**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the administration failed to develop behavior management policies; failed to perform resident background checks within 24 hours of admission; failed to follow the facility's Identified Offender Policy and Procedure resulting in residents with a history of qualifying identified offender criminal conviction offenses being admitted to the facility for treatment for mental health services, without having an adequate amount of staff or adequate staff training on managing mental health disorders and behaviors, without care planning or acquiring specialized needs services as documented on those residents' PASRR (Pre-admission Screening and Resident Review) Level II screenings and their pre-admission screenings; failed to ensure resident behavioral health needs were met and behavioral interventions were developed and implemented, failed to ensure the facility's discharge policy was followed, failed to ensure the facility provided adequate direct care staff and social service staff to provide behavioral health needs, failed to ensure a licensed administrator conducted thorough abuse investigations, and failed to ensure residents were protected from abuse. These failures resulted in residents having an unsafe environment, residents exhibiting increased behaviors causing multiple resident to resident abuse altercations, resident rights not being protected, staff experiencing burnout and frustration, and residents being involuntarily discharged to a homeless shelter and a long-term care facility that was unable to meet this resident's needs prior to admission. These failures have the potential to affect all 131 residents within the facility. These failures resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy started on 12-4-23 when the facility admitted R37 who was a known high risk identified offender and did not inform staff or implement a plan of care to address R37's identified offender behavioral interventions, did not provide adequate supervision of R37 to prevent resident-to-resident altercations, and did not provide R37 a private room. V1 (Administrator-In-Training) was notified of the Immediate Jeopardy on 2-9-24 at 9:45 AM. While the immediacy was removed on 2-9-24, the facility remains out of compliance at a severity Level II as the facility continues to in-service all staff and newly hired staff on Emergency Care: Behavior Problem policies and watches facility training videos: How to Strategies for Intervening with Challenging Individuals, as well as Calming the Agitated Resident two times a month for three months, all residents' care plans are reviewed quarterly, or sooner, including behaviors and interventions focusing on residents with Level II PASRR's, by the Care Plan Coordinator (V30) and other members of IDT (Inter-Disciplinary Team), and all abuse investigations will be reviewed for thoroughness by a Licensed Nursing Home Administrator or Regional Director until the next QA (Quality Assurance) meeting. Regional Directors will monitor compliance of the above mentioned through internal QA process quarterly. The facility's Midnight Census form (dated 1-29-24) indicates that 131 residents are currently residing in the facility. On 2-2-24 at 12:00 PM V2 (Director of Nursing) provided a list that documents 32 residents (R1, R3, R4, R7, R8, R10, R12, R13, R16, R21, R25, R26, R27, R32, R35, R36, R37, R42, R56, R57, R58, R59, R61, R62, R63, R64, R67, R68, R69, R70, R73, R75) have a level two PASRR (Preadmission Screening and Resident Review) indicating R1, R3, R4, R7, R8, R10, R12, R13, R16, R21, R25, R26, R27, R32, R35, R36, R37, R42, R56, R57, R58, R59, R61, R62, R63, R64, R67, R68, R69, R70, R73, and R75 have mental illness requiring specialized mental health services. R1, R3, R4, R7, R8, R10, R12, R13, R16, R21, R25, R26, R27, R32, R35, R36, R37, R42, R56, R57, R58, R59, R61, R62, R63, R64, R67, R68, R69, R70, R73, and R75's current Care Plans do not include level two PASRR recommendations. 1. R2's Social Services Note Late Entry dated 9-5-23 at 10:08 AM and signed by V26 (Prior Social Service Director) documents, (R2) was involved in an alleged altercation with a female peer (R3) on 9-4-23. R2's Progress Notes dated 11-1-23 at 10:52 PM and signed by V24 (RN/Registered Nurse) documents, (R2) reportedly spitting multiple times on peers today. R2's Progress Notes dated 11-12-23 at 12:35 PM and signed by V24 (RN/Registered Nurse) documents, (R2) reportedly spit on a peer today. Re-directed and behavior not reported by peer again. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R2 was in a physical altercation with R1 on 1-25-24 and R2 was in a physical altercation with R5 on 1-6-24. R2's current Care Plan does not include interventions addressing R2 spitting on other residents, addressing R2 targeting R1, and addressing R2 kicking R1 in the face on 1-25-24. R2's Social Services Notes dated 1-30-24 at 2:24 PM and signed by V14 (Social Service Director) documents R2 will be moving to another long-term care facility. 2. R11's current Face Sheet documents R11 admitted to the facility on [DATE]. This same document lists R11 as being his own responsible party. R11's CHIRP (Criminal History Information Response Process) dated 12-22-2020 documents, Result: HIT. R11's CHIRP documents several convictions, Retail theft, possession of cannabis, criminal damage to property, coin machine theft, and theft. The following convictions are included on the identified offender list: Retail theft, Coin machine theft, and theft. Although requested, this was the only background check document the facility was able to provide that was completed on R11. R11's Care Plan dated 11-20-23 to 1-23-24 does not include a plan of care to address R11's CHIRP document indicating R11 was an identified offender. R11's Medical Record and Business Office Record does not include a request for a live scan State and Federal Bureau of Investigation (FBI) fingerprint check. R11's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing Nursing Home Residents form dated 1-23-24 documents an emergency transfer or discharge issued to R11 on 1-23-24 due to the safety of individuals in (the facility) being endangered. 3. R37's IDPH (Illinois Department of Public Health) Identified Offender Program Criminal History Analysis Security Recommendation Report dated 10-5-18 and signed by V55 (Clinical Psychologists) and V56 (Clinical Psychologists) documents, (R37) is high risk. (R37) has convictions for violate order protection, retail theft offenses three times, disorderly conduct, domestic battery/bodily harm, and possession liquor by minor. (R37) has a history of substance abuse and many physical difficulties as the result of a traumatic brain injury. (R37) is dysphagic, paraplegic, and uses a wheelchair to ambulate. Since his admission (to another facility) on August 27, 2018, he has been both verbally and physically aggressive. He has been involved in verbal altercations with other residents and threw a urinal full of urine on another resident. He had threatened to kill his roommate as he felt he was stealing from him. He has been verbally aggressive at his last placement at (another long-term care facility). His compliance with medical treatment and abstinence from alcohol/drug use should be closely monitored. I would deem (R37) a high risk due to verbal aggression, threats to kill another resident, and his throwing a urinal at another resident. R37's Face Sheet documents R37 was admitted to the facility on [DATE]. R37's Care Plan dated 12-4-23 to 2-5-24 does not include a plan of care to address R37 being a high risk identified offender with the recommendations as documented on R37's IDPH Identified Offender Program Criminal History Analysis Security Recommendation Report dated 10-5-18. R2, R4, R7, R8, R13, R17, R21, R25, R26, R32, R42, R56, R64, R66, R68, R69, R70, R71, R73, and R76's Business Office File and Medical Records do not contain evidence of the facility obtaining background checks of these residents since admission to the facility. R3, R27, R34, R36, R54, R57, R59, and R75 UCIA (Uniform Conviction Information Act) background checks document R3, R27, R34, R36, R54, R57, R59, and R75 had a documented hit that would require criminal fingerprinting to be conducted to determine of a resident is high, moderate, or low risk offender. No fingerprinting has yet to be conducted for R3, R27, R34, R36, R54, R57, R59, and R75. The facility's 2023-2024 Identified Offenders List documents R3, R18, R27, R34, R36, R37, R41, R44, R48, R49, R50, R51, R53, R54, R56, R57, R59, and R75 are identified offenders. R27, R37, R51, and R57's current care plans do not include a plan of care that addresses the identified offender risks and interventions to address those risks. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R37 was in a verbal altercation with R71 on 2-4-24, R37 was in a physical altercation with R25 on 2-4-24 and was in a physical altercation with R46 on 1-30-24. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R27 was in a verbal altercation with R25 on 2-2-24. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R57 had a verbal altercation with R66 on 2-4-24 and 1-10-24 and R57 had a physical altercation with R66 on 12-10-23. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R35 was in a verbal altercation with R42 on 2-2-24, was in a physical altercation with R73 on 12-18-23, R68 was in a verbal altercation with R72 on 12-15-23, R10 was in a physical altercation with R66 on 12-21-23, R25 was in a physical altercation with R40 on 12-19-23, and R66 was in a verbal altercation with R12 on 1-22-24. The facility's Abuse Log dated November 2023 to current date (February 6, 2024) documents R44 was in a verbal altercation with R7 on 12-26-23, R44 was in a physical altercation with R30 on 12-26-23. On 1-29-24 at 10:30 AM R1 was sitting in a recliner in the sitting area across from the nurse's desk. R1's left eye was surrounded with golf-ball sized purple bruising with a 3 cm (centimeter) by 1 cm hematoma beneath the left eye. R1 had a 3 cm laceration to the left eyelid that was approximated with steri-strips. R1 had a 1 cm laceration to the right side of her nose that was approximated with a steri-strip. R1 stated, I was sitting on the floor in my doorway and (R2) came up and kicked me three times in the face and then stomped on me. It hurt really bad. I grabbed (R2's) leg and yelled for help. (R2) threw water on me the day before and spits on me. I was abused. I was scared of (R2). (R2) always walked by me and would call me bad names. On 1-29-24 at 11:05 AM R3 was well-groomed and alert and orientated. R3 stated, (R2) always asks me for a phone to call her brother. I do not have a phone. If I do not give (R2) a phone she calls me a b***h. (R2) spit on me a month ago in the dayroom. (R2) called me a b***h yesterday. (R2) calls me a b***h about three to four times a week. I am tired of it. (R2) has also hit me in the cheek because I would not give her my soda. I try to stay away from her. Next time (R2) touches me I will hit her back! On 1-29-24 at 12:45 PM R5 was lying flat in his bed. R5 was groomed appropriately, and no odors were noted. V4 (AIT) was in R5's room. R5 stated, Around a month ago this black lady (R2) and I got into an argument in the hallway. (R2) called me a little b***h and calls other residents b*****s. (R2) is very mean. Right when I turned around R5 hit me in the back of my head. (R2) has anger issues and I am scared to even be around her. I sit in my room a lot to stay far away from her because you never know when she will just go off. On 1-29-24 from 1:10 PM through 1:45 PM and on 1-30-24 from 11:00 AM through 11:45 AM R2 was walking around without staff supervision throughout the hallways, dining room, and sitting area. All other residents who reside on the same unit (R3, R5, R12-R47) as R2 were in the dining room, sitting area, and hallways where R2 was wandering around unsupervised. On 2-6-24 at 9:45 AM R37 was in the room with his roommate R67. R37 was not in a private room as recommended by his IDPH Identified Offender Program. On 2-6-24 at 10:00 AM V1 (Administrator-In-Training/AIT) provided a list of current staff who have not received behavioral training for mental illness, or CPI (Crisis Prevention and Intervention) Nonviolent Crisis Training. This list documents V1 (AIT), V2 (Director of Nursing), V4 (AIT), V7 (CNA/Certified Nursing Assistant), V8 (CNA), V12 (CNA), V17 (Laundry Aide), V20 (CNA), V24 (Agency RN/Registered Nurse), V25 (Prior Administrator), V30 (Care Plan Coordinator), V37 (CNA), V38 (CNA), V39 (CNA, V40 (CNA), V41 (CNA), V42 (CNA), V43 (Unit Aide), V44 (Unit Aide), V46 (CNA), V47 (CNA), V48 (LPN/Licensed Practical Nurse), V49 (LPN), V50 (Nursing Assistant), V51 (Nursing Assistant), V52 (CNA), V53 (CNA), V54 (CNA), V55 (CNA), V57 (CNA), and V58 (CNA) have not received the CPI Nonviolent Crisis Interventions Training. The facility's Annual Mandatory Training Log dated 1-1-23 through 12-31-23 documents staff should be trained annually on behavior management. This same document indicates no staff has been trained within the last year on behavioral management. The facility's CNA staffing sheets dated 1-16-24 through 1-22-24 and signed by V4 (Administrator-In-Training/AIT) document the facility did not have the required amount of CNA staff needed according to the facility's minimum staff calculator to meet the needs of the residents. On 1-29-24 at 2:00 PM, V4 (Administrator in Training) confirmed that the daily CNA staffing sheets (dated 1-16-24 through 1-22-24) were accurate and staffing was below (the facility's) minimum requirements based off the staffing calculator utilized to determine staffing needs. V58's (CNA) Notice of Termination form dated 9-12-23 documents V58 was terminated from employment immediately due to an inappropriate interaction with a resident. V58's Employee Business File documents V58 was re-hired to the facility on 1-25-24. On 1-29-24 at 9:45 AM V1 stated (the facility) had to initiate an emergency