stated, I saw orange on him like orange pepper spray. V47 stated R6's face and eyes were red. On 1/9/2024 at 10:02 AM, surveyor reviewed facility's surveillance footage of the incident with V3 (Director of Nursing), V25 (Assistant Administrator-in training), and V45 (Human Resources). No audio was with the footage. First review was of the fourth floor nurses' station camera angle which showed, on 11/15/2023 at 7:26:52 AM, V20 (Certified Nurse Aide) and V39 (Day Nurse) were at the nurses' station. Elevators are in front of the nurses' station. R6 came out of the bedroom and pressed the elevator button at 7:27:02 AM. R6 remained standing in front of the elevator door with R6's back turned to V20 and V39 waiting. No observation of physical aggression from R6 observed. At 7:30:50 AM, V7 (Wound Tech) emerged from the big elevator and went to grab the wound cart. There is a hand seen out of the elevator stopping R6 from getting on. At 7:31:04 AM, V7 brought the wound cart into the big elevator and V26 (former Restorative Aide) stepped left out of the elevator. At 7:31:10 AM, V26 is west of the elevator (if facing the elevator, V26 is on the right side) motioning in front of R6 and pointing towards east hallway - R6's room. R6 is facing V26. During video footage review surveyor does not observe R6 to be puffing chest, running, or swinging arms. At 7:31:11 AM, V26 holds a small, black, cylindrical item with a silver split key ring with right hand. At 7:31:15 AM, V26 raises up the black cylindrical item with right hand as the left hand starts messing with it. V26 steps out of frame. At 7:31:29 AM, R6 remains facing west where V26 exited the frame. V5 (Anonymous Staff) is facing R6 standing to R6's right front. V39 came out of the nurses' station and grabbed gloves from the top of one of the medications carts. V20 is standing behind V39. V20 and V39 are facing R6. R6 takes a step, and a dark orange/almost brown substance shoots linear into frame and hits directly at R6's face. R6 raises left hand up over face. R6 stumbles back towards the nurses' station and hits the medication carts with right side at 7:31:34 AM. Staff start to disperse away from the scene. V20 (Certified Nurse Aide) has a hand over nose and mouth. V46 (Maintenance) uses blue shirt to cover nose and mouth. V39 (Nurse) is covering mouth. R6 remains by the medication carts holding head. At 7:32:20 AM, V5 (Anonymous Staff) is waving a white item to swat the air. At 7:32:40 AM, V26 (former Restorative Aide) passes R6 and heads to the dining room which is behind the nurses' station. At 7:33:40 AM, R6 remains near the medication carts. No staff has approached R6. R6 is bent over with head down. R6 grabs [R6's] face with the left hand. At 7:34:00 AM, multiple staff come out of the big elevator including V7 (Wound Tech), V21 (Certified Nurse Aide), V27 (Nurse), and V35 (Nurse). V27 can be seen bending at the hip, leaning forward, and coughing. At 7:34:18 AM, V26 is walking around R6 who remains near medication carts. V26 gets on the elevator at 7:34:22 AM. R6 remains in place while switching from standing to bending at the hip and leaning forward. At 7:36:23 AM, as R6 is hunched over, two large, liquid/fluid drops come from R6's face which appears to be saliva/spit. At 7:37:15 AM, V26 emerges from the elevator and returns to the unit. At 7:37:36 AM, R6 leaves the nurses' station unassisted to return to the bedroom. During video footage review surveyor does not observe any staff come near R6 to assess or assist R6 in rinsing eyes or face out. At 7:38:15 AM, V47 (Manager on Duty) is seen standing by R6's room talking to someone (person can't be seen from camera angle). V26 remains on the unit and is seen at the nurses' station at 7:38:50 AM. At 7:41:09 AM, V26 has a white spray bottle and sprays repeatedly in the air. V26 does this multiple times throughout the unit including a few times in front of R6's room. At 7:46:38 AM, V26 went into R6's room. At 7:47:02 AM, V26 leaves R6's room, then went back in at 7:47:06 AM, and back out at 7:47:15 AM. At 7:47:35 AM, staff bring out coffee and breakfast carts from the big elevator. V26 grabbed a mug and pours a liquid into it. At 7:47:54 AM, V26 went into R6's room with