**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adequately supervise a known wandering resident (R1), failed to have systems in place to monitor the front door alarms after hours and failed to have interventions in place for a known faulty (electronic wandering device) door alarm system for one (R1) of twenty-two residents reviewed for elopement/wandering. These failures resulted in R1, a moderately cognitively impaired resident with the diagnosis of Vascular Dementia, eloping from the facility to a grassy area out front of the building, by a curb, close to a busy road attempting to get on a city bus. This failure has the potential to affect all seven (R4-R10) Elopement Risk residents who reside off the secured floor in the facility.These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 8/28/25, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits.Findings include:The facility policy titled Door Alarm Policy, reviewed 8/22/25, documents but not limited to, It is the policy of Generations at Rock Island to ensure resident safety and security through the use of door alarms. All doors leading to the outside MUST meet these requirements: 1. The alarm must only be disengaged at the door itself, either by push button code or key. No alarm may be disengaged from the nurse's station or any other location without physical evidence gathered by a staff member of reason for trigger reported directly to the person silencing the alarm. 2. The alarm must ring continuously until physically disengaged through key or code. 3. Exit doors MUST NOT have the alarm codes posted. Door alarms require immediate attention and response by facility staff to ensure the safety of all residents.3. Immediate response requires any employee to physically go to the door that has an alarm sounding to establish why the alarm was triggered. 5. Testing (including actual activation) and documentation of testing will be completed weekly. Any malfunctions are to be reported to the Administrator and repaired as quickly as possible.R1's admission record documents R1's date of admission to the facility was 8/9/24 and his diagnoses include but are not limited to: Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease, Acute on Chronic Systolic (congestive) Heart Failure, Anxiety Disorder and Vascular Dementia Unspecified Severity with Agitation.R1's Minimum Data Set (MDS) Assessment, dated 6/2/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment, documents R1 has non-Alzheimer's dementia and documents R1's ambulation for distances over 10 feet as supervision or touching assistance.R1's physician orders dated 4/6/25, documents R1 has an order for a (electronic wandering device) ankle bracelet to prevent elopement from facility and orders dated 4/7/25 to check/record (electronic wandering device) placement and function every shift.R1's current care plan documents R1 Has cognitive deficits related to vascular Dementia and non-traumatic intracerebral hemorrhage and at risk for wandering r/t (related to) dx (diagnosis) of dementia. At times will wander around without purpose. Has entered other rooms and easily redirected. (electronic wandering device) in place. R1's current Care Plan contains no documentation of R1's elopement risk prior to 8/1/25.R1's elopement risk assessment dated [DATE], documents R1 is an elopement risk with a score of four (4).On 8/26/25 at 3:00pm, V1 (Administrator) stated, We do not have any documentation stating what the elopement risk assessment score means but anything greater than a one (1) means they are at risk so probably the higher the score the greater risk.R1's Risk Management Report, dated 7/31/25, documents, Exit behavior actively attempting to leave building staff successful in redirecting and (V14/Licensed Practical Nurse/LPN) statement: I (V14/LPN) received a phone call from dispatch around 8:33pm making us aware that a resident was trying to get on the bus. I was outside bringing him (R1) back in the facility when the police arrived. The resident was still on the facility property in the grass near the smoking patio/courtyard. He did not leave the property. He was easily redirected back inside. We moved him to the 4th floor for heightened supervision and increased security.On 8/22/25 at 1:30pm, V14 (Licensed Practical Nurse/LPN) stated on 7/31/25 around 8:30pm he (V14) was getting off the elevator onto the first floor when he noted the front lobby door alarm was going off and the reception phone ringing. V14 (LPN) answered the phone, and the local police dispatch was calling to inform the facility of a suspected resident attempting to get on the bus. V14 (LPN) went outside and found R1 in a grassy area, next to the curb in front of the facility attempting to