involuntary discharge to R11 because R11 was spitting on staff and entering staff areas without permission, and the facility had several staff walk out because of R11. V1 stated she did not know R11 was an identified offender and the facility emergency discharged R11 to (homeless shelter). On 1-29-24 at 10:05 AM V8 (CNA) stated, We could use some more staff here. It is hard to get everyone up and dressed and deal with residents' behaviors with the number of staff we have now. On 1-29-24 at 10:30 AM V7 (CNA) stated, We do not have enough staff here. Most resident have behaviors or mental health concerns. There is not enough staff to supervise all of the residents with behaviors. The staff here are getting burned out. On 1-29-24 at 2:00 PM V1 stated she was unaware when she re-hired V58 that V58 had been terminated from employment on 9-12-23 for an inappropriate interaction with a resident. On 1-29-24 at 2:10 PM V17 (Laundry Aide) stated, I have never been trained in de-escalating behaviors. On 1-30-24 at 11:19 AM V59 (LPN/Licensed Practical Nurse) and V60 (LPN) stated they are unaware of any policies readily available to them regarding dealing with mental illness and behaviors. On 1-31-24 at 2:05 PM R10 stated, I had a camera I wanted to use so the facility could see how staff was treating me and my roommate (R11). (V25/Prior Administrator) came into my room and took my camera without my permission. I have not seen the camera since. I bought the camera with my own money. I have my own hot spot on my phone that I can use for Wi-Fi connection. I do not need the facility's Wi-Fi. (V25) never offered to have me sign a consent form to use the camera. I would have signed the consent form so I can use my camera. The facility will try anything in their ability to allow me to not be able to use my camera. On 2-1-24 at 1:15 PM R11 stated, I lived at (the facility) for three years and have had no issues until (V25/prior Administrator) started to come into me and my roommate's room without my permission. (V25) was taking my roommates items without his permission. I confronted (V25) about it, and (V25) then put his foot in front of my wheelchair and would not let me move forward. I was tired of seeing the way administration was treating other residents, so I started advocating for the other residents and staff did not like it. Staff would laugh at me and treat me like an animal. They were treating me like a dog and making me stay in my room like I was in a prison around there (the facility). When I would say something back to the staff, I was told that staff were quitting because of me and that they would have to discharge me. I had put in an appeal and the facility did not even allow me to meet for the appeal. They decided to hurry up and do an emergency discharge right before the appeal (1-30-24) because their reasoning was staff were quitting because of me. I was forced to leave by the facility calling the police and intimidating me with the police. I had to go to the (homeless shelter). The (homeless shelter) was unable to accommodate my wheelchair to enter the building, I am sleeping on a floor which has caused me to be in excruciating pain due to my lower back. I have had major chest pains, and I am a nervous wreck. I am angry and I am scared I will not find anywhere to live or have transportation to make it to any doctor's appointments. I miss the staff at the facility that treated me good. On 2-2-24 at 10:30 AM V14 (Social Service Director) stated, I did not know PASRR level II's existed. All residents with PASRR level II recommendations have not had care plans developed with those recommendations. On 2-2-24 at 11:15 AM V33 (R2's POA/Power of Attorney) stated, The facility admitted (R2) from the same facility that they just discharged (R2) back to on Wednesday. That facility was not able to manage (R2's) behaviors either. I did not want (R2) to go back to that same facility. I did not even get a chance to decide on whether I was okay for the facility to transfer (R2) to another facility. (R2) had major behaviors when living at that facility before. The facility left messages on my phone and did not get my permission before sending (R2) to another facility. I called the facility and was told they had already transferred (R2) back to the old facility again because (R2) was having behaviors that they facility could not manage. The facility knew (R2) had behaviors when they accepted (R2) that she had major behaviors. (R2's) behaviors is the reason why the prior facility transferred her to this facility. (V14Social Service Director) told me the facility transferred (R2) to another facility so that (R2) would have a clean medical record