**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to ensure room temperatures were within the heat index/apparent temperature guidelines inside the facility and did not exceed 81 degrees Fahrenheit (F), the Facility failed to follow their Heat Emergency Policy as residents were not moved out of their rooms when temperatures were reached over 81 degrees for 4 of 4 residents (R1, R2, R3 and R11) reviewed for room temperatures in the sample of 16. This failure resulted in residents being left in rooms with the heat index indicating extreme caution to the residents. On 8/27/2025 at 9:55 AM, the Immediate Jeopardy/IJ was called with V1, Administrator. V2, Director of Nursing. and V17, Regional Director Operations The Immediate Jeopardy began on 8/7/2025 when resident room temperatures were not within the heat index/apparent temperature guidelines inside the facility and exceeded 81 degrees Fahrenheit (F), the Facility failed to follow their Heat Emergency Policy. The first abatement plan dated 8/27/2025 at 10:03 AM, was not accepted. The second abatement plan dated 8/27/2025 at 12:32 PM, was accepted. The surveyor confirmed by observation, interview, and record that the Immediate Jeopardy was removed on 8/27/2025, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the facility's policies and procedures and in-service training.Findings include:On 8/12/2025 at 9:45 AM, V1, Administrator stated, the air conditioning (AC) broke last Thursday (8/7/2025), and we were waiting for a part. All the air temperatures are good now. The AC repair man is here, and he is fixing everything. We brought in fans and some small AC units to the 500 halls, and we are having staff pass out drinks for hydration. The AC unit on the 500 hall was affected. We are not having issues with the other halls, and we are installing a new unit on the 500-hall unit today. Our maintenance man has been taking temperatures and took temperatures this morning and everything is good.On 8/12/2025 at 10:02 AM, V25, Registered Nurse (RN) was putting an IV (intravenous therapy medication) on a metal pole and quickly pulled her hand back and yelled out. On 8/12/2025 at 10:03 AM, V25 stated, This pole has been in the storage unit, I just took it out and it is so hot in there that this metal pole is hot, I cannot even touch it. It was being stored on the storage unit that is on the North Hall, that one with the broken AC (air conditioning) and it is super-hot!On 8/12/2025 at 10:03 AM, the metal pole was touched and was very hot to the touch and the hand had to be removed immediately. On 8/12/2025 at 10:31 AM, V6, Maintenance Director stated the AC (air conditioning) got struck by lightning on the South/West Hall and we finally got it repaired and up and running and then on Thursday the AC unit went out on the 500 halls. The 500 halls have been without AC for the past six days. I have been taking temperatures in all the rooms, and I have been using a laser thermometer. I did not use a Humidity Meter Hygrometer I do not even know what that is and I did not know I needed to factor in the humidity. I took temperatures this morning before you got here.On 8/12/2025 at 10:41 AM, V31, Contractor for HVAC system stated, we were called on Friday (8/8/2025) by (the facility) telling us they were having problems with their AC unit. I am replacing the thermal expansion valve today. The North Hall unit was out. I needed the parts, which I had to order and am replacing everything today. Hopefully, this will take care of everything for that hall.1-R2's Physicians Order Sheet (POS) for August 2025 documents diagnoses of Morbid Severe Obesity, Heart Failure, diabetes mellitus 2, kidney Failure, hypertension; chronic pain syndrome; unspecified protein calorie malnutrition; acute kidney failure; shortness of breath; hypertension; and generalized anxiety.R2's Minimum Data Set/MDS dated [DATE] document R2 was cognitively intact for decision making of activities of daily living, uses a wheelchair, and is dependent on staff for most activities of daily living.R2's Care Plan with a start date of 7/29/2024 documents, the resident has an ADL (Activities of daily living) self-care performance deficit r/t (related to) respiratory failure, obesity, chronic pain, depression. The resident has diabetes mellitus start date 8/28/2024; Intervention: Avoid exposure to extreme heat or cold.On 8/13/2025 at 10:03 AM, R2's room was measured with a Humidity Meter Hygrometer and Indoor Digital Thermometer with Temperature Gauge and Humidity Gauge which was calibrated and documented R2's room was 86 degrees with 61 percent humidity = for 91-degree Fahrenheit (F) room (extreme caution). On 8/12/2025 at 12:08 PM, V5, Family of R2 stated, The nursing home has failed to repair the broken air conditioner. It broke on Thursday August 7th, the system stopped functioning in my mom's room. There is no Air conditioning on their wing at all. Nurses have opened the windows and are using what fans they can find. The temperature outside has been in the high 80's and 90's all 5 days the air conditioner has been down. There was a thermometer in her room and her room was 87 degrees inside. My mom was sweating and complaining of headaches and how she was having issues sleeping because the room was so hot. The temperature inside the building exceeds outside temperatures at times. We are worried for my mom's and others' safety. It is too hot, for too long. She is bedridden and cannot escape the heat. They don't have the staff to get her up and move her throughout the day. She has asked for ice water, but (Facility) is experiencing problems with their ice.On 8/12/2025 at 12:08 PM, V5, Family of R2 stated, The nursing home has failed to repair the broken air conditioner. On Thursday August 7th the system stopped functioning in my mom's room. There is no Air conditioning on this wing at all. Nurses have opened the windows and using what fans they can find. The temperature outside has been in the high 80's and 90's all 5 days the air conditioner has been down. The temperature inside the building exceeds outside temperatures at times. We are worried for her and others' safety. It is too hot, for too long. She is bedridden and cannot escape the heat. They don't have the staff to get her up and move her throughout the day. She has asked for ice water, but Arcadia is experiencing problems with their ice machine as well, so it is in short supply. I came to visit my mother and noticed there wasn't air in the room, and it was very hot. I asked staff why it was so hot, and they stated the air doesn't work. There had been a storm, and it knocked out the air conditioning unit (A/C). When I asked how long it had not been working, they said for over a week now. I sat up a fan for my mom. The facility had put a box fan at the bottom of her bed, and I was dripping in sweat. Her room was so hot. They were not passing out any liquids. I was there for about two hours and a half, and no liquids or ice water were being passed out. I moved the fan up off the floor so it would circulate better. I am not sure if it really does anything because the fans are blowing around hot air. I was not sure what else to do to cool her down. I gave her a washcloth, but it got hot fast. It was hot outside too, but it was even hotter in my mom's room.On 8/13/2025 at 12:08 PM, R2 stated, the a/c had been broken for over a week. It is finally better today. Last week was miserable, the whole week we were without air conditioning. I was having issues sleeping and I was having problems breathing and suffering from headaches and I was sick to my stomach. Sleeping was so difficult, because the room was so hot. The maintenance man brought in a thermometer, and I know it read it was 87 degrees inside this room at that time. I can't get up on my own. I was trapped in the heat, and it was horrible, it was just horrible. I was just laying here suffering. Thank goodness it is better today as I am not sure how much more I could have taken. I can now breathe better, and my