get on a city bus.On 8/22/25 at 1:50pm V1 (Administrator) and V2 (Administrator in Training/AIT) stated that the front door alarm will alarm on the panel at the nurse's station on the second floor.On 8/22/25 at 1:55pm observation of alarm panel on second floor at the nurse's station shows no door alarm sounding when V1 (Administrator) set off the door alarm. V14 (Licensed Practical Nurse/LPN) was present at second floor nurse station and verified that the front door alarm was not sounding on the panel at the nurse's station.On 8/22/25 at 2:00pm, V16 (Maintenance Director) stated that he became aware approximately the middle of July 2025 of an issue with the facility's (electronic wandering device) door alarm system not always working as it should, meaning it should alarm at the nurse's station on the second floor if set off but it does not always do this. V16 verified V16 did not notify V1 (Administrator) or attempt to contact the electronic wandering device company regarding the faulty system. At this time, V16 showed the panel on the second floor at the nurse's station where the electronic wandering device system will sometimes alarm if set off. When asked about the door alarm going off not related to the (electronic wandering device), V16 stated, I don't know of any panel except for the front reception desk that will alarm if the front door is alarming. V16 verified that the front door alarm cannot be heard over the alarm panel at the second-floor nurse's station.8/22/25 at 2:10pm V13 (Human Resources) stated, No, if the front door alarm goes off and it is not because of a (electronic wandering device) then I am not aware that it is heard on any of the floors except the reception desk.On 8/22/25 at 2:30pm, V1 (Administrator) was noticeably frustrated and stated today is the first she has heard anything about there being issues with the door alarms. V1 verified V16 did not report the facility's (electronic wandering device) door alarm system not always working as it should to V1.On 8/26/25 at 11:55am, V17 (Registered Nurse/RN) stated, I was R1's nurse the evening he got out of the building. Approximately 8:30pm I received a phone call on my personal cell phone from V14 (Licensed Practical Nurse/LPN) stating he (V14) was outside with R1 because he (R1) was trying to get on the bus. I went down to assist getting R1 back into the building and then called V2 (Administrator in Training/AIT) and told her what had occurred and was advised to move R1 to the 4th floor to the secured unit for increased safety. R1 was fully dressed in only socks on his feet when he was found but did have his (electronic wandering device) in place to his ankle. The (electronic wandering device) was checked to make sure it was functioning, and it showed that it was but unsure why the door did not stop him from going out. I do not recall hearing any door alarms sounding from the panel at the second-floor nurse's station. I don't know how V14 (LPN) knew R1 was outside but if it wasn't for him, I'm not sure when we would have known R1 was gone since there is no one watching the front door after 8:00pm. I was informed a few days later that there is a glitch to the door system when it comes to the (electronic wandering device).On 8/26/25 at 11:44am, V18 (Certified Nursing Assistant/CNA) stated, I saw (R1) around 7:30pm-8:00pm when I was doing rounds on (R1's) roommate. (R1) had asked me if his shirt looked like it fit so I helped him button it up and then started telling him how nice he looked. He was wearing that button up shirt, a pair of boxers and socks sitting on the side of his bed. He then laid down in bed. I did not hear any door alarms go off on the panel at the nurse's station but was informed by V17 (Registered Nurse/RN) that (R1) was outside, so I ran down the stairs to assist getting him in the building and then realized he needed his wheelchair, so I went back up to get it. Once I got back downstairs, they had him in the building. I assisted him into the wheelchair, and he (R1) was yelling at me I told you I was going to the tavern to see the ladies. (R1) never said anything to me about going to the tavern prior to that statement.On 8/26/25 at 10:17am, V37 (City Bus Head of Security) stated, It is documented that our driver called 911 at 8:32pm stating there was a confused man in socks trying to get on the bus.On 8/26/25 at 10:39am, V38 (Front desk Clerk of Police department) stated, (City Bus) called around 8:21pm, police dispatched but no need to engage due to staff had resident and were taking him back to the building.On 8/26/25 at 12:25pm, V20 (Licensed Practical Nurse/LPN) stated, There is no way to hear the front door alarm up here on the third floor. Just the stairwell door alarms