3. R52's 1/2/24 Minimum Data Set assessment shows her cognition and memory are intact. R52's active care plan shows she requires staff assistance with her activities of daily living, can become incontinent of urine and is a stand by assist for toileting. The care plan also shows she can has the potential to be a victim of abuse. On 3/12/24 at 10:37 AM, R52 said she had a problem with the CNA (later identified as V8) last night who yelled at her. R52 said, I am mostly independent, but sometimes have a problem with incontinence, so last night I got up to use the bathroom and didn't grab a pull up on the way, so I put my light on for the CNA to get me one. The CNA got mad at me and started going off on me, saying I should have got the pad before I went to the bathroom and she didn't have time for my nonsense. She then tossed the pad at me, refused to get me new pants, slammed the door, and left. On 3/12/24 at 10:45 AM, V7 (Social Worker) said it was reported to her at 8:35 AM, that a potential abuse incident occurred between R52 and a CNA. She went and talked to her right away and started to obtain statements from the CNA and the resident and R52's roommate (R98). On 3/12/24 At 12:32 PM, R52 said she did file a report with her Social Worker who came right away to talk to her. R52 also said she felt totally disrespected by V8, and was so upset she cried herself to sleep. On 03/12/24 12:34 PM, R98 said she never saw the CNA (V8), but she heard the incident and she was very rude to R52 and slammed the door. On 3/12/24 at 1:56 PM, V7 said based on her interviews, she considers what V8 said and did to R52 a form of verbal abuse. V7 said yelling, downgrading, and disrespecting a resident is a form of abuse. V7 said V8's statement she refers as not being serious and joking about it. V7 said, In my opinion, this is grounds for termination, not just suspension. On 3/13/24 at 9:49 AM, V1 (Administrator) said she is still working on the investigation and has not yet determined if the abuse is substantiated. The facility provided witness statements from the investigation show V8 emailed V7 her statement which states exactly as written, So yesterday at around 7/8 O clock (R52) put her light on, I went to go answer her light. She was fine but I grabbed the pull up for her & as I'm handing it to her, I simply suggested/asked why she doesn't grab her (incontinence brief) before she goes into the bathroom & that it would be easier for her in case while others are on break & I happen to be with someone else so she is not waiting on the toilet for while. I don't know if she was having a bad day or something but she starting going on an entire rant of why does everyone ask her this all the time and why am everyone is so mean to her. I responded and told her it wasn't meant to be that serious & that it was just a question. The facility provided investigation submitted to the Illinois Department of Public Health (IDPH) on 3/14/24 by V1 (Administrator) states, The facility conducted a thorough investigation pertaining to an allegation of abuse. Staff members and residents were interviewed as part of the investigation. Based on conducted interviews and review of The Abuse Prevention Program-Policy, the facility is making the determination to substantiate the allegation of abuse. V8 was attempted to be contacted by phone during the survey with no return call. The facility provided Abuse policy reviewed 1/2019 identified verbal abuse as oral, written, or gestured language that willfully includes disparing and derogatory terms to residents or families. Mental abuse includes, humiliation, harassment, threats of punishment or deprivation by a licensee, employee or agent. Deficiencies at this level require more than one Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to protect R102 from physical abuse, resulting in R102 having muscular skeletal pain to his left arm and redness and swelling to his left cheek for 1 of 32 residents (R102) reviewed for abuse in the sample of 32. The Immediate Jeopardy began on 03/09/2024 at 5:30AM, when V37, CNA-Certified Nursing Assistant, became aggressive with R102, by pinning R102's hands to his chest and bearing all his weight on to R102. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 03/14/2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On 03/13/24 at 1:46 PM, R102 was lying in bed on his back, with the head of the bed elevated at a thirty-degree angle. R102 had a bruise to the left cheek. On 03/13/24 at 1:46 PM, R102 said, One man hurt me here. I was grabbed and my face went into the side rail and he punched me. I have pain to my left cheek and left arm. On 03/14/24 at 9:04 AM, V37, CNA, was contacted by phone. A message was left requesting V37, CNA, to call back. V37, CNA, has not returned call prior to exiting from the facility. On 03/14/24 at 9:06 AM, V38, CNA, said, (V37, CNA) had (R102) the night of Friday (03/08/24) to Saturday morning (03/09/2024). At 12:30AM, (V37) asked for assistance with a combative resident. I went in to change (R102). (R102) did throw his hand up, maybe he began to resist, I could not tell, because (V37) had already grabbed (R102) and pinned him down. He had the resident's hands balled up and pinned to (R102's) chest. (R102) can