**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from mental abuse for 3 of 8 residents (R2, R3, R6) reviewed for abuse in the sample of 14. This failure resulted in R2 feeling fearful of R1 and socially isolating due to R1's threats against him. This failure resulted in R6 suffering mental anguish related to R1's threats to physically harm and kill R6. This failure resulted in R3 being fearful of physical and mental retaliation from R1. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/17/25 when R2 reported to V1 Administrator that sometime late February (2025) R1 had threatened to kill him. These failures resulted in R2, R3, and R6 experiencing psychosocial harm. The Immediate Jeopardy was identified on 3/31/25. V1 Administrator was notified of the Immediate Jeopardy on 3/31/25. This surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 3/31/25 however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: An initial facility abuse investigation report dated 3/17/25 showed R2 reported to V1 Administrator that R1 had threatened to kill and strangle him if R2 told facility staff that R1 had sold R2 marijuana. The final facility abuse investigation report dated 3/24/25 showed, on 3/18/25, R6 reported to V1 Administrator that R1 had offered R6 drugs in the facility. When R6 refused the drugs from R1, R1 became angry and told R6 that he would knock out his teeth if R6 reported to anyone that R1 had offered him drugs. R6 stated R1 threatened to break R6's neck and throw you out the window to make it look like a suicide. Per the report, R6 stated, on another occasion, R1 came into R6's room and told R6, I will kill you if you snitch on me. I have no one to lose. I will kill you and make it look like you are having a seizure. The final facility abuse investigation report showed, on 3/18/25, R3 reported to V1 Administrator that he too was afraid of R1. R3 stated R1 hid alcohol bottles in R3's room. R3 stated R1 is very threatening and intimidating. I don't want to be here if he is here. Once he threatened to beat me . I am terrified and want to be left alone . He (R1) knows a lot of people on the street, if he finds out I can get killed easily. The report showed R3 was visibly shaking, when speaking about R1, to V1 Administrator on 3/18/25. The facility's final abuse investigation report dated 3/24/25 showed abuse was substantiated related to the actions of R1. A police report was filed. R1's admission Record showed R1 was admitted to the facility on [DATE] for rehabilitation therapy services due to his diagnosis of low back pain. R1's current care plan showed R1 was cognitively intact, ambulatory, and needed no staff assistance to complete his activities of daily living. The plan showed R1 had a history of verbally aggressive behaviors towards others. The plan showed R1 was an identified offender due to his criminal history of attempted armed violence. R1's progress and nursing notes dated November 2024-March 2025 were reviewed. These notes showed multiple documented episodes of R1 having alcohol, drugs, and drug paraphernalia in the facility. The notes showed incidents of R1 being verbally aggressive and threatening towards residents and staff. The notes showed incidents of R1 repeatedly disobeying facility rules and leaving the facility despite his community pass privileges being revoked due to his behaviors. They showed multiple incidents of the local police being called to the facility due to R1's behaviors. A note dated 2/6/25 showed the facility served R1 a 30-day discharge notice due to his behaviors and R1 no longer needing skilled nursing services. R1 appealed his discharge. A note dated 3/3/25 showed a coat, belonging to R1, was found in the facility containing 9 bags of marijuana, a scale and a pipe. A note dated 3/11/25 showed R1 was sent to a local behavioral health hospital due to R1 threatening to shoot V1 Administrator and V2 Assistant Administrator. R1 was allowed to return to the facility on 3/19/25 pending the appeal related to his discharge. Upon return from the hospital, R1's notes dated 3/20/25-3/31/25 showed R1's behaviors continued. On 3/21/25, R1 walked out of the facility and did not return until noon on 3/22/25. On 3/23/25, R1 was verbally aggressive with staff. On 3/23/25, it was reported to facility staff that R1 had been smoking crack with another resident. On 3/25/25, R1 was found in another resident's room. R1 took food from the resident's room, and left. On 3/27/25 at 8:45 AM, R1 was in his room, lying in bed. R1 denied selling drugs to any residents in the facility. When this surveyor asked R1 about his interactions with R2 and if he had ever threatened R2, R1 began to get upset and his voice became louder. He immediately stood up from his bed, took a step towards this surveyor and stated, I have already told this story before. I already talked to the police. R1's voice continued to raise his voice as he spoke. R1 began walking towards the door of his room. R1 very loudly asked this surveyor to leave his room. This surveyor exited R1's room. 1. R2's admission Record dated 12/5/24 showed R2 was admitted to the facility with diagnoses of autism, developmental delays and a heart transplant. R2's admission nurse practitioner note dated 12/30/24 showed R2 was cognitively intact. On 3/27/25 at 8:30 AM, R2 was in his room, lying in bed, with the lights off. R2 stated R1 threatened to kill R2 sometime in late February if I snitched and told anyone where I got my pot (marijuana) from. R2 stated he had bought marijuana from R1 in February. R1 stated, After I bought pot from him, there were a couple of times when (R1) would just come into my room (unannounced). I was definitely scared of him then. He never asked to come in my room . after that, I finally told on him because I was angry from what he said to me and I was also a little scared of him . Now that (R1) is back from the hospital, I just stay away from him. I stay in my room to avoid him. I know he has other people (residents) watching me so he knows who I talk to. I am still a little scared of him . On 3/27/25, V5 Social Services stated R2 had reported to V5 in the past that R2 did not feel safe around R1 because R1 had threatened to choke him (R2) out if R2 told anyone he bought marijuana from R1. V5 stated when R1 returned from the hospital, R2 reported feeling afraid because of (R1). (R2) has been spending more time in his room to avoid conflicts . V5 stated, (R1) is very intimidating. He becomes verbally aggressive. Staff are afraid he will hit them if they try to enforce the rules. I worry that (R1) will attack me or other staff . I don't feel comfortable with (R1) and he intimidates me. The dilemma is that we don't know what to do with him when he acts out other than call the police . A social service noted for R2, dated 3/25/25, showed R2 reported to social services that a co-resident came into his room when he wasn't present and the he doesn't want this co-resident to come into his room anymore . On 3/27/25 at 12:27 PM, V4 Social Services was asked about the resident referenced in R2's social service note dated 3/25/25. V4 stated, The resident in (R2's) room was (R1). (R2) came to me and told me that the day before (3/24/25), (R2) walked into his room and found (R1) standing in his room, talking to (R2's) roommate. (R2) reported to me that he immediately felt uncomfortable and walked back out of his room. I think he was a little fearful when he saw (R1) in his room. Since his return from the hospital, we try to monitor where (R1) is at when he is in the building but he goes where he wants. We have tried to revoke (R1's) community pass privileges due to his