Jerseyville Manor

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

residents, then he was moved to the 200 hallway, where he didn't know the staff or other residents. V8 stated Resident R1 wasn't confused, he wasn't always able to fully understand different scenarios or situations. V8 stated Resident R1 also had a history of UTIs. V8 stated she had never observed Resident R1 being aggressive, his emotions would fluctuate, he would be happy/sad/tearful at times. V8 stated she worked with Resident R1 for a long time and didn't see any anger or aggression with him. V8 stated she has not seen Resident R1 since he was moved to the 200 hallway, they were waiting on more visits to be approved prior to Resident R1 being sent to the hospital.On 9/2/25 at 10:13 AM, V10, LPN (Licensed Practical Nurse) stated she was passing medications on 8/24/25, when she heard Resident R2 yelling, upon entering the room, Resident R1 was agitated, she was unsure why and Resident R2 was unable to explain what had happened or what was wrong. V10 stated Resident R1 stood up from his bed and attempted to go towards Resident R2, they attempted to redirect Resident R1 but were unable to, so they moved Resident R2 to a room on the 300 hallway and once Resident R2 was moved from the room, Resident R1 calmed down and Resident R2 was calm and okay in the other room. V8 stated prior to this incident, she had seen Resident R1, he wasn't agitated, aggressive, or irritable, he seemed fine but was growling and rolling his eyes. She talked with him briefly, then left the room, and about

an hour later was when the incident with Resident R1 and Resident R2 in their room happened. V8 stated the next morning, Resident R1 found Resident R2, pushed him to the ground, Resident R1 was also kicking/hitting at staff when they were trying to intervene. V8 stated they were able to deescalate the situation and Resident R1 was placed on 1:1 observation.On 9/2/25 at 10:25 AM, V11, CNA, stated she was charting and heard Resident R2 yelling, she thought he had crawled onto the floor, which he frequently did. V11 stated she entered the room and found that Resident R2 had spilled his Jello and was upset. V11 stated she helped Resident R2 clean it up, while doing this Resident R1 ripped the curtain back and looked like he was going to hit Resident R2, she tried to get Resident R1 to calm down, but he wasn't listening. V11 stated Resident R1 was trying to rip through them to get to Resident R2. V11 stated they finally got Resident R1 to sit down on the bed, but that didn't help, he began kicking V10, LPN, and twisted her (V11's) arm. V11 stated they were keeping Resident R1 away from Resident R2 and moved Resident R2 to another hallway. V11 stated once Resident R2 left the room, Resident R1 calmed down. V11 stated she was not aware of any prior incidents with Resident R1 or Resident R2. The Abuse Prohibition and Reporting Policy, dated 11/1999, documents the following: The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation, and use of any physical or chemical restraint not required to treat resident symptoms. Special attention will be given to identifying behavior that increases the residents potential for abusing self or others or being the victim of abuse, These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as: entering other residents rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff.

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