headaches are gone, and my stomach feels better. It is amazing how that heat can wipe you out.R2's August 2025 vitals document here weight was documented on 8/3/2025, blood sugar 8/22/2025, oxygen and pain on 8/22/2025. No other documentation was present addressing vitals and or any resident assessment related to heat.2- R1's POS for August 2025 documents diagnoses of chronic kidney disease stage 4, severe sepsis with septic shock; acute respiratory failure with hypoxia, major depression, sleep apnea; chronic pain, major depressive disorder, heart failure, and type 2 diabetes mellitus with diabetic neuropathy.R1's MDS dated [DATE] document R1 was cognitively intact for decision making of activities of daily living. R1 has impairment on one side on her upper extremity, she uses a wheelchair, and needs some assistance with her ADL's, (Activities of Daily Living). R1's Care Plan with a revision date of 4/19/23 document she (R1) resident has an ADL self-care performance deficit r/t obesity, pain, difficulty walking.On 8/12/2025 at 9:58 AM, R1 is a large woman in a bariatric wheelchair. R1's forehead is covered with droplets of sweat. R1 is in the main room when entering the facility near a fish tank. R1 does not have any water and/or cup near her.On 8/12/2025 a 9:59 AM, R1 stated my room is a furnace. I had to go and order myself another fan because it is just too hot for me to stay in there, and I am a large woman and can't take the heat. The A/C has been broken since Thursday. It has been over a week. I just can't take it. I guess they had to order a part to get it fixed. They tinkered with it, but it is still broken and not working. It has been miserable trying to sleep in this heat. We have ice water passed out to us, but no popsicles or anything like that. I have had a headache since the heat started, which I think is due to the extreme heat.On 8/13/2025 at 10:02 AM, R1's room registered 86 degrees Fahrenheit with 62% humidity = 102 degrees F (extreme caution). R1's August 2025, Medical records were reviewed and does not document any vitals were taken except for pain on 8/9/2025 and 8/21/2025. No other vitals were documented for any other days. No other documentation was present addressing vitals and or any resident assessment related to heat.3- R3s POS August 2025 documents diagnoses of acute osteomyelitis, left ankle and foot, morbid (severe) obesity with alveolar hypoventilation, type 2 diabetes mellites without complications, acute respiratory failure, chronic systolic heart disease, and major depression. R3's MDS dated [DATE] document R3 was cognitively intact for decision making of activities of daily living.R3's Care Plan: The resident has an ADL self-care performance deficit r/t respiratory failure, obesity, weakness, lack of coordination, reduced mobility. The resident has Diabetes Mellitus; Avoid exposure to extreme heat or cold. (2/14/2025)On 8/12/2025 at 10:24 AM, R3 stated it was so hot, it was like living in a furnace. He was very uncomfortable, and the heat was out of control and the AC had been out for 8 days now. He had just gotten out of the hospital and was not sure that the room being so hot was good for him. He stated he has asked for multiple bed baths, and they give them to him, but he is still sweating really bad because of the heat.On 8/12/2025 at 10:22 AM, R3's room temperature was 86 degrees Fahrenheit with 60 degrees humidity = 91 degrees (extreme caution for heat index). R3's August Medical Records/Vital Signs only document the weight on 8/3/2025, blood sugar, 8/22/2025, oxygen 8/22/2025, and pain 8/22/2025. No other documentation was present addressing vitals and or any resident assessment related to heat.4- R11's POS for August 2025 documents, diagnoses of chronic obstructive pulmonary disease, acute kidney failure, type 2 diabetes without complications, shortness of breath and specified abnormal findings of blood chemistry. R11's MDS dated [DATE] document R2 was cognitively intact for decision making of activities of daily living.R11's Care Plan with a revision date of 1/13/2025, documents, Resident has an actual skin impairment of (specify type: pressure/skin tear/bruise/surgical incision/rash/venous/stasis ulcer/arterial/ischemic ulcer/cellulitis/diabetic ulcer/) to (location). *Do not list stage* diabetes, diuretics, edema, fragile skin, impaired mobility, incontinence. Avoid exposure to temperature extreme.On 8/13/2025 at 10:02 AM, R11's room registered 86 degrees Fahrenheit with 62% humidity = 102 degrees F (extreme caution). On 8/15/2025 at 1:11 PM, R11 stated, The AC did break, and it was so hot in here and I am so thankful it is fixed now. They brought in some fans for my room, but it was just blowing around hot air, and it was not pleasant. It was so uncomfortable, and I felt so tired.R11's August 2025 Vital Documents for breathing 8/12/2025, and 8/19/2025. No other documentation was present for the month of August. No other documentation was present addressing vitals and or any resident assessment related to heat.On 8/13/2025 at 2:32 PM, V16, Medical Director stated, I would expect the residents' room temperatures to follow the policy and standards for the temperature guidelines. I know the AC is up and working now. For this population extreme heat is not always good thing but sometimes there can be other things going on as well with the patient. I would expect fans to be placed in residents' rooms and attempts to lower the room temperatures made by the facility. The Heat Emergency Policy with a revision date of 11/1/2024 documents, The purpose of this guideline is to provide precautionary and preventative measures for our residents during the hot and humid summer months. Older adults are extremely vulnerable to heat related disorders. Heat Exhaustion: A disorder resulting from overexposure to heat or to the sun. Early symptoms are headache and a feeling of weakness and dizziness, usually accompanied by nausea and vomiting. There may also be cramps in the muscles of the arms, legs, or abdomen. The person turns pale and perspires profusely, skin is cool and moist, and pulse and breathing are rapid. Body temperature remains at a normal level or slightly below or above. The person may seem confused and may find it difficult to coordinate body movements. Heat Stroke: A profound disturbance of the body's heat-regulating mechanism, caused by prolonged exposure to excessive heat, particularly when there is little or no circulation of air. The first symptoms may be headache, dizziness and weakness. Later symptoms are an extremely high fever and absence of perspiration. Heat stroke may cause convulsions and sudden loss of consciousness. In extreme cases it may be fatal. If the heat in the building increases above state mandated guidelines evacuate if necessary and follow evacuation policy.The Facility Vital Signs Monitoring Policy with an effective date of 4/2025 documents, Definition includes temperatures, pulse, respirations, and blood pressure, May also include pain level and oxygen saturations. Blood pressure 90/60 mm Hg to 120/80 mm Hg. Breathing 12-18 breaths per minutes; Pulse 60-100 beats per minute. Temperature 98.8 F to 99.1 F (36.5 C to 37.3 C/ average 98.6 F (37.0). Vital signs may be obtained more frequently with change of condition. Abnormal vital signs will be reported to the physician.The Immediate Jeopardy and deficiency practice that began on 8/7/2025 when the air conditioning was no longer working and the IJ was corrected/removed on 8/27/2025 after the facility took the following actions to correct the noncompliance prior to the start of current survey: AC unit was immediately repaired. Facility purchased extra fans and portable AC unit. Facility initiated Heat Emergency Policy making hourly rounds, offering water, wet rags, offering to relocate residents. R1, R2, R3 and R11 have been accessed and documented for risk of heat induced illness. All staff was in-serviced on Heat Emergency Policy. All nursing staff were in-serviced on documenting and monitoring resident's vitals and identify signs and symptoms of head induced illness. Also offering to relocate residents while under a Heat Emergency. All residents were assessed, and a QA (Quality Assurance) meeting was held to ensure compliance with facility Heat Emergency Policy.