are heard here. I was not aware of an issue with the alarm system until (R1) got out. If a (electronic wander device) is near the doors, they lock down so you can't go out, so I don't know at what point it stopped working.On 8/27/25 at 9:15am, V1 (Administrator) stated, The alarms, front door alarm and (electronic wander device) are supposed to be sounding on the second-floor alarm panel.On 8/26/25 R4, R5, R6, R7, R8, R9 and R10's elopement risk assessments reviewed indicating they are all at risk for elopement and facility census report documents they all live on the second and third floors of the building which are not secured units. V1 (Administrator) and V2 (Administrator in Training/AIT) were notified of the Immediate Jeopardy on 8/27/25 at 11:32am.The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R1 was immediately assessed by nursing and moved to the 4th floor secured unit on 7/31/2025.2. Staff were in-serviced/trained on elopement precautions and facility's policy and procedure for monitoring residents at risk for elopement on 8/1/2025 by facility management.3. Resident elopement assessments for all residents reviewed and updated accordingly on 8/1/2025 by the IDT/Interdisciplinary Team. Elopement care plans reviewed and updated by the IDT team.4. Staff educated by QAT (Quality Assurance Team) members on 8/1/2025 on identifying residents at risk for elopement and policy and procedure for reporting to leadership to ensure proper interventions/care plans are initiated timely. Residents at risk were placed/updated in missing resident binder at the reception desk.5. Social services assessed current residents for elopement precautions on 8/1/2025 and ensured all at risk residents have updated care plan and intervention in place.6. Code [NAME] (Elopement-missing person) drill was performed on 8/1/25 and ongoing by Administration.7. Maintenance Director (V16) completed an immediate audit of door security systems on 8/1/2025 and daily thereafter.8. On 8/1/2025 Local Vendor was in facility to check over the Access and Wander guard and noted it to be working with a low volume and inconsistently. Quote for upgrade was being drafted for wander guard system.9. 8/22/2025 Facility implemented 24/7 reception area observation until such time that all staff are educated on the camera monitoring process and/or the repairs are completed.10. 8/22/2025 facility placed a designated camera alert system at the main entrance to alert 2nd floor staff when the (electronic wandering system) and or main entrance door alarm sounds. This system will remain in place until (electronic wandering system) is fully operational. (V1) will conduct random audits every shift to ensure that the camera alert system at the main entrance functions appropriately.11. 8/22/2025 Local Vendor and (electronic wandering system) Vendor in communication with Maintenance Director and Facility V1 (Administrator)/V2 (Administrator in Training) in relation to repairs vs replacement. On 8/25/25 after communications with vendors it was determined that repair was not feasible, and system replacement would be required. On 8/26/2025 Quote for replacement of system was approved and signed for installation. 12. 8/29/25 Vendor representatives are scheduled to be on-site to coordinate final installation details and requirements. Installation will be initiated promptly thereafter.13. On 8/22/2025 all staff in all departments were in-serviced on Elopement prevention, Missing residents and Door Alarm Policies and procedures by QAT members. No staff will be allowed to work after 8/22/2025 without the listed training.14. Code [NAME] (Elopement-missing person) drill will be performed randomly for one month and monthly thereafter for 6 months by QAT members.15. Maintenance Director/Designee will do daily door alarm audits for 30 days and then weekly and as needed going forward.16. V1/V2 will enforce the interventions of plan of removal of immediacy and assurance of continued compliance.17. V1/V2 and QAT will ensure that monitoring interventions are implemented immediately, and care planned appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement interventions to ensure a resident was free from physical abuse resulting in potential injury for 2 of 3 residents (R2, R11) reviewed for abuse in the sample of 12. The immediate jeopardy began on 6/11/25 at 6:50 PM when R1 returned to the facility from being evaluated at the acute care hospital after grabbing R11 by the neck. R1's care plan was updated to include 1:1 supervision on 6/11/25. No evidence was found of R1 being on 1:1 supervision until 6/18/25 after the second incident when R1 pushed R2 to the floor. V1 (Administrator) was notified of the Immediate Jeopardy on 7/18/25 