be angry, but I have never seen him combative. Most people know to walk away. The next incident happened at 5:30AM. (V37) asked for help. I went to (R102), and asked him to give me five minutes to change him. (R102) agreed. (R102) usually refuses the first bed check. We just report to the nurse, then in the morning, (R102) allows it. (R102) threw his hands up and said ok. I took his hands being up as (R102) submitting to be changed. (V37) then pinned (R102's) hands to this chest. It looked like he was choking him, except he was pushing (R102's) crossed hand onto (R102's) chest instead of being around his neck. Then (V37) put more weight on him. (V37) told (R102) to turn. I said, '(V37) let him go', then I said it again. I went to get (V40, LPN-Licensed Practical Nurse). (V37) was being too aggressive, too rough. (V37) should not take care of residents anymore. (R102) looked scared; I was scared also. He looked more scared the second time as (V37, CNA) tried to provide care than the first time. I think that is why (R102) threw his hands up. He was surrendering. I had never seen (R102) like that. During that time, (V40, LPN) was doing her med pass. The nurse did not know what the protocol was. (V40, LPN) said she was going to ask the other nurse. The other nurse said we need to talk to (V2, DON-Director of Nursing). I told the nurse (V37) put all his weight on (R102). (V37) became aggressive and put all his weight on (R102). If the patient says I don't want to be touched, we leave them alone. I reported the abuse to (V40, LPN-Licensed Practical Nurse). (V40, LPN) said she did not know the protocol. I then went to the first floor and reported the incident to (V39, Charge Nurse). The first time (V37) provided care to (R102) he was too aggressive, I thought I should say something. The second time I knew I needed to say something. On 03/15/24 at 10:01 AM, V35, CNA, said, I spoke with (R102) on 03/09/24. He told me (V37, CNA) came into his room and punched him in the face. The second time (V37, CNA) came in the room, he tossed him toward the side rail of the bed. On 03/14/2024 at 10:54 AM, V41, RN-Registered Nurse, said, (V40, LPN) told me there was an incident where (V37, CNA) was restraining a resident. (V35, CNA) and I went to see (R102). (R102) told me that he was punched with a closed fist. (R102) had redness and swelling to the left cheek, and his left arm was hurting. (R102) said (V37, CNA) was rough with care. (R102) never complained of forearm pain before. I would report a patient being pinned down; I would say that is abuse. R102's Progress Notes, dated 03/09/2024 at 7:40AM, created 03/11/2024 at 1:40AM, by V41, RN-Registered Nurse, shows, received resident at 7:00 AM. Informed by night shift LPN that an incident occurred between CNA and resident during early AM hours of care before 7:00 AM. Two police officers here in building doing an investigation and interviewing staff. Resident is alleging that he was struck in the left side of his face with a closed fist by the CNA and that he was being rough during care. Resident complained of pain to his left arm. Upon assessment left cheek looks slightly swollen with a small amount of redness. Assessed left arm pain. Resident continues to have AROM (Active Range of Motion) to both upper extremities. Able to flex and extend both arms without pain. Able to lift arms above head and squeeze RN fingers without pain. Only complaint of muscle pain to top of forearm. No swelling or redness noted at this time to either arm. Informed daughter of incident. Shortly after the daughter arrived and was at bedside. RN explained at this time we will manage pain with scheduled acetaminophen and if pain worsens or other symptoms arise the RN can obtain X-Ray for left arm but at this time it is not necessary. Informed Nurse Practitioner. R102's Aggravated Battery Police report, dated 03/09/2024 at 6:41AM, shows, responding officer spoke with (V37, CNA), who provided the following information. (V37, CNA) had his first encounter with (R102) at approximately 0030 (12:30AM) hours. (V37, CNA) was changing (R102's) diaper and in the process, (V37, CNA) requested help from (V38, CNA) since he knew the history of (R102) being combative. (R102) was pinned down in anticipation of being combative. On the second occasion, at approximately 0530 hours (5:30AM), (V37, CNA) changed (R102's) diaper. (V38, CNA) saw (V37, CNA) and assisted in the process. (V37, CNA) then held (R102) by the wrist to prevent from him being combative. Responding Officer then spoke with V38, CNA, who provided the following information. V38, CNA, was assisting V37, CNA, at approximately 0030 hours. V38, CNA, noticed V37, CNA, pinning down R102. She told V37, CNA, to get off R102, and not use that amount of force. She kept telling V37 numerous times to get off and she saw R102 look at her. She explained R102 looked at her in a manner that hinted that he was scared and if the excessive force of V37 CNA was justified. In the heat of the moment, V38, CNA, walked away since she was afraid of V37, CNA. The second incident occurred at approximately 0530 hours. V37, CNA and V38, CNA were changing R102`s diaper. As V38, CNA, was changing the diaper, V37, CNA, stepped in and held R102's