Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnosis of dementia (the loss of cognitive process) with combative behavior (aggressiveness/eagerness to fight) was free from physical restraints (any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident) for purposes of discipline or convenience, by failing to: 1. Protect Resident 1 from physical injury on 8/20/2024, when Licensed Vocational Nurse (LVN) 1 restrained Resident 1's right and left arms by crossing Resident 1's arms across the chest and above the head and pull/drag the resident from the resident's room to the Nursing Station when Resident 1 exhibited episodes of mood swings [a sudden or intense change in a person's emotional state]. 2. Implement Resident 1's care plan interventions on Dementia, and Communication Problem related to Language Barrier [a difficulty for people communicating because they speak different languages] by establishing rapport and eye contact with the resident, use appropriate words and gestures, listen carefully and attend to verbal/nonverbal expressions when LVN 1 physically restrained Resident 1's left and right arms with both of her hands, while the resident was exhibiting episodes of mood swings, anxiety and agitation on 8/20/2024. 3. Ensure the facility's Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals for residents) develop a comprehensive care plan when Resident 1 exhibited (showed) new behaviors manifested by combativeness, punching, scratching, and kicking, chasing staff, including touching the roommate (Resident 2) on 6/9/2024, 7/7/2024, and 8/18/2024, in accordance with the facility's policy and procedure [P&P] titled Person Centered Plan of Care. 4. Develop care plan interventions on 8/22/2024, to address Resident 1's combative behavior and agitation and identify the root cause (the fundamental reason for the occurrence of a problem) of the resident's behavior symptoms (combativeness and agitation) to prevent further injury to Resident 1. 5. Prohibit the use of physical restraints, in accordance with the facility's policy and procedure titled Physical Restraint Management, when LVN 1 held Resident 1 down with both hands to prevent LVN 1 from being hit, kicked and spit on by Resident 1 and restrained Resident 1's right and left arms by crossing Resident 1's arms across the chest and above the head and pull/drag the resident from the resident's room to the Nursing Station, on 8/20/2024. As a result, LVN 1 restrained Resident 1's freedom of movement and the resident sustained (continued over time) redness/bruising to the back of the left hand and verbalized pain to both hands and shoulders on 8/20/2024. On the same day, on 8/20/2024 timed at 7:48 PM, during a telemedicine (the use of electronic information and communications technologies to provide and support) visit with Psychiatrist 1, Resident 1 verbalized being scared. Resident 1 was unable to verbalize the reason for being scared. These deficient practices placed other residents with behavioral issues (acting in a way that causes harm) residing at the facility [24 residents], at risk for staff abuse and restraints and cause psychosocial (covers a person's mental, emotional, social, and spiritual health) decline, physical (relating to the body) injuries, hospitalization, and death. On 8/26/2024 at 6:22 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance [not following rules] with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure of unnecessary physical restraint for a resident (Resident 1) who had behavioral issues which included combativeness. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) of the IJ situation on 8/26/2024 at 6:22 PM, due to the facility's unnecessary use of physical restraint for Resident 1, while in an agitated state. On 8/28/2024 at 1:46 PM, the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 8/28/2024 at 5:15 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the DON. The IJ Removal Plan dated 8/28/2024, included the following: o The facility interviewed 30 interviewable residents on 08/26/2024 and screened for any incidents of being physically restrained during care by the Social Services Designee (SSD) and 12 non-interviewable residents received body check (examine the body) on 08/26/2024, to determine any unexplained bruising (blood pooling under the skin) or redness by licensed nurses and the DON. o The facility started Training and Education on 8/26/24 headed by the Nurse Consultant Director of Staff Education and the DON, regarding abuse (the act of causing harm) and physical restraints. The training on Managing Behavior and Care plan will be completed by 08/28/2024. o The facility started ln-service (continuous) training for staff nurses on 8/26/24, regarding updating comprehensive care plans for residents that exhibit combative behaviors to be completed and to include on the care plan not to use any type of restraints. o The facility started an In-service training for staff and nurses on 8/26/24, on managing residents that exhibit combative behaviors. Staff from nursing department (Registered Nurse (RN), LVN, Certified Nurse Assistants [CNA], Restorative Nurse Assistants [RNA]) Dietary Department, Housekeeping, Maintenance and