at 11:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 6/18/25, prior to the start of the survey and was therefore Past Noncompliance or removed on 6/18/25 and the deficient practice corrected on 6/18/25, prior to the start of the survey and was therefore Past Noncompliance.Based on observation, interview, and record review the facility failed to implement interventions to ensure a resident was free from physical abuse resulting in potential injury for 2 of 3 residents (R2, R11) reviewed for abuse in the sample of 12. The immediate jeopardy began on 6/11/25 at 6:50 PM when R1 returned to the facility from being evaluated at the acute care hospital after grabbing R11 by the neck. R1's care plan was updated to include 1:1 supervision on 6/11/25. No evidence was found of R1 being on 1:1 supervision until 6/18/25 after the second incident when R1 pushed R2 to the floor. V1 (Administrator) was notified of the Immediate Jeopardy on 7/18/25 at 11:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 6/18/25, prior to the start of the survey and was therefore Past Noncompliance or removed on 6/18/25 and the deficient practice corrected on 6/18/25, prior to the start of the survey and was therefore Past Noncompliance. The findings include:R1's face sheet showed she was admitted to the facility 7/2/23 with diagnoses to include severe dementia with agitation, Alzheimer's Disease, Type 2 Diabetes, generalized anxiety disorder, psychotic disorder not due to a substance or known physiological condition, insomnia, and depression. R1's facility assessment dated [DATE] showed she had been experiencing physical and verbal behavioral symptoms directed toward others 4-6 days of the 7-day review period. This same assessment indicated these behaviors had become worse since compared to R1's prior assessment.R1's Care Plan initiated 2/6/25 showed, Coping Psychotic Disorder. Resident has dementia and confusion. Can get angry and lash out at other residents and staff, both verbally and physically. Most times, there is no obvious trigger. Interventions: 6/11/25: 1 on 1 until at baseline for mood and behavior.R2's face sheet showed she was admitted to the facility 7/2/20 with diagnoses to include dementia with other behavioral disturbance, vascular dementia, heart failure, cerebrovascular disease, chronic kidney disease, peripheral vascular disease difficulty in walking, lack of coordination, and a history of falling. R2's facility assessment dated [DATE] showed she has severe cognitive impairment.R11's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease with late onset, cerebral infarction, vascular dementia with agitation, hypertension, psychophysiologic insomnia, nontraumatic subdural hemorrhage, anxiety disorder, and major depressive disorder. R11's facility assessment showed she has severe cognitive impairment.R1‘s Incident Report dated 6/11/25 at 2:50 PM showed, Resident to Resident Altercation. Statement from the CNA (Certified Nursing Assistant) was that this resident became agitated by another resident [R11] when [R11] banged her walker on the floor, which made [R1] stand up and grab the resident [R11] by the neck.R11's Incident Report dated 6/11/25 at 2:50 PM showed, This nurse was told by the CNA that this resident was banging her walker against the floor when another resident stood up and grabbed this resident by the neck.R1's Nursing Note dated 6/11/25 at 6:50 AM showed, Resident returned to the facility with no changes to her medication. Information packet on managing stress was attached to discharge orders.R1's Incident Report dated 6/18/25 at 4:01 AM showed, Resident to Resident Altercation. Nursing Description: At 3:45 AM, this nurse was called by CNA at doors to locked area while nurse was a nurse's station to come help because [R1] was agitated in her room. While quickly walking the 20 or so feet to the door to assist CNA this nurse and CNA witnessed resident quickly charge out of her room and self-ambulate across the lounge. CNA and myself hurried to [R1] and before we reached [R1] she reached another resident who was walking with a cane in the hallway next to the lounge and shoved her over causing her to fall back. CNA and myself separated [R1] and the other resident. [R1] continued to be aggressive swinging at and pinching staff while screaming nonsensical words. This nurse attempted to talk with [R1] and to calm her and to redirect her with no progress. Resident continued to be agitated.