**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that 4 of 4 residents (R1, R2, R5, and R6) were free from physical abuse. This failure affected R1, R2, R5, and R6 who had verbal altercation that resulted in R1 injury and bleeding to mouth and R6 injuries resulting in stitches to eyebrow and injury to forehead. This has the potential to affect all 103 residents residing in the facility. Findings include: On 02/27/25 at 12:44pm, R1 observed in the room sitting on the bed. The surveyor asked R1 about the incident of 01/25/25. R1 stated that I (R1) can't remember what happened, but (R2) and I (R1) had a misunderstanding. I (R1) did not steal anything from (R2). (R2) hit me and punched me in my face and my mouth. I (R1) was bleeding from my mouth. On 2/27/25 at 12:55pm, R2 was observed in the room. when the surveyor asked about the incident of 01/25/25, R2 stated R1 was drunk and was taking my pop drinking them. R2 stated that I (R2) came to the nurse's station and told them (staff) about it, and they did nothing. R2 stated that when I (R2) went back to the room (R1) was still drinking my Pop. R2 stated that I (R2) pushed (R1) down on the bed and held (R1) because (R1) was stealing from me. R1 medical record showed V17's documentation in the progress note date 01/25/25 timed 10pm that indicated that R1 noted fighting with roommate (referring to R2). Roommate (R2) hit (R1) in the face and the mouth with moderate bleeding noted from R1's mouth. On 03/04/25 at 12:25pm, R5 stated that R6 and I shared the same bathroom. R6 is always urinating on the floor and everywhere. R5 stated that on the day of the incident I tried to let R6 know that (R6) must clean it up because R6 always leaves the place dirty, and I end up clean it. When asked whether the housekeeper/staff know about these concerns. R5 stated Yes, because they clean it all the time and R6 will dirty it again and again. And nobody (referring to staff) does nothing about it. I (R5) have reported it but (R6) kept (urinating) on the floor, I feel like (R6) is saying whatever I (R6) do you are going to clean it up. R5 stated that I am a grown man, and no one is going to be treating me like hat. R6 punch me in my face so I hit (R6) hard. A fight broke out and R6 started bleeding in the face. At 1:20pm, R6 observed with three wound closure strips on the right eyebrow and approximately 2 inches of healing wound to the fore head. When the surveyor asked about what happened to R6's face. R6 stated that I fought with (R5). (R5) is not my boss, (R5) thinks he can fight, and I (R6) showed him. (R5) keeps putting everything that is wrong on me, and (R5) hit me, and I (R6) hit him back. R1 medical record Face Sheet showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to chronic obstructive pulmonary disease unspecified, schizoaffective disorder, bipolar type, alcohol abuse uncomplicated Type 2 diabetesmellitus with hyperglycemia. R2 medical record Face Sheet showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to Type 2 diabetes mellitus with hyperglycemia, non-pressure chronic ulcer of other part of left foot with unspecified severity -left foot. R5 medical record Face Sheet showed that R1 was admitted originally to the facility on [DATE] with latest admission date of 02/21/25. Diagnosis list includes but not limited to Major depressive disorder, drug induced subacute dyskinesia, schizoaffective disorder, acquired absence of eye-right eye, and blindness one eye unspecified eye-right eye. R6 medical record Face Sheet showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to chronic obstructive pulmonary disease unspecified, schizoaffective disorder, bipolar type, alcohol abuse uncomplicated Type 2 diabetes mellitus with hyperglycemia. On 03/04/25 at 2:15pm, V2 stated that she expected the licensed nurses to separate the resident immediately when there is a suspicion of any abuse. In the case of R1 and R2 the nurse (V17) should have separated the residents before the altercation escalated into actual physical abuse. V2 stated hitting, holding down of resident by another resident is a form of physical abuse and should not happen. V2 stated that both R1 and R2 should have been separated and placed on 1:1 supervision. On 03/12/25 at 1:49pm, V1 (Administrator) stated that she (V1) expected the nurse to first separate the residents, assess them, and depending on the type of altercation put the resident on 1:1 supervision, call the medical doctor (physician) and both residents must be sent out. The nurse should call me the abuse coordinator. V1 stated that when (V18) informed the nurse (referring