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to implement interventions, for R2 to prevent overdose of medication. Faculty was aware R2 had medications in her purse and previously had meds. R2 was being seen by a Psychiatry Nurse Practitioner. R2 had shown a decrease in Mental status and the Psychiatry Nurse Practitioner, nor the Physician was notified. Based on interviews and record review the facility failed to accurately assess, monitor, implement and provide services, for R2's Mental and Psychosocial wellbeing, due to R2 recently sustaining physical abuse, and having major depressive disorder and anxiety. This resulted in R2 overdosing on Xanax and Tylenol. Then being admitted to hospital and subsequently expiring. The Immediate Jeopardy began on 04/18/2024 when R2 was admitted to facility, with known history of spousal abuse, depression, and anxiety. V1, (Administrator), was notified of Immediate Jeopardy on 06/06/2024 at 8:16am. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 06/06/24, but noncompliance remains at Level Two, because additional time is needed to evaluate the implementation and effectiveness of the in-service training of staff. Findings include: R2 admit date to facility on 4/18/2024, with diagnoses of Parkinson's Disease, Encounter for Mental Health Services for Victim of Spousal or Partner abuse, Depression, unspecified, and Generalized Anxiety Disorder. Hospital discharge prior to admit to facility, dated 4/12/2024, documents, Chief Complaint R2 Reportedly being battered by her husband, states, she was struck in the head multiple times, she also fell and hit her right ribs. The patient presents after an altercation with her husband. He has been aggressive and has had history of abusing her physically in the past. She states that he became angry earlier today and threw several things at me. She was struck to the face, possibly with an ashtray. Patient sustained some lacerations and abrasions. R2's trauma informed care document, dated 4/22/2024 documents, physical assault-yes, how much are you bothered by the problem- extremely, comment section documents- husband has beaten her, [NAME] her neck with a case of soda and broke her leg with walker. R2's PHQ-9 assessment dated [DATE] documents, little interest, or pleasure in doing things-yes, 7-11 days, feeling down, depressed, or hopeless-yes, 12-14 days, trouble falling asleep-yes, 12-14 days, feeling tired-yes, 12-14 days, poor appetite-yes, 12-14 days, total score of 16 -moderately severe depression. R2's abuse/neglect screening dated 4/22/2024 documents, history of abuse-yes, diagnosis of depression-yes- total score of 3 indicating moderate risk. R2's behavior charting dated, 5/23/2024 documents, disruptive sounds, anxious, delusions, agitated hallucinations on dayshift and second shift. V11, Psychiatry Nurse Practitioner notes dated 5/14/2024 documents, Chief Complaint Psychiatric Evaluation, related to Depressive symptoms. R2 has a history of major Depressive Disorder and generalized Anxiety Disorder. Staff reports, R2 is anxious, restlessness, paranoid regarding her abusive husband finding her here. R2 denies feeling sad, depressed, or hopeless. R2 stated, her mood was alright. V11 (Nurse Practitioner), Progress Note dated 5/11/2024, documents, R2 has an order of protection against her husband. She is now discharged to skilled rehab facility. During exam patient is lying in bed, in no acute distress, Psych: cooperative, anxious during exam. R2's Progress Note dated 5/23/2024, at 9:02pm, documents, V6, (CNA), questioned R2 and R2 reported taking approximately 15 Alprazolam and 25 Tylenol. On 5/28/2024 at 2:05pm, V5, (LPN), stated, that on the evening of 5/23/2024, R2 had been yelling and hallucinating earlier in the evening and that V6, (CNA), came to her and said that she had found an empty bottle of prescription medication on R2's bed and that R2 stated, I should be gone by the end of the night. V5, (LPN), stated, the empty bottle was labeled Alprazolam with a fill date of 5/06/2024, and it said 60 tabs on it. V5 stated, that V6 also, found an empty bottle of Tylenol on the floor next to R2's bed. V5 stated, that both bottles were empty. V5 stated, that R2 stated, she had taken 15 tabs of the Alprazolam and 25 tabs of the Tylenol. V5 stated, that she was not aware, prior to this occurrence that R2 had any medications on her. V5 stated, that R2 did not have any signs of Depression. V5 stated, that V4 brought the medications into R2. V5 stated, that R2 did go several days without her Alprazolam, earlier in May, due to having difficulty getting a new a script. On 5/28/2024, at 2:35pm, V6, CNA stated, that a few days prior to this event, (5/23/2024), R2 had been Hallucinating and stated, that a black boy was stealing her stuff and she had dumped all her stuff from her purse on her lap. V6, CNA stated, that she reassured her that no one was stealing her stuff and that she saw prescription bottle of medication and Tylenol bottle in her lap and put these medications back into R2's purse. V6 stated, she did not tell anyone about the medications in R2's purse. V6 stated, that on the evening of 5/23/2024, R2 was yelling so much and so loud that other residents were complaining about R2's yelling. V6 stated, that R2 was making comments about wanting to be home with her husband and that she missed her family and that she didn't want to be here. V6 stated, that R2 was having hallucinations on 5/23/2024, that R2 was making comments, that people were beating her up. V6 stated, that she told V5 about it and V5 gave R2 her bedtime medications to calm her down. On 5/29/2024, at 9:00am, V3, (Social Service Director), stated, that R2 was her own decision maker, that R2 was completely with it when she first admitted to facility. V3 stated, that R2 was admitted after being in the Hospital for being beaten by her husband. V3 stated, R2 had an Order of Protection, against her husband and her husband was to not have any kind of communication with R2. V3 stated, on 5/02/2024 the Activity Aide delivered a letter, to R2 from her husband and R2 read the letter. V3 stated, that R2 started, to have Delusions and Hallucinations after receiving the letter from her husband. V3, SSD, stated, that R2 was feeling down and seemed sad, about not seeing her family/kids but, not to the extent of harming herself. V3 stated, that she did ask R2 if she felt like harming herself and R2 would say, NO. V3 stated, that Adult Protective Services, would call and check on R2. V3 stated, that R2 scored a 16 on her PHQ assessment and that is a Moderately Severe Depression score. V3 stated, that the facility does not provide any Psychosocial Programs, small groups, or any Counseling Services for any of the residents. V3 stated that they don't do anything different for the residents who score high or low. V3 stated, she believes that more services should be provided for residents with Psych needs and that she herself has requested more training on this. V3 stated, she was not aware of R2 having medications at her bedside, prior to R2's Hospitalization and that it was not safe for any resident to have medication at the bedside. V3, SSD, stated, after this situation, she went room to room and collected any medications/ointments that residents had in their rooms. V3 stated, that R2 is currently on a Ventilator at the Hospital. On 5/29/2024, at 11:50am, V3, SSD, stated, that the staff attempt to redirect and divert a resident if they are having behaviors, but they do not have any Psychosocial Programs available or any community counselling services available for the residents. V3 stated, she has been trying for the last year to get some kind of counseling services for the residents but, there have been issues with