Department Managers (Social Service, Medical Records staff, Rehabilitation Department, Minimum Data Set (MDS), DON, DSD, IPN, Business Office Manager [BOM]), have been trained and will continue training until all staff have attended. o The facility conducted an In-service training for staff (RN, LVN, CNA, RNA, Housekeeping, Dietary Department, Maintenance and Department Managers) on 8/26/24, on what constitutes a physical restraint and its definition. o The nurse consultant conducted an In-service to all RNs, LVNs, CNAs, and RNAs, Housekeeping, Maintenance staff, Dietary staff, and Department Managers on 08/28/2024, regarding Behavior Management, Abuse and Physical Restraints. o The SSD, DON and Activity Director (AD) will conduct interviews of alert residents to determine if they have been physically restrained during care at least daily for the next 3 days and weekly for two weeks and monthly thereafter. o CNAs will continue to conduct body checks for all residents to identify any unexplained redness or bruising during showers and will be reported to the Charge nurse/Treatment nurse (TN) 1 and/or to DON for further intervention and reporting. Findings: During a review of Resident 1's admission Record [AR], the AR indicated the facility admitted the resident on 6/6/2024, with diagnoses that included dementia and encephalopathy (damage or disease that affects the brain). During a review of Resident 1's History and Physical Examination (HPE, a comprehensive physician's note regarding the assessment of the resident's health status) signed by the attending physician (Physician 1) on 6/7/2024, the HPE indicated Resident 1 had fluctuating (changing frequently) capacity to understand and make decisions. During a review of Resident 1's Post COC [Change in Condition]/SBAR [Situation, Background, Assessment, Recommendation] notes dated 6/9/2024 timed at 1:20 PM, the Post COC indicated Resident 1 became combative towards the end of the shift and was brought back to bed several times. During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated 6/12/2024, the MDS indicated the resident had moderately impaired cognition (thought process). During a review of Resident 1's Interdisciplinary Team [IDT] Conference Record dated 6/12/2024, indicated that Resident 1 did not present with any behavioral issues, needs encouragement to join activities of choice and enjoys music. The IDT Record indicated the facility did not use physical restraints and restraints were not recommended at this time for Resident 1. During a review of Resident 1's care plans initiated in June 2024, the care plans indicated the following information: -On 6/12/2024, the facility developed a care plan titled [Resident 1] has a communication problem related to language barrier. The care plan interventions included allowing adequate time to respond, face the resident when speaking, making eye contact and reducing environmental noise, and monitoring for physical/nonverbal indicators of discomfort or distress. -On 6/12/2024, the facility developed a care plan titled [Resident 1] has diagnosis of dementia, at risk for decline in communication and activity participation . The care plan interventions included establishing rapport and eye contact with the resident, use appropriate words and gestures, listen carefully and attend to verbal/nonverbal expressions, reducing environmental noise, and maintaining a calm, unhurried manner. During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note dated 7/7/2024 timed at 12:47 PM, indicated that on 7/7/2024 at about 8 AM, Resident 1 began to swing fist (refers strictly to the action of throwing one's fist) at the CNA when Resident 1 was reoriented by the CNA not to pull on her roommates' (Resident 2) gown. The SBAR indicated Physician 1 ordered Ativan (medication for anxiety) 0.5 milligrams [mg- unit of measurement) by mouth every 12 hours as needed for agitation for 14 days on 7/7/2024. During a review of Resident 1's care plans, for July 2024, the care plan did not indicate documented evidence that a care plan for Resident 1's agitation was developed on 7/7/2024, to specify the goals and care plan interventions the facility staff needed to implement to manage the resident's agitation. During a review of Resident 1's Telephone Order (TO) dated 8/5/2024, indicated a physician's telephone order to administer Depakote (medication to treat episodes of mania [extreme changes in mood]) oral tablet to 125 mg, one tablet by mouth one time a day for mood swings manifested by outbursts (uncontrolled feelings) of anger. During a review of Resident 1's SBAR Communication Form and Progress Note dated 8/18/2024, timed at 3:22 PM, authored by LVN 3, the SBAR Form indicated Resident 1 attempted to touch Resident 2 and when Resident 1 was redirected, the resident shook her head in denial and punched LVN 3. The SBAR form indicated Resident 1 began to chase facility staff down the facility hallway attempting to punch and kick staff. The SBAR Form indicated Resident 1 was combative, punching, scratching, and kicking staff. The SBAR Form indicated that LVN 3 called 911 emergency services, and a police officer spoke to Resident 1 in her primary/native language and the police