down by the wrist against his bed while using the full weight of his body. V38, CNA, thought this was excessive due to R102 having both of his legs amputated and due to weighing 100 Lbs. or less. V38, CNA, stated that R102 was not combative and did not need to be restrained. Responding Officer spoke with R102 and was given the following information. R102 was having his diaper changed by V38, CNA, at approximately 0030 hours. During that time, he was pinned down with his arms crossed. R102 stated he did feel pain in his arms when being pinned down. In the second incident, R102 was having his diaper changed by V37, CNA and V38, CNA. As V38, CNA, was changing him, V37, CNA, stepped in and held R102 by the wrist on the bed. R102 advised responding officer he was punched by V37, CNA, in the upper torso. Responding Officer asked R102 what time frame that occurred between the two incidents, but R102 did not know an approximate time of when it happened. Responding Officer checked R102 for any signs of injuries including marks or bruises. Responding Officer did not notice any bruises, but did notice redness and a small cut on R102's left upper cheek. Responding Officer took pictures of the cut and both arms that were a result of being held down by V37, CNA. The facility's Final Report on R102's abuse allegation of 03/09/2024 shows abuse has been substantiated. The facility's Policy, dated 01/2019, shows, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The Immediate Jeopardy that began on 03/09/2024 was removed on 03/14/2024 when the facility took the following actions to remove the immediacy. 1. V37 was removed from the schedule on date of alleged incident pending investigation. 2. V37's employment from facility is terminated. 3. All staff will be educated on all types of abuse, 03/13/2024. 4. All staff will be educated on the standard of immediately reporting abuse, 03/13/2024. 5. All staff will be educated on protecting residents after an alleged abuse, 03/13/2024. 6. All staff will be educated on the components of the abuse policy, 03/14/2024. 7. All Residents will be re-evaluated for the potential at risk for abuse or neglect. 8. As all current staff are educated, new hires will be trained accordingly and an Abuse Prevention Training Program-Post Test will be completed to assess for comprehension, 03/14/2024. 9. Any/All allegations of abuse will be brought to the IDT in Morning Meetings and reviewed in detail at weekly IDT Meetings, 03/14/2024. 10. Any/All Abuse allegations will be reviewed and monthly QAPI/Quarterly QA. 2. On 3/12/24 at 9:04 AM, this surveyor was in the hall by the doorway of R125's room. V32 (Registered Nurse) went into R125's room to provide him with medication. R125 started yelling at V32 that he needed to see the doctor so he could go home. V32 exited the room and R125 followed her. When R125 got to his doorway, R80 walked to his doorway, which is across the hall from R125's room, and told R125 to be quiet. R125 then went around the nurse and into the hallway and stuck his middle finger up at R80 and stated, F**k you, mind your f***ing business. R80 was still standing in his doorway and put up both of his fists in a fighting position. V32 then went to R125 and directed him back to his room. At the same time, V28 (Certified Nursing Assistant) assisted R80 back into his room. When R125 got to inside his doorway, he stated, I'm going to tear his f***ing larynx out. R125's Nursing Notes, dated 3/12/24 at 9:21 AM, shows, Resident in hallway started to yell loudly saying he wants to go home, asking for doctor, other resident opposite to his from [sic] got irritated and started to talk back/yelled at this resident. Staffs tried to calm him down, redirect to his room but couldn't. After a while he himself went back to his room. NOD (Nurse on Duty) informed Social Services and DON (Director of Nursing) R125's Social Service Note, dated 3/12/24 at 2:33 PM, shows, Writer was informed about a verbal argument between 2 cognitively impaired male residents. Writer met with resident due to verbal aggression towards another male resident . On 3/12/24 at 12:20 PM, R80 was in his room laying in bed. R80 said that this morning he heard that guy yelling, so he went to the doorway and told him to be quiet. R80 said that R125 then started yelling at him and threatening him. R80 said that he (R125) is very violent and he gets ticked off by the smallest things and starts yelling. On 3/12/24 at 12:23 PM, V32 said R125 has a history of yelling when he is upset. V32 said she texted V15 (Memory Care Director) about the incident. (R80 and R125 do not reside on the secured Memory Care Unit). On 3/12/24 at 12:30 PM, V15 (Memory Care Director) said V32 texted her at 9:08 AM, but she did not see it until about 10:00 AM, and said the two residents had verbal aggression between each other that was initiated by R125. V15 said she told V32 to keep them separated and she would have R125 see the psychiatrist the next day. On 3/12/24 at 1:47 PM, V7 (Social Services) said some types of abuse include: physical, verbal, financial and sexual. V7 said abuse can happen between anyone, staff to residents or resident to resident. V7 said examples of verbal abuse include: yelling at someone, downgrading