behaviors but he doesn't care. He feels like he's above the rules and leaves anyway. On 3/27/25 at 9:13 AM, V1 Administrator stated on 3/17/25, R2 reported to V1 that R1 had threatened to kill R2 if he told anyone R1 had sold him marijuana. V1 stated all staff and many residents are afraid of R1 due to his behaviors. V1 stated, We were finally able to send (R1) out to the hospital after he threatened to kill me, (V2 Assistant Administrator), and our families but he was allowed to return. When he came back, we tried to put him (R1) in a private room, but he refused. We tried to move him to a room on the first floor, but he refused. We revoked his community pass privileges but he doesn't care, he still leaves the facility. We try to monitor where he is every hour that he is in the facility . V1 stated facility staff are afraid to enforce the facility's rules with R1 because they are afraid he will try to hurt and physically assault them. 2. On 3/27/25 at 10:45 AM, R6 was asked about his interactions with R1. R6 was initially hesitant to speak with this surveyor, stating, I don't want to get involved. If I say something, there is nothing you can do. I already made my statement (during the abuse investigation) . R6 continued to talk and then stated he had been threatened by R1 in the past. R6 stated, One night, when he (R1) wasn't sober, he came into my room and threatened to break my neck and throw me out a window. He said he could break my neck and tell staff it was a seizure since there is no cameras in my room. I started yelling and a CNA (certified nursing assistant) came and got him out of my room . Many residents are afraid of him. He has power and no one can stop him. He is big and intimidates people . It would be better if he left and never came back. The police just bring him back and he does whatever he wants . (R1) has said before he can leave people crippled in a wheelchair or a vegetable, what are they waiting for? Someone to die or get hurt? On 3/27/25 at 9:13 AM, V1 Administrator stated on 3/18/25, R6 reported to V1 that he was scared of R1 because R1 had threatened to break R6's neck. 3. On 3/27/25 at 11:10 AM, R3 refused to speak to this surveyor about R1. On 3/27/25 at 11:10 AM, R4 stated R3 won't come down and talk to you guys because he's fearful of his safety. (R1) is big and has threatened (R3) before. I have seen (R1) drinking (alcohol) in (R3's) room before. (R3) is timid and shy .He doesn't want to get beat up by (R1) . R4 stated she was the resident that reported R1 had threatened to kill V1 Administrator and V2 Assistant Administrator. R4 stated, (R1) was pissed off because he thought (V2) was trying to get him kicked out of the facility. He told me that he could be sitting in a bar and have someone shoot (V1) and (V2) and their families so I reported that to (V2). R4 stated she has seen R1 smoke weed and drink alcohol in the facility. A social service note dated 3/19/25 for R3 showed, Resident is upset and scared that a co-resident (R1) got admitted back to the facility . On 3/31/25 at 10:24 AM, V7 Social Services was asked about the note she documented on 3/19/25 for R3. V7 stated R3 said he was scared because R1 had been readmitted to the facility. On 3/27/25 at 9:13 AM, V1 Administrator stated on 3/18/25, (R3) told me he felt terrible. He said he was afraid of (R1). He said (R1) was very threatening. He said (R1) hides alcohol and drugs in (R3's) room. (R3) can't tell on him because (R3) is scared of him. On 3/27/25 at 10:20 AM, V2 Assistant Administrator stated, I spoke with (R3). He told me he is afraid of (R1). (R3) said his room is where (R1) hides his drugs and alcohol. (R3) is afraid that if he snitches and tells on (R1), (R1) will have people come and get (R3) and kill him .(R4) came to me and told me (R1) threatened to kill me and my family . Since then, I don't stay home alone . V2 became tearful during the interview. V2 stated, We are all afraid that (R1) is back. We are sitting ducks right now . On 3/27/25 at 1:00 PM, V6 Psychiatric Nurse Practitioner stated he has been treating R1 for a mood disorder but recently also for substance abuse and his threatening behaviors. V6 stated, (R1) doesn't follow the rules. When staff try to enforce the rules, he gets upset and starts threatening staff and residents. It's a big deal. That is why we sent him to the hospital and then he was allowed to come back. He's threatened to hurt staff and residents. I am very concerned about his behaviors. His behaviors are worsening. I am not sure if that's related to his substance abuse or there is something else going on. Staff and residents are fearful of him. He is a risk. His homicidal threats are a big deal. The facility's Abuse Prevention-Program Policy revised 2/26/25 showed, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment . Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident . Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . Mental abuse is also the use of verbal or nonverbal contact which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . The facility presented an abatement plan to remove the immediacy on 3/31/25. The survey team reviewed the abatement 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 second revised abatement plan on 3/31/25. The abatement plan was returned to the facility for revisions. The facility presented a third revised abatement plan on 3/31/25 and the survey team accepted the abatement plan on 3/31/25. The Immediate Jeopardy that began on 3/17/25 was removed on 3/31/25 when the facility took the following actions to remove the immediacy: 1. On 3/31/25, R1 was placed on 1:1 monitoring. 2. On 3/31/25, the police will be called for assistance every time R1 violates community restriction. R1 will be discharged in 10 days per court order. 3. On 3/31/25, an order of protection will be filed on R1, by R2, R3, and R6 pending their consent. 4. On 3/31/25, recent abuse in-services/education will be continued on all newly hired employees and agency nurses. 5. On 3/31/25, the resident admission process was reviewed with the Admissions Director and Social Services and will be implemented per facility guideline. It will ensure that resident background checks are being completed on time. The background checks will also be reviewed to ensure that appropriate interventions are put into place for the safety of all residents. 6. On 3/31/25, it was decided that should a resident become noncompliant with facility protocols and guidelines, the resident will be counseled by staff. If the resident continues to be noncompliant, he/she will be sent out for psychiatric evaluation and will be served a 30-day discharge notice as deemed appropriate. Should he/she become harmful to other residents, he/she will be placed on 1:1 monitoring. V1 Administrator will be responsible for overall compliance to the plan of correction in conjunction with the Social Services Director by making sure that the above plan is being implemented. A QA (quality assurance) will be used to monitor for compliance by checking if the monitoring sheet is followed. The Quality Assurance/Quality Improvement (QAQI) Team meets monthly. The event will also be brought to the next monthly QAQI meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to: 1. Protect a resident's right to be free of sexual and mental abuse from staff and other residents. This failure resulted in R1 being inappropriately touched by V8 (CNA-Certified Nursing Assistant) in the shower and being subjected (verbally and via phone message) to inappropriate and lewd comments of a sexual nature about R1's body. This failure also resulted in R1 being exposed to R6, who formerly sexually abused R1. R6 was in close proximity to R1 without supervision. These failures caused R1 to experience emotional distress and feel unsafe in the facility and caused her to discharge herself AMA (against medical advice). 