[physician] notified of resident status and situation and order to send to ER (emergency room) for evaluation was obtained.R1's care plan initiated 2/6/25 showed, . Psychotic Disorder. Resident has dementia and confusion. Can get angry and lash out at other residents and staff, both verbally and physically. Most times, there is no obvious trigger. Interventions: 6/11/25: 1:1 until at baseline for mood and behavior. R1's complete medical record was reviewed including her abuse investigations dated 6/11/25 and 6/18/25 with no evidence of 1:1 being conducted for R1 between 6/11/25 and 6/18/25.R1'S Care Plan initiated 2/6/25 showed, Behavior Management. Resident can be triggered by nothing and start to act angry and hard to calm down. It can lead to her hitting and getting belligerent toward other residents and staff. Has been known to shove tables when agitated. 1:1 Supervision initiated 6/18/25.R1's One on One Direct Care Log dated 6/18/25 showed she returned from the hospital at 7:15 AM and 1:1 supervision started.The facility's staffing scheduled showed they started scheduling staff to do 1:1 supervision starting 6/19/25.R1's Behavior Monitoring and Interventions Report showed, . 6/15/25: cursing at others, screaming at others, agitated, neglecting self care, refusing care.On 7/16/25 at 1:07 PM, V8 CNA said, With [R1] it is all about how you approach her when it comes to her behaviors. If you explain to her what you are doing, she complies pretty well. If she is agitated, she gets very aggressive. She hits and kicks, scratches. I was here when [R1] and [R11] had the incident (6/11/25). [R11] had been fine throughout the whole morning. It was in the afternoon when she gets agitated, she gets to shaking, I asked her what is wrong, that didn't help. [R11] proceeded to grab her walker and bang her walker on the floor. [R1] was sitting in [R1's] designated area and was resting her eyes and when [R11] banged the walker on the floor, it woke [R1] up. [R1] was confused and scared. [R11] was walking toward me aggressively so [R1] got up and walked toward [R11] and proceeded to try and hit [R11]. I separated them but she grabbed her by the neck. [R11] screamed. I separated them really quickly. She had no injuries from that. [R11] didn't know why [R1] did that. [R11] is very aggressive as well.On 7/16/25 at 12:01 PM, V9 CNA (Certified Nursing Assistant) said, [R1] has behaviors, she gets combative with cares, and she is attention seeking. If she sees you 1:1 providing care with another resident that irritates her. She comes at the patient you are caring for. She starts to yell but it depends on what kind of day she is having. She will try to hit them. Redirection is hard for [R1]. If she is going after another resident, she does not handle redirection at all, she gets locked in on them, you just have to try to intervene and keep the patient safe. The incident with [R1] and [R2] on 6/18/25, [R1 pushed [R2]. [R1] was getting irate, and I peeked out to the outside of the closed unit doors to let the nurse know [R1] had charged at [R2]. [R2] was pushed to the ground that day, she said she was hurting so the nurse sent her out and nothing was wrong with her. [R1] has been a 1:1 here lately.R1's Acute Care Hospital documents showed she arrived at the acute care hospital 6/18/25 at 4:45 AM for aggressive behavior. R1's same hospital documents showed, . Patient apparently pushed another resident down this morning.R2's 6/18/25 Nursing Note entered at 5:45 AM showed, At 3:45 this morning, Resident was witnessed self-ambulating with cane in hallway next to the lounge when another resident who came walking out of their bedroom and appeared to be agitated and quickly self-ambulated across the lounge, charging at this resident. Resident shoved her which caused her to lose her balance and fall to her back. Initially resident stated that she had no pain but quickly stated that she did indeed have pain in her lower back and bilateral hip area, unable to rate and states it is ‘bad'. Resident returned at 5:45 AM from emergency room with no new orders. Resident denies pain at this time. R2's care plan initiated 12/13/24 showed, The resident is at risk for falls related to confusion, gait/balance problems. On 7/16/25 at 11:15 AM, V6 CNA Scheduler (Certified Nursing Assistant scheduler) said, I schedule both nurses & CNAs. Only have one 1:1 resident here currently. That is [R1]. She has been 1:1 since mid June, maybe around the 15th, due to really bad behaviors. She needs 1:1 on all shifts, including while she is sleeping. The nursing staff gets an order for it and the Director of Nursing, or the Administrator tell me who needs it and how long they need to be on it. All schedules were requested from V6 for R1's 1:1 supervision. The first time 1:1 was documented on the schedule showed 6/19/25. On 7/16/25 at 12:25 PM, V12 CNA (Certified Nursing Assistant) said [R1] is really combative, she has been combative since she has been there. She has put her hands on damn near all the staff