officer was able to redirect the resident to calm down and go back to her room. During a review of Resident 1's Progress Notes New dated 8/19/2024, timed at 5:52 PM, the Progress Notes indicated the physician ordered to increase the resident's medication [Depakote] 120 mg from once a day to two times a day as a result of the behavior manifested by the resident on 8/18/2024. During a review of Resident 1's TO dated 8/19/2024, the TO indicated to administer Ativan oral tablet 0.5 mg, one tablet by mouth, every 12 hours to the resident as needed for 14 days manifested by verbalization of nervousness. During a review of Resident 1's Medication Administration Record [MAR], the MAR indicated to give the resident one tablet of Ativan 0.5 mg starting 8/19/2024, by mouth every 12 hours for 14 days, as needed for anxiety manifested by verbalization of nervousness. The MAR did not indicate Ativan was administered as needed for anxiety, from 8/19/2024 or 8/20/2024. The MAR indicated an order to monitor behavior for anti-anxiety manifested by verbalization of nervousness and tally by hashmarks (a way to count and record count numerically), starting on 8/19/2024. The MAR did not indicate Resident 1's anxiety manifested by verbalization of nervousness was monitored and counted by the licensed nurses from 8/19/2024 through 8/27/2024. During a review of Resident 1's TO dated 8/19/2024, indicated Depakote oral tablets dosage was increased from the original dose that was ordered on 8/5/2024 from 125 mg, one tablet once a day to 125 mg, one tablet two times a day, for mood swings manifested by outbursts (uncontrolled feelings) of anger. During a review of Resident 1's MAR in August 2024, the MAR indicated for the Depakote medication, Resident 1's behavior issues of outbursts of anger was monitored and documented 16 days after the original order of the Depakote oral tablets was ordered on 8/5/2024 starting 8/21/2024. During a review of a Short Message Service [SMS - a text messaging service that allows users to send short text messages between mobile devices] sent via text message [TM] from LVN 1 to the Director of Nursing (DON) dated 8/20/2024 timed at 6:48 AM, the TM indicated Resident 1 keeps hitting other residents and LVN 1 was unable to physically control the resident. The TM indicated Resident 1 was very aggressive and LVN 1 had to hold Resident 1 to prevent Resident 1 from going back to Resident 1 and 2's room and from hitting and kicking LVN 1. The TM indicated the DON asking LVN 1 What prompted crossing her arms? Or dragging her [Resident 1] to the station with both arms/hands held? LVN 1's response indicated She [Resident 1] did not want to stop. Where else should she go if not the station. Holding her hands so she [Resident 1] doesn't hit me. The TM indicated the DON stating that Resident 2 denied being hit by Resident 1 and Resident 1 sustained injuries/bruising to both the right and left hand. During a review of Resident 1's SBAR Communication Form and Progress Note dated 8/20/2024 timed at 12:27 PM, the SBAR indicated Resident 1 was allegedly hitting the roommate, Resident 2 on 8/20/2024. The SBAR indicated the charge nurse, LVN 1, reported that Resident 1 hit Resident 2. The SBAR indicated that upon interview of Resident 1, Resident 1 denied hitting Resident 2. The SBAR indicated Physician 1 was made aware of the allegation that Resident 1 hit Resident 2, but no new orders were given by Physician 1, as a result of the allegation. During a review of Resident 2's SBAR Communication Form and Progress Note dated 8/20/2024, indicated Resident 2 was allegedly hit by the roommate (Resident 1). The SBAR Form indicated Resident 2 was interviewed and Resident 2 stated she was not hit by Resident 1. The SBAR Form indicated Resident 2 did not have any injuries or bruising upon body assessment of the licensed nurse. During a review of Resident 2's Progress Notes, dated 8/20/2024 and timed at 9:32 AM, the Progress Notes indicated Resident 2 was discharged back to home on 8/20/2024. During a review of Resident 1's Skin Observation Tool dated 8/20/2024, timed at 1:48 PM, the tool indicated that 2 centimeters (cm- unit of measurement) by 2 cm bluish discoloration was observed on the back of Resident 1's left hand. During a review of Resident 1's IDT Conference Record dated 8/20/2024, the IDT Record indicated the IDT team met with Resident 1 with the aid of translator services and asked Resident 1 if her injury (bruising to the left hand) caused by LVN 1 was hurting, Resident 1 did not respond. The IDT record further indicated that Resident 1 denied hitting Resident 2. During a review of Resident 1's care plan, titled [Resident 1] was involved with an alleged abuse, initiated on 8/20/2024, indicated a goal that Resident 1 would not display any further behavior (no specific behavior indicated) for one month. The care plan interventions developed on 8/20/2024, included visual monitoring hourly and a STAT (immediately) X-ray of Resident 1's bilateral (both) hands and shoulders due to pain. During a review of Resident 1's care plan titled [Resident 1] has a new behavior of punching, kicking, and scratching staff, attempting to touch and grab other residents indicated the care