2. Protect a resident's right to be free from physical abuse by a resident and failed to protect residents from further abuse from the abusive resident. This failure resulted in R5 hitting R7, R5 hitting R4 twice within two days, and R5 hitting R6 between 2/5/25 and 2/20/25. This failure also resulted in R2 being hit by R3. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 2/16/25 when R1 was sexually and mentally abused by V8. V1 (Administrator) was notified of the Immediate Jeopardy on 2/26/25 at 9:45 AM. The surveyor confirmed by observation, interviews, and record review that the Immediate Jeopardy was removed on 2/27/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the interventions and in-service training. This applies to 5 of 5 residents (R1, R2, R4, R6, and R7) reviewed for abuse in a sample of 16. The findings include: 1. Facility Final Investigation Report Form, submitted 8/26/24, shows the facility substantiated that R6 sexually abused R1. R1's Face sheet, dated 2/20/25, shows R1's diagnoses include Huntington's disease, major depressive disorder, and suicide ideation and attempt. The face sheet shows R1 was admitted to the facility on [DATE] and discharged on 2/18/25. MDS (Minimum Data Set), dated 2/5/25, shows R1 was cognitively intact and required supervision or touching assistance for bathing, hygiene, and lower body dressing. Face sheet, dated 2/25/25, shows R6's diagnoses include alcohol abuse, depression, and chronic obstructive pulmonary disease. MDS, dated [DATE], shows R6 was cognitively intact and was able to independently ambulate. Care plan, initiated 8/22/24, shows R6 was admitted to the facility with a history of a Class 4 felony, was at moderate risk, and requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Care plan, initiated 9/5/24, shows R6 is to remain on his designated floor (2nd floor) and is not to enter other residents' rooms. [R6] will be escorted to and from floors if he is to participate in the designated smoke times, attend activities or go to therapy. Interventions include educating the resident on appropriate behavior redirect resident if seen on the first floor other than to smoke or participate in activities and monitor resident when in community areas to make sure actions are appropriate. 2. Facility Final Incident Investigation Report Form, provided 2/22/25, shows the facility substantiated R1 was abused by V8. The report shows the abuse occurred on 2/16/25 and R1 left the facility AMA on 2/18/25 at approximately 10:30 PM. Facility abuse investigation documents show V8 was interviewed and stated he assisted R1 with a shower, stood outside her curtain, assisted R1 as she stumbled, and then only washed her back and lower legs for R1. V8 denied touching R1 in inappropriate ways. V8 stated he and R1 connected on Facebook on 2/16/25 and messaged each other on the application. On 2/20/25 at 9:56 AM, V4 (PRSC- Psychiatric Rehabilitation Services Coordinator) stated R1 showed her a message from V8 on R1's phone regarding V8 becoming sexually aroused when V8 was near R1. V4 stated she was shocked and felt the messages were very inappropriate. V4 stated R1 told her that R1 kept the conversation going via the messages because she wanted proof of how V8 was talking to R1. On 2/20/25, V3 (assistant admininstrator) stated she was informed on 2/17/25 that V8 was messaging R1 via phone in a sexual nature. V3 stated she interviewed R1, R1 read V3 some of the messages, and V3 read messages which showed V8 was referring to becoming sexually aroused when he saw R1. V3 stated, I saw enough- they were very concerning. V3 stated by the time the police arrived, V8 deleted the messages on the messaging application. On 2/20/25 at 1:13 PM with V25 (R1's Friend), stated, R1 stated V8 would often bring R1 food from outside the facility including the day V8 inappropriately touched R1. R1 stated, Then as we were showering, he ended up washing my [internal reproductive area] and then my [buttocks]. R1 stated she almost fell prior in the shower and V8 steadied her but then continued washing areas of R1's body that she did not need assistance washing. R1 stated V8 never asked if he could wash R1's body. R1 stated after the shower R1 and V8 were in R1's room and V8 stated, Nice butt. R1 stated V8 stated, Could I tell you something without getting fired? You have a really nice butt and nice boobs. R1 stated after the comments, V8 asked to connect on Facebook with R1 and V8 used R1's phone to add V8 as her friend. R1 stated at that time they were sitting next to each other in her room and V8 stated, He told me how cute I was, that I had a cute butt and boobs again, and then he left. R1 stated V8 later messaged R1 telling her that V8 was sexually aroused, suggested he could have sexual intercourse with her while she was in the shower, and referenced the size of his sexual organ. R1 stated all of the administrative staff left the facility because it was late on a Sunday, so R1 reported the interactions the next day to V4 (PRSC- Psychiatric Rehabilitation Services Coordinator). R1 stated she showed V4 and V3 (Assistant Administrator) the messages from V8 before V8 deleted the messages on the application. R1 stated she didn't initially mention her concerns about the shower because R1 thought V8 was helping her but after R1 told her children about the interaction, they told R1 no staff should be helping her in the shower and R1 was capable of washing herself even if she became off balance. R1 stated she told V26 (Restorative CNA) about V8 washing her peri area in the shower and R1 stated V26 told R1 that R1 did not need assistance from staff to perform those tasks. R1 stated V26 never washed R1's peri area in all the times V26 provided R1 assistance in the shower. R1 stated she experienced prior sexual assault at the facility by a resident and stated, Hence I am no longer there. I am not safe at all at that facility Nobody asked me if I felt safe at the facility this time. I had friends come and get me on Tuesday because I don't feel safe! On 2/20/25 at 3:15 PM, V26 (Restorative CNA) stated R1 could independently wash herself in the shower. V26 stated R1 could sit on a shower bench and wash all of their body in the shower. V26 stated R1 only needed supervision to help her get set up and regulate the water temperature in the shower. V26 stated she assisted R1 with a shower on 2/18/25 and R1 did not require assistance to physically wash R1. On 2/20/25 at 11:54 AM, V23 (R1's Daughter) stated R1 was sexually assaulted at the facility in the past and V23 stated R1 was sexually abused a second time by facility staff. V23 stated the facility staff did not need to assist R1 to walk to the shower but recently a male CNA was allowed to wash her body and her privates. V23 stated on 2/17/25 at 12:44 AM, R1 messaged V23 stating she had to report a male CNA because he helped R1 in the shower and made verbal and written sexual comments toward R1 via phone, and suggested R1 allow V8 have sexual intercourse while being showered by V8. R1 identified the staff as V8. V23 stated she called the facility at approximately 2:15 PM on 2/17/25 and spoke to V4 (PRSC- Psychiatric Rehabilitation Services Coordinator). V23 stated she told V4 she was aware of V8 sexually messaging R1 as well as touching R1 inappropriately in the shower. V23 stated she called the police at 2:30 PM to report the allegation that V8 touched R1 inappropriately