getting one. On 5/29/2024, at 1:15pm, V8, CNA, stated, that at the end of R2's stay, R2 cried a lot, said she missed her husband, that she stopped eating and was more incontinent of urine, that R2 stopped calling for help to the bathroom and just wet on herself instead. V8 stated, that R2 made comments, about her husband hitting her with a case of pop in the back of the head and that was why R2 had pain in her neck and back. V8 stated, that R2 did not make comments, about taking her life, she just cried a lot. V8 stated, she had not seen any medications in R2's room. On 5/29/2024, at 1:45pm, V9 CNA, stated, that in the beginning of R2 would talk about her husband a lot, and at the end of her stay she was angry a lot, that she threw her tray one time, because she was mad at the phone. On 5/29/2024, at 1:50pm, V10, CNA, stated, that R2 was one assist with cares when R2 was first admitted but, then R2 started getting more confused and was seeing people in her closet. V10 stated, that R2 became more fearful during her stay, saying she was afraid her husband was coming back to get her, that R2 even began asking for the light to be left on and wanted V10 to check the closet and make sure no one was in the closet. V10 stated, that R2 was afraid and tearful a lot, before she went to the hospital. V10 stated, that R2 was tearful and scared about things in her past. V10 stated, that R2 stopped going to the dining room, for meals and isolated herself in her room. V10 stated, R2 was very quiet, when she was first admitted but, towards the end of her stay, R2 became very scared, just seemed very afraid. V10 stated, she was not aware of R2 having any meds in her room. On 5/29/2024, at 3:00pm, V11, Nurse Practitioner, stated, that she expected Psych evaluation, for R2 and that would provide recommendations to the facility, for R2's Psych needs. V11 stated, that the last time she saw R2, she was very Anxious and tearful but, V11 was not aware that R2 had received a letter from her husband. V11 also, stated, she was not aware that R2 had missed, 7 consecutive doses of her Xanax in the month of May. V11 stated, that R2 would benefit from Psychosocial Therapy if that was available. V11, Nurse Practitioner, stated, that she did not feel that it was safe for R2 to have medications at the bedside, and V11 did not trust, R2 to take it appropriately. On 5/29/2024, at 3:25pm, V12, Medical Director, stated, that R2 was admitted to facility for Physical Therapy, and that if the facility had Psych services, R2 could have used some but, the facility does not have those services. V11, Nurse Practitioner, stated, that V4 should not have brought in the medication, for R2 because, R2 had Psych issues. On 5/30/2024 at 11:30am V16, Certified Occupational Therapist Assistance, (COTA), stated, that R2 was Paranoid, that she stated, one time, R2 thought this place was safe, that she had visitors come in over the weekend but, no one came in to see her over the weekend. V16 stated, R2's cognition had gotten worse during her stay, that in the beginning, R2 was good but, near the end she didn't want to do much. On 5/30/2024, at 1:30pm, V15, Psych Nurse Practitioner, stated, that R2 was struggling with Intermittent Depression and Anxiety, on V15's visit on 5/14/2024, R2 was in a decent mindset, that spousal abuse is absolutely considered trauma/PTSD, that her services are available 24-hours a day but, V15 did not receive any update on R2's behaviors. V15, stated that R2 having behaviors of crying, angry, scared, tearful, afraid, missing her family and hallucinating are all clues of worsening depression and someone should have been talking/seeing R2, that someone should have called V15, and she could have come to see R2 more frequently or medications could have been adjusted. V15 stated, that with R2 exhibiting those behaviors the facility should have been monitoring/tracking her behaviors and checking on her more frequently as in every 15-30 minutes. V15 stated, that she is not involved in the Care Plan Process, that she rarely makes recommendations to a facility for interventions. V15 stated, she was not aware of R2 received a letter from her husband on 5/02/2024, but it was her understanding that R2's husband was not to have any contact. V15 stated, that this could have been prevented, if facility had made V15 aware of R2's behaviors. V15 stated, that she has a Clinical Team that is available and even have specially trained, Trauma Counseling Services, available if needed. V15 stated, I can't do anything if I am not aware of anything. Based on resident's Care Plan, dated 04/2024, the facility noted the following: Administer medications and observe for adverse side effects, if noted, document and report to MD (medical doctor). Contact Social Services, prn, (as needed). Discuss with resident ways to utilize present coping skills to deal with situations that arise. Encourage and allow open expression of feelings and reinforce appropriate expression of feelings. Encourage frequent contact with family and friends, per resident's request/approval. Ensure ADL, (Activities of Daily Living), needs are met. Investigate the need for psychological support. Observe for signs and symptoms of depression, document, if noted, and report to improvise emotional support. Report, assess and record any changes in mood. Report to MD changes in mood. However, the facility failed to provide any of the above-mentioned interventions or cares for R2 as nothing was identified within residents Care Plan or within the Nursing Notes provided by the facility. The surveyor confirmed by observation, record review and interviews that the Immediate Jeopardy was removed on 6/06/2024, but noncompliance remains at level two, because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The Immediate Jeopardy that began on 4/18/2024 was removed on 6/06/2024. When the facility took the following actions to remove the immediacy. Facility ensured all residents are safe and not at risk and Psychosocial needs are being met. Initiated on 5/24/2024 per V3. Evaluation of Risk for Suicide and Self Harm completed on the whole house by V3 on 6/4/2024. 3.) Trauma assessments completed by V3 on 6/6/2024. 4.) Assessment of Depression completed on the whole house by V3 6/6/2024. 5.) All trauma distress depression assessments are being completed on whole house to ensure appropriate services are in place on 6/6/2024 by V3 and V25. 6.) Directive has been posted at timeclock and Nurses' Station if any signs or symptoms of distress/depression to report to nurse. 7.) Staff educated if any signs or symptoms of depression/distress noted, facility will update Psychiatry for further orders. 8.) Staff education for signs and symptoms of depression completed on 5/24/2024 by V2. 9.) 6/6/2024 Staff education sheet posted by timeclock per V24. 10.) Residents that have exacerbation of depression, V2 and V3 followed up with Psychiatry for guidance, for 1:1, 15-minute checks or hospitalization. 11.) Reviewed behavior monitoring. 12.) All staff educated on monitoring behavior per standards of practice. 13.) Education completed on 5/24/2024 by V2 for medications at bedside and signs and symptoms of depression. 14.) 5/24/2024 rooms were swept for meds with resident consent and education to residents at that time by V1, V2 and V3. 15.) All residents on Psychoactive Medications are referred to Psychiatry upon admission by V2, this is ongoing. 16.) 6/5/2024 V26 has increased visits to every three weeks. 17.) Depression is assessed upon admission, quarterly, and with a significant change by V3. Residents that have exacerbation of depression, SS and DON followed up with Psychiatry and Medical Physician for guidance, for 1:1, 15-minute checks or hospitalization. 18.) Policy for suicide watch was reviewed and no changes necessary V27 6/6/2024. 19.) Behavior monitoring is documented per shift per CNA staff and reviewed by Interdisciplinary team daily in QA meeting which consist of nursing management, social services and administrator. 