white spray bottle in left hand and mug in right hand. At 7:48:09 AM, V26 leaves R6's room with the white spray bottle in right hand. V26 continues to walk around and spray the hall with the white spray bottle. At 7:51:24 AM, V26 went inside R6's room and leaves room at 7:51:38 AM. At 7:52:04 AM, V26 gets into the elevator. At 8:00:50 AM, V26 (former Restorative Aide) emerges from the elevator and returns to the unit. Paramedics arrive on scene at 8:09:56 AM. R6 went onto their stretcher at 8:10:59 AM and R6 is in the elevator at 8:12:46 AM. V26 remained on the unit with other residents. On 1/5/2024 at 11:22 AM, surveyor reviewed the Fourth Floor [NAME] Hall camera angle surveillance footage with V3 (Director of Nursing), V25 (Assistant Administrator-in-training), and V45 (Human Resources). V26 is at the top of the frame. Housekeeping cart is behind V26. View of the left side of hall near nurses' station is blocked by an open door. At 7:31:29 AM, V26 is standing near the elevators. V26 then starts moving left with right hand up. V45 stated, Yeah, I see [V26] go forward and bring that right hand up. On 1/5/2024 at 11:30 AM, surveyor reviewed the Fourth Floor East Hall camera angle surveillance footage with V3, V25, and V45. At 7:31:29 AM, V26 brings up the right arm as V26 moves left. V45 stated, [V26] brought [V26's] right hand up after [R6] stepped forward. V26's Employee Report documents in part: Investigation Review that something was sprayed, and several staff were coughing. Witness statement indicate that employee did spray pepper spray at resident. R6's 11/15/2023 ambulance records (page 2 of 6) document in part: [Patient] is complaining of eye pain from being maced. [Patient] appears to have been maced. [Patient] is coughing and [patient's] eyes are irritated. Scene smells like [NAME] was discharged . R6's 11/15/2023 hospital records document in part: Patient was pepper sprayed. When I reevaluated the patient, patient reports persistent pain in [R6's] left eye after irrigation (page 3 of 16). [Patient] was reportedly maced by [Nursing Home] staff. [Patient] arrives with red, irritated face and eyes. [Positive] tearing. [Positive] pain (Page 6 of 16). V26 signed Receipt and Acknowledgement Employee Handbook - Local No. 4 (11/99) on 11/16/2011. V26 signed Certificate of Receipt of Employee Handbook on 3/8/2013. V26 signed additional Code of Conduct Attestation Statement on 4/5/2013. Facility's Employee Handbook dated 6/11/2021 documents in part: The Facility will not tolerate any physical, verbal or mental abuse, bullying, or intimidation 'Workplace Violence' whether of residents, patients, employees, visitors, vendors, and/or volunteers. We do not tolerate fighting (physical or verbal) or disorderly conduct on the job. In addition, we prohibit the possession of firearms, knives, or any other weapon on company property or while conducting business on behalf of the Company (page 14). V26's signed Compliance/False Claims Act/Ethics Program and Code of Conduct Employee Understanding Agreement dated 11/15/2013 documents in part: Don't mistreat a resident in any way. V26 signed facility's educational in-service for Managing Difficult Behaviors on 02/07/2023. Slide 23 titled 10 Tips for Communication documents in part: Set a positive mood for interaction. Watch your body language and verbal tone. When the going gets tough, distract and redirect. Slide 24 titled Specific Strategies-Agitation document in part: Distract the persons with an activity or snack. Confronting a confused person increases anxiety. Allow the person to do as much for themselves as possible. Support independence. Facility's Abuse Prevention Program last revised 03/08/2016 documents in part: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. Abuse is any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. The facility will take steps to prevent potential abuse while the investigation is underway. Employees of this facility who have been accused of abuse, neglect, mistreatment or misappropriation of resident property will be removed from the resident contact immediately until the results of the investigation have been reviewed by the administrator. The Immediate Jeopardy that began on 11/15/2023 