in the shower and the inappropriate messages because V4 stated they were not going to call the police but instead would handle it in house. V23 stated she pulled R1 out of the facility and sent R1 to the hospital to be examined on 2/18/25. On 2/20/25 at 12:53 PM, V24 (R1's Friend) stated she was with R1 at the hospital on 2/17/25 and R1 told the staff V8 asked R1 if she needed help with her shower and R1 told him she did not because she was fully capable of washing herself. V24 stated R1 told the staff V8 proceeded to wash her vaginal and buttocks areas which shocked R1. V24 stated on 2/16/25 evening, R1 messaged V24 stating V8 made verbal sexual comments toward R1. On 2/20/25 at 4:00 PM, V9 (Police Officer) stated V3 told her that V3 did see some of the messages and described the messages as very disturbing. At 7:00 PM, V9 stated V8 came to the police station to do an interview but would not speak with the police officers and requested a lawyer. On 2/20/25 at 11:15 AM, V5 PRSD (Psychiatric Rehabilitation Services Director) stated she spoke with V8 who stated he stood outside the shower curtain during R1's shower until R1 stumbled. V8 stated he helped R1 and then helped R1 wash her legs and back. V5 stated V8 was very short with his answers and not forthcoming. On 2/20/25 at 9:15 AM. V1 (Administrator) stated on 2/17/25 he received report that R1 alleged V8 (CNA) sent sexual messages via phone to R1. V1 stated the messages included phrases such as you are hot or you are sexy. V1 stated when he asked to see the messages, the messages were deleted. V1 stated he spoke with V8 who admitted to messaging R1 but denied ever physically touching R1. V1 stated V8 resigned from facility employment. V1 stated later in the day on 2/17/25, R1 contacted V1 and informed V1 she spoke with her daughter who informed R1 that V8 assisting R1 in the shower was sexual abuse because R1 did not require physical assistance with her showers. V1 stated R1 told V1 that V8 unnecessarily wiped R1's peri area and buttocks during her shower. On 2/25/25 at 12:38 PM with V27 (R1's Friend), stated, R1 stated since R6 sexually abused R1, R1 experienced R6 in close physical proximity and unsupervised to her several times and as recent as January 2025. R1 stated, I was freaked out and stated she told a staff member. R1 stated R6 would visit the table at which she was sitting for approximately 10 minutes and talk to all of the residents at the table other than her. R1 stated R6 at times pushed a resident around the first floor in his wheelchair unsupervised where she resided. R1 stated R6 was not supposed to be on the first floor and was supposed to remain on the second floor where he resided because of the sexual abuse she experienced by R6. R1 stated R6 came down to the first floor unsupervised other than during designated smoking breaks. On 2/20/25, V23 (R1's Daughter) stated R1 messaged her on 1/26/25 at 11:25 AM telling V23 that R6 was walking by R1. V23 stated R1 pressed charges against R6 last year after R6 sexually assaulted her and R1 recently went to court on the case and there was an upcoming court date in April of 2025. V23 stated R1 left the facility because R1 was not safe at the facility. On 2/20/25 at 1:13 PM with V25 (R1's Friend), R1 stated she was sexually assaulted by R6 the prior year and she was in disbelief she was sexually assaulted again the facility recently by staff. R1 stated she no longer felt safe at the facility because she experienced sexual abuse twice and she chose to discharge AMA from the facility to a friend's home until she could find a different facility in which to live. On 2/24/25 at 3:55 PM, R6 stated he travels up and downstairs by himself to smoke breaks at the facility. On 2/25/25 at 1:35 PM on the first floor, R6 walked off the elevator with female resident and independently walked into the dining room. R6 then began walking around the dining room talking to residents with no direct supervision from staff. V28 (Social Services) was sitting at a table with a resident engaged 1:1 in an interview of the resident. R6 stood at R14's table talking to residents with no direct supervision and then walked to R9's table and then back to R14's table. At 1:40 PM, an announcement was made overhead the facility that the smoking patio would be opened in five minutes. R6 continued to walk around the dining room speaking to R9 and other residents. There were 11 females and 11 males in the dining room in addition to R6. On 2/26/25 at 9:45 AM, V1 stated R6 did not need any kind of supervision at the facility. V1 stated R6 was moved to the second floor because of his isolated behavior of sexual abuse toward R1 (which was substantiated) and to reduce interactions with R1 when the incident was new. V1 stated he did not deny R6 was coming down to the first floor unsupervised. On 2/24/25 at 3:47 PM, V31 (CNA- Certified Nursing Assistant) stated R6 travels back and forth on the elevator to the first floor independently without supervision. On 2/24/25 at 3:45 PM, V30 (Registered Nurse) stated R6 was not allowed to go downstairs due to an incident a year ago which was why R6 was moved to the second floor. V30 stated R6 did travel back and forth on the elevator without an escort to the first floor. 2. Face sheet, dated 2/22/25, shows R5's diagnoses included Huntington's disease and mood disorder. R5 was admitted to the facility on [DATE]. MDS, dated [DATE], shows R5 was cognitively intact and R5 was able to propel in a wheelchair once set up in the wheelchair. Care plan, dated 4/23/24, shows R5 was admitted to the facility on [DATE] with a criminal history of violating an order of protection and domestic battery. Approaches include, Review of my past behavior and evaluate the potential for me to engage in inappropriate / high risk behavior, provide R5 with supportive group intervention and/or 1:1 via a qualified provider, to promote safety intervene when I am observed to be engaging in inappropriate behavior, teach me impulse control strategies and communicate to me that I am responsible for all my actions/behavior and must therefore exercise control over my impulses and behavior. Care plan, dated 10/17/24, shows R5 had a history of a hit and run accident and may have flashbacks, become upset, and become aggressive verbally and physically with staff. Care plan, dated 11/4/24, shows R5 was observed with manipulative behaviors and approaches included providing educations to not fabricate stories, perform check-ins with residents, and providing 1:1 interaction with R5 to help find solutions towards issues. Behavioral care plan, initiated 2/10/25, shows R5 displayed verbal and physical aggressive behaviors toward others, uncontrolled behavior outbursts and requires the use of non-pharmacological and pharmacological interventions to address and mitigate behaviors. Interventions included Social Services will continue to educate resident on aggressive behaviors and encourage resident to utilize healthier ways to communicate thoughts and feelings. Social services will work with resident to establish better communication and mechanisms. Delusions/paranoia care plan, dated 2/14/25, shows R5 was diagnosed with Huntington's disease and believes everyone is making fun of his disability. Interventions include psychiatric management, minimizing risk factors through interventions such as assessment, team, consultation, supervision, observation, structured environment, peer-buddy system, contracting and medication management. Other interventions include teaching stress/anxiety management techniques, discussing benefits of therapy with physicians, encouraging resident to follow mental