20.) All residents assessed to ensure resident based intervention care plan services are in place. 21.) Initiated and completed on 6/6/2024, reviewed all residents for individualized care plan interventions for behaviors - by V2, V3, V28 and V7. 22.) Education provided to staff on trauma/mental disorder. 23.) Initiated and completed on 6/6/2024 V1 with all staff educated prior to taking shift. 24.) Audits completed by V25 weekly. 25.) All charts audited for psychosocial assessment, trauma assessments, self-harm/suicide risk assessment and the patient healthcare assessment 6.6.2024 per V24 and V30 26.) Regional team V29 with complete weekly starting next week. 27.) QAPI meeting held to ensure compliance. 28.) Be reviewed and discussed daily in morning meeting with Interdisciplinary team. 29.) QAPI completed 6/6/2024 by V24 and V30 30.) For residents identified by the facility as requiring services for trauma/mental illness/depression facility will notify Psychiatry and Medical Physician for guidance for 1:1, 15-minute checks or hospitalization. Notifications will be made immediately by nursing or social services. This is ongoing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the abuse of 2 of 8 residents reviewed for abuse in the sample of 9. This failure resulted in R1 and R2 being abused by V2, Former Administrator. The Immediate Jeopardy began on 03/09/23 when R2 left the facility without staff knowledge to smoke a cigarette. R2 was grabbed by V2 and pulled back into the facility. V2 then placed R2 up against the wall as if R2 was being arrested. R2 was taken to his room in which V2 began verbally abusing R2. V1 Administrator was notified of the Immediate Jeopardy on 05/02/2023 at 3:00 PM. The Surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 05/04/2023, but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings Include: 1. On 4/27/23 at 2:50 PM, V1, Director of Nurses (DON), stated she and V3, Minimum Data Set (MDS) Nurse, were standing at the nurse's station. V3 had just called V17, Regional Nurse Consultant, regarding an allegation of abuse with V2, Former Administrator and R2 that occurred on 3/9/23. V11, Activity Director, came to the nurse's station and stated yesterday (3/8/23) R1 was swinging his cane and V2 twisted the cane out of R1's hands. V1 stated she asked V11 why she did not report this on 3/8/23 and V11 stated because she didn't feel like it was abuse. V1 stated she notified V18, President of Operations of the allegations of abuse. On 4/27/23 at 1:56 PM, V11, Activity Director, stated the incident with R1 and V2, Former Administrator, occurred on 3/8/23. V11 stated R1's roommate came to her and told her R1 was throwing things. V11 went to R1's room, there were things all over the place, clothes, the bed side table was out in the middle of the floor, the nightstand had been moved and R1 was swinging his cane. V11 stated she asked R1 why he was swinging his cane, and he stated he was mad at the nurses, the aids, just mad at everyone. V11 stated R1 stated he was going to hit someone with the cane but never did, he just threatened to do it. V11 stated she went to V2 and requested he go and help her to get the cane away from R1 and to help R1 calm down. V11 stated she and V2 went into R1's room, V2 asked R1 what he was going to do with the cane? V2 then stated to R1, you're not going to hit anybody. V2 then asked for the cane and R1 stated no, you're not going to get the cane. V2 then walked up to R1 and took the cane away from R1. V2 was holding onto R1's cane on both ends and R1 was holding the cane in the center. V2 then twisted the cane out of R1's hand. V11 stated she felt it was excessive but didn't see that it did any harm to R1. V11 stated R1 didn't act like it hurt. V11 stated R1 then picked up his cup and threw it at V2, grazing his left arm. V11 stated V2 stepped forward towards R1 and stated, you can't act like this, hit people or throw things at people. V11 stated R1 was lying down flat on his bed and flinging his arms in the air and V2 walked over to R1 and stated, what's wrong with you. V11 stated V2 then took his hands and placed them on R1's hands on R1's chest. V11 stated she felt V2 was trying to calm R1 down and no harm was being done. V11 stated she did not report the incident that day because she didn't feel it was abuse. V11 stated when she heard about the abuse between R2 and V2, she felt like she needed to report it to the DON. V11 stated she did not approve of how V2 dealt with R1, twisting the cane, and putting his hands down on R1's hands. V11 stated V2 is [NAME] with R1 and V2's approaches were not the best. On 4/28/23 at 9:00 AM, V11, Activity Director, stated the day before the incident with V2 and R2, there was an incident with V2 and R1. V11 stated she did not report the incident with V2 and R1 because she didn't feel that it was abuse, she felt that it was inappropriate and excessive. On 4/28/23 at 2:10 PM, V1, DON, stated she assumed R1's abrasion occurred during the incident on 3/8/23 with V2. It was found during a skin assessment after the abuse allegation was reported on 3/9/23. R1 no longer resides in the facility. R1's Face Sheet, undated, documents R1 has a diagnosis of Post Traumatic Seizures, Altered Mental Status and Difficulty in Walking. R1's MDS, dated [DATE], documents R1 is cognitively intact. R1's Care Plan, dated 2/10/23, documents R1 has a behavior problem towards others and will throw things and swing his cane at staff when he gets upset and is at risk for abuse/neglect. R1's Care Plan Interventions include providing a safe and secure environment. R1's Progress Note, dated 3/9/2023 at 6:09 PM: At approximately 4:20 PM, staff reported an allegation of physical abuse. The alleged perpetrator immediately suspended pending the results of the investigation. Physician/Ombudsman/Local Police Department/Resident representative notified. Investigation initiated. R1's Skin Condition Report, dated 3/9/23, documents R1 has an abrasion/scratch to the right wrist measuring 2.3 centimeters (cm) x 1 cm and to monitor the area. The Abuse Investigation Final Report dated 3/16/23 by V18, President of Operations, documents on 3/9/23, an allegation of staff to resident physical abuse was reported. The alleged perpetrator was V2, Former Administrator. V11, Activity Director, was asked about an occurrence between V2 and R1. V11 stated R1's roommate asked for assistance with R1. V11 responded and noted R1 waving his cane around. V11 stated she attempted to calm R1 and asked him for the cane. V11 stated she asked V2 for help and he responded. V11 stated V2 asked R1 for the cane and R1 refused. V11 stated R1 had one hand on the middle of the cane swinging it. V11 stated V2 then twisted the cane, releasing the cane from R1's grasp. V11 stated R1 and V2 then had a conversation and R1 calmed down and apologized for his behavior. R1 was interviewed and stated he doesn't want to be at the facility anymore. R1 was asked if there was an occurrence with V2, and R1 stated he was trying to hit them with a cane because they aren't medical doctors and shouldn't be messing with the sores on his feet. In a subsequent interview, R1 stated the bald guy did take his cane, but he got it back and the bald guy did get hit with the cane. V2, was asked if there was an occurrence between him and R1 regarding R1's cane. V2 stated R1 was attempting to sling his cane towards V11. V2 stated he sat down to talk with R1 and R1 was swinging his cane around. V2 stated he caught the cane and took it from R1. V2 denied twisting the cane to remove it from R1. V2 was again interviewed and asked if he twisted the cane from R1's hands. V2 stated he pulled the cane. V2 stated R1 had the cane with his right hand swinging it. V2 stated he grabbed the top and bottom of the cane and pulled it up because the weak spot is between the index finger and thumb. Conclusion and action taken: V2 utilized previous behavior management training (CPI) to remove the cane from R1's possession. V2 is no longer employed at the facility. The Abuse Allegation Interview with R1 by V13, Regional Nurse Consultant, dated 3/10/23, documents R1 stated he didn't hurt anyone with the cane, it ended with his shoulder getting sprained and it was with the guy that runs this place. 