them, being very disrespectful to them or being aggressive towards them. On 3/13/24 at 9:49 AM, V1 (Administrator/Abuse Coordinator) said types of abuse include: physical, mental, sexual, involuntary seclusion, verbal and misappropriation of property. V1 said verbal abuse includes: derogatory remarks, verbal threats of physical harm or any verbal response that could cause mental anguish to someone. V1 said abuse can be between staff and residents or between a resident and resident. V1 said that even if a resident has dementia, they can still verbally abuse another resident. The facility's Abuse Prevention Program, reviewed on 1/2019, shows, This facility is committed to protecting our residents from abuse .by anyone including, but not limited to, facility staff, other residents .verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within hearing distance, regardless of an individuals age, ability to comprehend, or disability. B. Based on observation, interview, and record review, the facility failed to ensure a resident was free from sexual abuse (R61), and failed to ensure residents were free from verbal abuse (R80 and R52), for 3 of 32 resident reviewed for abuse in the sample of 32. 1. The Facility Reported Incident (FRI) as Final Report, dated 3/5/24 with date of incident as 3/1/24, shows (R61) was observed to have his hand on (R132's) breast. Both residents were on 2nd floor. (R132) was up and about, while (R61) was sitting in his wheelchair able to wheel himself around. Both were in the nurse station on 2nd floor, several staff were behind the nurses station documenting. Upon looking, it was observed that (R61) had his hand on (R132's) left breast. Upon observation, staff immediately intervened and separated the two residents. R132 is a 73 y/o female with diagnoses of Alzheimer's disease, hyperlipidemia, major depression recurrent, muscle weakness unsteadiness on feet . alert and oriented x1, with impaired memory judgement and decision making abilities. R132 is unable to make her wants and needs knows and relies on staff to anticipate needs. R132 does speak and mumbles but is generally non-.sensical. R132 has severe cognitive impairment as evidenced by her most recent BIMS and is a long term care resident since 11/23. R132's careplan shows Resident may be a potential risk for abuse related to behavior problems as evidenced by aimless wandering in and out of other resident rooms, and walking up closely to other residents, impaired safety awareness. R61 is a 73 y/o male with diagnoses of displaced fracture of left femur, hemiplegia, abnormalities of gait and mobility, alert and oriented x 2 with impaired memory judgement and decision making abilities. R61 has moderate cognitive impairment and is a long term care resident since 1/2023. On 3/11/24 at 9:15 AM, R132 was up and about in the hallways, mumbling to herself. When asked by this surveyor if she was ok, R132 smiled and continued to walk around the 2nd floor. On 3/11/24 at 12:30 PM, R61 was in his room with a sitter. R61 stated, I got the idea to touch her (R132) cause she lifted her shirt up and a I saw a bare breast. I am a man. Staff all saw it and got upset about it, but no one said the other resident got upset. I should have known this was wrong. We have to respect each other in a nursing home. Never done this before, no. After it happened, I was admitted to the hospital on a psych unit. I know it was wrong for me to do this, yes. I wasn't thinking the resident may not be in her right mind. This statement was witnessed by R61's sitter (V13, Restorative CNA) On 3/12/24 at 12:10 PM, V16 (License Practical Nurse-LPN) said she was the nurse working on 3/1/24 when the incident happened. V16, LPN, said she was sitting at the nurses station. R61 was sitting in his wheelchair, and R132 was standing by the nurses station. V16 said when she looked up, she saw R61's hand was under R132's shirt touching her left breast. V16 said she told R61 to take his hands off R132. R61 did not remove his hands. V16 stated, I had to get up and physically remove (R61's) hand from (R132's) breasts. (R132) did not react to what happened and seemed unaware. (R61) was provided 1:1 immediately. V16 said she reported the incident to V15 (Dementia Director), both families, and their physician. R61 was sent out to the psych ward. R61 was back at the facility but on a different floor. V16 said, When a resident touches another resident inappropriately, that is sexual abuse. On 3/11/24 at 11 AM, V15 (Dementia Unit Manager) said on 3/1/24, it was reported to her R61 touched R132's breast. Both residents were separated. R61 was provided 1:1 until he was sent out to the psych ward. V15 said she reported the incident to V1 (Administrator), the Abuse Coordinator. R132 was now back at the facility, but was moved to first floor with a sitter. On 3/13/24 at 9AM, V1 (Administrator) said she takes abuse seriously and abuse was not allowed at the facility. V1 said she was working on R61's discharge. The facility Policy entitled Abuse Prevention Program, date review of 1/2019, shows, Definitions: Abuse mans any physical or mental injury or sexual assault inflicted upon a resident other than by accident means. Abuse is the willful infliction of injury unreasonable confinement intimidation or punishment resulting in physical harm, pain, or mental anguish to a resident. This also includes deprivation by an individual, including caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Sexual abuse- includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident.