health treatment plans and encouraging resident to attend groups. Illinois State Police report, dated 1/2/24, shows R5 was convicted of domestic battery/bodily harm, revisiting a peace officer, criminal trespassing, possession of drug paraphernalia, manufacturing/delivering controlled substances. Facility Final Incident Investigation Report Form, dated 2/10/25, shows on 2/6/25 R5 stood up and attempted to hit R7 in the face. The report shows R5 was sent to the hospital and R7 declined to press charges. The report shows R5 has a history of dwelling in the past which leads him to become physically aggressive with co-residents. The report shows R5 was educated on the facility policy and proper way of communicating. R7 was educated on the proper way to speak to his co-residents. Investigation witness statement, shows R7 reported R5 repeatedly came into R7's room and when R7 asked if R5 had a problem, R5 stood up and started punching R7. The statement shows R7 covered his head while R5 swung but R5 missed which caused R7 to fall. Investigation witness statement shows V17 (Registered Nurse) heard R7 was calling R5 the n word and R7 told R5 to get away from R7. The statement shows R5 stood, leaned into R7 and hit him in the left side of the face. The statement shows R7 pushed R5 off of him and R5 lost his balance and fell. Investigation witness statement shows V11 (Registered Nurse) saw R7 and R5 arguing, R5 stood and hit R7, and R5 fell to the floor. The report shows the facility did not substantiate the abuse because R5 stood up from his wheelchair and attempted to hit [R7], but has an unsteady gait, which caused him to lose balance and fall into [R7]. Nursing note, dated 2/5/25, shows, Writer was standing near nursing station, turned around to note this resident standing up and using profanity towards a co-resident. As soon as writer began to approach the situation, this resident stood up, leaned into co-resident and was physically aggressive. Co-resident pushed this resident to the ground. The writer and other staff members separated the resident from each other. On 2/25/25 at 2:59 PM, R7 stated he had a previous altercation with R5 approximately a year ago when the two were roommates and R5 hit (R7) in the head several times. R7 stated the most recent altercation happened a few weeks ago when R5 hit him in the head several times and R7 stated he had several knots on his head. Social Services note, dated 2/5/25, shows the PRSD was informed that R5 and another co-resident got into a physical altercation by the nursing station, R5 hit another co-resident, and R5 was being sent out for a psychiatric evaluation. Social Services note, dated 2/5/25, shows R5 got in a physical altercation with co-resident as resident claimed that this co-resident had insulted him. PRSC explained to resident that he cannot get physical with co-residents whatsoever. PRSC explained to resident that if he has an issue with co-resident, he must find a PRSC to intervene. Resident was therefore educated on facility policy and proper communication. Will continue to monitor. Review of R5's clinical record showed no interventions were put into place to prevent further physical aggression by R5. Progress note, dated 2/6/25, shows R5 angrily knocked on R7's door to get in, entered R7's room, and knocked R7's belongings around the room and was verbally aggressive. The note shows R5 hit R7 the day prior and R5 was told to stay away from R7. The progress notes show R5 was sent to the hospital for evaluation and returned the same day to the facility. Review of R5's clinical record showed no interventions were put into place to prevent further physical aggression by R5. 3. Face sheet, dated 2/20/25, shows R4's diagnoses included schizoaffective disorder, epilepsy, convulsions, post-traumatic stress disorder, and cocaine/cannabis abuse. MDS, dated [DATE], shows R4 was cognitively intact and could independently ambulate at the facility. Care plan note, dated 1/28/25, shows R4 was reported to be making inappropriate remarks, becoming aggressive with staff, and verbally aggressive with co-residents. Care plan notes, dated 1/28/24, show R4 experiences auditory and visual hallucinations and paranoia when discussing his symptoms. Progress note, dated 2/9/25, shows R5 was in a second physical altercation at the facility. The note shows, Writer was notified that [R5] was fighting with other resident at the end of the hallway 400. We proceeded to separate them, assess them, and place them in different areas. I notified [Psych Nurse Practitioner], who ordered to send the resident to the [Psychiatric Hospital] for a psychiatric evaluation Facility Final Incident Investigation Report form, submitted 2/14/25, shows on 2/9/25 in the 400 hallway, R5 stood up and hit R4 in the face after R4 was speaking with V14 (Housekeeping). V14's statement shows R4 did nothing to provoke R5 to hit R4 and V14 was hit during the altercation. The investigation shows R4 stated R5 caught R4 off guard and R5 smacked [R4] on the lips. The investigation showed R4 was protecting his head because of his seizures and was trying to run away but was not able to do so because of his clinical condition. The statement shows staff assisted to stop R5 and staff assisted R4 up off the floor and took him upstairs. The report shows R4 was educated not to go to the first floor, R5 was sent to the hospital for a psychological evaluation, local police were called, and R5 was educated on facility policies and the proper way of communicating. The report shows the facility substantiated R5 physically abused R4. Progress notes, dated 2/9/25, shows R5 was sent to the psychiatric hospital and returned to the facility the same day. Review of R5's clinical record showed no interventions were put into place to prevent further physical aggression by R5. Social Services note, dated 1/24/25, shows R4 was reported to have called a co-resident in a wheelchair a vegetable. The note shows R4 had a history of bullying co-residents and was told he could not bully residents. Social Services note, dated 2/10/24, shows R4 was educated to stay away from R5 and R4 was encouraged to stay on the second floor during meal times. The note shows R4 verbalized understanding. 4. Progress notes, dated 2/13/25, show R5 was in a third physical altercation at the facility (R5's second altercation with R4 within two days), 911 was called, the police and fire department arrived at the facility and R5 was escorted from the facility by the police. The progress notes show R5 was being involuntarily admitted to the psychiatric hospital with diagnoses including aggression/mood disorder. Facility Final Incident Investigation Report Form, dated 2/18/25, shows on 2/13/25 at approximately 7:40 AM, R5 again hit R4 which was witnessed by staff. Witness statement by V15 (Registered Nurse) shows R5 suddenly got up from his wheelchair and pushed [R4] against the wall, [R4] hit his head to the wall and fell on the floor. [V15] immediately ran towards and separated [R5] from [R4], [R4] was on the floor, he was unconscious [V11] called 911 while we were monitoring[R4]. R5's statement stated R4 was picking on R5 so R5 got up from his wheelchair to try to hit [R4] but lost his balance and grabbed onto his sweatshirt instead to gain back balance. R4's statement shows R4 briefly spoke to R5 when he walked past R5 with nice words and when walking away from R5 R5 pulled his sweatshirt and fell to the floor, and R4 thought he fell to the floor because he had a seizure. Investigation witness statement by V11 (Nurse) shows V11 saw R5 and R4 next to each other and V11 immediately told R4 to move. The statement