plan was initiated on 8/18/2024 and revised on 8/22/2024. The care plan interventions dated 8/18/2024, indicated to notify attending physician of significant changes in behavior, notify responsible party, and provide psychosocial support. The care plan did not indicate the care plan interventions added, when the facility revised the care plan on 8/22/2024. The revised care plan dated 8/22/2024, did not include resident specific interventions to address Resident 1's behavior symptoms of combativeness with staff, agitation, and outbursts of anger. During a review of Resident 1's Psychology [the scientific study of the human mind and its functions, especially those affecting behavior] Note, dated 8/20/2024, the Psychology Note indicated Resident 1 verbalized being scared. The Psychology Note indicated that when Resident 1 was asked why or what happened, Resident 1 was unable to reply. During a review of CNA 2's handwritten Investigation Statement dated 8/19/2024 (corrected by DON as 8/20/2024), indicated CNA 2 heard LVN 1 calling to get Resident 1 out of the room because Resident 1 was hitting Resident 2. CNA 2 wrote witnessing Resident 1 walking out of the room heading by the facility hallway towards the Nurses Station, at around 6 AM, CNA 2 wrote that before Resident 1 reached the Nurses Station, LVN 1 stopped Resident 1 and spoke with the resident through the translator services using the phone, however Resident 1 got mad when LVN 1 confronted her and was about to kick and spit on LVN 1. CNA 2 further wrote that to avoid the assault, [LVN 1] restrained Resident 1 by holding the [resident's] hands while [the resident] was still trying to kick and spit on LVN 1. CNA 2 wrote that Resident 1 was screaming and kept talking in her language while LVN 1 tried to sit the resident on a wheelchair. CNA 2 wrote that LVN 1 held Resident 1's hand hard that it left a red mark at the back of Resident 1's hand. During a review of CNA 4's Investigation Statement dated 8/20/2024, indicated CNA 4 (night shift CNA) stated she witnessed Resident 1, inside her room, tapped Resident 2's foot with an open hand trying to wake her (Resident 2) up, on 8/20/2024 at around 6:20 AM. The Investigation Statement indicated CNA 4 told Resident 1 to stop tapping Resident 2's foot and Resident 1 started talking in her primary/native language as Resident 2 woke up . During a review of CNA 3's (night shift CNA) Investigation Statement dated 8/20/2024, indicated CNA 3 heard yelling coming from Resident 1's room and when she entered the room, CNA 3 observed Resident 1 yelling and standing by Resident 2's bed. The Investigation Statement indicated CNA 3 left the room and reported Resident 1 to LVN 1. The Investigation Statement indicated CNA 3 stated that LVN 1 was trying to calm down Resident 1 in the facility hallway and held Resident 1's hands to prevent LVN 1 from getting hit. The Investigation Statement indicated CNA 3 got a wheelchair and sat Resident 1 down while another CNA (CNA 1) arrived from the morning shift and started to talk to Resident 1 to calm her down. During an interview on 8/26/2024 at 10:34 AM with Housekeeper (HK) 1, HK 1 stated that on 8/20/2024 at around 6:40 AM, he heard arguing by the hallway, across the Nurses Station. HK 1 stated witnessing Resident 1 standing by the Nursing Station while LVN 1 was behind Resident 1 restraining Resident 1's left and right arms with both of her hands. HK 1 stated that Resident 1 right and left arms and hands were crossed and restrained for about 5 minutes. HK 1 stated while LVN 1 was restraining the resident, Resident 1 was screaming, yelling, and kicking. HK 1 stated LVN 1 was calling for someone to get a wheelchair, while LVN 1 was physically restraining Resident 1. HK 1 stated that CNA 1 from the 7 AM to 3 PM shift, came to help calm down Resident 1. HK 1 stated Resident 1 had calmed down when CNA 1 had spoken to her. HK 1 stated that Resident 1 was pointing and complaining of left-hand pain to CNA 1. HK 1 stated that CNA 1 applied an ice pack to Resident 1's left hand. During an interview on 8/26/2024 at 10:47 AM, CNA 1 stated she arrived at the facility at around 6:45 AM. CNA 1 stated that she witnessed Resident 1 screaming in front of the Nurses Station, sitting on the wheelchair while LVN 1 physically restrained Resident 1 by holding Resident 1's left and right hand and Resident 1's arms were crossed above her head. CNA 1 stated she was able to calm down Resident 1, so LVN 1 had stopped restraining Resident 1. CNA 1 stated she noticed Resident 1 had redness on the back of the left hand. CNA 1 stated after she applied an icepack on Resident 1's left hand, CNA 1 took Resident 1 back to her room. During an observation and interview on 8/26/2024 at 11:06 AM, in Resident 1's room, in the presence of another employee [Translator 1] translating for Resident 1, Translator 1 stated that according to Resident 1, it was hard to remember what happened on 8/20/2024, during the early morning, because it happened a while back. Resident 1 stated she did not have any pain anymore. Resident 1 had pointed to the back of her left hand with yellowish discoloration. During an interview on 8/26/2024 at 11:21 AM, the Treatment Nurse (TN 