Based on observation, interview, and record review, the facility failed to follow their abuse policy and procedure by not protecting R102 from abuse by not removing a staff members who's observed actions were suspected to be abusive, and not performing a full body assessment of a resident who was suspected of being abused for 1 of 36 residents (R102) reviewed for abuse in the sample of 36. The Immediate Jeopardy began on 03/09/2024 at 12:30AM, when V38, CNA-Certified Nursing Assistant, failed to report her suspicion of abuse when she observed V37, CNA, becoming aggressive, grabbing R102's hands and pinning them down to R102's chest, resulting in R102 being abused by V37, CNA, at 5:30AM. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. The surveyor confirmed by interview and record review the Immediate Jeopardy was removed on 03/14/2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On 03/13/24 at 1:46 PM, R102 was lying in bed on his back, with the head of the bed elevated at a thirty-degree angle. R102 had a bruise to the left cheek. On 03/13/24 at 1:46 PM, R102 said, One man hurt me here. I was grabbed and my face went into the side rail, and he punched me. I have pain to my left cheek and left arm. On 03/14/24 at 9:06 AM, V38, CNA, said, (V37, CNA) had (R102) the night of Friday (03/08/24) to Saturday (03/09/2024). At 12:30AM. (V37) asked for assistance with a combative resident. I went in to change (R102). (R102) did throw his hands up, maybe he began to resist, I could not tell, because (V37) had already grabbed (R102) and pinned him down. He had the resident's hands balled up and pinned to (R102's) chest. (R102) can be angry, but I have never seen him combative. Most people know to walk away. The next incident happened at 5:30AM. (V37) asked for help. I went to (R102) and asked him to give me five minutes to change him. (R102) agreed. (R102) usually refuses the first bed check. We just report to the nurse, then in the morning, (R102) allows it. (R102) threw his hands up and said ok. I took his hands being up as (R102) submitting to be changed. (V37) then pinned (R102's) hands to this chest. It looked like he was choking him, except he was pushing (R102's) crossed hand onto (R102's) chest instead of being around his neck. Then (V37) put more weight on him. (V37) told (R102) to turn. I said, '(V37) let him go', then I said it again. I went to get (V40, LPN-Licensed Practical Nurse). (V37) was being too aggressive, too rough. (V37) should not take care of residents anymore. (R102) looked scared; I was scared also. He looked more scared the second time (V37, CNA) tried to provided care than the first time. I think that is why (R102) threw his hands up. He was surrendering. I had never seen (R102) like that. During that time, (V40, LPN) was doing her med pass. The nurse did not know what the protocol was. (V40, LPN) said she was going to ask the other nurse. I told the nurse he put all his weight on (R102). (V37, CNA) became aggressive and put all his weight on (R102). If the patient says I don't want to be touched, we leave them alone. I reported the abuse to (V40, LPN-Licensed Practical Nurse). (V40, LPN) said she did not know the protocol. I then went to the first floor and reported the incident to (V39, Charge Nurse). The first time (12:30AM) (V37, CNA) provided care to (R102) he was too aggressive, I thought I should say something. The second time (5:30AM), I knew I needed to say something. On 03/14/24 at 9:37 AM, V39, RN Charge Nurse, said, I am the charge nurse. (V38, CNA) let me know about the incident. The incident was reported to me (03/09/2024) between 6:15 AM to 6:30 AM, (approximately six hours after the first event was witnessed). Because it was abuse, I contacted (V1-Administrator). I followed her instruction. I called the police to make a report. I did not assess (R102). The nurse on the floor did the check, I think it was (V40, LPN). I did not make any changes to the assignment sheets. We pulled (V37, CNA) off the floor when I was told, and called the police so he could talk with police, and I could get a statement from him. I pulled him off the floor around 6:30 AM to 7:00 AM. (approximately one hour after allegation of abuse was reported), when we brought him to the office. On 03/14/24 at 9:55 AM, V40-LPN, R102's Nurse said, The incident was never brought to my attention. If I would have known, I would have charted it. I believe I was (R102's) nurse; I was (R102's) nurse; I cannot recall. I do not work there anymore. I quit Monday (03/11/2024). On 03/14/2024 at 10:54 AM, V41, RN-Registered Nurse said, (V40, LPN) told me there was an incident where (V37, CNA) was restraining a resident. (V35, CNA) and I went to see (R102). (R102) told me that he was punched with a closed fist. (R102) had redness and swelling to the left cheek and his left arm was hurting. (R102) said (V37, CNA) was rough with care. (R102) never complained of forearm