**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure two of three sampled residents (Residents 1 and 3) diagnosed with mild intellectual disabilities (a condition in which people have more memory or thinking problems than other people their age) were free from physical restraints (any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement) imposed for discipline. The facility failed to use less restrictive interventions which included verbal interventions/redirections, one of one line of sight supervision, or offering of PRN (as needed) medication, as indicated in the facility's policy for Management of dangerous behavior, and adjust staff responses to the level of danger present, as indicated in the facility Pro- ACT (an acronym for Professional Assault Crisis Training- a nationally recognized certified training program for professionals who work with individuals whose disabilities sometimes manifest in assault and dangerous behavior) 2020 manual prior to the use of physical restraints, to address Residents 1 and 3's aggressive behaviors. On 5/29/23, while in the facility's courtyard, Resident 1 was put on a two-person supine (flat) floor containment (brief physical restraint of a person to gain quick control of a person displaying aggressive or agitated behavior while lying on the ground) by Licensed Psychiatric Technician [LPT] 1 and Counselor [C] 1) from 8:49 PM to 8:53 PM (4 minutes). During the supine floor containment, LPT 1's two hands were placed over Resident 1's left hand, while C 1's hand was placed over the resident's wrist and C 1's other hand was placed over the resident's neck. LPT 1, C1, and Certified Nurse Assistant (CNA) 1 subsequently (afterwards) placed Resident 1's arms and legs on four-point soft tie restraints (a form of physical restraints used to restrain both wrists and both ankles while lying flat in bed, restricting freedom of movement to extremities) to a bed from 8:54 PM to 9:35 PM (41 minutes). As a result, Resident 1 sustained bruising (skin injury that results in a discoloration of the skin that has suffered trauma) to the left side of the neck measuring 0.5 centimeters (cm- unit of measurement) by 2.5 cm and bruising to the right upper arm. Resident 1 complained of pain to the left side of his body and informed Program Manager (PM) 1 he did not want to be in the facility anymore. On 6/01/2023 at 7:19 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified, and an IJ template (a template developed to document the information necessary to establish each of the key components of immediate jeopardy) was reviewed in the presence of the Administrator (ADM) and interim Director of Nursing (DON), regarding the facility's failure to ensure Resident 1 was free from physical restraints and containment imposed for discipline. On 6/1/2023 at around 1:23 to 1:24 PM, while at the facility's Smoking Area, Resident 3 was put on an eight-person (C3, C4, C5, C6, C7, C8, C9, and Program Manager [PM] 2) floor containment from 1:24 to 1:34 PM (10 minutes). Program Manager (PM) 2, C3, C5, and LPT 1 were unable to recall who were holding on Resident 3's specific body part but recalled a total of eight facility staff were observed holding Resident 3's arms and legs, and some facility staff hands were on Resident 3's back. During the eight-person supine floor containment, Resident 3 verbally threatened staff because he was put in containment. Resident 3's bed was rolled out the facility's Smoking Area and Resident 3 was placed on four-point soft tie bed restraints in bed from 1:34 PM to 2:55 PM (1 hour and 21 minutes). Resident 3 was released from the four-point soft tie bed restraints at 2:55 PM after calming down. As a result, Resident 3 sustained redness to both arms. Resident 3 was transferred to a psychiatric hospital via a 5150 hold (a specific code that refers to involuntary mental health hospitalization authorized by a mental health professional or a qualified officer) on 6/1/23 timed at 8:56 PM (6 hours and 1 minute after being released from the four-point soft tie bed restraints), for psychiatric evaluation. On 6/3/2023 at 11:40 AM, an extended survey (a type of survey conducted when substandard quality of acre has been verified) was conducted to investigate the facility's systemic problems causing substandard quality of care. On 6/5/2023 at 6:15 PM, the IJ situation was removed after the ADM submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the IJ removal plan while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM. The acceptable IJ Removal Plan included the following actions: 1. C1 was immediately suspended and terminated on 06/05/2023. C2 and LPT 1 received written counseling notice on 06/03/2023 by the ADM. 2. On 06/01/2023 the facility immediately initiated re-education to the staff members regarding Management of Dangerous Behaviors, Use of Restraints, and Abuse Prohibition. This education has included the following disciplines: Program, Nursing, Dietary, Maintenance / Housekeeping and ADM to ensure no other resident will be affected by this alleged deficient practice. 