1) stated that Registered Nurse (RN) 2 reported to her that Resident 1 needed treatment on her left dorsal hand bruising, on 8/20/24. TN 1 stated that Resident 1 was pointing to her left hand when she went to assess the resident. TN 1 stated that Resident 1 had a 2 cm by 2 cm bluish discoloration to the resident's left dorsal (back of the hand) hand, with no swelling, on 8/20/2024. TN 1 stated that Resident 1's bruising to the left hand had now changed to yellowish discoloration with no pain or swelling. During an interview on 8/26/2024 at 11:36 AM, the ADM stated when she arrived at the facility on 8/20/2024 at 7:30 AM, HK 1 reported that he observed LVN 1 had physically restrained Resident 1 on 8/202024 at around 6:40 AM, at the Nurses Station. The ADM stated she had immediately started the abuse investigation. The ADM stated during the course of her investigation, LVN 1 physically restrained Resident 1 by holding Resident 1's left and right hands while inside her room and was forcefully pulled by holding both of her hands in a strong manner towards the Nurses Station. The ADM stated Resident 1 sustained bruising to the back of her left hand. The ADM stated CNA 4 reported to LVN 1 that Resident 1 had allegedly abused her roommate [Resident 2] by tapping her foot on 8/20/24 at around 6:20 AM, when CNA 4 was walking by Resident 1's room. The ADM stated that LVN 1 had communicated with the DON via TM regarding the incident with Resident 1. The ADM stated that LVN 1 texted to the DON the reason why she physically restrained Resident 1 was because she assumed that Resident 1 would hit Resident 2 while in the resident's room. The ADM stated LVN 1 restrained Resident 1's hands because she did not want to get hit by the resident. The ADM stated LVN 1 forcefully pulled Resident 1's left and right hand out of the room and pulled the resident to the Nursing Station. The ADM stated the DON requested LVN 1 to submit a written statement, but LVN 1 did not submit and respond to any further communication with the ADM or the DON. The ADM stated LVN 1 was suspended on 8/20/2024 and was later terminated on 8/23/2024. During an interview, on 8/26/2024 at 12:08 PM, the DON stated LVN 1 stopped communicating via text messages and LVN 1 did not call back or respond to her for a written statement of what occurred on 8/20/2024. The DON further stated that LVN 1 forcefully pulled Resident 1's right and left hand on 8/20/2024 towards the Nursing Station. The DON stated LVN 1 did not follow the facility policy on Restraint Management and did not use good nursing judgement to deescalate [to decrease difficulty of a situation] Resident 1's agitated state. The DON stated the physical force used by LVN 1 caused injury (bruising) to Resident 1's left and right hand and may have caused psychosocial distress (unpleasant emotions which negatively impacts quality of life) by making Resident 1 feel helpless. The DON stated LVN 1 should have talked to Resident 1 in a calm voice or walked away, and just monitor Resident 1 until she calmed down. During an interview on 8/26/2024 at 2:05 PM with LVN 2, LVN 2 stated she arrived at the facility around 6:50 AM, on 8/20/2024, and observed LVN 1 restrained Resident 1's left and right hands and crossed the resident's arms across the resident's abdomen/chest area with LVN 1's right hand. LVN 1 used her left hand to hold her cell phone while trying to call the translator services to communicate with Resident 1. LVN 2 stated Resident 1 had been restrained for about two minutes. During the same observation, on 8/26/2024 at 2:05 PM, LVN 2 stated Resident 1 was not agitated or combative. LVN 2 stated CNA 1 came to Resident 1 and started to speak with her to comfort her. LVN 2 stated after CNA 1 talked to Resident 1, LVN 1 released her hand from Resident 1. LVN 2 stated CNA 1 took Resident 1 back to her room and reported to LVN 1 about Resident 1's injury (bruising) to the left hand and CNA 1 placed an ice pack to Resident 1 left and right hand. LVN 2 stated that LVN 1 should have not physically restrained Resident 1. LVN 2 stated LVN 1 caused physical and psychological harm to Resident 1 because LVN 1 used force which led to Resident 1 getting injured physically. During a telephone interview on 8/26/2024 at 2:29 PM, Resident 2 was interviewed and stated that Resident 1 would wake up at night and just walk up and down the hallway. Resident 2 stated that Resident 1 never hit her and did not bother her. During a concurrent interview and record reviews on 8/26/2024 at 3:10 PM, Resident 1's Nursing Progress Notes titled Post [COC] dated 6/9/2024 timed at 1:20 PM and SBAR Communication Form and Progress Note dated 7/7/2024 timed at 12:47 PM were reviewed with the DON. During the concurrent interview, the DON stated he was unaware of Resident 1's Post COC on 6/9/2024 that indicated Resident 1's combative behavior. The DON further stated that he was unaware of Resident 1's combative behavior exhibited on 7/7/2024, as indicated in the SBAR Form. The DON stated there was no resident specific care plan developed for Resident 1's combative behaviors prior to 8/18/2024, because there was no IDT conference conducted to address Resident 1's aggressive behavior since