to V17 LPN), she did what she was supposed to do it is not her (V18) responsibility to separate the resident. R1 just had tooth extraction may be the alcohol caused R1 to bleed because R2 said I did not hit R2 from my interview. When asked whether pushing and holding down another resident a physical contact holding another resident down in a physical altercation, is that appropriate behavior. V1 stated no, it is not allowed that is like restraining a person. The surveyor then asks are residents allowed to restrain another resident. V1 stated No. The facility policy on Abuse with reviewed date 1/18/2024 documented that the facility affirms the right of our (facility) residents to be free from abuse. the policy under definitions documented in part that abuse is the willful infliction of injury and the term willful means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse listed includes but not limited to hitting, slapping, and controlling behavior through corporal punishment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement appropriate measures to ensure adequate supervision is afforded to two residents R1 and R2 reviewed for physical abuse. This failure affected R1 and R2 who had an altercation that resulted into physical abuse and R1 injury to mouth and has the potential to affect all 103 residents residing in the facility. Finding include: R1 medical record Face Sheet showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to chronic obstructive pulmonary disease unspecified, schizoaffective disorder, bipolar type, alcohol abuse uncomplicated Type2 diabetes mellitus with hyperglycemia. R1 was sent to the local hospital on 1/15/25 and the discharge record showed that R1 was treated for alcohol intoxication. R2 medical record Face Sheet showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to Type 2 diabetes mellitus with hyperglycemia, non-pressure chronic ulcer of other part of left foot with unspecified severity left foot. According to facility investigation witness statement presented dated 1/31/25, V18 stated that on 1/25/25 R2 came to the front desk and reported that R1 was stealing R2's food and this was reported to V17 (Nurse). V17 went to the resident's room and came out and said R1 and R2 were fine. V18 made V17 aware that R1 was drunk and V17 went back into the office (referring to medication room used as the nurse's office). V18 (Receptionist) stated R2 came back to the nurse's station and said someone needs to come and get R1. V18 stated that while sitting at the nurse's station she heard them fighting (referring to R1 and R2). V18 witness statement documentation showed that V17 was first notified at 7:30pm. According to the V17's witness statement V17 documented in part that at 7:00pm she was notified that the two residents R1 and R2 that something is going on with these 2 (referring to R1 and R2). V17 did not separate the resident R1 and R2 from each other. At 9:30am V18 documented that R1 had unsteady gait and suspected alcohol intoxication. V17 documented that R1 had bleeding from the mouth. R1 medical record showed V17's documentation in the progress note date 01/25/25 timed 10pm indicated that R1 noted fighting with roommate (referring to R2). Roommate (R2) hit (R1) in the face and the mouth with moderate bleeding noted from R1's mouth. On 03/04/25 at 2:15pm, V2 stated that she expected the licensed nurses to separate the resident immediately when there is a suspicion of any abuse. in case of R1 and R2 the nurse (V17) should have separated the residents before the altercation escalated into actual physical abuse. V2 stated hitting, holding down of resident by another resident is a form of physical abuse and should not happen. V2 stated that both R1 and R2 should have been separated and placed on 1:1 supervision. On 03/12/25 at 1:49pm, V1 (Administrator) stated that she (V1) expected the nurse to first separate the residents, assess them, and depending on the type of altercation put the resident on 1:1 supervision, call the medical doctor (physician) and both residents must be sent out. The nurse of cause should call me the abuse coordinator. V1 stated that when (V18) inform the nurse (referring to V17 LPN), she did what she was supposed to do it is not her (V18) responsibility to separate the resident. R1 just had tooth extraction may be the alcohol caused R1 to bleed because R2 said I did not hit R2 from my interview. When asked whether pushing and holding down another resident a physical contact holding another resident down in a physical altercation, is that appropriate behavior. V1 stated no, it