Edwardsville Care And Rehab

Social Services Y stated the check ins were only done verbally, and were generalized check ins.

She

jeopardy to resident health or incident.

Social Services Y stated R2 had cancer and a wide range of behaviors.

Social Services Y safety stated R2 would sometimes be alert and with it, and at other times R2 was delusional and yelled at staff.

She stated R2 was at baseline and denied any changes in behavior related to the incident.On

Administrative Staff A stated he sent DS BB home quickly and then reviewed the camera footage. He stated he did not hear DS BB make threats but did hear DS BB use vulgar language.

Administrative Staff A stated DS BB called R2 an [expletive] and he could hear it on the camera's audio.

Administrative Staff A stated staff intervened and got between the two and named CMA R as a direct witness to the incident. He stated after he reviewed the camera footage DS BB was contacted and her employment was terminated.

Administrative Staff A stated he did not take down any witness statements in his investigation as he saw and heard everything on camera.

Administrative Staff A stated he typically leaned more on the camera footage as he could see and hear everything. He stated that sometimes witness statements could be biased, exaggerated, or downplayed.

Administrative Staff A stated there was no staff education completed after the incident as DS BB was terminated, and the other staff had previously had ANE training.

Administrative Staff A stated other staff knew what had happened was not okay and it was not acceptable. He stated staff intervened appropriately in relation to the incident.

Administrative Staff A stated R2 only asked for more food when DS BB yelled at her. He stated R2 did not deserve to be treated like that and did not report any concerns or grievances to him after the incident.

The facility's Abuse Prevention Program F 600 policy, dated 08/2025, documented residents had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation, and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition.

Abuse is the willful infliction of injury, unreasonable confinement intimidation, or punishment resulting with physical harm, pain, or mental anguish.

Abuse also included the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental or psychological well-being.

Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. On 01/29/26 at 05:01 PM, the facility received the Immediate Jeopardy [IJ] Template and was informed that the facility's failure to ensure R2 remained free from verbal abuse placed R2 in IJ.The facility provided an acceptable plan for removal of the immediate jeopardy on 01/29/26 at 06:39 PM.

Which included the following:The facility would conduct interviews with each resident to identify if any residents were having adverse outcomes due to staff yelling and shouting profanities and/or any other incidents that may have gone unreported.

This would be completed by 01/30/26 at 05:00 PM.The facility would educate all staff that shouting profanities, calling residents vulgar names, or acting in any other excessive, obtuse, obscene, or nonsensical way would not be permitted at the facility.

The facility would also complete Abuse, Neglect, and Exploitation training with staff, with an emphasis on their duty to report.

This would be completed on 01/29/26 and/or prior to their next scheduled shift.The survey team validated the immediate jeopardy was removed on 01/30/26 at 10:20 AM following the facility's implementation of the plan for removal of the immediate jeopardy.

The deficient practice remained at a D following the removal of the immediate jeopardy.