the resident's behavior symptoms were not reported to him [DON]. The DON stated the SBAR Form dated 7/7/2024, indicated the physician ordered Ativan 0.5 mg every 12 hours as needed for agitation. The DON stated Resident 1's aggressive behavior and the physician order for the use of Ativan should have been communicated and addressed to identify and manage Resident 1's behavioral issues to avoid abuse or physical restraints. During a concurrent interview on 8/26/2024 at 3:34 PM and record review of Resident 1's care plan titled [Resident 1] has a new behavior of punching, kicking, and scratching staff, attempting to touch and grab other residents, dated 8/18/2024 and revised on 8/22/2024 with the DON, the DON stated that Resident 1's care plan interventions for Resident 1's new behavior of punching, kicking and scratching staff were not specific to the Resident 1's behavioral needs. The DON stated the licensed nurses only developed three care plan interventions which included to notify the physician, notify Resident 1's family, and provide psychosocial support. The DON stated the care plan did not indicate how the staff would provide psychosocial support such as to talk to the resident so she could voice any concerns. The DON stated the care plan did not address triggers or root cause that may have been causing Resident 1 to touch other residents especially Resident 2, including punching, kicking, and scratching staff. The DON stated because the care plan on 8/18/2024 did indicate addressing the root cause of Resident 1's aggressive behavior, LVN 1 led to escalating Resident 1's aggressive behavior by physically restraining Resident 1 on 8/20/2024. The DON stated restraining Resident 1 was not the appropriate action to protect the resident and calm her down. The DON stated LVN 1 used physical force (on 8/20/2024) and led to Resident 1's increase in aggression. During the same interview, on 8/26/2024 at 3:34 PM, the DON stated the facility's IDT conference should have been conducted the next day, on 8/19/2024, when resident 1 had an episode of combativeness on 8/18/2024. The DON stated the IDT conference was not conducted the next day, 8/19/2024, because it was a weekend (Sunday). The DON stated the next incident happened on 8/20/2024, early morning, and should had been prevented if Resident 1's combative behaviors was addressed by the IDT on 8/19/2024. During a phone interview on 8/26/2024 at 4:40 PM, LVN 3 stated he worked on 8/17/2024 from 11 PM to 7 AM shift. LVN 3 stated he had cared for Resident 1 in the past and Resident 1 previously had behaviors of agitation when Resident 1 would get startled. LVN 3 stated after Resident 1 had been redirected back to her room, Resident 1 became aggressive and began making threatening gestures with her fist. LVN 3 stated Resident 1 slapped him across the face while trying to calm her down. LVN 3 stated after several attempts to redirect Resident 1, the resident began chasing staff in the hallway. LVN 3 stated when Resident 1 began chasing staff, he called 911 emergency services. LVN 3 stated police officers arrived in the early morning of 8/18/2024 at around 1 AM. LVN 3 stated there was an officer who speaks Resident 1's native language and was able to calm her down. LVN 3 stated Resident 1 went back to her room and told the police officer she was tired. During an interview on 8/27/2024 at 4:18 PM, with RN 1 stated she worked on 8/17/2024 from 3 PM to 11 PM shift and she did not see Resident 1 in an agitated state and was not chasing, yelling, and kicking staff but noticed the resident with episodes of anxiously pacing up and down the hallway. RN 1 stated Resident 1 would pace up and down the hallway but return to her room. RN 1 stated she did not know if Resident 1's behaviors (verbalization of nervousness and outburst of anger) was being monitored or counted in the resident's records. During a review of the facility's P&P titled Physical Restraint Management dated 3/2017, the P&P indicated physical restraints are not used for purposes of discipline or convenience, but only as required to treat the resident's medical symptoms. The P&P indicated physical restraints are defined as 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 or normal access to one's body. The P&P indicated physical restraints include, but are not limited to, leg restraints, arm restraints, hand mitts, soft ties, or vests, lap cushions, and lap trays the resident cannot move easily. During a review of the facility's P&P titled Person Centered Plan of Care dated 12/20[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview. and record review, the facility failed to ensure residents were free from involuntary seclusion (separation of a resident from other residents) for two of 4 sampled residents by failing to: 1. On [DATE], Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1 confined (keep someone in a closed space by force) a resident (Resident 1) who had a history of major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and required extensive assistance with transferring from bed to chair, inside the bathroom by placing a bed against the bathroom door to prevent Resident 1 from getting out, for approximately 40 minutes. This deficient practice resulted in Resident 1 being secluded (hidden or isolated) against her will and resulting in psychosocial harm to Resident 1. Resident 1 verbalized crying, yelling, and calling out for help, scared when doors were closed or being in dark/closed spaces, unable to sleep at night, and feeling terrified. 