2. On 4/26/23 at 10:24 PM, V9, Office Manager, stated R2 was going out the south door and V2, Former Administrator went after him. R2 made it to the sidewalk at the south door. The door alarm was sounding. V2 was telling R2 that he needed to come back inside and R2 was refusing. R2 was yelling, cussing, this place is f****** ridiculous, I will hit you with my wheelchair. R2 was stating this to V2. V2 then wrapped his left arm into R2's right arm. V9, stated V5, Agency LPN (Licensed Practical Nurse) stated to V2, what are you doing. V9 stated V2 did not respond to V5 and kept going, trying to get R2 inside. V2 was walking R2 back inside through the south door, as R2 was walking towards the doorway, he put his left arm on the building to keep from going back inside. When R2 and V2 got back inside the building, they were in the hallway near the south hall door, V2 put R2 against the wall for approximately a minute. As V2 was holding R2 against the wall, R2's face was sideways touching the wall and V2 had his hands on R2's back. R2 was able to move his arms, his hands, and head. V2 let R2 go because R2 wasn't yelling anymore and had calmed down. V9 stated R2 and V2 kept going back and forth talking about getting R2 to another facility that allows smoking. V9 stated V2 then went back to his office and R2 was sitting at the south door in his four-wheel Rollator Walker. On 4/26/23 at 11:12 AM, V10, Assistant Director of Nurses (ADON) stated on 3/9/23, she was in her office, heard the south door alarm going off, she looked down the hallway and saw a bunch of people at the south door. V10 stated she saw R2 and V2 coming in the door with their arms hooked together. V2 had a stern facial expression when he came through the door and started to walk closer to R2. As V2 and R2 made it through the door, they were saying something to each other, but she couldn't hear what was being said, they were both talking angrily. V10 stated she saw R2 against the wall but couldn't see if V2 was physically holding him, there were too many people standing in the way. V10 stated R2's face was against the wall. V10 stated V2 started walking towards his office and one of the CNAs got R2 situated and put him back in his Rollator [NAME] and began walking towards R2's room. V10 stated it wasn't right how V2 handled the situation. V10 stated that she and V3, MDS Nurse, called V13, Regional Nurse Consultant and V18, President of Operations and told them of the alleged abuse with V2. V10 stated she went to check on R2 and he was okay but mad, R2 was yelling at the CNA's (Certified Nurse Assistant) about the situation. V2 was in his office with his door shut. On 4/26/23 at 1:49 PM, V16, CNA, stated on 3/9/23 the door alarm was sounding. Upon entering the south hall, V2, Former Administrator, was observed pulling/tugging R2 through the door. R2 had his left hand on the bricks outside of the south door. V2 was taking R2 in the door and V2 was trying to get R2's hands off the bricks. Once inside, V2 yanked R2's left arm and twisted his (R2) arm around R2's back, putting R2's face and body against the wall. V16 stated R2 couldn't move at all and R2 stated to V2 to keep your hands off of me. V2 then pushed R2 to his room. V16, went to check on R2 approximately 15 minutes later and V2 was in R2's room and they were nose to nose V16 stated R2 stated to V2 if he touched him again, he was going to grab something and hit him on the side of the head. R2 was mad. V16 stated she told V2 he needed to go and told R2 he needed to calm down. V16 stated V2 walked out of R2's room and later told V16, thanks for stepping in. V16 stated V2 was still in the building for an hour and a half after the incident. V16 stated the incident happened around 4:00 PM and management was still in the facility, and no one intervened except V16. V16 stated R2 had a red mark on his right middle forearm. V16 stated R2 was crying and stated to her that he was embarrassed, and his pride was hurt. On 4/26/23 at 4:14 PM, V11, Activity Director, stated she heard the door alarm go off and saw a bunch of CNAs down at the south hall door and V2, was running down the hall. V11 states R2 would go outside with the alarm sounding, stating he wanted to go out and smoke. V11 stated R2 was not allowed to go out and smoke because it's a smoke free facility, but R2 was alert and oriented, after the incident R2 was allowed to go outside to the sidewalk, after he signed a paper to go outside and would smoke. On 4/26/23 at 4:38 PM, V8, CNA, stated she observed V2, grab R2's arm and R2 was holding onto the building and V2 was pulling R2 by the arm, V2 then grabbed R2's arms forcefully and pushed R2 up against the wall. R2 and V2 were yelling at each other in the hallway. V8 stated V2 then went to his office shut the door and then left the building. V8 stated V2 should not have gone out and grabbed R2. After the incident R2 showed her his arms and he had scratches on his arms. On 4/27/23 at 3:02 PM, V3, MDS Nurse, stated the door alarm went off, V3 turned down the hall and V2, had his arms locked with R2, coming back towards the building. R2 put his hand and wrists against the bricks wall by the south hall door and V2 was forcefully pulling R2's arm off the brick wall, it wasn't gentle. V2 did not ask R2 to take his arm off the brick wall. V2 and R2 came to the door and V2 took R2 and placed him up against the hallway next to the door while V2's arms were still locked with R2's arm. V2 then took his arm out of R2's arm. V3 stated she could see in V2's face, it was like a realization of handling the situation inappropriately. V3 stated she then notified V1, DON. V3, stated she was instructed by V13, Regional Nurse Consultant and V18, that V2 needed to leave the facility right now. V3 stated V2 stated he was calling V18 as she followed V2 to the door. On 4/27/23 at 3:33 PM, V3, MDS Nurse, stated things happened so quickly that they didn't have time to separate V2 and R2. V3 stated she was not aware that V2 had escorted R2 to his room. On 4/27/23 at 3:35 PM, V2, DON, stated that V2 had only been at the facility for about two weeks and had an authoritative demeanor, like he was an in-charge kind of person. He acted like military in general. In meetings he would say this is how it's going to be. V1 stated she was not aware and did not witness the incident with V2 and R2 until V3, MDS Nurse, reported it to her. On 4/27/23 at 4:25 PM, V20, CNA/Transportation Coordinator, stated the door alarm was going off and V2 was man handling R2 back into the door. V2 had both hands on R2 forcing R2 back in the building, he was using his body to shove R2 back in the building. V2 then put R2 up against the wall, face first with his arms wrapped around R2's arms so R2 couldn't move and R2's arm was twisted behind his back. V20 stated R2 kept repeating to V2 there's nothing to talk about. V2 was talking very harsh to R2. V20 stated she was in shock that (V2) could do this. On 4/28/23 at 9 AM, V3, MDS Nurse, stated she looked outside of her window in her office when she heard the door alarm sounding and saw V2, locked with R2. Once V2 and R2 were inside, V2 had R2 against the wall. V2 separated himself from R2 and walked down the hall. She thought V2 was walking to his office. V3 stated the whole incident occurred within 2-5 minutes and she is not sure how long it was between the incident with R2 occurred and when V2 exited the facility. V3 stated she did not see V2 go all the way to his office after the incident with R2. On 4/28/23 at 9 AM, V1, DON, stated V3, MDS Nurse, reported the incident with V2 and R2 to her (V1). She and V3 called V13, and V18, but V18 did not answer at first. V1 stated V18 called V3 and instructed her to walk V2 out. V1 is unsure of how long V2 was