regarding (R2's) behaviors and that would allow (R2) to get closer to me eventually. (R2) has had increased behaviors and anxiety the last two days since being sent to the other facility, and (R2) has been blowing up my phone. On 2-2-24 at 11:30 AM V14 (Social Service Director) stated, I tried to call (V33) four times on 1-30-24 about the facility transferring (R2) to another facility. (V33) did not answer. The other facility was a safer place for (R2). (V33) called me back the next day on 1-31-24 and I let him know we transferred (R2) to the other facility. (V33) did not really like that (R2) was transferred to the facility that she had was at before. V14 stated she was not aware of any documentation in R2's record of the needs the facility could not provide to R2 or the interventions attempted to meet those needs prior to transferring R2 to another facility. On 2-2-24 at 1:00 PM V54 (Business Office Manager/BOM) stated, I am responsible to ensure any resident that has a HIT with a qualifying conviction on their background check, gets set up for fingerprinting. I follow our policy and guidelines to ensure every step is being taken and things are followed appropriately. Once a HIT is identified we will put that resident in a private room until all steps have been completed per policy and we receive an email from the state police that lists security measures and recommendations for an identified offender. The report usually states if the resident is at low, moderate, or high risk with recommendations. V54 acknowledge R11 is an identified offender and confirmed that the only paperwork she could locate was R11's background check. V54 stated she was not here when R11 admitted , but she is now conducting a facility wide audit to ensure correct resident offender status. V54 also confirmed R11 had a roommate (R10) while residing at the facility. On 2-2-24 at 1:15 PM V18 (Corporate Regional Nurse) verified R11 is an identified offender. V18 stated the facility must have not set up R11 to have fingerprints done because (the facility) cannot find any documentation that R11 was ever set up for fingerprints. On 2-2-24 at 3:34 PM V37 (CNA) stated, I have worked at the facility for around six months. (R11) had very few behaviors when I first worked for him. Within the last couple months, I noticed his behaviors were increasing. I believe it was after the involuntary discharge was given to him. I never see (R11) get physical with residents. There was one time a resident was talking to herself and (R11) went up to her and started to be bossy, but that's about it. The facility did not train me or tell me behavioral interventions to deal with (R11's) behaviors besides getting the nurse. I never received any behavioral training. I was not taught any other behavior interventions to deal with (R11). On 2-6-24 at 2:00 PM V1 and V54 (BOM) both stated they were not aware that R37 was a high risk identified and needed a private room. V1 and V54 both stated R37 has had a roommate (R67) since admission on [DATE]. On 2-7-24 at 2:00 PM V16 (CNA Supervisor) verified she tracks the employee trainings and the employees have not received behavioral management training since last year. The facility's Administrator's Job Description (undated) documents, The administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting, and the physical management of the facility, residents, and equipment in a way that the purpose of the facility shall be maintained in accordance with all established practices, policies, laws, and applicable State Regulations. The Administrator will manage and conduct the business of the facility in a manner that protects the facility licensed and certification at all times. The major goal of the Administrator is to provide an atmosphere in which residents may achieve their highest physical, mental, and social well-being. Responsibilities: 1. Operate the facility in compliance with all Federal and State rules and regulations. 2. Operate the facility in accordance with established policies and procedures. 5. Ensure that an adequate number of appropriately trained professional and auxiliary personnel are on duty at all times to meet the needs of the residents. Resident Rights: 2. Ensure that the resident's rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints are well established and maintained at all times. 5. Ensure that policies governing a timely notice for resident discharges and room, or roommate changes are strictly followed by all personnel. Administrative Functions: 2. Maintain written policies and procedures that govern the operation of the facility. 6. Ensure that all employees, residents, and visitors follow established policies and procedures. 