2. Resident 2, (Resident 1's roommate) who required total dependence on staff with transferring from bed to chair, witnessed Resident 1's involuntary seclusion while inside the same room, on [DATE]. This deficient practice resulted in Resident 2 verbalizing how the incident that happened to Resident 1 made her feel uncomfortable and anxious and thought that it could happen to her too, especially that she is bed bound and could not walk. On [DATE] at 3:26 PM, during the investigation of a complaint, the Department of Public Health (DPH) called 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) in the presence of the Administrator (ADM) and Director of Nursing (DON), in regard to one (1) resident in the facility (Resident 1) that was involuntarily secluded in the bathroom by LVN 1 and CNA 1. On [DATE] at 7:21 PM, the Department of Public Health removed the IJ while onsite after the surveyor verified the facility implemented the facility's IJ Removal Plan (a detailed plan to address the IJ findings) given by the ADM which included: 1. The assigned licensed nurse conducted a change of condition assessment for Resident 1 on [DATE] related to the possible emotional trauma or post-traumatic stress (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident) related to the involuntary seclusion. 2. The physician was notified on [DATE] . The Social Service Designee re-interviewed Resident 1 on [DATE] to allow resident to express her feelings and concerns to further identify triggers and develop a comprehensive plan of care to minimize any emotional distress. 3. The IDT will conduct a meeting on [DATE] to update Resident 1's plan of care to address the resident's potential emotional trauma related to the involuntary seclusion. Resident 1's behavior will be observed, and the Social Service Designee will complete a new trauma informed assessment by [DATE] to determine event triggers. The evening shift Licensed Nurses and Certified Nursing Assistants will be responsible to provide emotional support to the resident and on the night shift. Resident 1 currently has a hard time sleeping at night, so the nursing staff will comfort her with a bedtime routine (such as soft music, room lighting), and offer medication as ordered by the physician. 4. The assigned licensed nurse conducted a change of condition assessment for Resident 2 on [DATE] related to the possible emotional trauma or post-traumatic stress related to witnessing the involuntary seclusion that occurred with her roommate on [DATE]. The physician was notified on [DATE], and no new orders given. Social Service Designee re-interviewed resident on [DATE] to allow resident to express her feelings and concerns to further identify triggers and develop a comprehensive plan of care to minimize any emotional distress. 5. The DON, Social Services Designee (SSD), Director of Staff Development (DSD), and ADM will conduct an Interdisciplinary Team (IDT) meeting on [DATE] to update Resident 1's plan of care to address the resident's potential emotional trauma related to the involuntary seclusion. The facility's Medical Director and the Responsible Party will be invited to attend via phone as well. Resident 2's behavior will be observed, and a new trauma informed assessment will be completed by the SSD as of [DATE] to determine event triggers. 4. Based on resident interviews, the facility will update Resident 1's care plan to eliminate triggers by providing more lighting in the room, leaving doors open in the room, and providing an alternative for privacy in the room (such as shower poncho, privacy screens). The interventions to be initiated as of [DATE]. 5. The facility will initiate in-services for all staff providing direct patient care as of [DATE] regarding the revised care plan for Resident 1. The care plan information will also be disseminated to staff during each shift huddle, and department managers during stand-up meeting . 6. A trauma informed assessment will be initiated as of [DATE] for Resident 1 and Resident 2 . by social service designee. 7. As of [DATE], the SSD and/or Activity Director to conduct room visits to Resident 1 and Resident 2. The goal will be to allow to verbally vent feelings, provide activity of choice, verbally ensure they are feeling comfortable, and provide verbal reassurance to make them feel safe. These visits will occur daily at minimum of 1 a day for the next 90 days. The facility will implement a log to track the daily visits for the next 90 days as well. 8. Resident 1 was seen by the psychologist (a person who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) on [DATE] after returning from the acute hospital. On [DATE], the SSD and ADM requested the psychologist to make a visit for Resident 1 and Resident 2. The facility scheduled the psychology visit for both residents to be seen on [DATE] by the psychologist for additional emotional support. The plan is to see Resident 1 two times a week in person and/or via facetime, and for Resident 2, once a week. The DON and/or will ensure a follow-up call is made to the psychologist to ensure the scheduled visits resume. 