pain before. I would report a patient being pinned down; I would say that is abuse. On 03/18/24 at 1:36 PM, V38, CNA, said, I started in November of 2023. I have never received new hire orientation. The facility never provided me with abuse training until after the incident between (R102) and (V37, CNA). The facility requested that I amend my report. I was told I could quit, or they would terminate me for abuse and report me to the state. The facility's assignment sheet, dated 03/08/2024 through 03/09/2024, shows V40, LPN, was assigned to R102. R102's Medical Record, dated 03/09/2024, shows, R102 was not assessed for injury until after 7:40AM. The assessment was not documented until 03/11/2024 at 1:40AM. R102's Progress Notes, dated 03/09/2024 at 7:40AM, created 03/11/2024 at 1:40AM, by V41, RN-Registered Nurse, shows, received resident at 7:00 AM. Informed by night shift LPN that an incident occurred between CNA and resident during early AM hours of care before 7:00 AM. Two police officers here in building doing an investigation and interviewing staff. Resident is alleging that he was struck in the left side of his face with a closed fist by the CNA and that he was being rough during care. Resident complained of pain to his left arm. Upon assessment left cheek looks slightly swollen with a small amount of redness. Assessed left arm pain. Resident continues to have AROM (Active Range of Motion) to both upper extremities. Able to flex and extend both arms without pain. Able to lift arms above head and squeeze RN fingers without pain. Only complaint of muscle pain to top of forearm. No swelling or redness noted at this time to either arm. Informed daughter of incident. Shortly after the daughter arrived and was at bedside. RN explained at this time we will manage pain with scheduled acetaminophen and if pain worsens or other symptoms arise the RN can obtain X-Ray for left arm but at this time it is not necessary. Informed Nurse Practitioner. The facility's Abuse Policy, dated 01/2019, shows, employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be removed from resident contact immediately. Orientation and Training of Employees: during orientation of new employees, the facility will cover at least the following topics: What constitutes abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property; how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff; an employee's obligation under the law for reporting a suspected crime to the facility, the state survey agency and local law enforcement; the time frames for reporting; and management's obligation to prohibit retaliation against anyone who makes a report. Physical Abuse, Conduct a full body exam, particularly in areas of resident complaint. The facility's Final Investigation Report on R102's abuse allegation of 03/09/2024 shows abuse has been substantiated. The Immediate Jeopardy that began on 03/09/2024 was removed and the deficient practice corrected on 03/14/2024 when the facility took the following actions to remove the immediacy and correct the noncompliance. 1. All staff will be educated on all types of abuse, 03/13/2024. 2. All staff will be educated on the standard of immediately reporting abuse, 03/13/2024. 3. All staff will be educated on protecting residents after an alleged abuse, 03/13/2024. 4. All staff will be educated on the components of the abuse policy, 03/14/2024. All Residents will be re-evaluated for the potential at risk for abuse or neglect, 03/14/2024. 5. As all current staff are educated, new hires will be trained accordingly and an Abuse Prevention Training Program-Post Test will be completed to assess for comprehension, 03/14/2024. 6. Any/All allegations of abuse will be brought to the IDT in Morning Meetings and reviewed in detail at weekly IDT Meetings, 03/14/2024. 7. Any/All Abuse allegations will be reviewed and monthly QAPI/Quarterly QA, 03/14/2024.

Based on observation, interview, and record review the facility failed to immediately report a suspicion of physical abuse for 1 of 36 residents (R102), and failed to ensure and allegation of verbal abuse was immediately reported for 1 of 32 residents (R80) reviewed for abuse in the sample of 36. The Immediate Jeopardy began on 03/09/2024 at 12:30AM, when V38, CNA-Certified Nursing Assistant, failed to report her suspicion of abuse when she observed V37, CNA, becoming aggressive, grabbing R102's hands and pinning them down to R102's chest, resulting in R102 being abused by V37, CNA, at 5:30AM. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 03/14/2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1.On 03/13/24 at 1:46 PM, R102 was lying in bed on his back, with the head of the bed elevated at a thirty-degree angle. R102 had a bruise to the left cheek. On 03/13/24 at 1:46 PM, R102 said, One man hurt me here. I was grabbed and my face went into the side rail, and he punched me. I have pain to my left cheek and left arm. On 03/14/24 at 9:06 AM, V38, CNA, said, (V37, CNA) had (R102) the night of Friday (03/08/24) to Saturday (03/09/2024). At 12:30AM, (V37) asked for assistance with a combative resident. I went in to change (R102). (R102) did throw his hands up, maybe he began to resist, I could not tell, because (V37) had already grabbed (R102) and pinned him down. He had the resident's hands balled up and pinned to (R102's) chest. (R102) can be angry, but I have never seen him combative. Most people know to walk away. The next incident happened at 5:30AM. (V37) asked for help. I went to (R102), and asked him to give me five minutes to change him. (R102) agreed. (R102) usually refuses the first bed check. We just report to the nurse, then in the morning, (R102) allows it. (R102) threw his hands up and said ok. I took his hands being up as (R102) submitting to be changed. (V37) then pinned (R102's) hands to this chest. It looked like he was choking him, except he was pushing (R102's) crossed hand onto (R102's) chest instead of being around his neck. Then (V37) put more weight on him. (V37) told (R102) to turn. I said, '(V37) let him go', then I said it again. I went to get (V40, LPN-Licensed Practical Nurse). (V37) was being too aggressive, too rough. (V37) should not take care of residents anymore. (R102) looked scared; I was scared also. He looked more scared the second time as (V37, CNA) tried to provided care than the first time. I think that is why (R102) threw his hands up. He was surrendering. I had never seen (R102) like that. During that time, (V40, LPN) was doing her med pass. The nurse did not know what the protocol was. (V40, LPN) said she was going to ask the other nurse. The other nurse said, 'We need to talk to (V2, DON)'. I told the nurse he put all his weight on (R102). (V37) became aggressive and put all his weight on (R102). If the patient says 'I don't want to be touched', we leave them alone. I reported the abuse to (V40, LPN-Licensed Practical Nurse). (V40, LPN) said she did not know the protocol. I then went to the first floor and reported the incident to (V39, Charge Nurse). The first time (V37) provided care to (R102) he was too aggressive, I thought I should say something. The second time I knew I needed to say something. On 03/14/24 at 9:37 AM, V39, RN Charge Nurse, said, I am the charge nurse. (V38, CNA) let me know about the incident. The incident was reported to me (03/09/2024) between 6:15 AM to 6:30 AM, (approximately six hours after the first event was witnessed). Because it was abuse, I contacted (V1-Administrator). I followed her instruction. I called the police to make a report. I did not assess (R102). The nurse on the floor did the check, I think it was (V40, LPN). I did not make any changes to the assignment sheets. We pulled (V37, CNA) off the floor when I was told, and called the police so he could talk with police, and I could get a statement from him. I pulled him off the floor around 6:30 AM to 7:00 AM, (Approximately one hour after second allegation of abuse was observed and reported to (V40, LPN), when we brought him to the office. On 03/14/24 at 9:55 AM, V40-LPN said, The incident was never brought to my attention. If I would have known, I would have charted it. I believe I was (R102's) nurse; I was (R102's) nurse; I cannot recall. I do not work there anymore. I quit Monday (03/11/2024). On 03/14/2024 at 10:54 AM, V41, RN-Registered Nurse, said, (V40, LPN) told me there was an incident where (V37, CNA) was restraining a resident. (V35, CNA) and I went to see (R102). (R102) told me that he was punched with a closed fist. (R102) had redness and swelling to the left cheek and his left arm was hurting. (R102) said (V37, CNA) was rough with care. (R102) never complained of forearm pain before. I would report a patient being pinned down; I would say that is abuse. The facility's assignment sheet, dated 03/08/2024 at 11:00PM through 03/09/2024 at 7:00 AM, shows, V40, LPN, was assigned to R102. The facility's Abuse Policy, dated 01/2019, shows, employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. The facility's Final Investigation Report on R102's abuse allegation of 03/09/2024 shows abuse has been substantiated. The Immediate Jeopardy that began on 03/09/2024 was removed and the deficient practice corrected on 03/14/2024 when the facility took the following actions to remove the immediacy and correct the noncompliance. 1. All staff will be educated on all types of abuse, 03/13/2024. 2. All staff will be educated on the standard of immediately reporting abuse, 03/13/2024. 3. All staff will be educated on protecting residents after an alleged abuse, 03/13/2024. 4. All staff will be educated on the components of the abuse policy, 03/14/2024. 5. All Residents will be re-evaluated for the potential at risk for abuse or neglect, 03/14/2024. 6. As all current staff are educated, new hires will be trained accordingly and an Abuse Prevention Training Program-Post Test will be completed to assess for comprehension, 03/14/2024. 7. Any/All allegations of abuse will be brought to the IDT in Morning Meetings and reviewed in detail at weekly IDT Meetings, 03/14/2024. 8. Any/All Abuse allegations will be reviewed and monthly QAPI/Quarterly QA, 03/14/2024. 