14. Ensure that appropriate policies and procedures are followed when conducting background checks and when providing information to the Nurse Aide Registry. The facility's Identified Offender Policy and Procedure documents, Policy Statement: It is the policy of this facility to establish a resident sensitive and resident secure environment. In accordance with the provisions of the Nursing Home Care Act, this facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. It is the policy of (the facility) that no person will be admitted if they are sex offenders. Responsibility: Administrator or a person designated by the Administrator. Identifying Offenders: 3. Conduct a Criminal History Background Check: Within 24 hours of admission, request a name-based Uniform Conviction Information ACT (UCIA) criminal history background check based on name, date of birth , and other identifiers required by the Department of State Police for any resident seeking admission to the facility. 4. Check the UCIA response against the statue citation numbers from IDPH (Illinois Department of Public Health) identified offender conviction list and the IDPH sex offenses list. b. If the UCIA response contains convictions that match the identified offender or sex offender statute citation numbers, the resident is an identified offender and must be reported to Identified Offenders Program. Reporting Results If the Resident is an Identified Offender: 1. Once the facility determines the resident is an Identified Offender, the facility must request in 72 hours for the resident to undergo a live scan State and Federal Bureau of Investigation (FBI) fingerprint check within five business days. 2. Immediately complete and submit the IDPH Identified Offender Information (IOI) form attached and fax it to the IDPH Identified Offender Program (IOP) along with a copy of the UCIA response. 4. After the confirmation from the (IOP), the facility will receive a phone call from the Illinois State Police Division of Internal Investigation within three business days scheduling an on-site facility interview with the resident and the administrator. 6. The facility will receive an Identified Offender Report and Recommendations within four to six weeks. The identified Offender Report Recommendations shall detail whether and to what extent the Identified Offender's criminal history necessitates the implementation of security measure with the long-term care facility. The Identified Offender Report and Recommendations shall be incorporated into the facility's plan of care. Maintain written documentation of compliance with the above requirement. The Facility Assessment Policy (reviewed 10-23-23) documents the following: Resident admission based on common diseases, conditions, physical and cognitive disabilities, or a combination of conditions that require complex medical care and condition management. The list below describes residents' that (the facility) accommodates for and regularly manages. Category: Psychiatric/Mood disorder- Psychosis, Hallucinations (auditory), delusions, mental disorders, MR (Mental Retardation) disorders, anxiety, schizoaffective disorder, bipolar disorder, PTSD (Post Traumatic Stress Disorder), behavior requiring interventions, suicidal ideations, and hx (history) of substance abuse. Evaluation of the overall number of facility (direct care) staff members to ensure a sufficient number of qualified staff is determined based on the number of residents requiring skilled services. (The facility) acuity level to assist in identifying the intensity of care and services needed to provide and meet resident care needs: Special Treatments and Conditions- Behavioral Health Needs- 123 average number of residents. The Illinois Department of Public Health (IDPH) Identified Offenders Program Criminal History Analysis Security Recommendation Report (undated) documents, High Risk-The resident requires a single room in close proximity to the nursing station to permit ongoing visual monitoring. The level of observation should be sufficient for early detection of behavioral changes. Regular assessment is necessary to determine whether closer monitoring or more frequent individual contact is indicated. Moderate Risk-The resident requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral changes that may signal a need for closer observation or sustained visual monitoring on a time-limited basis. Periodic assessments should ascertain whether the level of supervision is sufficient. Low Risk-the resident is subject to standard requirements for supervision in an open facility. Behavioral changes suggesting a need for closer observation should be noted and responded to according to standard facility procedures. On 2-14-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediacy: 1. On 2-7-24 V34 (Medical Director) reviewed and approved the Emergency Care: Behavior Problem policy. 