3. On 06/02/2023 the facility initiated a Resident Care Summary form and log to capture critical information regarding residents' diagnoses, behaviors, potential triggers and possible interventions to use in crisis situations . This is to ensure each employee reviews and understands resident diagnosis and interventions to aid in the management of dangerous behavior. 4. Registered Nurse (RN) supervisor reviewed physician orders for physical restraints and identified that (0) residents are currently in restraints or are affected by this deficient practice. 5. ADM to develop a Code Yellow (called when assistance is needed for escalating patient behavior) Crisis Team on each shift to assist in the management of aggressive and problematic behaviors. A Code team will consist of a minimum of 3, maximum of 7 team members designated and posted for each shift on the assignment sheet by the Charge Nurse and reviewed during shift change huddle. Nurse Consultant initiated in-service on 06/05/2023 for RNs, Licensed Vocational Nurses (LVNs), LPTs, CNAs, Program Directors, Program Managers, and Program Counselors. The Code Captain will be the licensed nurse that directs the incident and who will practice calm communication with the resident unless otherwise delegated. Under the direction of the Charge nurse, CNAs and Program staff will assure the ongoing safety by directing the uninvolved residents. RN Charge nurse will be responsible for documentation and notification of physician and responsible party. 6. On 06/03/2023, the ADM phoned the Ombudsman (works independently as an intermediary to provide individuals with a confidential avenue to address complaints and resolve issues at the lowest possible level) at 09:58 PM and left a message to schedule an in-service on Patient Rights for Direct Care Staff to include RNs, LVNs, LPTs, CNAs, Program Directors, Program Managers, and Primary Counselors. Spoke with Ombudsman office on 06/05/23 at 2:57 PM, requested above trainings. 7. ADM initiated a training for direct care staff from Residents 1 and 3's main unit that included RNs, LVNs, LPTs, CNAs, Program Director, Program Managers, and Primary Counselors on 06/03/2023 on caring for residents with autism disorder (a neurodevelopmental [how brain functions] disorder that affects how people interact with others, communicate, learn, and behave) on 06/03/2023. ADM confirmed with the in-house Psychologist (a person who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) to continue with trainings on mild intellectual disabilities, oppositional defiant disorders (a disruptive behavior disorder that emerges during childhood or adolescence and is characterized by persistent angry or irritable mood, unruly and argumentative behavior), and other trainings specific to the diagnosis of the facility's client population monthly starting 06/08/2023. Skills competency will be provided by the Clinical Resource for all direct care staff on Behavior Management of the facility's specific client population on 06/06/2023. 8. Starting 06/8/2023, staff will utilize a progressive process of responding to escalating resident behavior. Clinical Resource created the Management of Dangerous Behavior Template on 06/05/2023 to be used when Code Yellow is called. The determination of an intervention to be used will be based upon the resident's assessed needs and the immediacy of the situation at hand. Employees are expected to begin the intervention process at the lowest and least restrictive level which will ensure safety, and progress to higher level interventions only when a less restrictive intervention has been attempted and danger to a resident or other persists. The progressive list of interventions is listed below. Note that clinical nursing judgement is needed to determine the appropriate level and sequence for individual patients and when to change or omit an intervention if a resident is non-responsive. Verbal prompting/encouragement to discontinue behavior. a. Encourage identification and verbal expression of feelings. b. Suggestion of alternative activity c. Offer Choice-of alternative behavior/activity/environments d. Offer of individual time with staff e. Use of cues and prompts as established in treatment planning. f. Change of physical environment g. Removal of stimuli or reinforcement h. Use of behavioral rewards and consequences i. Use of relaxation techniques j. Communicating the need to maintain a safe environment for everyone. k. Voluntary time-out or physical prompt to calm and support a patient, and/or guide them away from negative stimuli. l. One-to-one or line of sight supervision m. Offer as needed medication, as ordered. o. 911 (local law enforcement) to be called in emergent (sudden, urgent) situations p. Professional Assault Crisis Training (Pro-ACT) strategy to be used as last resort after all the above have been attempted and exhausted and ineffective. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms), mild intellectual disabilities, oppositional defiant disorder, and autistic disorder (marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others). A review of Resident 1's Psychiatrist (medical practitioner specializing in the diagnosis and treatment of mental illness) 1's progress note dated 5/4/2023, indicated Resident 1's cognition (mental processes including thinking, attention, language, learning, memory and perception) was grossly intact (normal), judgement (the ability to make considered decisions or come to sensible conclusions) and insight (the capacity to gain an accurate and deep intuitive understanding of a person or thing) were impaired (weakened or damaged). A review of Resident 1's Minimum Data Set (MDS, a care area screening and assessment tool) dated 3/3/2023, indicated the resident's cognition was intact. The MDS indicated Resident 1 had no functional impairments and required supervision (oversight) with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 1 did not have physical or verbal behaviors exhibited or directed towards others and other behavioral symptoms not directed toward others. The MDS indicated Resident 1 did not reject evaluation or care during the assessment period. The MDS indicated under Restraints and Alarms that any type of restraints (alarms or four-point soft tie restraints) was not being used. A review of Resident 1's Behavior Contract and Individual Treatment Plan dated 3/22/2023, signed by Resident 1, the resident's primary counselor, and PM 1, indicated a contract that Resident 1 agreed to which included not being verbally and physical aggressive to staff and other residents, not making false statements, following all the rules of the facility, and using his coping skills when upset. The individual treatment plan indicated strategies for Resident 1 to progress toward his goals that included: 1. Group participation. 2. Staff should model verbal responses instead of saying stop or that's rude. 3. To reduce the current frequency of Resident 1's property destruction . staff should gently and calmly redirect Resident 1's attention to prevent further damage to property. If needed, Resident 1 could be redirected to an outdoor open area to give him space to de-escalate (a method to prevent potential violence). Staff should refrain from placing additional attention on the behavior . When Resident 1 damages any property staff should remove potentially dangerous items away from him and other residents. 4. As a last resort only, and after all other strategies have failed to work, staff can implement Pro-ACT strategies. A review of Resident 1's physician's order indicated a verbal order dated 5/29/23 timed at 10:57 PM, indicated Denial of rights (involves restricting normal freedoms of a patient); movement for safety a) 3-person escort b) 2-person supine floor containment c) 4-point soft tie restraint until resident is no longer present any danger to self and others. A review of Resident 1's Order Summary Report indicated the following physician orders for 5/29/23: 1. Denial of rights of movement for safety 3-person escort from 8:53 PM to 8:54 PM. 2. 2-person supine floor containment from 8:49 PM to 8:53 PM. 3. 4 point soft tie restraint 8:54 PM to 9:35 PM until resident is no longer present any danger to self and others. 4. Inject (use a needle and syringe) emergency dose of Zyprexa (antipsychotic medication that can treat several mental health conditions) intramuscular (under the muscle) solution 10 milligrams (mg), one time only for severe agitation. A review of Resident 1's Progress Note dated 5/29/23 timed at 10:18 PM, authored by Program Manager (PM) 1, indicated that at approximately 7:30 PM, on 5/29/23, Resident 1 was in a group counselling session. When the group counselling session was over, Resident 1 verbalized he did not want to go back to his room for bedtime. The note indicated that at 8 PM, PM 1 asked Resident 1 to go back to his room but Resident 1 continuously stated he was not going back to his room. The progress note indicated that PM 1 reminded Resident 1 that he can stay awake but must go to his room, so he does not disturb his peers (other residents). The progress note indicated Resident 1 was not receptive and began to kick a bench. The note indicated that staff (unknown) had verbally redirected Resident 1 multiple times not to kick the bench and when the wood of the bench became loose, staff again verbally redirected Resident 1 to stop kicking the bench for safety measures. The note indicated that Resident 1 turned around and attempted to swing at staff with a closed fist. The note indicated that Code Yellow was called, and a two-person floor containment was performed from 8:49 PM to 8:53 PM and Resident 1 continued to be combative. During the floor containment, the note indicated how Resident 1 verbalized that he was going to hit the staff with the piece of wood, and that staff was abusing and choking him. The note indicated that Resident 1 was reassured that staff was performing a floor containment and resident needed to calm down so staff could let him go. During the same record review Resident 1's Progress Note dated 5/29/23 timed at 10:18 PM, PM 1's notes indicated that Resident 1 continued to be combative while in floor containment, so staff performed a three-person escort to the resident's room from 8:53 PM to 8:54 PM and placed Resident 1 on soft tie mechanical restraints from 8:54 PM to 9:35 PM. The note indicated that while Resident 1 was restrained in bed, Resident 1 screamed that he would call the Ombudsman to get staff fired and that he would like to be send out to a hospital. The note indicated Resident 1 was again reminded that he was okay, and he needed to calm down. A review of Resident 1's Progress Note dated 5/29/23 timed at 10:26 PM authored by LPT 1, indicated staff performed 2-person floor containment (8:49 PM - 8:53 PM), 3-person escort (8:53 PM- 8:54PM), and 4-point soft tie restraint (8:54 PM - 9:35 PM) due to severe physical aggression. A review of a facility document titled ABC Investigation Form dated 5/30/23, authored by PM 1 indicated that at approximately 11:45 AM, Resident 1 was in line to see the physician. The form indicated Resident 1 reported to the physician about an incident that occurred the other day (5/29/23), and that staff had choked him. The form indicated Resident 1 stated that he does not want to be in the facility and wants to leave the facility. A review of a facility document authored by the Interim DON titled, Blue Incident and Observation/ABC Report dated 5/30/23 timed at 11:45 AM, indicated an abuse allegation made by Resident 1. The report indicated injury observations that included bruises on left neck and right arm. The report indicated a body check completed and noted a 0.5 cm by 2.5 cm bruises on the left side of the neck and some light bruises to the right upper arm. A review of nursing progress notes by the Interim DON dated 5/30/23 timed at 4:10 PM, indicated the Interim DON and a charge nurse performed body check on resident in the Nursing Station. A 2.5 cm x 0.5 cm size of fresh bruise noted on the left side of neck and some light bruising areas noted on the right upper arm. The progress note indicated when Resident 1 was asked when and how the bruises appeared, Resident 1 stated, I don't know I noticed a red mark on my neck this morning when I looked at the mirror. A review of Resident 1's Progress Notes indicated an interdisciplinary team (IDT, group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for a patient or group of patients) notes documented on 5/31/23 timed at 1:04 PM. The IDT note indicated that at approximately 11:45 AM on 5/30/2023, Resident 1 reported to the physician about an incident that occurred on 5/29/2023 where the residents stated that staff had choked him. Resident 1 stated that he does not want to be at the facility and wants to leave the facility. At approximately 12 PM, the ADM came to investigate and to speak with Resident 1. RN 1 and LPT 1 performed body check on Resident 1 in the Nursing Station. The IDT note indicated that a 2.5 cm x 0.5 cm size of fresh bruise noted on the left side of neck and some light bruising areas noted on the right upper arm. When Resident 1 asked when and how those bruises caused, Resident 1 stated, I don't know I noticed a red mark on my neck this morning when I looked in the mirror. During a concurrent observation inside the facility's conference room and interview with Resident 1, on 5/31/23 at 12:10 PM, Resident 1 was observed with a scratch mark about 1.5 cm by 0.5 cm, the right upper arm near around the axillary (armpit) area had light bruising. Resident 1 stated the incident happened around 8 PM at nighttime but could not recall the exact date. Resident 1 stated that prior to the incident, he was very upset that facility staff did not give him a carton box to put his electronic device. Resident 1 stated that the other residents were back to their rooms already that night, since 8 PM is the facility's room time. Resident 1 stated he did not want to stay inside his room, so he went outside the facility's courtyard. Resident 1 stated he was kicking the bench and C1 was there with him outside the courtyard and was telling Resident 1 to go back to his room. Resident 1 stated he kept kicking the bench and broke the bench. Resident 1 stated LPT I and C1 was trying to stop him from kicking the bench. Resident 1 stated he was striking out towards C 1 but missed and hit LPT 1 instead. Resident 1 stated LPT 1 and C1 put him down on the ground and called other facility staff for help. Resident 1 stated he was contained on the ground lying down while LPT 1 both hands were holding Resident 1's left arm and C 1 put one hand on his right wrist and one hand on his neck. Resident 1 stated he did not know what hand C 1 used to hold his neck. Resident 1 stated it felt like he was choking for a couple seconds, then C1 took his hand off. Resident 1 stated the other staff arrived and three or four staff lifted him up and took him to his room. Resident 1 stated that LPT 1, C1 and CNA1 put a restraint on Resident 1's both arms and legs in the bed. Resident 1 stated he could not remember how long he was on the restraint, maybe one and a half hours. Resident 1 expressed that he was crying, yelling, and was very mad, as he was trying to lose the restraint. Resident 