2. On 3/12/24 at 9:04 AM, this surveyor was in the hall by the doorway of R125's room. V32 (Registered Nurse) went into R125's room to provide him with medication. R125 started yelling at V32 that he needed to see the doctor so he could go home. V32 exited the room and R125 followed her. When R125 get to his doorway, R80 walked to his doorway which is across the hall from R125's room and told R125 to be quiet. R125 then went around V32 who was still standing in his doorway and went into the hallway. R125 stuck his middle finger up at R80 and stated, F**k you, mind your f***ing business. R80 was still standing in his doorway, and put up both of his fists in a fighting position. V32 then went to R125 and directed him back to his room. At the same time, V28 (Certified Nursing Assistant) assisted R80 back into his room. When R125 got to inside his doorway, he stated, I'm going to tear his f***ing larynx out. V32 was standing in R125's doorway when it was stated. R125's Nursing Notes, dated 3/12/24 at 9:21 AM, shows, Resident in hallway started to yell loudly saying he wants to go home, asking for doctor, other resident opposite to his from [sic] got irritated and started to talk back/yelled at this resident. Staff tried to calm him down, redirect to his room but couldn't. After a while he himself went back to his room. NOD (Nurse on Duty) informed social services and DON (Director of Nursing) R125's Social Service Note, dated 3/12/24, at 2:33 PM shows, Writer was informed about a verbal argument between 2 cognitively impaired male residents. Writer met with resident due to verbal aggression towards another male resident. 03/12/24 10:12 AM, V1 (Administrator) said she has had one allegation of abuse reported to her about a resident alleged abuse from a CNA the night prior, but no other incidents were reported to her. On 3/12/24 at 12:20 PM, R80 was in his room laying in bed. R80 said that this morning he heard that guy yelling, so he went to the doorway and told him to be quiet. R80 said R125 then started yelling at him and threatening him. R80 said he (R125) is very violent and he gets ticked off by the smallest things and starts yelling. On 3/12/24 at 12:23 PM, V32 said R125 has a history of yelling when he is upset. V32 said she texted V15 (Memory Care Director) about the incident. (R80 and R125 do not reside on the secured Memory Care Unit). On 3/12/24 at 12:30 PM, V15 (Memory Care Director) said V32 texted her at 9:08 AM, but she did not see it until about 10:00 AM, and said that two residents had verbal aggression between each other that was initiated by R125. V15 said she told V32 to keep them separated and she would have R125 see the psychiatrist the next day. V15 said she did not let V1 (Administrator/Abuse Coordinator) know of the incident, because it was just verbal aggression, and was not a physical altercation. V15 said she had not had a chance to speak with R125 yet. On 3/12/24 at 1:47 PM, V7 (Social Services) said types of abuse include: physical, verbal, financial and sexual. V7 said all allegations or witnessed abuse needs to be investigated right away, so the story does not change. V7 said abuse can happen between anyone, staff to residents, or resident to resident. V7 said examples of verbal abuse include: yelling at someone, downgrading them, being very disrespectful to them or being aggressive towards them. V7 said if staff see or hear about abuse they should go and tell the manager on duty or the abuse coordinator right away. V7 said she just got wind of the incident that happened between R125 and R80 a few minutes ago, and V15 is working on an investigation. On 3/13/24 at 9:49 AM, V1 (Administrator/Abuse Coordinator) said types of abuse include: physical, mental, sexual, involuntary seclusion, verbal and misappropriation of property. V1 said verbal abuse includes: derogatory remarks, verbal threats of physical harm or any verbal response that could cause mental anguish to someone. V1 said abuse can be between staff and residents or between a resident and resident. V1 said even if a resident has dementia, they can still verbally abuse another resident. V1 said staff have been educated to report any allegation of abuse they see or hear about immediately to her or the manager on duty if she is not available, and the manager will notify her immediately. V1 said an investigation is initiated immediately, and a report is sent to the State Survey Agency with two hours. V1 said she heard about the incident between R125 and R80 after this surveyor had interviewed V15 (on 3/12/24 at 12:30 PM). V1 said at that time, she spoke to corporate, and they instructed her to do an abuse investigation. V1 said the initial incident report was sent to the State Survey Agency around 1:00 PM on 3/12/24. An email provided shows V1 received confirmation that a Facility Reported Incident was received on 3/12/24 at 1:32 PM regarding R125. The facility's Abuse Prevention Program reviewed on 1/2019 shows, This facility is committed to protecting our residents from abuse .by anyone including, but not limited to, facility staff, other residents .verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within hearing distance, regardless of an individual's age, ability to comprehend, or disability .Employees are required to report any incident, allegation or suspicion of potential abuse .they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer .Any allegation of abuse will be reported to the Illinois Department of Public Health immediately, but not more than two hours of the allegation of abuse.