2. On 2-7-24 V18 (Corporate Regional Nurse) in-serviced V1 (AIT) and V4 (AIT) on Emergency Care: Behavior Problem and on the facility assessment regarding services and cares the facility is able to provide based on residents needs/diagnoses. 3. On 2-7-24 V1 (AIT) in-serviced the IDT (Inter-Disciplinary Team) and Nursing Staff regarding the Emergency Care: Behavior Problem policy and on the facility assessment regarding services and cares the facility is able to provide based on residents needs/diagnoses. 4. All staff prior to their next scheduled shifts reviewed the facility training videos: How to Strategies for Intervening with Challenging Individuals, as well as Calming the Agitated Resident and were in-serviced on 2-7-24 by V1 (AIT) and/or IDT designee on Emergency Care: Behavior Problem revised policy. 5. On 2-7-24 V1 (AIT) and/or IDT designated staff in-serviced all staff on any newly developed resident behavior interventions and where in (Electronic Medical Record) monitored behaviors and interventions are located. 6. On 2-2-24 V18 in-serviced Social Service Staff regarding PASRR level II recommendations and implementation of recommendations. 7. On 2-9-24 V1 completed a screen of all employees, including re-hired staff for abusive backgrounds using IDPH (Illinois Department of Public Health) healthcare worker registry. 8. On 2-13-24 and 2-14-24 V61 (Trained CPI Instructor) trained staff currently not certified in CPI. 9. On 2/9/24 a staff survey was made available for staff to complete for recommendations on improved employee engagement and burnout and a PIP (Plan of Improvement) was developed to include front line staff. 10. The facility continued to follow and implement the plan to accrue more staff to meet the needs of the mental health residents and residents with behavioral needs and the IDT Team reviewed the staffing PIP on 2/9/24. 11. On 2/9/24 V62 (Director of a Behavioral Management Company), has been scheduled through 2/16/2024 to complete training in regard to staff burnout and stress and ways to deal with it focusing on how to deal with residents with mental illness. 12. On 2-9-24 the Facility QA Team initiated a Behavior Management PIP focused on Abuse including resident to resident abuse, to aide in promoting an abuse free environment. 13. On 2-2-24 V18 in-serviced V4 on the thoroughness of abuse investigations. 14. On 2-9-24 V54 (Business Office Manager) completed all current resident background checks. 15. On 2-9-24 V54 ensured all identified offenders with qualifying convictions were fingerprinted. 16. On 2-9-24 V31 (MDS Coordinator) implemented care plans of all residents who are identified offenders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to remove an alleged perpetrator V4 (Certified Nursing Assistant) from resident cares following staff (V4) to resident verbal abuse, failed to protect residents from an alleged abuser (V4), and failed to recognize verbal abuse for one of three residents (R1) reviewed for abuse in the sample of three. These failures resulted in V4 returning to work with all residents within the facility after verbally abusing R1, resulting in R1 feeling angry and experiencing fear. These failures have the potential to affect all 134 residents residing within the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9-6-23 when the facility failed to remove V4 (Certified Nurse Assistant/CNA) from the facility after verbally abusing R1 and failed to protect R1 and all other residents from V4 after V4 verbally abused R1. V1 (Administrator) and V9 (Activity Director) were notified of the Immediate Jeopardy on 9-8-23 at 2:28 PM. The immediacy was removed on 9-8-23. On 9-13-23 the surveyor confirmed through observation, interview, and record review that the facility took actions to remove the Immediate Jeopardy. While the immediacy was removed, the facility remains out of compliance at a severity Level II as the facility continues to train staff and all new staff on the abuse policy weekly for four weeks, then monthly for four months, and then quarterly, the Quality Assurance (QA) monitors the abuse training, and the QA identifies residents at risk of abuse and care plan as appropriate, including new admission residents. Findings include: The facility's Abuse Prevention Program policy dated 05/2021 documents, This facility affirms the right of our resident to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The facility is committed to protecting our residents from abuse by anyone including facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members, or legal guardians, friends, or any other individuals. Protection of Residents: The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property while the investigation is underway. Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse, or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed. The facility's CMS (Centers for Medicare and Medicaid Services) Form 672 dated 9-8-23 and signed by V1 (Administrator) documents 134 residents reside within the facility. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is a [AGE] year-old admitted to the facility on [DATE]. This same MDS documents R1 is cognitively intact and requires extensive assistance of staff for all ADLs (Activities of Daily Living). R1's Illinois Department of Public Health Notification Form dated 9-6-23 and signed by V1 (Administrator) documents, On this date (R1) reported that two CNAs were verbally abuse towards him. Time of Incident: 12:30 PM. The facility's Incident Investigation Forms (undated) and signed by V1 (Administrator) document R1, V3 (CNA), and V7 (CNA) reported to V1 that V4 verbally abused (sic) R1 in the dining room on 9-6-23 at 12:30 PM. On 9-8-23 at 8:30 AM V3 (CNA) stated V4 verbally abused R1 while in the dining room on 9-6-23 at 12:30 PM and V4 is still working within the facility with all the residents. On 9-8-23 at 10:10 AM R1 was sitting in a wheelchair in his room. R1 was alert and orientated to person, place, and time. R1 stated with tears in his eyes, On Wednesday (9-6-23) at lunchtime I was trying to eat Chinese food that I had for lunch. (V4) is always mean to me and never wants to help me. I asked (V4) for help eating and (V4) said to me I am not helping you. You are an a**. I called (V4) names and (V4) said to me, Stop f*****g talking to me! I have reported this to (V1 Administrator) and V8 (Social Service Assistant/SSA). Something needs to be done with (V4) or I am going to get legal advice. (V4) should not talk to me that way. I felt abused and it made me cry. I am still upset over it. (V4) is still here today. I do not want her (V4) anywhere around me. On 9-8-23 at 10:25 AM R1 was sitting in the sitting area in front of the nurse's desk. V4 was standing within one foot of R1 at this time. R1 had his head down. On 9-8-23 at 10:30 AM V4 stated, (R1) refuses cares from me and on Wednesday (9-6-23) (R1) was talking about his egg roll. I said something about the egg roll and (R1) said to me It is none of your business you f*****g b***h. I responded to (R1) and asked him to not talk to me and please leave me alone. I was allowed to return to work today and was not told that I could not take care of (R1). I am able to help take care of all of the residents within the facility whenever other CNA's need help or when I am in the dining room. On 9-8-23 at 11:00 AM V7 (CNA) stated V4 verbally abused R1 in the dining room on 9-6-23 around 12:30 PM and is working today (9-8-23) with the residents. On 9-8-23 at 11:35 AM V1 (Administrator) stated, I did not consider it willful when (V4) cussed at (R1). I did not feel like cussing at (R1) was verbal abuse. I allowed (V4) to return to work today. (V4) really should not have been able to work with (R1), but I did not make that clear to (V4). (V4) really should not have been on the hallway with (R1) today. On 9-13-23 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V15 (Regional Director of Operations) in-serviced V1 (Administrator) on the facility's Abuse Policy, types of abuse, and how to respond to resident behaviors on 9-8-23. 2. The facility Social Service department and designees interviewed all appropriate residents regarding feeling safe and comfortable in the facility on 9-8-23. 3. V1 in-serviced all staff on 9-8-23 on the facility's Abuse Policy, types of abuse, how to reduce resident behaviors, abuse prevention, and how to respond appropriately to resident behaviors. 4. V4 (Alleged Perpetrator) removed from the floor and schedule on 9-8-23. 5. Facility staff will continue to be trained by (V1) on how to reduce behaviors, abuse prevention and reporting weekly times four weeks then monthly times four and then quarterly and prn (as needed). 6. All newly hired staff will be trained by (V1) on how to respond appropriately to resident behaviors, abuse prevention and reporting. 7. The Quality Assurance (QA) team will monitor abuse in-servicing through the QA process and determine its effectiveness, and changes that may need to occur to ensure abuse training is effective to all staff. 8. The QA team will identify resident at risk of abuse of new admissions and care plan as appropriate. Completion Date: 9-8-23