was removed on 1/12/2024 when the facility took the following actions to remove the immediacy: The following Plan of Abatement shall also serve as the Facility's written credible allegation of compliance that will be or has been achieved by the stated date of completion. Submission of this Plan of Abatement does not constitute in any way an admission of any facts and/or conclusions of law reflected in the alleged deficiencies, nor does it constitute a waiver of the Facility's right to contest the deficiencies and/or any remedies imposed because of this or future surveys. On 11/15/2023, The restorative aide V26 was accused of spraying pepper spray towards resident R6. Employee was suspended pending investigation. The incident occurred at 7:30am. V38 was informed immediately and was in route to the facility with an arrival at 8:15am. The employee punched out at 9:35am (see timecard). Preliminary incident investigation was sent to IDPH. Investigation was initiated, based on witness statements and review of video camera, employee was terminated. The final abuse investigation report was sent to IDPH on 11/21/2023. I. 1. All residents will always be free from abuse. 2. R6 is no longer in the facility after being sent to the hospital the day of the incident he left AMA. 3. V26 was relieved of her duties immediately and was subsequently terminated in accordance with the facility policy. She then filed a grievance, the facility responded and maintained that the termination was justified. 4. Abuse In-service was conducted on 11/28/23 after the incident occurred. The Inservice included: individual including a caretaker of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Review physical abuse, sexual abuse, verbal abuse, mental abuse, and misappropriation of resident property, involuntary seclusion, and neglect. Review that employees are required to report any incident, allegation or suspicion of potential abuse, neglect, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the Administrator immediately or to an immediate supervisor who must then immediately report it to an administrator. Reviewed that employee accused of allegations of abuse will be suspended pending investigation. II. 1. A review of the requirement that all residents be always free from physical abuse. 2. A review of the alleged deficiency. 3. All staff will be re- in serviced on the facility abuse policy and procedures. The Inservice will include: individual including a caretaker of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Review physical abuse, sexual abuse, verbal abuse, mental abuse, and misappropriation of resident property, involuntary seclusion, and neglect. Review that employees are required to report any incident, allegation or suspicion of potential abuse, neglect, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the Administrator immediately or to an immediate supervisor who must then immediately report it to an administrator. Reviewed that employee accused of allegations of abuse will be suspended pending investigation. The facility employee list will be used to ensure all staff are in service in each department to be completed by 1/10/24 conducted by V1, RN, LNHA and V24, ASST ADMINISTRATOR. Any staff not available at the time of these in services will be retrained upon arriving at work. All new nursing staff will be trained in these policies at the time of hire. All agency staff who have not worked at the facility before will be required to arrive one hour before their shift to be trained on the facility abuse policy. V3, DON, RN will conduct Inservice. 4. Any staff on vacation will be trained upon returning to work. V3, DON, RN will conduct Inservice. All staff will be Inservice on facility policy on calling code grey when resident is observed with increased behavior and/or agitation. Inservice will be conducted by V25, ASST ADMINISTRATOR completed by 1/16/24. 5. All staff will be in serviced on their responsibilities for the care and the safety of all residents in a crisis. Inservice will be conducted by V25, ASST ADMINISTRATOR will be complete by 1/16/24. 6. All staff will be in serviced on the facility code of conduct policy which include the facility prohibit the possession of firearms, knives, or any other weapon on company property or while conducting business on behalf of the company, this also includes pepper spray or any other caustic agent that could harm a resident, this Inservice will be conducted by V1, RN, LNHA and V25, ASST ADMINISTRATOR to be completed by 1/16/24. 7. Social service consultants V66 LCSW will conduct an Inservice on De-escalation and conflict resolution to be completed by 1/18 /24. 8. Social Service consultant V65, LCSW will be conduction ongoing CPI training by 01/24/24. All allegations of abuse will be reviewed immediately as the event occur to assure the timeliness of reporting and the removal of staff immediately. Each event will be discussed daily during morning meeting and reported monthly to the QA. The Asst. Administrator V25 will conduct a QA audit via random direct questions during daily rounds to determine staff retention of abuse policy. A QA audit will be conducted monthly x 3 months quarterly thereafter and upon hire to ensure continued compliance. The results of the QA audit will be submitted to the QAPI committee for review and follow up. The QAPI committee will ensure that the systems are in place and are effective. This will be done monthly x 3 months the quarterly thereafter unless additional meetings are deemed appropriate to prevent reoccurrence. The facility presented a plan to remove the immediacy on 1/5/2024. The survey team reviewed the abetment plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised plan on 1/8/2024, 1/11/2024, and 1/12/2024. The survey team accepted the plan on 1/12/2024. On 1/16/2024 and 1/18/2024 the surveyor, via observation, interview and record, confirmed the implementation of facility's removal plan. On 1/16/2024 at 9:15 AM, V46 (Maintenance) stated V46 did not receive recent abuse or code of conduct in-services. On 1/16/2024 at 9:37 AM, V10 (Certified Nurse Aide) stated attending the in-services for abuse and de-escalation techniques; however, did not receive code of conduct in-service. On 1/16/2024 at 9:42 AM, V5 (Anonymous Staff) stated attending abuse in-service but did not receive one for de-escalation, code greys, or code of conduct. On 1/16/2024 at 9:47 AM, V6 (Nurse) stated attending the in-services on abuse and de-escalation techniques but did not receive the ones for code grey or the code of conduct. On 1/16/2024 at 9:49 AM, V20 (Certified Nurse Aide) stated attending the abuse in-service but did not receive one on code of conduct. On 1/16/2024 at 9:55 AM, V13 (Nurse) stated attending the abuse in-service but did not receive one on code of conduct. On 1/16/2024 at 9:59 AM, V17 (Nurse) stated attending the abuse in-service but did not receive one on code of conduct. On 1/16/2024 at 10:05 AM, V48 (Activities) stated attending the abuse in-service but did not receive the ones for code grey or the code of conduct. On 1/16/2024 at 10:08 AM, V50 (Dietary Manager) stated attending all the in-services. On 1/16/2024 at 10:16 AM, V49 (Receptionist) stated attending the abuse in-service but did not receive the ones for code grey or the code of conduct. Discussed the above interviews with V1 (Administrator) and V25 (Assistant Administrator in-training) on 1/16/2024 at 10:45 AM. Facility did not complete the target goals on 1/16/2024. Surveyor returned 1/18/2024 to confirm the implementation of facility's removal plan. On 1/18/2024 at 9:43 AM, V1 and V25 stated they re-in-serviced all the required topics with the staff. Facility also has ongoing de-escalation in-services and will have CPI (Crisis Prevention Intervention) training in the coming weeks. During interviews on 1/18/2024 from 9:49 AM to 10:48 AM, V9 (Restorative Aide), V44 (Certified Nurse Aide), V53 (Dietary), V54 (Dietary), V48 (Activities), V46 (Maintenance), V56 (Housekeeping), V57 (Social Services), V59 (Certified Nurse Aide), V60 (Nurse), V61 (Certified Nurse Aide), V62 (Housekeeping), and V49 (Receptionist) stated they received in-services on abuse, de-escalation techniques, code grey, and code of conduct. On 1/16/2024 and 1/18/2024, did not observe any staff carrying weapons or caustic agents. Reviewed facility's in-service summary sheets, in-service materials, and sign-in sheets.