shows R4 began to walk away and then R5 suddenly got up from his chair and tried to walk toward R4 but because of R5's disease R5 fell. The witness statement shows R4 had a seizure and the police removed R5. The report summary shows the facility concluded that the allegation of physical abuse by R5 was substantiated. The report shows R4 was educated to keep his distance from R5, was told not wander to the first floor during mealtimes and wait until mealtimes are over to go to the first floor. The report shows R5 was educated to not use physical violence towards co-resident and to speak to case workers to resolve issues with residents. The report shows R5 believed people are against him and residents make fun of him even if they are not. R5 was sent to the hospital for psychological evaluation and returned to the facility, the residents were separated by floors, and plans were made to move R5 to a private room. On 2/20/25 at 11:27 AM, V16 (PRSC) stated R5 felt like residents like R4 make fun of R5's disability and that was why R5 hit R4. Social Services Note, dated 2/14/25, shows, Resident is no longer a part of the work program due to numerous aggressive incidents in past week. Progress note, dated 2/14/25, shows the facility spoke with [V12 (Psychiatrist)] to place [R5] in a different nursing due to increase aggressive behaviors. [V12] is working with hospital caseworkers to find a appropriate placement. Progress note, dated 2/18/25, shows R5 was readmitted to the facility from the psychiatric hospital. Review of R5's clinical record showed no interventions were put into place to prevent further physical aggression by R5. 5. Progress note, dated 2/20/25, shows R5 was in a fourth physical altercation at the facility with a co-resident in the back patio of the facility. Facility Final Incident Investigation Report Form, submitted 2/25/25, shows the facility substantiated the allegation that R5 physically abused R6. The report shows R6 was punched unprovoked by R5 and the altercation was witnessed by R8-R11. Witness statements shows R8 stated he intervened to try to prevent R5 from hitting a staff member and fell, R9 was talking to R6 and R5 began hitting R6 without provocation, R10 stated R5 got up and grabbed R6, and R11 stated R5 got out of his chair and swung at R6. Staff witness statements show V18 (Activities) stated R5 started swinging at R6 and R8 tried to intervene. On 2/21/25, V22 (Hospital Case Manager), stated when R5 was admitted to the hospital emergency department, there was no medical necessity to admit R5 to the hospital, but the facility would not allow R5 to return to the facility. V22 stated R5 reported to hospital staff that he was constantly being placed near a resident that constantly bullied and harassed him and R5 felt like he needed to defend himself. V22 stated while R5 had been in the hospital R5 had not shown any aggression. V22 stated, While he has been at the hospital, he has been fine. Maybe they aren't moving him away from this person like he is asking! Hospital Nurse Practitioner note, dated 2/21/25, shows, R5 was previously admitted to the inpatient psychiatric unit between 2/13/25 and 2/18/25. The note shows R5 was returned to the emergency room on 2/20/25 with the facility stating he was not welcome back to the facility. The note shows R5 was discharged previously from the facility to a different hospital for the same reason and returned to the facility at that time. During this admission, R5 was unable to be admitted to inpatient psychiatry due to not meeting criteria. The note shows the facility stated R5 was aggressive and injured six other residents and the facility would not allow him to return. On 3/325 at 12:30 PM, V12 (Physician) stated when R5 arrived at the hospital R5 was appropriate and there was no sign of aggression from R5. V12 stated there was no reason to admit R5 to the hospital however the hospital was forced to take R5 because the facility would not accept R5 back. 6. MDS, dated [DATE], shows R2 was cognitively intact. Review of R2's care plan showed no concerns with aggressive behaviors. MDS, dated [DATE], shows R3 was cognitively intact. Care plan, initiated 9/11/24, shows R3 displayed verbal aggressive behaviors toward others, uncontrolled outbursts, and changes his story to make himself look like the victim. On 2/20/25 at 3:30 PM, R3 stated he was attempting to wake his friend, who was sleeping on a table, so he began banging on the table. R2 told R3 he was going to go to the hospital and R2 hit R3. R3 stated he was hit first by R2, but R3 hit him back. On 2/20/25 at 3:00 PM R2 stated R3 began messing with a resident and R3 threw a punch at R2. R2 had a healed scratch on his left upper cheek. R2 stated if he had not slipped, he would have fought back and hit R3. Social Services note, dated 2/13/25, shows at 3:55 PM in the first-floor dining room, R3 was having a conversation with another co-resident when he alleged another resident interrupted him. R3 alleged that the other resident then punched R3 in the side of the head and R3 responded by punching him and knocking him to the ground and then hit him again. Final Incident Investigation Report Form, dated 2/18/25, shows on 2/13/25 R3 hit R2 after a verbal argument in the first-floor dining room. The Form shows V6 (Registered Nurse) witnessed the end of the occurrence and R2 sustained a scratch on his left check. The report shows the police were called, R3 was sent to the hospital for a psychiatric evaluation, and R2 was treated at the facility. The Form shows R3 was educated on not using physical violence toward other residents and the facility substantiated R2 was physically abused by R3. Abuse Prevention Program - Policy, dated 11/22/17, shows, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents including verbal, mental, sexual or physical abuse .The facility has a no tolerance philosophy; persons found to have engaged in such conduct will be terminated. Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means Abuse is also the willful infliction of injury Willful, as used in this definition of abuse, 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 and that requires medical attention Sexual abuse is non-consensual sexual contact of any type with a resident Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, or offensive physical contact by a licensee, employee or agent. Mental abuse is also the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation Facility Abuse Prevention Training Program, dated 11/22/17, shows, .Protection - The facility will remove any alleged perpetrator(s) of abuse or neglect from any further contact with residents pending an investigation . If the perpetrator is a resident, the residents will be separated from the alleged victim The facility presented an abatement plan to remove the immediacy on 2/19/25. The survey team reviewed the abatement 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 abatement plan on 2/19/25, and the survey team accepted the abatement plan on 2/19/25. The Immediate Jeopardy that began on 2/16/25 was removed on 2/20/25 when the facility took the following actions to remove the immediacy. - On 2/20/2025 R5 was given an immediate discharge to St [NAME] Hospital, R5 no longer a resident of River View. - On 2/26/25, R6 was reassessed on Screening Assessment for Ind[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by V3 (Agency LPN-Licensed Practical Nurse). This failure resulted in R1 experiencing physical abuse by a staff member (V3). This applies to 1 of 3 residents (R1) reviewed for staff-to-resident abuse in the sample of 3. The Immediate Jeopardy began on January 