1 stated that C3 was inside the room with him during the time he was on the physical restraints. Resident 1 stated he could not remember when the restraints were removed. Resident 1 stated that the next day, (5/30/2023) around noon time, Resident 1 stated he showed the physician the bruising and scratch mark on his neck and right upper arm. Resident 1 stated he still have pain when he turned his head to the left side, about 7 over 10 pain (10 being the highest pain level and 1 being the lowest) level. During an interview, on 5/31/2023 at 12:50 PM, PM 2 stated she knew Resident 1 very well. PM 2 stated she spoke with Resident 1 when Resident 1 approached her this day (5/31/2023) and informed PM 2 how he should not had been handled that way on 5/29/23. PM 2 stated Resident 1 told him that he wanted a carton box and the facility staff did not give him a carton box because PM 2 was not in the facility that day, so Resident 1 ended up having to experience containment and restraints. PM 2 stated she told Resident 1 that if he could have waited until PM 2 is back so he could have that box, so he did not have to experience containment and restraints. PM2 stated that when she spoke to Resident 1 the resident (Resident 1) was already back to baseline (the way he was prior to the incident). PM 2 stated that all counselors were taught to use verbal counsel to deescalate the situation. During an interview on 5/31/23 at 3:20 PM, PM 1 stated Resident 1 was very upset and agitated that night (5/29/23). PM 1 stated that it seemed that something was bothering Resident 1 and started that behavior episode. PM 1 stated that on 5/28/2023 she recalled Resident 1 asking for a box to put his electric device and Resident 1 was told he had to wait for approval to get a box. Resident 1 stated that later that same day (5/29/23), around 8 PM, Resident 1 refused to go back to his room and went out to the courtyard where C1 was there. PM 1 stated that Resident 1 became argumentative to C1 and stated he did not want to go back to his room. Then, Resident 1 started kicking the wooden bench. PM 1 stated C1 performed verbal de-escalation (to reduce the intensity of a volatile or potentially dangerous situation) a couple of times but was unsuccessful. PM 1 stated that Resident 1 was trying to get the wood loose from the bench to strike. LPT 1 and C1 performed the containment to Resident 1, but Resident 1 continued to act combative, saying he does not want to be in the facility. PM 1 stated that after a few minutes, C1, C2 and LPT1 lifted and escorted Resident 1 back to his room. C1, CNA1 and LPT1 applied the four-point soft tie restraint to Resident 1. PM 1 stated Resident 1 was still agitated and yelling when he was on the restraints. Then, PM 1 stated she left Resident 1's room to document and write the incident reports. PM 1 stated that containments were usually conducted on the floor when situations were unsafe for everyone, leading to the decision of the RN supervisor to apply physical restraints with a physician's order. PM 1 stated that excessive force from facility staff should not happen during containments. PM 1 stated that during floor containments, a minimum of two facility staff must be present. PM 1 stated if facility staff continued to yell or instigate (prompt) the situation, the resident would have increased agitation, leading to calling a Code Yellow, and floor containment and/or use of physical restraints. PM 1 stated that facility staff should never put a hand above resident's shoulder. During an interview on 6/1/2023 at 12:40 PM, CNA1 stated that on 5/29/2023, he was working the evening shift, CNA1 stated he did not see what happened outside the facility courtyard because he was inside the facility. After dinner, CNA 1 stated he heard noise coming from outside and saw Resident 1 in the courtyard with LPT1 and C1. CNA1 stated LPT1 and C1 were holding Resident 1's arms on each side. After LPT 1, C1, and C2 escorted Resident 1 back to his room, Resident 1 was agitated, yelling, and shouting and still insisting to get out of the room. CNA1 stated he assisted to place the four-point soft tie restraint to Resident 1 inside his room. CNA1 stated that Resident 1 was cursing the staff, kicking, and wanting to get out of the restraint. CNA1 stated LPT1 injected the antipsychotic medication (Zyprexa) to Resident 1 because Resident 1 was still agitated. CNA1 stated he could not remember how long the restraint was applied to Resident 1. CNA1 stated if there were any situation that a resident becomes combative and could be harmful to self or others, the facility would initiate a Code Yellow and ask for other staff for assistance. CNA1 stated he was not sure if facility staff need to call 911 (emergency services) and police. CNA1 stated he did not see the police or paramedics were at the facility that night when the incident happened. During an interview on 6/1/2023 at 1:40 PM, LPT1 stated that on 5/29/23 at around 8 PM, LPT1 was inside the facility and heard someone screaming and shouting outside. LPT1 stated he went out the courtyard and saw Resident 1 was kicking the wooden bench. LPT1 stated he told Resident 1 to stop but Resident 1 was not listening and continue to kick the bench. LPT 1 stated the leg of the bench was loose and Resident 1 was about to pick it up. LPT1 stated he told Resident 1 not to do that. Resident 1 turned around trying to hit staff with closed fist. C1 was holding Resident 1's right shoulder and Resident 1 was resisting and shoving staff around, trying to kick staff (LPT1, C1) using his legs and yelling. LPT1 stated Resident 1 was contained on the ground by LPT1 and C1 while holding his open arms, LPT1 was holding Resident 1's left shoulder and C1 the right shoulder, so Resident 1 cannot move. LPT1's legs were on top of Resident 1's leg. LPT1 stated Resident 1 was screaming let me go. LPT1 stated that there were no other residents outside the facility courtyard, only Resident 1 acting disruptive. LPT 1 stated Resident 1's floor containment lasted about approximately three minutes. After Resident 1 got back to his room, LPT 1 stated they tried to calm Resident 1 down but Resident 1 was still combative, yelling and screaming, and not listening to facility staff. LPT1 stated he decided to put restraint on Resident 1 and the four-point soft tie restraint was applied to Resident 1 at 8:54 PM. LPT1 stated that after that, he texted Resident 1's psychiatrist for a medication order and Psychiatrist 1 ordered Zyprexa and was administered at 9:08 PM. LPT 1 stated that it took 30 minutes to one hour for the Zyprexa IM injection to work. C2 stayed with the resident inside the room while on restraints. LPT1 stated RN1 assessed Resident 1 around 9:35 PM and Resident 1 was calm and not agitated anymore. LPT1 stated Resident 1's restraint was released. LPT1 stated they did not call the police or 5150 for Resident 1's combative situation. During an interview on 6/1/2023 at 2:10 PM, C1 stated that on 5/29/2023, C1 observed Resident 1 wandering outside his room and outside the facility courtyard. C1 redirected Resident 1 and told Resident 1 he should go back to his room. C1 stated Resident 1 did not want to go back and stay inside his room. C1 stated he instructed Resident 1 that he could be left alone but do not make any noise while he stayed outside. C1 stated Resident 1 started banging the wall, windows, and kicked the wooden bench at the courtyard. C1 stated he verbally counseled Resident 1 to stop kicking the bench and banging the windows and wall, because there would be consequences. C1 stated that Resident 1 ignored C1 and continued the destructive behavior. C1 stated that LPT 1 heard the noise and came out to the courtyard. Code Yellow was called and LPT1 and C1 contain resident on the floor. C1 stated he put his left hand on resident right arm and his right arm on resident's shoulder. C1 denied putting his hand on Resident 1's neck. C1 stated LPT1 made the call to put the restraint on Resident 1 since Resident 1 was still kicking and yelling on the bed. LPT1, C1 and CNA1 applied the four points soft tie restraint. C3 stayed in the room with Resident 1 while the restraint was applied to Resident 1. 2. A review of Resident 3's admission Record indicated the facility readmitted the resident on 2/18/2022 with diagnoses of mild intellectual disabilities, paranoid schizophrenia (a type of schizophrenia (mental illness that affects how a person thinks, feels, and behaves) that includes delusions and hallucinations), and gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]) with esophagitis (inflammation of the stomach). A review of Resident 3's care plan developed on 2/18/2022, indicated Resident 3 had the potential to AWOL (absence without leave [going away without permission]). The care plan indicated Resident 3's history of attempts to leave the facility without permission on 2/18/2022, when Resident 3 climbed a window to leave the facility. The care plan indicated another attempt to leave the facility on 5/17/2022, when Resident 3 attempted to climb the facility fences and pushed/threatened a staff to leave the facility. The care plan was revised on 6/1/2023, indicating Resident 3's latest attempt to leave the facility. The interventions indicated the following information: a. Denial of Rights (DOR): Supine floor containment as ordered, initiated 2/18/2022 and 2/21/2022. b. Verbal counseling provided, initiated on 2/18/2022 and 2/21/2022. c. Deny family passes in the community and staff supervised outings, initiated on 2/19/2022. d. Redirect resident away from exit doors, initiated on 2/19/2022. e. Resident will be closely monitored during smoke breaks. A review of Resident 3's Psychiatric Progress Note dated 5/4/2023, indicated Resident 3 had impaired insight/judgment and inability to function in less structured setting. A review of Resident 3's MDS dated [DATE], indicated Resident 3 was cognitively intact and required supervision (oversight, encouragement, or cueing) with activities of daily living. The MDS indicated Resident 3's behavior had potential indicators of psychosis that included hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). A review of[TRUNCATED]