in the building between when the incident with R2 occurred and V2 actually left the building. V1 stated V16, CNA, had to separate R2 and V2. V1 stated R2 discharged to a sister facility. V1 stated R2 did not have any family and was homeless, R2 wanted to smoke and was angry that V2 was making him come back into the building. V1 stated R2 had his own cigarettes and tried to go smoke. V1 stated they tried to take R2's cigarettes but he hid them. V1 stated after a couple of weeks of R2 being in the facility, they got to know him and because of his cognition, it was determined that he was safe to sign himself out, and would walk to the tree, the same place where the incident with V2 started. V1 stated prior to the incident with V2 and R2, R2 didn't get far enough to smoke. R2 would stand at the door and yell for someone to let him out so he could go and smoke. R2 was allowed to go to the sidewalk off the property to smoke after the incident with V2. On 4/28/23 at 10:05 AM, V18, President of Operations, stated she completed the majority of the investigation involving R2 and V2, and R1 and V2. V18 stated she was notified the evening of 3/9/23 of the allegation between R2 and V2. V18 stated they don't substantiate or unsubstantiate allegations of abuse, they just list the facts at the conclusion of the investigation. V18 stated V2 was terminated because he didn't meet the expectations on how situations should be handled. V18 stated V2 had abuse training upon hire. V18 stated she would expect staff to report instances of abuse and ensure that the resident is safe and separate them. V18 stated if abuse involves staff, they are asked to leave the building or get out of the immediate area, and she would expect staff to have stayed with V2 until he left the building. V18 stated the incident between R1 and V2, it was her understanding that R1 was swinging his cane and V11, Activity Director, asked for assistance from V2 and V2 went with V11 to R1's room to help. R2's Face Sheet, documents R2 has a diagnosis of Atherosclerotic Heart Disease, Hypertension and Homelessness. R2's MDS, dated [DATE], documents R2 is cognitively intact. R2's Care Plan, dated 2/28/23, documents R2 is at risk for abuse/neglect with an intervention to provide a safe and secure environment. R2's Progress Notes, document the following: On 3/9/2023 at 6:06 PM, at approximately 4:20 PM, staff reported an allegation of physical abuse. The alleged perpetrator immediately suspended pending the results of the investigation. Physician/Ombudsman/Local Police Department notified. Investigation initiated. On 3/9/2023 at 9:32 PM, Follow up assessment completed for alleged abuse. Resident is alert and oriented. R2 appears to have a sad, worried facial expression. R2 stated my pride is hurt worse than my arm. New injury noted on assessment. Abrasion to left forearm measurers 12.2 cm X 2.5 cm. Redness, inflammation noted at site. No bruising noted. No swelling noted. R2's Skin Condition Report, dated 3/9/23, documents R2 has an abrasion/scratch the left forearm measuring 12.2cm x 2.5cm. The Abuse Investigation Final Report dated 3/16/23 by V18, President of Operations, documents on 3/9/23 an allegation of staff to resident physical abuse was reported. The alleged perpetrator was V2, Former Administrator. R2 was assessed for physical and psychosocial distress. R2 was noted to have minor discoloration to his forearms. V3, MDS Nurse, was interviewed and stated she stepped out of her office, located on the south hall because she heard the south hall door alarming, and she observed V2 escorting R2 back into the facility. V3 stated V2 and R2 were locked at the elbows with V2 walking slightly in front of R2. V3 stated V5, Agency LPN (Licensed Practical Nurse), was behind V2 and R2. V3 stated that V2 appeared to be pulling R2. V3 stated once R2 and V2 were inside the door, R2 was against the wall and R2 and V2 were still locked at the elbows. V3 stated V2 then stepped away from R2. V3 stated she immediately reported the incident. R2 was interviewed and stated he wanted to go out to smoke, he understands the facility is a non-smoking facility, but stated he could walk around the block or off the property to smoke. R2 stated he went out the south hall door and grabbed his cigarette to smoke and V2 came out to bring him back in the building R2 stated V2 grabbed both of his arms to bring him back in the building. R2 stated both were talking loudly to each other. In a subsequent interview, R2 denied being resistive with staff but he was pulling in the opposite direction of V2. R2 denied being up against the wall when he returned to the building. V2 was interviewed and stated R2 had been having behaviors most of the day on 3/9/23. V2 stated R2 was cursing and exit seeking to go outside to smoke. V2 stated R2 walked out of the south hall door, and he escorted R2 back into the facility. V2 stated R2 was resistive as he attempted to get him back in the facility. V2 denied placing R2 against the wall upon re-entering the facility. Conclusion and action taken: R2 was exhibiting exit seeking behaviors related to wanting to smoke. R2 exited the facility out the south hall door to smoke. V2 and other staff members responded to return R2 to the facility. V2 utilized previous behavior management training (CPI) to assist R2 to return to the facility. V2 is no longer employed at the facility. The facility abuse investigation documents the following: Interview with V5, Agency LPN on 3/14/23 at 12:54 PM, with V13, Regional Nurse Consultant, V5 stated she was out back of the facility on break, V3, MDS Nurse, asked her (V5) to go around to the south hall exit door, a resident was attempting to leave. V5 stated when she rounded the facility, R2 was facing the road with his walker and V2 was behind him telling him to come inside, we're not going to do this. V5 stated she approached R2, and he turned towards V2, V2 then grabbed R2's right arm and started pulling him towards the door. V5 stated V16, CNA, V7, CNA and V9, Office Manager, was there V5 stated she said oh no we can't to R2. V5 stated R2 had one hand on the walker and let go of the walker. V5 stated she placed the walker behind R2 because it had a seat on it. V5 stated R2 and V2 got to the threshold of the door and R2 grabbed the brick wall and before she could make contact with R2's hand, R2 pulled his hand off the brick wall rubbing his hand/forearm on the bricks. V5 stated once they were inside, she placed the walker beside R2 as R2 was against the wall on his front side, V2 had R2's right arm with his right arm and V2's left arm was across R2's shoulders. V5 stated she reported this to V3. V5 stated R2 was cursing but not combative. V5 stated this was R2's second or third attempt to go outside to smoke. Interview with V27, CNA, on 3/10/23 with V13, Regional Nurse, documents R2 hasn't really been out of his room today, he's been sleeping more. On 3/9/23, V2, Former Administrator, was agitated with R2 because R2 wanted to smoke. Interview with V28, CNA, on 3/10/23 with V13, Regional Nurse, documents V28 didn't notice any changes with R2, he doesn't seem to be bothered by it, but she hasn't seen R2 out of his room today, he is usually up and in the hallways. An undated, written statement, signed by V29, CNA, documents V29 witnessed V2 forcibly grabbing R2 by the wrist causing him to scrape his arm on the brick wall and then once inside, V2 put R2 against the wall like he was arresting him. A written statement signed by V7, CNA, dated 3/9/23, documents she witnessed V2 grab a resident (does not name a resident) by the arm and forcibly walk him into the building. During the process V2 used force and the resident received scratches from the outer brick wall. Once inside the building, V2 forcibly escorted him (unnamed resident) to his room, where another employee split them apart. Interview with V2, Former Administrator, dated 3/9/23 at 5:44 PM, documents, V2 stated the staff had trouble with R2 all day. V2 stated R2 had been cursing at him because he would not let R2 go outside to smoke. V2 stated R2 walked out the south hall door and he (V2) had to escort R2 back into the facility. V2 stated R2 was resistive. V2 stated R2 raised his hands up and he (V2) had to put his hands up to defend himself. V2 stated this occurred inside R2's room. V2 stated V16, CNA, came in to R2's room during that time. V2 stated R2 kept sitting by the door, making comments that he was going to harm someone if he didn't get out. V2 stated the staff on south hall just stood there with saucer eyes. V2 stated R2 kept saying he was going to leave throughout the day. V2 stated once R2 was back in the facility, he doesn't know if he V2 was a little more excessive when trying to walk R2 back in but R2 was being resistive. V2 stated no other staff members were outside with him, R2 was only in the yard area and did not make it to the road from the south hall door. V2 denied placing R2's chest against the wall like he was being arrested. Interview with V2, dated 3/15/23 at 2:31 PM, with V13, Regional Nurse Consultant, documents V2's intent was to bring R2 back into the facility for his safety. V2 stated when R2 came back into the facility, he was belligerent, threatening staff and him. V2 stated R2 was stating I will kill a mother f**** if someone touches me, punch you in the face and throw my walker at you. V2 stated he attempted to re-assure R2 and calm him down but R2 continued to threaten. V2 stated he was not trying to push R2 against the wall, he had his left hand on the wall and R2's left shoulder against the wall. Interview with R2, dated 3/10/23 with V13, Regional Nurse Consultant, documents he wanted to go smoke, R2 knew it was a smoke free facility, but he can walk around the block or off the property and smoke a cigarette. I know what I'm doing with my life. I went out of the door, grabbed my cigarette and was starting to walk to smoke. The guy, the administrator guy, ran to get me and tried to forcefully get me back in the building. He grabbed both of my arms and was pulling and pushing me into the building. It didn't have to be like that. I was able to get my right arm out of his grip but he's a bigger guy than me, so he still had my left arm in his hand. We were both yelling. He tried to push me up against the wall, but I used self-defense. Interview with R2, dated 3/10/23 at 12:36 PM by V18, President of Operations, documents R2 stated he exited the south hall door because he wanted to smoke, he was not going to be around the facility. R2 stated he had his clothes and a coat on, he walked to the door and out it. R2 stated within 5 minutes V2 came rushing out and grabbed him by both arms. Writer asked R2 to re-enact how V2 had his arms, R2 held writer's forearms just above the wrists. R2 stated he was not being resistive or fighting. R2 stated he was pulling in the opposite direction of V2. R2 stated once they were back into the facility, he sat in his walker and told V2 he wasn't going to his room, V2 kept wanting him to go to his room while he (R2) was saying he was going back outside. R2 stated as they were coming back into the building, he grabbed the brick wall. R2 stated nobody overpowers him or has authority over him and V2 was strict. On 4/28/23 at 10:30 AM, the outside area just outside the south hall door was observed. The tree and sidewalk were approximately 40 feet from the building and approximately 45 feet from the road to the building. The road was not heavily traveled during the observation. On 4/28/23 at 10:20 AM, V19, Current Administrator, stated V11, Activity Director, should have reported the incident regarding V2 and R1 and they would have been the one to decide if it was or was not abuse. V19 stated she teaches the staff that even if they aren't sure if it's abuse, but it doesn't look right or feel right, they should report it. On 4/28/23 at 1 PM, V6, Medical Director, stated the incident that occurred with R1 and V2, Former Administrator, should have been reported on 3/8/23, when it occurred. V6 stated he had worked with V2 prior and wouldn't have expected this. V6 stated he wouldn't expect R1 or R2 to have been treated this way by V2. V6 stated R2 has Heart Disease, Diabetes, had been homeless but was harmless. V6 stated he would expect the facility to protect its residents. V2, Former Administrator's, Corrective Action Form, dated 3/16/23, documents V2 was terminated on 3/16/23 for poor job performance, employee failed to meet expectations regarding resident behavior management. The Abuse Prevention and Reporting policy, dated 11/2016, documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The Immediate Jeopardy that began on 03/09/2023 was removed on 05/04/2023 when the facility took the following actions to remove the immediacy: A.) Identification of Residents Affected or Likely to be Affected: 1. All residents with a Brief Interview for Mental Status (BIMS) 12 and greater currently in-house had abuse interview completed to ensure no other residents had been harmed and they feel safe in the facility. 100% Completed by V19 Administrator, V13 Regional Nurse Consultant, V1 DON, V10 ADON, V3 MDS coordinator on 05/02/23 between 17:28 and 18:22. 2. All residents with a BIMS 11 and below and skin assessments completed to ensure no other residents had been harmed and they feel safe in the facility. 100% completed by V3 MDS, V1 DON, V10 ADON on 5/2/23 between 15:26 and 17:24. 3. Family members/POAs of those residents with a Brief Interview for Mental Status (BIMS) of 11 and below currently in-house had abuse interviews completed to ensure no other residents had been harmed and they feel that their loved one is safe in the facility. 100% of phone calls to families/POAs completed by V11 Activity Director, V21 Business of Manager (BOM), and V22 Dietary Director on 5/2/2023 between 15:26 and 17:37. 85% of these families answered the phone and were interviewed. A message to return the phone call has been completed with the remaining 15% of families. As of 5/3/2023 11:00am, Facility only has (3) families that have not returned calls. Facility Social Service Director V23 will make daily calls until 100% compliance is met. Administrator to monitor for compliance. B.) Actions to Prevent Occurrence/Recurrence: 1.) All residents currently in-house had an abuse/neglect screening completed with care plans updated to reflect level of at risk for abuse as indicated. 100% Completed by V23, SSD on 05/02/23 between 15:28 and 17:52. 2.) Regional VP Operations reviewed Abuse Prevention/Reporting - Illinois Policy. Completed by V18 VP of Operations on 05/02/23 at 16:35. 3.) Facility Administrator V1, or Designee will interview 5 residents per week for 12 weeks to ensure residents feel safe and have no concerns with abuse. Facility will utilize the abuse Allegation Interview questions for residents. Initiated by V3 MDS and V10 ADON on 05/02/23 at 17:28. 4.) Abuse in-servicing for all staff. 99% Completed by V18 VP of Operations, V25 Regional Nurse Consultant, V3 MDS, V10 ADON, V1 DON on 05/02/23 between 15:26 and 18:18. 5.) Facility Administrator, V19, and V11 Activity Director were in-serviced on the facility abuse policy on 05/02/23 at 17:26 by V25, Regional Nurse Consultant. The remaining 1% will be educated prior to being able to next scheduled shift. Abuse Training will remain ongoing with all new hires. 6.) Facility Administrator or Designee will interview 5 staff members per week x 12 weeks to ensure staff know reporting requirements. Facility will utilize an audit tool related to Abuse/Abuse Reporting/Abuse investigation. Facility Administrator or designee will monitor for completion. 7.) AD HOC QA reviewing Abuse Prevention/Reporting - Illinois Policy and the components of F600, F609, F610 IJ. Completed on 5/2/23 at 16:40 with V24 VP of Clinical Services, V18 VP of Operations, V13 Regional Nurse Consultant, V25 Regional Nurse Consultant, V6 Dr., V3 MDS coordinator, V1 DON, V23 SSD, and V10 ADON. 8.) QA will meet May 5, 2023, and monthly, and as needed.