here. [R1] has terrible behavior. We are scared of her. She is like this with both staff and residents. If you aren't familiar to her, she gets really bad. She is not a good resident to have, and she is a lot of care. They have 1:1 now. [R1] gets agitated with redirection, sometimes it gets better, sometimes it doesn't. You got to know how to work with her and that is not an easy task because she will turn on you. You have to get her away from noise, light, and people. We have to keep her separated from the other people. The 1:1 has been going on for maybe a month now. Her behavior has been going on since she has been here.On 7/16/25 at 2:02 PM, V18 (Housekeeper) stated R1 gets irritated if the CNAs rush her during care. R1 yells out, Slow down when she is rushed. It is a defense mechanism. I saw R1 attack another resident in the past. It was 6 or 8 months ago. She grabbed another resident's head and shook it. It was [R12], I had to step in between both of them to get R1 to let go. [R12] was upset and crying. It happened really fast and quick. I told the nurse about it but can't remember her name. I haven't seen any behaviors recently. Lately she is just spaced out. On 7/18/25 at 12:45 PM, V2 (Regional Director of Clinical Operations) said, R1 has been on 1:1 since 6/18/25. On 7/18/25 at 1:50 PM, V3 DON (Director of Nursing) said, . If someone is placed 1:1 supervision, this means there are eyes on the resident. They also need to keep track of what is going on around them, maybe someone else is getting agitated and you know it is going to get this resident agitated as well. If a resident is on 1 on 1 supervision, I would expect a staff member to always be with the resident.The facility's policy and procedure with revision date 01/2019 showed, Abuse Prevention Program. Policy: It is the policy of this facility to prohibit and prevent resident abuse. Residents who allegedly mistreated another resident will be immediately removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of the other residents and employees of the facility. Physical Abuse: Hitting, slapping, pinching, kicking, etc. The Immediate Jeopardy that began on 6/11/25 was removed on 6/18/25 when the facility completed the following actions: Investigation of abuse completed and reported to IDPH, alleged perpetrator and alleged victim's physician notified of alleged abuse. Both R11 & R2 were immediately separated and assessed for any signs of injury or trauma.R1 placed on 1 on 1 supervision effective 6/18/2025.The whole house audit for residents with aggressive behaviors completed and ensured care plan interventions are in place on 7.18.2025 by the MDS Nurse and Regional Reimbursement SpecialistAll staff In-servicing by LNHA and Designee initiated on 6/18/2025 on Abuse reporting policy and repeated on 7/18/2025 Abuse Prevention Policy, one on one supervision and dementia care including behavior emergencies.In-servicing training by QAT members on the Abuse Prevention Policy, supervision and dementia care including behavior emergencies. and one on one supervision with all staff will continue, and any remaining employees must be trained prior to reporting for work for their next shift scheduled. Quality Assurance Activities to ensure the alleged deficient practice will not recur include: QAT will Audit 3 Resident Behavior Tracking and Behavior care plans weekly x 4 to monitor for continues compliance. The facility will follow state and federal guidelines regarding Abuse Reporting by requiring reporting of all reports of abuse to be reported to the Regional Consultants and facility QA Committee for follow up and review.In-service training by DON/LNHA on Abuse Prevention Policy, supervision and dementia care including behavior emergencies with all staff will continue monthly for the next 3 months, then quarterly x 3 by the LNHA/Designee. LNHA will enforce the interventions of plan of removal of immediacy and assurance of continued compliance. The Removal Plan is executed as required in response to a Statement of Deficiencies against the facility know as Generations at Rock Island. This Removal Plan is not an admission of an agreement with, the validity of any facts or violations cited in the summary statements of deficiencies. This Removal Plan is not a waiver of any rights of defense, which may be available under Illinois Statues, Illinois Administrative Code, or Federal Law of Regulations. The facility believes that the immediacy was removed as of 6/18/2025 with the establishment of residents initiated 1 on 1 & Staff training of facility Abuse Prevention and one on one supervision policies. Staff have been re-educated on facility policies and procedures and in-servicing will be ongoing.completion date: 7.18.2025