7, 2024 when V3 (Agency LPN) worked at the facility without receiving abuse training and physically abused R1. V1 (Administrator) was notified of the Immediate Jeopardy on January 25, 2024 at 2:12 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on January 25, 2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On January 22, 2024 at 10:00 AM, R1 was sitting in a chair in her room. R1 said she was physically abused by V3 (Agency LPN) on January 7, 2024. R1 said, It started over medications that I normally get at 8:00 AM. It was 1:00 in the afternoon, and I had not received my medications for the day. [V10] (CNA-Certified Nursing Assistant) said we had a temporary nurse, and she was sitting in the lobby area at the nurse's station, and if you wanted your medications, you had to line up for the medications, and those who could not line up were disregarded. It is my preference to take my medications in my room. I walk with a cane, and it is hard for me to walk to the nurse's station. Also, I am a high risk for falls, so I usually stay in my room all day. When I stand up I get dizzy and I fall easily, so I did not walk to the nurse's station to get my medications. At 2:00 PM, [V3] (Agency LPN) finally came to my room with my morning medications. She came to the doorway and said, Come and get your medications. She said it very rudely. I did not get up, so she then said, Did you hear me say come get your medications? Come and get them! I told her she needed to bring the medications to me. She handed me the medications and turned to leave the room. I was yelling to her that some of my medications were missing. She continued walking out of the room and slammed the door. I got up after she did not come back and stood in the doorway of my room. When she came out of the room across the hall, she looked at me and made another smart remark. I threw my pills down and she ran up in my face, pointing at my face and yelling at me. She was shaking her hand at me with a pointed finger and hitting the tip of my nose with her finger. I said stop hitting my nose and I put my hand up to block her from hitting my nose. When I made that motion, she grabbed my hair and my hands and threw me down to the floor and hit me. She said, Are you going to stop? Are your going to stop? She was screaming it loudly and trying to make people think I was attacking her. I have never seen [V3] working at this facility before. She left me there in the room and walked out. I went over to my telephone and called 911. I explained to the operator that I had been attacked and where I was at. She assured me the police were on their way. [V10] (CNA) could back up the problems we were having with getting our medications that day, but she did not witness the altercation. [V11] (CNA) came and saw me crying when it was all over. I told the police I wanted to press charges because [V3] threw me to the floor by the hair. The police kept asking me if I wanted to go the hospital, and I said no. I had just been in the hospital recently, and the last place I wanted to go was the hospital. Later in the evening I had chest pain, and I went to the hospital. The paramedics said my blood pressure was over 200. I went to the hospital and came back the same night. It happened two weeks ago, and I still have some neck pain, back pain, and a headache. On January 23, 2024 at 2:45 PM, V3 (Agency LPN) said, The first time I worked at the facility was around December 31, 2023. The second time was on January 7, 2024. I did not receive any abuse training from the facility. I did not receive any training from the facility regarding dealing with resident behaviors. They never pointed out an agency binder or did any education with me. When you come into a facility, they give you an assignment, and they put you to work. I know when you are working at a facility with residents with mental illness, you are at risk as a caregiver. I learned some techniques to restrain residents, not to hurt the person. As you restrain them, you are putting them in a compromising position. [R1] was aggressive and combative. She struck me and she grabbed me by the hair. I said she should let go and she did not. This was all because she was not happy with her medications. My main thought was to get her loose. I know I cannot hit her, but I don't want to be hurt either. Earlier she was verbally aggressive towards me. I walked away, closed the door, and went about my business. I did not call the doctor. I did not ask another nurse to help me or to give [R1] her pills. [R1] came out of the room and threw her pills. I asked her, Why did you throw your pills? That's your health. She struck me in the face and pulled me in. She got my hair, and I asked her to let go. I grabbed both of her hands over my head, while lowering her down to the ground. Once I got her down to the floor I put her hands on her chest and held them there and I said I am going to let go of your hands if you promise to let go. I asked her if she wanted me to help her get up, and she said no. I left the room and went and gave medications to two other residents. Then I went to the bathroom to fix my hair. I went over to the nurse's station and said what do I do, [R1] just attacked me, and the nurse said she didn't know. Before I could ask what to do, the resident had called 911 and the police were there. This is normal for these type of residents to curse at you and call you names. This is a psych facility. I did not see [R1's] diagnoses so I don't know if she has any psychiatric issues. No one gave me a heads up about the resident and if she had behaviors. All of this was because of her medications. On January 22, 2024 at 10:45 AM, V8 (RN-Registered Nurse) said, [R1] has never tried to hit me. She cannot chase anyone down. There are times she will refuse her medications but will take them later. She will say I prefer later. On January 22, 2024 at 10:49 AM, R2 said, [V3] did not give me my medications. She said they weren't important. She only gave me one pill. When I asked for my other medications, she had a lousy attitude and said I would be last. On January 22, 2024 at 10:55 AM, R3 said, [V3] had an attitude. Usually, the nurses go room to room to give medications. She came to work around 9:00 AM. She said, You have to line up at the medication cart,, do you see these other people, they are all in line, you have to wait. I asked for medication, and she gave me attitude. On January 22, 2024 at 12:48 PM, V9 (CNA-Certified Nursing Assistant) said, I saw [V3] (Agency LPN) was rude to the residents and wasn't very respectful. She was that way to everybody, all of the residents. She was irritated. She kept giving a reason why she was busy. I have never seen [R1] get physical and grab someone's hair. She really does not come out of her room. She cannot run after anyone. She uses a cane. On January 22, 2024 at 1:06 PM, V10 (CNA) said, I worked here that day. It was a busy day. We were short a CNA, and that nurse (V3) came late. I never met [V3] before. It would be out of character for [R1] to hit someone. She can be angry but be respectful. She can use her words sometimes, and say she's upset. She has a limp and walks with a cane. [V3] (Agency LPN) was expecting the residents to come to the desk to get their medications. I was actually on my break when the incident happened. When I got back, a police officer was here. I saw [R1] right after the incident. She was bawling and said, I don't know why she would do this to me. She told me that [V3] pulled her hair and pushed her on the ground. [R2] was asking for anti-nausea medication and [V3] was rude and said you have to hold on, you have to give me a second. On January 22, 2024 at 1:26 PM, V11 (CNA) said, I was here that day (January 7, 2024). That was my assigned hallway. I was on my lunch break. I did not hear about it until I came back. When I came back, there was an ambulance, and the police were here. [R1] called me over and told me what happened. She said the nurse tried to give her medicine and [R1] told [V3] (Agency LPN) she had waited quite some time and the nurse got upset, and [R1] threw her medication. I was surprised because [R1] has never been rude or aggressive towards me. I have never seen her hit or scratch someone. She was crying. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, acute respiratory failure with hypoxia, COPD (Chronic Obstructive Pulmonary Disease), cerebral infarction, heart disease, traumatic subarachnoid hemorrhage, muscle weakness, cognitive communication deficit, abnormal gait and mobility, lack of coordination, abnormal posture, need for assistance with personal care, falls, hypertension, anxiety disorder, and major depressive disorder. R1's MDS (Minimum Data Set) dated January 4, 2024 shows R1 is cognitively intact, has a lower extremity functional limitation in range of motion on one side and uses a cane for mobility. R1 is able to eat and dress her upper body independently, requires supervision with transfers between surfaces and walking, and partial/moderate assistance with oral hygiene, toilet hygiene, showering, lower body dressing, and personal hygiene. R1 is occasionally incontinent of bowel and bladder. R1's care plan, initiated July 24, 2023, shows R1 is high risk to be susceptible to abuse and/or neglect. This is determined by the resident's comprehensive assessment revealing a history of abuse, resident's physical and mental condition and/or compromised medical health. Interventions initiated on July 24, 2023 include: Assure resident that she is in a safe and secure environment with caring professionals to help, assure resident that staff members are here to help, explain that psychological adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse and/or CNA) and by verbalizing thoughts, needs, and feelings. Observe resident for signs of fear and insecurity during delivery of care. Take steps to calm resident to make her feel safe. The facility's undated Final Incident Investigation Report Form, received by the State Agency on January 12, 2024 shows: Upon further investigations, the incident was substantiated as the nurse [V3] (Agency LPN) was acting unprofessional to a point that it escalated this incident where the resident (R1) needs to be physically controlled and lowered down to floor for her safety. The police, NP/MD (Nurse Practitioner/Medical Doctor) and family members were informed, and the Resident was assessed by the nurses for injuries and was sent to the local hospital for evaluation. No injury was noted. The Final Incident Investigation Report Form continues to show the facility substantiated R1 was abused by V3 (Agency LPN). The local police department Field Case Report dated January 7, 2024 shows, On arrival, I went to [R1's room]. [R1] was crying, incredibly emotional, and unable to speak clearly. [R1] had a red mark on her left cheek, which appeared to be bleeding . On January 22, 2024 at 3:37 PM, V12 (Police Officer) said, We arrested [V3] (Agency LPN). I was present for the arrest part. [V3] was charged with aggravated battery. It was because she hit the resident. Aggravated means because the victim was over 65 or disabled. [V14] (Police Officer) must have had probable cause to arrest [V3]. There had to be video surveillance or marks on the victim (R1). I am reading the notes of the police report. [R1] had a red mark on her left cheek which appeared to be bleeding. In the report it is noted [V3] had called a supervisor and told the supervisor she had engaged physically with [R1] because of some aggression. It says [V3] had also stated she had to go hands-on after a scuffle with the patient. The probable cause would have been the admission of the physicality of the incident, the marks on the victim, and advised to pursue charges. On January 22, 2024 at 9:24 AM, and on January 22, 2024 at 3:54 PM, V1 (Administrator) said, R1 does not have a history of violent outbursts or attacking staff or residents. V1 continued to say the facility does not have behavior tracking for R1. V1 said, I substantiated the allegation as physical abuse based on the interview, and that [V3] physically held [R1] and put her down on the ground. On January 25, 2024 at 10:29 AM, V17 (NP-Nurse Practitioner) said she examined R1 on January 8, 2024. V17 said, I am familiar with [R1]. I have never known her to be physically aggressive with anyone. When I saw her she complained of scalp and neck soreness. I documented the resident had a neck sprain based on what [R1] was saying. No resident should be abused while residing in a facility. The facility's policy entitled; Abuse Prevention Program - Policy adopted 1/20 shows: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Immediate Jeopardy that began on January 7, 2024 was removed on January 25, 2024 when the facility took the following actions to remove the immediacy: On January 7, 2024, once the abuse allegation was reported, V3 (Agency LPN) was removed immediately from residents' presence and sent home pending investigation, but subsequently arrested in the parking lot by the local police, who were called by the facility. On January 7, 2024, resident was examined by Charge Nurse who notified the Attending Physician and transferred resident to the local hospital for evaluation of injuries. She returned to facility the same evening. On January 7, 2024, Charge Nurse notified V18 (Daughter of R1) of incident and need for hospital visit. On January 8, 2024, R1 was examined in facility by V17 (NP-Nurse Practitioner). On January 25, 2024, the facility began re-educating the current staff, including agency staff on abuse prevention. This re-education will continue until all staff have been re-educated by January 27, 2024. Focus of re-education includes: • Managing residents with behaviors/agitation • Abuse • Burn-out • Identifying triggers • Screening • Types • Reporting • Investigating • Consequences/Discipline • Post-Test Beginning January 25, 2024 and ongoing, all future staff, including agency staff, will be mandated to receive abuse training from Administrator or Designee prior to caring for residents. Training will include the information listed above. Beginning January 25, 2024 and ongoing, all future agency nurses will be mandated to arrive at facility prior to start of their shift for general orientation. Beginning January 25, 2024 and ongoing, Human Resources Director will obtain the healthcare background check and license lookup on all future agency staff nurses prior to starting orientation. As of January 25, 2024 and ongoing, R1 is being followed by in-house caseworkers and Social Service Department. R1's pain is continually being managed by medication as prescribed by Attending Physician. On January 26, 2024, R1 was seen by the psychiatrist. V1 (Administrator) will be responsible for overall compliance to plan of correction in conjunction with V2 (DON) by actively participating in the general orientation process, ensuring all mandated in-services are completed prior to resident care. The general orientation checklist and abuse post-test will be maintained in the employees' files for future reference. The QAQI (Quality Assurance Quality Improvement) Team meets monthly. This event will also be brought to the next monthly QAQI Team meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly.