**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent and protect a resident (R1) from staff-to-resident sexual abuse. This failure affected one (R1) resident out of three residents reviewed for abuse. As a result of this failure, R1 felt hurt, scared, and afraid. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/11/2025 when R1 was sexually abused by V5 (Certified Nursing Aide). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 3/24/2025 at 1:00 PM. The survey team confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 3/26/2025, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's face sheet, dated 3/18/2025, documents R1 is a [AGE] year-old resident admitted to facility on 2/13/2025. R1 has diagnoses including, but not limited to: dislocation of internal left hip prosthesis, infection following procedure, and chronic obstructive pulmonary disease. R1's Minimum Data Set (MDS) section C0500, dated 2/17/2025, documents a Brief Interview for Mental Status (BIMS) score of 14, which indicates cognition is intact. MDS section GG0130, dated 2/17/202,5 documents resident needs supervision or touching assistance with the following: eating and personal hygiene. Resident needs partial/moderate assistance with the following: oral hygiene and shower/bathe self. Resident needs substantial/maximal assistance for the following: toileting hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. Progress note, dated 3/11/2025 at 2:14 PM, documents in part: V6 also made aware that R1 is requesting that no male CNAs provide her care. Facility agrees to only assign female CNA per resident's request. Concern form, dated 3/11/2025, written by V1 documents nature of concern, resident expressed issue with previous evening CNA. Per resident would prefer female CNA, with the exception of one AM CNA she gets along with. Also expressed not wanting her brief checked. Follow up action taken: Will assign female CNA's only with the exception of the specified CNA. Discussed importance of having brief checked by staff to ensure that resident is clean/skin checked. Initial report of allegation, dated 3/18/2025, documents: R1 is a [AGE] year-old female, admitted to facility on 2/13/2025, with diagnoses stated above for skilled Physical Therapy/Occupational Therapy. On 3/18/25, Illinois Department of Public Health (IDPH) Surveyor came to facility for a complaint investigation. Made Administrator aware of a resident who was alleging that she was inappropriately touched by a male CNA. Alleged CNA suspended pending investigation. Investigation initiated. Final report to follow. Progress note, dated 3/19/2025, documents: Note Text: Writer spoke with V26 (Physician Assistant) for V27 (Doctor) and notified of resident's allegation with no new orders given at this time. Per documented facility schedule, V5 continued to work until 3/18/2025, when surveyor informed facility of alleged abuse. V5 timecard punches show V5 worked 3/11/2025, 3/13,2025, 3/14/2025, 3/15/2025, 3/16/2025 and 3/17/2025. Time sheet for V5 documents V5 clocked in on 3/10/2025 at 9:59 PM. Time sheet documents V5 clocked out at 6:30 AM 3/11/2025. Bladder incontinence task sheet documents R1 was continent at 5:16 AM on 3/11/2025. This was the only entry for overnight shift starting 3/10/2025 at 9:59 PM to 6:30 AM on 3/11/2025. On 3/18/2025 at 11:05 AM, R1 and V6 (Family Member) were present in room. R1 was asked if R1 had been inappropriately touched. R1 stated, I was inappropriately touched. I was touched, but I was assured that the person who did it was censured. R1 was asked what does censured mean. R1 stated, It means that this would not happen to me or anyone else. V6 stated, We were assured by (V2) that a male staff (V5, Certified Nursing Assistant/CNA) was rough in checking (R1's) diaper, and he would not be working with (R1) anymore. I do not know his name. (R1) told me this happened Monday night last week. R1 stated, The only reason I feel safe in this environment is that the people came and responded so quickly. V6 stated, (V2) knows, (V1, Administrator) knows. I don't know who told (V1). I came here after that happened on Wednesday, because (R1) was upset. (R1) thought she had a broken hip because she fell out of bed Monday night last week (March 10, 2025). (R1) is here after hip replacement surgery, so we were concerned of the hip. Hip is ok. (R1) did not break anything. After I spoke to front desk, I came to talk to (R1). (V1) came to talk to me, with (R1) in the room, and also with me separately. (R1) told me that (V5) was rough with her when checking the diaper, and also put a finger into her vagina. I told (V1) that. (V2) talked to me the day before that. (V2) told me about him (V5) being aggressive before I found out the whole story. Police was not called regarding (V5) as far as we know. R1 stated, I wanted to call the state to report the issue after I left this place, but you are here now. V6 stated, (V1) asked me to walk out of the room to talk to privately about the situation, and also to talk about plans after (R1's) stay here. R1 stated, This happened after I fell out of bed. It was the next morning, and (V5) looked at me and said 'you couldn't still be dry' (speaking about my diaper). (V5) went in there and he was hurting me. I felt like he was moving things rough and put his finger in my vagina. This happened Tuesday morning, 3/11/2025, after the fall. It was just (V5) and me. I do not know (V5's) name. I had only seen (V5) a few times. (V5) was a big guy. (V5) was average height. (V5) had dark brown or black hair. I am unsure of markings or tattoos. I do remember that when (V5) got where he wanted to get to, (V5) said, 'yeah you are right you are dry'. I have not seen (V5) since that time. V6 stated, (V2) is the head nurse that works days. (R1) has some confusion, but I do think it happened. On 3/18/2025 at 11:42 AM, V2 stated, I am not aware of any sexual abuse allegation for (R1). I did speak to (V6), but did not speak to her regarding any sexual abuse allegation. I spoke to (V6) regarding (R1) having a fall the night before. Tuesday morning when I went to speak with (R1), she did not want me to call (V6) regarding the fall. (R1) told me she did not want a male CNA that night, and she did not want a male CNA per her preference. I verified (V6) was Power of Attorney (POA) and verified BIMS, and had to notify (V6). The only thing I spoke with (V6) about regarding a male CNA, was that (R1) preference was not to have a male CNA. There was no allegation of sexual abuse. The male CNAs name is (V5), and that was the only time she had a male CNA. (V5) is a night CNA, and he was assigned to (R1) Monday night when (R1) had the fall. On 3/18/2025 at 11:55 AM, V1 stated, I am not aware of any sexual abuse allegation for (R1). I did not speak to (V6) or (R1) regarding any sexual abuse allegation. I did speak with (V6) in person on Wednesday morning in private away from (R1), regarding discharge information. (V6) is very overwhelmed with (R1) going home, and (R1's) confusion. I was not made aware of any male CNA being rough with (R1), or any sexual abuse allegation. I did speak with (R1) Tuesday morning regarding her preference for no male CNA caregivers due to preference, except for the morning male CNA that she likes. I did ask (R1) why she did not want any male CNA caregivers and she stated she is uncomfortable with any male CNA's caring for her private areas except for (V4). (V4) is a female who appears as a male. (R1) stated '(V4) is like a son to me he is the only male I want caring for me'. Monday night there was a male CNA, (V5), caring for (R1). I did confirm to (V6) and (R1) that (V5) or any other male would not care for (R1), except (V4). (R1) or (V6) did not identify or specify something with (V5), they just said any male in general, except (V4). (V5) is still working here. (V5) works nights. My conversation with (R1) was to follow up with her fall from Monday night. We talked about that for the majority of the time. R1 stated, 'you know I had a man taking care of me during the night. I am uncomfortable with men taking care of me like that except for (V4)'. That was not a huge point of the conversation. (R1) then was telling me about (V6) and her life story and all of that. That conversation took place Tuesday morning (3/11/2025). Then Wednesday morning (3/12/2025), staff informed me (V6) was in the building. We quickly touched on (R1) preferring female staff only, we talked about her confusion getting worse since December and our plan for that, and she was very appreciative of everything. For the rest of the conversation, we were talking about (R1's) discharge planning and (V6) being overwhelmed and things like that. On 3/18/2025 at 12:41 PM, V6, Family Member, stated, I said to (V1) that (V5) was rough changing (R1's) diaper and he put his finger in her vagina, which is what (R1) said to me. I did not tell that to (V2) because I was not aware of that yet. I am sure I told (V1) about the situation. (V1) stated to me, '(R1) did not tell me the detail of (V5) putting his finger in her vagina, just that (V5) was rough with her'. (R1) said to me that she did not want any males to work with her after that experience with (V5). (R1) said that to (V2) and also to (V1), but that was after this incident. On 3/18/2025 at 1:14 PM, V1 provided surveyor with initial report of abuse, dated 3/18/2025. V1 stated, CNA (V5) is suspended pending investigation. On 3/18/2025 at 1:18 PM, V5 stated, I worked last Monday night (3/10/2025). I do recall (R1) having a fall. (R1) was not complaining of pain when we put her back in bed, but she was weak. (R1) said she was trying to get to the chair from the bed. Later that night, (R1) used the call light because she was wet, and I went to change (R1) by myself, because I was assigned to her. I did not have any problems changing (R1), and I directed her what to do, she obeyed, and (R1) had no complaints. I can remember only changing (R1) once after the fall, and in the morning she was dry. That was about 4:30 AM. I did not open (R1's) brief when she stated she was dry. I do not feel like I was rough with (R1) at any time. I did not stick my fingers in (R1's) vagina. I just did my normal routine by wiping once on the left side and the right and then the back. I do not remember (R1) telling me that she felt I was rough with her. I have never touched any other residents inappropriately or been rough with them. V5 was asked if he was accused of inappropriate touching of resident in the past. V5 stated, I remember one lady in (room #) stated that I was inappropriate with her. I do not remember her name. I think there was another lady in (room #) bed one that stated I was inappropriate with her. On both occasions the facility was on my side. I did not touch them inappropriately; I am just doing my job. On 3/18/2025 at 1:56 PM, R1 stated, A week ago Monday night I had a fall. When I woke up this guy (V5) grabbed me and put his hands in me; he was doing all this stuff with his hands back and forth, and I was scared. I am very clear about what was going on inside of me. This happened after the fall; it happened the next day. It was morning time then. It was before lunch, but I am not sure what time. The only thing he said was 'oh you were right' (about being dry). I was saying 'don't do that, oh my god stop it.' He (V5) was hurting me, and it scared me. I don't remember falling asleep, but I remember waking up in my bed after that happened. Someone told me that I need to report this, but I don't want to tell you who that is, because I don't want her to lose her job. I am looking out for (V6) and me right now, and I can't talk about it. I told what happened to (V22, CNA), (V21, Resident Care Coordinator), and (V2, DON). I told them the details that (V5) was rough with me and put his finger in my vagina. They are all upper management. I am feeling really bad telling you this much. They might uh, I don't know. I am in such a strange situation right now. I am afraid I may never get out of here. I don't know what is going to happen. I understand your situation. I really do. I just told you more than I wanted to. This place has a very good reputation, and I don't want to have to leave here except to go home. I have been here almost a month. For the most part it has been ok, except for this situation. The reason I do not want any other male staff working with me except (V4) is because of this incident. I cannot and will not tell you who that is. Right now, I am so afraid because of things that have happened in the last hour. I cannot tell you what. You have a really hard job, and I am sorry, but I did not mean to get involved in all this. There is a lot of stuff going on right now for me and I do not want to rock the boat. I do not want to talk about this anymore. On 3/18/2025 at 3:15 PM, V1 was aksed if V5 had any other previous allegations of abuse. V1 stated, (V5) has had a previous allegation of abuse. (V5) just had one that I am aware of. (V5) is my only male CNA in the whole entire building. On 3/19/2025 at 10:12 AM, V6 stated, I am POA for healthcare for (R1). When I came in upset at the front desk (on 3/12/2025), I spoke with (V24) front desk. I told (V24) I am here because (R1) wants me to call the police. (R1) thinks her leg is broken. I asked who is in charge. I told (V24) I am going to (R1's) room to see what's going on. I did not tell (V24) about the allegation, because (R1) was more focused on her leg being hurt. (V1) ended up coming into the room and talking to me and (R1), and then with me alone in the hallway. (V1) did speak about the allegation with (R1) and me in the room, and asked (R1) to describe what happened, and (R1) did. Then (V1) asked if she could talk to me outside. This all happened on Wednesday 3/12/2025. When we talked in the hall, (V1) asked me what I knew. I told her what (R1) told me. (V1) stated she was surprised because the detail of (V5) inserting his finger in R1's vagina was not a detail that (R1) had told (V1) previously. I think if you go speak to (R1), she is going to clam up. Let me speak to (R1) and see if I can get her to tell me who told her to report this. On 3/19/2025 at 10:30 AM, V1 stated, (V5) has not had any discipline at all. (V5) started with us last July. I am getting my interviews in order. (V5) has been suspended as of yesterday (3/18/2025), and in-services on abuse have been started today. Last abuse training was in February this year at skills fair. Police have not been called. I can reach out to (V6) to see if she wants us to file a police report. On 3/19/2025 at 11:24 AM, V1 was asked why a concern form was filled out. V1 stated, Regarding the concern form, the issue was not wanting a male CNA. (V5) came at 10pm Monday night and worked overnights not evenings. The concern form was written the following morning by me, and was meaning there was an issue with (V5), who worked overnights the previous night. The issue was that (R1) was uncomfortable with a male taking care of her down there. The issue with (R1) not wanting to have her brief checked, was that she did not want her brief checked in the morning. I explained the need for it, and (R1) was fine. We get requests all the time that residents do not want a male, so I did not think anything of it. (V6) was here because she thought (R1) thought she broke her leg. I went to speak with (V6) regarding this, and other things were brought up, but the male CNA was just a blip in our conversation. On 3/19/2025 at 11:56 AM, V25 (CNA) stated, I have worked here only one day through an agency. I have not witnessed any abuse here. I was trained for abuse at my old job in January 2024. The agency I work for does not train us for abuse that I know of. I have not had abuse training this year. This facility has not trained me on abuse. On 3/19/2025 at 12:29 PM, V17 (CNA) stated, (R1) did disclose to me that she did not want to be changed due to something happening, but did not want to get anyone in trouble. (R1) did not mention whether it was female or male. I told (R1) if something happened to (R1), she needed to tell me so I could report it. (R1) does get confused more at night, but in the daytime (R1) knows what's going on. I do believe something happened to (R1). On 3/19/2025 at 12:39 PM, V6 stated, My thoughts on the situation is that I am angry on her behalf. (R1) thinks I want revenge, I disagree. I think there are rules and protocols that are supposed to be in place and this guy (V5) did not follow them. I am trying to keep (R1) safe. For the most part (R1) is pretty clear, there are times (R1) is a little confused. (R1) is really clear right now that I am the enemy. (R1) said to me 'I have enough problems to deal with, I don't want to deal with this anymore I just want to go home'. I am so frustrated. I do know something happened. I am just so frustrated. I never expected to have to deal with this. I feel like I am drowning. On 3/20/2025 at 11:01 AM, surveyor asked V18 how was R1. V18 (CNA) stated R1 was just a little bit nervous and shaky. On 3/24/2025 at 10:52 AM, V1 was asked what is supposed to happen when an allegation of abuse is reported. V1 stated, The alleged perpetrator is to be put on suspension immediately pending investigation in an allegation of abuse. If it is unfounded, they can come back to work. If it is founded, probable termination, depending on severity. I am the Abuse Coordinator. My process involves investigating, suspending individual involved, reporting, and possibly calling the police. Each department has their part to do. Nursing may have to do head to toe body assessment, notify doctor, carry out orders, etcetera. My DON (V2) steps in as Abuse Coordinator for me if I was not here. On 3/24/2025 at 11:10 AM, V2 stated, If someone reports abuse, the Administrator is to be notified immediately. The alleged perpetrator is removed from the situation. The Administrator would be in charge of suspending alleged perpetrator. For nursing, we would notify family, doctor, and any required parties. We would need to do a body assessment. On 3/24/2024 at 6:58 PM, V1 stated, According to agency, abuse training is required prior to employees starting with the agency. V1 was asked if facility provides abuse training to agency staff prior to start date. V1 replied, No, this is something we have recognized and have put in place. On 3/25/2025 at 10:37 AM, V1 was asked if the document, dated 2/5/2025, was facility's annual abuse training. V1 stated, Yes, it was a skills fair that included abuse. V1 was asked if document submitted included abuse training for all staff. V1 stated, Yes. All employees were not listed. V1 stated, Some employees may have been called on the phone. I will look to see if I have any further documentation. V5 was not listed on the attendance document to have received abuse training on 2/5/2025. V1 provided Abuse Policy Acknowledgement Form signed by V5 on 7/26/24, when asked to provide documentation of previous abuse training. Abuse Policy, dated 09/20, documents in part: POLICY: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: 2. Orientating and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect and abuse; 3. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; 4. Identifying occurrences and patterns of potential mistreatment; 5. Immediately protecting residents involved in identifying reports of possible abuse; 6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; 7. Filing accurate and timely investigative reports; This facility is committed to protecting our residents from abuse by anyone including, but not limited to, 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. This facility will not knowingly employ individuals who have been convicted of abusing, neglecting or mistreating individuals. DEFINITIONS: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful means the individual acted deliberately, not that the individual must have intended the injury or harm. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental and psychosocial well-being. This includes suspicion of a crime. Assuring that physical restraints are used sparingly and properly, and that chemical restraints are not used. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Sexual Abuse is non-consensual sexual contact of any type with a resident. This includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. b. Staff obligations to prevent and report abuse, neglect, theft and how to distinguish theft from lost items and willful abuse from insensitive staff actions that should be corrected through counseling and additional training. Staff should report their knowledge of allegations without fear of reprisal. e. What constitutes abuse (physical, mental, sexual, verbal), involuntary seclusion, neglect, and misappropriation of resident property. g. Reporting reasonable suspicion of a crime. Annually staff will receive a review of the above topics. Supervisory personnel will receive training on their obligations under law when receiving an allegation of abuse, neglect, theft and suspicion of crime how to monitor and correct Inappropriate or insensitive staff actions, words or body language. 3. Prevention The facility desires to prevent abuse, neglect and theft by establishing a resident sensitive and resident secure environment. 4. Identification Employees are required to immediately report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or the administrator. An employee who actually witnesses an act of abuse should immediately try to stop the act. All residents, visitors, volunteers, family members or others are encouraged to immediately report their concerns or suspected incidents of potential mistreatment to a supervisor or the administrator. Such reports may be made without fear of retaliation against any employee who makes a report, causes a lawful report to be made. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions. 5. Protection of Residents The facility will take steps to prevent mistreatment while the investigation is underway. b. Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation. c. Employees of the facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation has been reviewed by the administrator or designee. e. Employees accused of possible abuse shall not complete the shift as a direct care provider to residents. The Immediate Jeopardy began on 03/11/2025 and was removed on 03/26/24, when the facility took the following actions to remove the immediacy: On 3/26/2025 at 10:53 AM, V1 stated, I was retrained on abuse on 3/24/2025. Basically it covered the abuse policy, abuse prevention, investigation, the immediacy and the thoroughness of it. It also covered identified vulnerable residents and providing emotional support after the fact. I am the Abuse Coordinator. The DON steps in as Abuse Coordinator if I was not here. If rough handling is alleged, it is considered abuse. Investigation starts immediately. If there is an alleged staff member, they would be placed on suspension immediately. Body check would be completed. MD would be notified. Family would be notified. Interviews would be started. A reportable would be filed within 2 hours. If I come across a resident that is afraid and states they do not want to get anyone in trouble, I would speak with the resident in a private area and encourage them to let us know what happened. I would let the doctor and responsible party know and see if they would open up to either one of them. I would interview staff. If they have a good repore with a specific staff member, I would try to have them talk to the resident. If they continue to refuse to share, I would try to provide support as best as we can. Ask them if we could make changes to care that would make them more comfortable. (V5) is still on suspension pending police investigation. As of yesterday afternoon, police still had not contacted (V5). The next step is to go to his house. Police said it is still at officer level and will next go to a detective. On 3/26/2025 at 11:09 AM, V16 (Registered Nurse/RN) stated, I was re-trained on abuse recently it was in the last couple days. It covered types of abuse, when to report abuse, and a quiz. Abuse Coordinator is the Administrator. Rough handling is considered abuse. If someone reported rough handling to me, I would report to my supervisor, and the Administrator, and the DON reports to the Administrator. I would remove the resident from harms way. The alleged perpetrator would be removed. If I had a resident that seemed scared and stated they did not want to get anyone in trouble, I would still report. They may just be afraid of retaliation. I would do the same steps in that instance. On 3/26/2025 at 11:14 AM, V29 (Housekeeping) stated, I was recently trained on abuse yesterday. They covered types of abuse, reporting abuse to Abuse Coordinator, (V1). Being handled roughly is abuse. If someone told me they were handled roughly, I would report to the nurse and the Abuse Coordinator. If I came across a resident that seemed afraid and said that they don't want to get anyone in trouble, I would try to be supportive but report to the nurse and Abuse Coordinator. On 3/26/2025 at 11:22 AM, V30 (2nd floor Unit Manager) stated, I was recently trained on abuse this past week. We talked about reporting to Administrator any suspected abuse or witnessed abuse. We also covered types of abuse which include verbal, mental, sexual, physical, misappropriation of property and exploitation, mistreatment, serious body injury, and neglect. Rough handling is considered abuse. If a resident told me they were handled roughly, I would offer to listen to patient, and get a nurse and report to Administrator immediately. Administrator, (V1), is our Abuse Coordinator. If (V1) is not here, the DON is our abuse coordinator. If I came across a resident that stated they were afraid and did not want to get anyone in trouble, I would listen to the resident and communicate it right away to the Administrator. On 3/26/2025 at 11:31 AM, V23 (Physical Therapist) stated, I was just retrained on abuse yesterday. It covered reporting structure, who, when, etc. Types of abuse was covered. The three R's which are remove, remove, report. Abuse coordinator is (V1). Rough handling is considered abuse. If a resident reported rough handling to me, I would ask the resident if they wanted to talk to someone, report to my supervisor, and to the Abuse Coordinator. If a resident reported they are scared and do not want to get anyone in trouble, I would do the same thing. I would ask them if they want to speak to someone about that, report to my supervisor and to the Abuse Coordinator. On 3/26/2025 at 11:37 AM, V31 (Housekeeping) stated, I was retrained on abuse yesterday. They talked about the 10 different kinds of abuse. They talked about reporting any problems to (V1), Abuse Coordinator, immediately. Rough handling is abuse. If a resident told me someone was rough with them, I would report it immediately to Administrator. If a resident told me they were scared and don't want to get anyone in trouble, I would report that to the Administrator as soon as possible and try to calm the resident. On 3/26/2025 at 11:42 AM, V32 (Building Manager) stated, I did recently get retrained on abuse yesterday. They covered the 10 different types of abuse, reporting immediately, remove, and report. (V1) is the Abuse Coordinator. Rough handling is considered abuse. If a resident reported rough handling to me, I would report immediately to (V1) and try to remove the resident and alleged perpetrator. If a resident reported they were afraid but did not want to get anyone in trouble, I would remember what room it was and go report it to (V1) immediately. On 3/26/2025 at 11:48 AM, V33 (Resident Care Coordinator) stated, I did recently get trained on abuse yesterday. They covered the 10 types of abuse, who to report to (Administrator), timeliness of reporting, and what to do if you see abuse occur. Abuse coordinator is (V1), the Administrator. Rough handling is considered abuse. If a resident reported rough handling to me, I would tell the Administrator immediately. If a resident reported to me that they were afraid and did not want to get anyone in trouble, I would still report immediately to the Administrator. On 3/26/2025, V34 (CNA) stated, I was recently trained on abuse yesterday or the day before. They covered the different types of abuse, who to report to (Administrator), what to do if you witness or experience any type of abuse. Rough handling is considered abuse. If a resident reported rough handling to me, I would remove the patient from the situation and report to the Administrator. If a resident told me they were afraid and did not want to get anyone in trouble, I would still report to the Administrator. On 3/26/2025 at 11:59 AM, V2 stated, I was retrained on abuse on 3/24/2025. We were re-trained on how to investigate abuse, how to respond to any allegation of abuse, how to interview the resident, informing family and doctors, and how to find who the resident is comfortable with to talk to the resident. Types of abuse were covered (10 types); we did quizzes. We educated the staff as well. Abuse Coordinator is the Administrator, and if she is absent, it is me. Rough handling is considered abuse. If a resident reported rough handling to me, I would try to get details from resident, remove abuser, and report to (V1). If I had a resident report to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its abuse policy related to training, prevention, reporting and investigating for one (R1) of three residents reviewed for abuse. As a result of this failure, R1 felt hurt, scared, and afraid. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/11/2025 when the facility failed to implement their abuse policy after an alleged abuse was reported by R1 to V2 (Director of Nursing). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 3/24/2025 at 1:00 PM. The survey team confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 3/26/2025, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's face sheet, dated 3/18/2025, documents R1 is a [AGE] year-old resident admitted to facility on 2/13/2025. R1 has diagnoses including, but not limited to: dislocation of internal left hip prosthesis, infection following procedure and chronic obstructive pulmonary disease. R1's Minimum Data Set (MDS) section C0500, dated 2/17/2025, documents Brief Interview for Mental Status (BIMS) score of 14, indicating cognition is intact. MDS section GG0130, dated 2/17/2025, documents resident needs supervision or touching assistance with the following: eating and personal hygiene. Resident needs partial/moderate assistance with the following: oral hygiene and shower/bathe self. Resident needs substantial/maximal assistance for the following: toileting hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. Concern form, dated 3/11/2025, documents resident expressed issue with previous V5 (previous evening CNA). Per resident would prefer female CNA, with the exception of one AM CNA she gets along with also expressed not wanting her brief checked. Follow up action taken: Will assign female CNAs only with the exception of the specified CNA. Discussed importance of having brief checked by staff to ensure that resident is clean/skin checks. Time sheet for V5 documents V5 clocked in on 3/10/2025 at 9:59 PM. Time sheet documents V5 clocked out at 6:30 AM 3/11/2025. V5 timecard punches show V5 worked 3/11/2025, 3/13,2025, 3/14/2025, 3/15/2025, 3/16/2025 and 3/17/2025. V5 continued to work until 3/18/2025, facility informed of alleged abuse. On 3/18/2025 at 11:08 AM, V6 (Family Member) stated, On 3/12/2025 after I spoke to the front desk, I came to talk to (R1). (V1, Administrator) came to talk to me and (R1) in (R1's) room, and with me separately. (R1) told me that (V5, Certified Nursing Assistant/CNA) was rough with (R1) checking the diaper, and putting a finger into (R1's) vagina. I told (V1) that. (V2, Director of Nursing) talked to me the day before that (3/11/2025). (V2) told me about (V5) being aggressive/rough with diaper change before I found out the whole story. On 3/18/2025 at 11:42 AM, V2 stated, I am not aware of any sexual abuse allegation for (R1). I did speak to (V6), but did not speak to her regarding any sexual abuse allegation. I am not aware of any sexual abuse. The only thing I spoke with (V6) about regarding a male CNA was (R1's) preference was not to have a male CNA. On 3/18/2025 at 11:55 AM, V1 stated, I am not aware of any sexual abuse allegation for (R1). I did not speak to (V6) or (R1) regarding any sexual abuse allegation. I did speak with (V6) in person on Wednesday morning (3/12/2025) in private, away from (R1) regarding discharge information. I did speak with (R1) Tuesday morning (3/11/2025) regarding her preference for no male CNA caregivers due to preference, except for the morning CNA (V4) that she likes. I did confirm to (V6) and (R1) that (V5, CNA) or any other male would not care for (R1) except (V4). (V5) is still working here. (V5) works nights. On 3/18/2025 at 12:41 PM, V6 (family member of R1) stated, I said to (V1, Administrator) that (V5, CNA) was rough changing (R1's) diaper, and he put his finger in (R1's) vagina, which is what (R1) said to me. I did not tell that to (V2) because I was not aware of that yet. I am sure I told (V1) about the situation. (V1) stated to me that (R1) did not tell me the detail of (V5) putting his finger in (R1's) vagina, just that (V5) was rough with (R1). (R1) said to me that she did not want any males to work with her after that experience with (V5). (R1) said that to (V2, DON) and also to (V1, Administrator), but that was after this incident. On 3/18/2025 at 1:14 PM, V1 provided initial report of abuse. V1 stated, (V5) is suspended pending investigation. On 3/18/2025 at 1:18 PM, V5, CNA, stated, I worked last Monday night (3/10/2025). I do not feel like I was rough with (R1) at any time. I did not stick my fingers in (R1's) vagina. I just did my normal routine by wiping once on the left side and the right and then the back. I do not remember (R1) telling me that (R1) felt I was rough with her. On 3/18/2025 at 1:58 PM, R1 stated, I told what happened to (V22, CNA), (V21, Resident Care Coordinator) and (V2, DON). I told them the details that he was rough with me and put his finger in my vagina. On 3/19/2025 at 11:26 AM, V1 stated, I am unsure if the doctor was notified of sexual allegation. I will find out if the doctor has been notified of the sexual abuse allegation and let you know. On 3/19/2025 at 12:31 PM, V17, Certified Nursing Assistant (CNA), stated, I am an agency CNA. I did report to (V19, Registered Nurse/RN) the nurse. (V19) is not here today. The situation was there was another CNA (V18) working, and she was talking to (R1), and (V18) came and got me for the conversation. (V18) is not here today. (V18) works pm or overnight shift. I do not know when it took place or anything. (R1) would just say 'I don't want to be changed' and 'I don't want to get anyone in trouble'. On 3/19/2025 at 1:10 PM, V20 (Physical Therapist) stated, I did look at (R1's) chart and see she had a fall, and then no male CNA is to care for her. I feel like (R1) was trying to tell me something without telling me something that I suspected as abuse, but it was already being handled. I guess yes, I should have reported, but I thought it was already reported. On 3/19/2025 at 2:00 PM, V19, RN stated, Nobody reported any type of abuse allegation to me. On 3/20/2025 at 11:05 AM, V18, CNA, stated, I heard about (R1) Thursday night (3/13/2025) and Saturday (3/15/2025) night, but (R1) did not say anything to me. Someone said there was abuse and they said it was (R1). (V17) was the one who told me. (V17) told me Thursday or Saturday. When (V17) told me this, I did not report it because she was not sure. I never reported it to anyone. I told (V17) to tell the nurse or DON. (V17) never told me if she told the nurse or not. (R1) never said nothing to me about being abused or nothing like that (sic). On 3/24/2025 at 11:13 AM, V2 stated, If the administrator is not here, I would step up in the place of the Abuse Coordinator. Staff would report abuse to me immediately, we would remove alleged perpetrator, we would start investigations immediately, interviews immediately, send reportable within a few hours. These would be my responsibilities if Administrator is not here. Abuse Policy, dated 09/20, documents: POLICY: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: 6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; 7. Filing accurate and timely investigative reports; 4. Identification Employees are required to immediately report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or the administrator. Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruising of unknown origin, lacerations or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions. c. Employees of the facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation has been reviewed by the administrator or designee. e. Employees accused of possible abuse shall not complete the shift as a direct care provider to residents. 7. Reporting Initial Reporting of Allegations shall be completed immediately upon notification of the allegation. The written report shall be sent to the Department of Public Health. The Immediate Jeopardy began on 03/11/2025 and was removed on 03/26/24, when the facility took the following actions to remove the immediacy: On 3/26/2025 at 10:53 AM, V1 stated, I was retrained on abuse on 3/24/2025. Basically it covered the abuse policy, abuse prevention, investigation, the immediacy, and the thoroughness of it. It also covered identified vulnerable residents and providing emotional support after the fact. I am the Abuse Coordinator. The DON steps in as Abuse Coordinator if I was not here. If rough handling is alleged, it is considered abuse. Investigation starts immediately. If there is an alleged staff member, they would be placed on suspension immediately. Body check would be completed. MD (Medical Doctor) would be notified. Family would be notified. Interviews would be started. A reportable would be filed within 2 hours. If I come across a resident that is afraid and states they do not want to get anyone in trouble, I would speak with the resident in a private area, and encourage them to let us know what happened. I would let the doctor and responsible party know and see if they would open up to either one of them. I would interview staff. If they have a good repore with a specific staff member, I would try to have them talk to the resident. If they continue to refuse to share, I would try to provide support as best as we can. Ask them if we could make changes to care that would make them more comfortable. (V5) is still on suspension pending police investigation. As of yesterday afternoon, police still had not contacted (V5). The next step is to go to his house. Police said it is still at officer level and will next go to a detective. On 3/26/2025 at 11:09 AM, V16 (Registered Nurse/RN) stated, I was re-trained on abuse recently it was in the last couple days. It covered types of abuse, when to report abuse and a quiz. Abuse Coordinator is (V1), the Administrator. Rough handling is considered abuse. If someone reported rough handling to me, I would report to my supervisor, and the Administrator, and the DON reports to the Administrator. I would remove the resident from harms way. The alleged perpetrator would be removed. If I had a resident that seemed scared and stated they did not want to get anyone in trouble, I would still report. They may just be afraid of retaliation. I would do the same steps in that instance. On 3/26/2025 at 11:14 AM, V29 (Housekeeping) stated, I was recently trained on abuse yesterday. They covered types of abuse, reporting abuse to Abuse Coordinator, (V1). Being handled roughly is abuse. If someone told me they were handled roughly, I would report to the nurse and the Abuse Coordinator. If I came across a resident that seemed afraid and said that they don't want to get anyone in trouble, I would try to be supportive but report to the nurse and Abuse Coordinator. On 3/26/2025 at 11:22 AM, V30 (2nd floor Unit Manager) stated, I was recently trained on abuse this past week. We talked about reporting to Administrator any suspected abuse or witnessed abuse. We also covered types of abuse which include verbal, mental, sexual, physical, misappropriation of property and exploitation, mistreatment, serious body injury, and neglect. Rough handling is considered abuse. If a resident told me they were handled roughly, I would offer to listen to patient and get a nurse and report to administrator immediately. Administrator, (V1) is our Abuse Coordinator. If (V1) is not here, the DON is our Abuse Coordinator. If I came across a resident that stated they were afraid and did not want to get anyone in trouble, I would listen to the resident and communicate it right away to the Administrator. On 3/26/2025 at 11:31 AM, V23 (Physical Therapist) stated, I was just retrained on abuse yesterday. It covered reporting structure, who, when, etc. Types of abuse was covered. The three R's which are remove, remove, report. Abuse Coordinator is (V1). Rough handling is considered abuse. If a resident reported rough handling to me, I would ask the resident if they wanted to talk to someone, report to my supervisor and to the Abuse Coordinator. If a resident reported they are scared and do not want to get anyone in trouble, I would do the same thing. I would ask them if they want to speak to someone about that, report to my supervisor and to the Abuse Coordinator. On 3/26/2025 at 11:37 AM, V31 (Housekeeping) stated, I was retrained on abuse yesterday. They talked about the 10 different kinds of abuse. They talked about reporting any problems to (V1) Abuse Coordinator immediately. Rough handling is abuse. If a resident told me someone was rough with me, I would report it immediately to Administrator. If a resident told me they were scared and don't want to get anyone in trouble, I would report that to the administrator as soon as possible and try to calm the resident. On 3/26/2025 at 11:42 AM, V32 (Building Manager) stated, I did recently get retrained on abuse yesterday. They covered the 10 different types of abuse, reporting immediately, remove, and report. (V1) is the Abuse Coordinator. Rough handling is considered abuse. If a resident reported rough handling to me, I would report immediately to (V1), and try to remove the resident and alleged perpetrator. If a resident reported they were afraid but did not want to get anyone in trouble, I would remember what room it was and go report it to (V1) immediately. On 3/26/2025 at 11:48 AM, V33 (Resident Care Coordinator) stated, I did recently get trained on abuse yesterday. They covered the 10 types of abuse, who to report to (Administrator), timeliness of reporting, and what to do if you see abuse occur. Abuse Coordinator is (V1), the Administrator. Rough handling is considered abuse. If a resident reported rough handling to me, I would tell the Administrator immediately. If a resident reported to me that they were afraid and did not want to get anyone in trouble, I would still report immediately to the Administrator. On 3/26/2025, V34 (CNA) stated, I was recently trained on abuse yesterday or the day before. They covered the different types of abuse, who to report to (Administrator), what to do if you witness or experience any type of abuse. Rough handling is considered abuse. If a resident reported rough handling to me, I would remove the patient from the situation, and report to the Administrator. If a resident told me they were afraid and did not want to get anyone in trouble, I would still report to the Administrator. On 3/26/2025 at 11:59 AM, V2 stated, I was retrained on abuse on 3/24/2025. We were re-trained on how to investigate abuse, how to respond to any allegation of abuse, how to interview the resident, informing family and doctors, and how to find who the resident is comfortable with to talk to the resident. Types of abuse were covered (10 types); we did quizzes. We educated the staff as well. Abuse Coordinator is the Administrator, and if she is absent, it is me. Rough handling is considered abuse. If a resident reported rough handling to me, I would try to get details from resident, remove abuser, and report to (V1). If I had a resident report to me that they were afraid, and did not want to get anyone in trouble, I would try to get details from resident, report to V1, inform family and doctor, and try get someone to talk to resident that they are comfortable with. On 3/26/2025 at 12:59 PM, Updated Abuse Policy reviewed. No concerns noted. On 3/26/2025 at 1:02 PM, QAPI (Quality Assurance Performance Improvment) meeting minutes for QAPI meeting held on 3/24/2025 reviewed. No concerns noted. On 3/26/2025 at 1:05 PM, Abuse, Abuse Prevention Policy and reporting and investigating,and Abuse Prevention policy and putting interventions in place to protect resident and provide support Inservice/Meeting Attendance Records reviewed for 3/24/2025. No concerns noted. On 3/26/2025 at 1:10 PM, Initial Incident Report and Final Incident Report reviewed for R1. No concerns noted. On 3/26/2025 at 1:11 PM, Incident Referral Card, dated 3/24/2025 reviewed. No concerns noted. On 3/26/2025 at 1:13 PM, Abuse Prevention Quizzes 2025 and Abuse Quizzes reviewed. No concerns noted. On 3/26/2025 at 1:15 PM, QAPI Assessment Tool Investigate/Prevent/Correct Alleged Violation, dated 3/20/2025, 3/21/2025, 3/22/2025, 3/23/2025, and 3/24/2025 reviewed. No concerns noted. On 3/26/2025 at 1:18 PM, QA/QI (Quality Assurance/Quality Improvement) Monitoring sheet labeled F607 and F600 Free from Abuse and Neglect dated 3/24/2025, 3/25/2025, and 3/26/2025 reviewed. No concerns noted.