is not allowed that is like restraining a person. The surveyor then asks are residents allowed to restrain another resident. V1 stated No. During this investigation both V17 and V18 cannot be reached by the surveyor. Both V1 (Administrator) and (V2 DON (Director of Nurse's) tried to reach the staff without success. The facility did not provide any supervision policy. The facility policy on Abuse with reviewed date 1/18/2024 documented that the facility affirms the right of our (facility) residents to be free from abuse. the policy under definitions documented in part that abuse is the willful infliction of injury and the term willful means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse listed includes but not limited to hitting, slapping, and controlling behavior through corporal punishment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their policy to protect the resident's right to be free from [A] verbal abuse by staff members for two (R83 and R242) residents, this failure resulted in R83 and R242 feeling scared when they come across the accused staff members, [B] mental abuse by staff to two residents (R83, R88) in sample of 18 reviewed for abuse. This failure resulted in R88 feeling humiliated and fearful of retaliation, and R83 feeling depressed, crying, and increase in anxiety. Findings Include: 1. On 11/07/2023 at 1:17 PM, R242 stated that staff members are very rude to residents. R242 stated that there were these receptionists who cursed at residents and did not treat them with respect. This made us feel like we couldn't say anything. It felt like we were in prison. R242's written witness statement (10/20/2023) documents in part: V18 is verbally abusive to him and other residents. V18 would yell at them and is mean. 2. On 11/07/23 at 09:19 AM, reviewed document titled Reportable Event which documents in part on 10/19/23 @ 5:33 PM reportable event occurred involving resident and employee and it was brought to the administrator's attention that some of the staff members have not been acting in a professional manner. Reviewed signed document by R88 on 10/20/23 which documents in part that smoking monitors are rude and talk to them like a kid. Document stated R88 could not give names of smoking monitors. On 11/07/23 at 10:25 AM, R88 stated that he is a smoker and that all of the smoking monitors are rude. R88 stated the smoking monitors talk to the residents in a disrespectful and mean manner. R88 stated I don't like the way they talk to me and I get spoken to like I'm a child and this makes me feel humiliated. R88 stated he is fearful to speak up for himself because he's worried the staff will take R88's cigarettes away. R88 stated he does not know the names of the smoking monitors and that it is not one specific staff member. On 11/07/23 at 10:04 AM, V1 (Administrator) stated many of the residents living at the facility have mental health issues and that staff should speak to the residents in a respectful and professional manner. V1 stated residents should not feel intimidated by staff or fearful of speaking up to the staff. V1 stated this facility is the resident's home and that the residents should feel safe here. R88's diagnosis included but not limited to Bipolar Disorder, Major Depressive Disorder with Recurrent Severe Psychotic Symptoms, and Generalized Anxiety Disorder. R88's MDS (Minimum Data Set) dated 10/09/23 BIMS (Brief Interview for Mental Status) score is 15/15 indicating intact cognition. R88's psychosocial well-being care plan goal dated 10/13/23 documents in part R88 will be free of abuse/neglect. 3. On 11/05/2023 at 10:30 AM, R83 stated that V18 (Former Receptionist) was very rude to her and that she would curse at other residents. V18 stated that she would yell at me all the time. V18 stated this would bring me anxiety and I would be scared to go out of my room. I just didn't want to cross paths with her. R83's written witness statement (10/20/2023) documents in part: V18 (Former Receptionist) is mean to her and other residents. She refused to get up and give her or other residents ice. V18 was rude to her and yelled at her. Reviewed R83's clinical record documents in part R83 was admitted to the facility on [DATE], with the medical diagnosis of hypertensive heart disease, depressive disorder, gastritis, anxiety disorders and insomnia. R83's face sheets, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status score of [15] indicates R83 is cognitively intact, alert/oriented x3, care plans, medication administration record, treatment administration record, community pass assessments and progress notes. There were no progress notes from 10/1/23 thru 10/18/23, no documentation during the time frame. On 11/5/23 at 10:38 AM, R83 stated, In order for me to leave the facility on my community pass, the nurse and the social worker must sign the pass, and the pass is given to the receptionist before I'm able to leave the facility. On 10/19/23, I went to my nurse, and she signed my pass, then I went to V14 [Social Worker] and he signed my pass. Then I took my signed pass to the receptionist to sign out and leave. V18 [Former Receptionist] told me that I could not leave the facility, because my pass privileges were restricted. I spoke with V1 [Administrator] she informed me that V13 [Social Service Director] placed my independent community pass on restriction for 30 days because I went out on pass on 10/13/23 and returned to the facility and staff smelled marijuana on me a week ago. On 10/13/23, I went out on pass, and when I came back into the facility and signed back in and went to my room. No one said anything to me that I smelled like marijuana. Later, that same day [10/19/23], V14 came to me with a The Behavior Intervention Program Counseling Form dated 10/19/23 read [ Resident [R83] was suspected to be under the influence of a substance while in the facility.] I signed that form, because V14 told me I had to sign it. I asked V14 why a week later that I was notified staff accused me of smelling like marijuana, V14 told me that V13 [Social Service Director] told him to place me on a 30-day pass restriction. On 10/13/23 no one, no nurse, no social worker said one word to me or asked me to give a urine sample for a toxicology drug screen. The first time anyone talked to me was on 10/19/23. Right before 10/19/23, V1 [Administrator] found a type of letter in the bathroom that named me as the writer, making accusations against the facility staff committing abuse. The letter V1 showed me was typed on a form. I told V1 to get out my room with that mess, how could I type and print off a letter on a form. I believe V1 got angry with me because she felt I typed the letter, but I did not. I feel V1 placed me on pass restriction because of the letter that someone placed under her bathroom door. I've been up every night, not able to sleep, crying because I feel like I'm in prison on false charges. I feel so depressed, and my anxiety has increased. R83 provided surveyor copy of The Behavior Intervention Program Counseling Form dated 10/19/23 read: [ Resident [R83] was suspected to be under the influence of a substance while in the facility [Attachment-A] On 11/5/23 at 12:15 PM, V14 [Social Worker] stated, I've been working here since January 2023. I was told by a few certified nurse assistants (CNA) that R83 smelled like marijuana when she came back from pass on 10/13/23. On 10/13/23, I asked V19 [Social Service Aide] to assist me with obtaining a urine toxicology screening from R83 because R83 and V19 were both females. I stood outside R83's room when V19 asked R83 for a urine sample and explained the reason. R83 refused to give urine. Then I presented R83 with the Behavior Intervention Program Counseling Form, and R83 and I signed the form. The form read: [Resident [R83] was suspected to be under the influence of a substance while in the facility.] and noted restriction will be from 10/13/23 thru 11/13/23. R83 and I signed the form. On the form it was dated for 10/19/23, but it was for the incident on 10/13/23. I presented the form on 10/19/23, because that was when V13 [Social Service Director] came up with R83's interventions. R83 should have been medically assessed, and it was all based on hearsay, I did not agree that R83 should be on pass restriction. On 11/5/23 at 1:36 PM, V13 [Social Service Director] stated, I was informed by a case manager that R83 came back from community pass smelling like marijuana. V18 [Former Receptionist] told V19 [Social Service Aide] then told me. This was R83's first offense, and she does not have a history of drug use. R83 was placed on a 30-day community pass restriction. The Behavior Intervention Program Counseling Form dated 10/19/23 reads in part- [ Resident [R83] was suspected to be under the influence of a substance while in the facility. Resident [R83] refused a urine toxicology screening and admitted to social service staff related to using marijuana. Intervention: Resident [R83] educated and counseled on the negative effects of using illegal substances and taking prescription medications. Staff reinforced the facility substance abuse policy and placed on a behavior intervention program.] [Surveyor asked V13, why the The Behavior Intervention Program Counseling Form dated 10/19/23 with R83 and V14's signatures have added information and surveyor showed V13 the copy of the original form. (Attachment B)] On 11/5/23 at 1:45 PM, V13 stated, I added to the original The Behavior Intervention Program Counseling Form dated 10/19/23, that V14 presented to R83. I wrote: Resident [R83] refused a urine toxicology screening and admitted to social service staff related to using marijuana. Intervention: Resident [R83] educated and counseled on the negative effects of using illegal substances and taking prescription medications. Staff reinforced the facility substance abuse policy and placed on a behavior intervention program. I did not know R83 got a copy of the form, wow. I updated the form after R83 signed the form, and no R83 was not aware. I did not know that I could not update R83's signed medical form without her knowing or agreeing to the change of the additional information. R83 is currently on pass restriction from 10/13/23 until 11/13/23, the only person that could override the policy is the administrator [V1]. The Behavior Intervention Program Counseling Form is a part of R83 medical record. R83 should have been presented with the Behavior Intervention Program Counseling Form on 10/13/23, the day of the occurrence. I do not remember why R83 was given the form on 10/19/23. On 11/6/23 at 9:51 AM, V1 [Administrator] stated, V2 [Director of Nursing] was sitting at the receptionist desk when R83 returned from community pass on 10/13/23. V14 was made aware and R83 was offered a urinary toxicology drug screen test, R83 declined. At that time R83 was made aware that her community pass was restricted for 30 days. V2 [Director of Nursing], V14 [Social Worker], V13 [Social Service Director], nor V19[Social Service Aide did not document that R38 smelled like marijuana. The appropriate protocol for a resident who is suspected of being under the influence of drugs or alcohol would be to notify their physician, ask the physician if there is any medication should be held, ask the resident to take a toxicology urine test, inform social services, monitor vital signs, frequent monitoring, and start wellbeing checks for 72-hours. V13 should have completed a new Behavior Intervention Program Counseling Form and asked R83 to sign the updated form. V13 was not to add information to the form that was signed by R83 and V14, without R83 and V14 consents, doing so is falsifying the document. Someone found a typed letter under the bathroom door, naming R83 and other residents referencing allegations against some staff and the state was going to be notified. Regarding the letter, R83 said, she did not have anything to do with the letter. On 11/6/23 at 2:00 PM, V1 stated, V13 was suspended for falsifying R83's document. The facility failed to document and handle things timely with R83, I will have social service re-evaluate R83 for a community pass now and end her restriction. On 11/7/23 at 11:10 AM, V2 [Director of Nursing] stated, I was sitting at the reception desk working on the nursing staff schedule, when R83 came back in the facility from community pass. R83 smelled like a strong odor of marijuana. I don't remember doing much of anything. It was an assumption that the marijuana came in with her, but I was not sure. I did not call the physician, take R83's vital signs or make any frequent rounds on R83. I did not notify R83's nurse. My focus was completing the nursing staff schedule. On 11/7/23 at 11:45 AM, R83 came to the conference room crying and stated, V14 just came to my room and tried to get me to sign another Behavior Intervention Program Counseling Form, that said I admitted to using marijuana on 10/13/23, and I refused a urine toxicology test. I told V14 I would not sign that form, because it is not true. I was not smoking marijuana, and I was not offered to take a urinary toxicology drug test. V14 is stressing me out, they are picking on me, causing me to feel bad and my anxiety is through the roof. They keep picking on me because I called the state and filed a complaint. V13, V14, and V1 think I'm stupid. I knew not to sign the paper, that I know it is not true. I cannot take any more harassment from any of them V13, V14, and V1. I was feeling better, I have one more week of restriction. Now, they are messing with my mental, I feel so bad, full of anxiety. I am scared that V1, V13 and V14 will retaliate against me for filing a complaint with IDPH and telling you the truth. I'm not sure why they will not leave me alone. V14 told me that V13 told him to have me sign the new form. On 11/7/23 at 12:00 PM, V1 stated, V28 [Nurse Consultant] asked V14 to have R83 sign the new updated form. Because the old form was not written correctly, they want to make sure R83 had a copy with her signature. If R83 would have signed the new form, with the exact wording from V13, then V13 wouldn't have falsified R83's document, but that was not our intent. On 11/7/23 at 12:10 PM, V14 stated, I re-wrote the Behavior Intervention Program Counseling Form, and asked R83 to sign the new form with the updated interventions. No one told me to ask R83 to sign information over all on a new form, using V13's exact words, so R83 would understand her interventions. I was trying to clear everything up. R83 refused to sign the new form, because R83 said the information on the new form was false. [Copy of The Behavior Intervention Program Counseling Form presented to R83 on 11/7/23 noted as [Attachment C] On 11/7/23 at 12:40 PM, V28 [Nurse Consultant] stated, I asked V14 to go and talk with R83 and give her the corrected document with the interventions. To assist with correction process. My intent was to cause R83 any emotional distress. Facility's Final Incident Report Form (10/25/2023) documents in part: Investigation has been completed. In the conclusion of the investigation staff member V18 was accused by several residents of verbal abuse. Based on the negative verbal interviews, V18 will not be continuing her employment at this facility. Policy: Documents in part: Abuse Prevention Policy dated 2/2017 -This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment - Abuse means any physical or mental injury or sexual assault infliction upon a resident -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish to a resident. Policy: Documented in part Resident Rights: -Resident has the right to be informed of their rights and all the rules and regulations governing resident conduct and responsibilities -A facility must not prohibit or in any way discourage a resident from communicating with federal, state surveyors -Resident has the right to be informed, participate in their treatment -Resident has the right to be informed in advance of changes in their plan of care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility social service staff failed to assist one resident[R83] in maintaining their mental and psychosocial health in a sample of 18. This failure resulted in R83 crying, feeling depressed, increase of anxiety and fear of retaliation Findings include: Reviewed R83's clinical record documents in part R83 was admitted to the facility on [DATE], with the medical diagnosis of hypertensive heart disease, depressive disorder, gastritis, anxiety disorders and insomnia. R83's face sheets, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status score of [15] indicates R83 is cognitively intact, alert/oriented x3, care plans, medication administration record, treatment administration record, community pass assessments and progress notes. There were no progress notes from 10/1/23 thru 10/18/23, no documentation during the time frame. On 11/5/23 at 10:38 AM, R83 stated, In order for me to leave the facility on my community pass, the nurse and the social worker must sign the pass, and the pass is given to the receptionist before I'm able to leave the facility. On 10/19/23, I went to my nurse, and she signed my pass, then I went to V14 [Social Worker] and he signed my pass. Then I took my signed pass to the receptionist to sign out and leave. V18 [Former Receptionist] told me that I could not leave the facility, because my pass privileges were restricted. I spoke with V1 [Administrator] she informed me that V13 [Social Service Director] placed my independent community pass on restriction for 30 days because I went out on pass on 10/13/23 and returned to the facility and staff smelled marijuana on me a week ago. On 10/13/23, I went out on pass, and when I came back into the facility and signed back in and went to my room. No one said anything to me that I smelled like marijuana. Later, that same day [10/19/23], V14 came to me with a The Behavior Intervention Program Counseling Form dated 10/19/23 read [ Resident [R83] was suspected to be under the influence of a substance while in the facility.] I signed that form, because V14 told me I had to sign it. I asked V14 why a week later that I was notified staff accused me of smelling like marijuana, V14 told me that V13 [Social Service Director] told him to place me on a 30-day pass restriction. On 10/13/23 no one, no nurse, no social worker said one word to me or asked me to give a urine sample for a toxicology drug screen. The first time anyone talked to me was on 10/19/23. Right before 10/19/23, V1 [Administrator] found a type of letter in the bathroom that named me as the writer, making accusations against the facility staff committing abuse. The letter V1 showed me was typed on a form. I told V1 to get out my room with that mess, how could I type and print off a letter on a form. I believe V1 got angry with me because she felt I typed the letter, but I did not. I feel V1 placed me on pass restriction because of the letter that someone placed under her bathroom door. I've been up every night, not able to sleep, crying because I feel like I'm in prison on false charges. I feel so depressed, and my anxiety has increased. R83 provided surveyor copy of The Behavior Intervention Program Counseling Form dated 10/19/23 read: [ Resident [R83] was suspected to be under the influence of a substance while in the facility [Attachment-A] On 11/5/23 at 12:15 PM, V14 [Social Worker] stated, I've been working here since January 2023. I was told by a few certified nurse assistances that R83 smelled like marijuana when she came back from pass on 10/13/23. On 10/13/23, I asked V19 [Social Service Aide] to assist me with obtaining a urine toxicology screening from R83 because R83 and V19 were both females. I stood outside R83's room when V19 asked R83 for a urine sample and explained the reason. R83 refused to give urine. Then I presented R83 with the Behavior Intervention Program Counseling Form, and R83 and I signed the form. The form read: [Resident [R83] was suspected to be under the influence of a substance while in the facility.] and noted restriction will be from 10/13/23 thru 11/13/23. R83 and I signed the form. On the form it was dated for 10/19/23, but it was for the incident on 10/13/23. I presented the form on 10/19/23, because that was when V13 [Social Service Director] came up with R83's interventions. R83 should have been medically assessed, and it was all based on hearsay, I did not agree that R83 should be on pass restriction. On 11/5/23 at 1:36 PM, V13 [Social Service Director] stated, I was informed by a case manager that R83 came back from community pass smelling like marijuana. V18 [Former Receptionist] told V19 [Social Service Aide] then told me. This was R83's first offense, and she does not have a history of drug use. R83 was place on a 30-day community pass restriction. The Behavior Intervention Program Counseling Form dated 10/19/23 reads in part- [ Resident [R83] was suspected to be under the influence of a substance while in the facility. Resident [R83] refused a urine toxicology screening and admitted to social service staff related to using marijuana. Intervention: Resident [R83] educated and counseled on the negative effects of using illegal substances and taking prescription medications. Staff reinforced the facility substance abuse policy and placed on a behavior intervention program.] [Surveyor asked V13, why the The Behavior Intervention Program Counseling Form dated 10/19/23 with R83 and V14's signatures have added information and surveyor showed V13 the copy of the original form. (Attachment B)] On 11/5/23 at 1:45 PM, V13 stated, I added to the original The Behavior Intervention Program Counseling Form dated 10/19/23, that V14 presented to R83. I wrote: Resident [R83] refused a urine toxicology screening and admitted to social service staff related to using marijuana. Intervention: Resident [R83] educated and counseled on the negative effects of using illegal substances and taking prescription medications. Staff reinforced the facility substance abuse policy and placed on a behavior intervention program. I did not know R83 got a copy of the form, wow. I updated the form after R83 signed the form, and no R83 was not aware. I did not know that I could not update R83's signed medical form without her knowing or agreeing to the change of the additional information. R83 is currently on pass restriction from 10/13/23 until 11/13/23, the only person that could override the policy is the administrator [V1]. The Behavior Intervention Program Counseling Form is a part of R83 medical record. R83 should have been presented with the Behavior Intervention Program Counseling Form on 10/13/23, the day of the occurrence. I do not remember why R83 was given the form on 10/19/23. On 11/6/23 at 9:51 AM, V1 [Administrator] stated, V2 [Director of Nursing] was sitting at the receptionist desk when R83 returned from community pass on 10/13/23. V14 was made aware and R83 was offered a urinary toxicology drug screen test, R83 declined. At that time R83 was made aware that her community pass was restricted for 30 days. V2 [Director of Nursing], V14 [Social Worker], V13 [Social Service Director], nor V19 [Social Service Aide] did not document that R83 smelled like marijuana. The appropriate protocol for a resident who is suspected of being under the influence of drugs or alcohol would be to notify their physician, ask the physician if there is any medication should be held, ask the resident to take a toxicology urine test, inform social services, monitor vital signs, frequent monitoring, and start wellbeing checks for 72-hours. V13 should have completed a new Behavior Intervention Program Counseling Form and asked R83 to sign the updated form. V13 was not to add information to the form that was signed by R83 and V14, without R38 and V14 consent, doing so is falsifying the document. Someone found a typed letter under the bathroom door, naming R83 and other residents referencing allegations against some staff and the state was going to be notified. Regarding the letter, R83 said, she did not have anything to do with the letter. 11/6/23 at 2:00 PM, V1 stated, V13 was suspended for falsifying R83's document. The facility failed to document and handle things timely with R83, I will have social service re-evaluate R83 for a community pass now and end her restriction. On 11/7/23 at 11:10 AM, V2 [Director of Nursing] stated, I was sitting at the reception desk working on the nursing staff schedule, when R83 came back in the facility from community pass. R83 smelled like a strong odor of marijuana. I don't remember doing much of anything. It was an assumption that the marijuana came in with her, but I was not sure. I did not call the physician, take R83's vital signs or make any frequent rounds on R83. I did not notify R83's nurse. My focus was completing the nursing staff schedule. On 11/7/23 at 11:45 AM, R83 came to the conference room crying and stated, V14 just came to my room and tried to get me to sign another Behavior Intervention Program Counseling Form, that said I admitted to using marijuana on 10/13/23, and I refused a urine toxicology test. I told V14 I would not sign that form, because it is not true. I was not smoking marijuana, and I was not offered to take a urinary toxicology drug test. V14 is stressing me out, they are picking on me, causing me to feel bad and my anxiety is through the roof. They keep picking on me because I called the state and filed a complaint. V13, V14, and V1 think I'm stupid. I knew not to sign the paper, that I know it is not true. I cannot take any more harassment from any of them V13, V14, and V1. I was feeling better, I have one more week of restriction. Now, they are messing with my mental, I feel so bad, full of anxiety. I am scared that V1, V13 and V14 will retaliate against me for filling a complaint with IDPH and telling you the truth. I'm not sure why they will not leave me alone. V14 told me that V13 told him to have me sign the new form. On 11/7/23 at 12:00PM, V1 stated, V28 [Nurse Consultant] asked V14 to have R83 sign the new updated form. Because the old form was not written correctly, they want to make sure R83 had a copy with her signature. If R83 would have signed the new form, with the exact wording from V13, then V13 wouldn't have falsified R83's document, but that was not our intent. On 11/7/23 at 12:10 PM, V14 stated, I re-wrote the Behavior Intervention Program Counseling Form, and asked R83 to sign the new form with the updated interventions. No one told me to ask R83 to sign information over all on a new form, using V13's exact words, so R83 would understand her interventions. I was trying to clear everything up. R83 refused to sign the new form, because R83 said the information on the new form was false. [Copy of The Behavior Intervention Program Counseling Form presented to R83 on 11/7/23 noted as [Attachment C] On 11/7/23 at 12:40 PM, V28 [Nurse Consultant] stated, I asked V14 to go and talk with R83 and give her the corrected document with the interventions. To assist with correction process. My intent was to cause R83 any emotional distress. Policy: Documented in part Resident Rights: -Resident has the right to be informed of their rights and all the rules and regulations governing resident conduct and responsibilities -A facility must not prohibit or in any way discourage a resident from communicating with federal, state surveyors -Resident has the right to be informed, participate in their treatment -Resident has the right to be informed in advance of changes in their plan of care