9. Inservice training of staff will be conducted on the following topics: -Abuse Prevention Policy - [DATE], [DATE], to be completed by [DATE] -Managing Residents with Difficult Behaviors - Initiated [DATE] and will be completed by [DATE] by Psychology Group/DSD (Director of Staff Development) -Involuntary Seclusion - Initiated on [DATE] and will be completed by [DATE] -Signs and Symptoms of Mental Abuse - Initiated [DATE] and on-going -Care Planning - Initiated [DATE] and will be completed by [DATE] -Plan of Care for Resident 1 and Resident 2 - Initiated [DATE] and will be completed by [DATE] -Trauma Informed Care - to be initiated on [DATE] and completed by [DATE]. -Diversity Training / Cultural Competency to be initiated [DATE] and completed by [DATE] 10. All interviewable residents potentially affected by the deficient practice of CNA 1, CNA 2 and LVN 1's action of involuntary seclusion was interviewed on [DATE], and not affected by this deficient practice. 11. All non-interviewable residents' representatives were interviewed on [DATE], and no other resident were affected by the deficient practice. 12. Yearly all staff will be provided training on trauma, involuntary seclusion and abuse prevention and will be completed beginning [DATE]. Cross referenced to F742 Findings: 1. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 1's History and Physical (H&P) dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Assessment (MDS; a care assessment tool) dated [DATE], indicated Resident 1's cognition (thought process) was intact. The MDS indicated Resident 1 required extensive (means when a resident requires weight bearing support while performing part of an activity), one person assistance during transfers, toilet use, dressing, locomotion in the unit, and personal hygiene. A review of Resident 1's telephone physician orders dated [DATE] timed at 5:19 PM, indicated to transfer to acute hospital for evaluation due to severe feeling of sadness secondary to death of a family member. A review of Resident 1's late entry Psychosocial Note dated [DATE] timed at 9:00 AM, indicated the social worker received a call from Resident 1's responsible party about Resident 1's family member's death. The Note indicated the funeral service would be on [DATE] at 2 PM. The Note indicated Resident 1 expressed sadness and episodes of crying. The Note indicated Resident 1 would be referred to a follow up psychology consult. A review of Resident 1's Licensed Nurses Notes indicated the following information: a. On [DATE] at 8:03 PM- indicated Physician 1 ordered for Resident 1 to be transferred to the acute hospital for evaluation due to sadness. The Progress Notes indicated Resident 1 would be transferred to the acute hospital the next day ([DATE]). b. On [DATE] at 8:20 PM- indicated Resident 1 came back at 4:30 PM from attending the family member's funeral. The note indicated Resident 1 looked sad. A review of the facility's Final Investigation Report Conclusion, dated [DATE], indicated the following information: On 10-28-2022, at approximately 7:07 am, Resident 1 reported to the Director of Staff Development (DSD) she was locked (confined) in her closet last night by a staff member. The DSD inquired to clarify the incident, then immediately reported the allegation to both the ADM and Director of Nursing. He (DSD) reported Resident 1 alleged her charge nurse, LVN 1 locked her in the closet last night. She (Resident 1) stated she was locked in a dark room and was not able to get out. Per LVN 1 and CNA 1, the resident had been very restless, and agitated throughout the 11 pm to 7 am shift. Further stated she (Resident 1) did not sleep at night and was wandering throughout the facility the entire shift (11 pm to 7 am). At one point, the resident attempted to elope out (walk out without notice) of the facility, and it was at that point LVN 1 and CNA 1 took her (Resident 1) to her room. Resident 1, because she would not stay in her room, she (Resident 1) alleged LVN 1 locked her inside a closet. Several interviews were conducted with Resident 1, and her story remained consistent. Resident 1, she stated she was locked in the closet and was unable to get out. Resident 1 stated she (Resident 1) tried to get out for a while, but she was not able to. Resident 1 stated I know it was LVN 1 who did this to me, that bastard. Resident 1 was not able to tell how she eventually got out of the closet, nor the approximate time this alleged incident occurred. The same review of the Final Investigation Report Conclusion dated [DATE] above, further indicated, Resident 2 (Resident 1's roommate) stated Resident 1 was locked in the bathroom. She (Resident 2) stated she witnessed staff place the bed up against the bathroom door, and she (Resident 2) believes the resident (Resident 1) was in there. She (Resident 2) stated she heard noises coming from the bathroom as if someone was trying to get out. Resident 2 showed me (Administrator) where she claimed two (facility) staff members placed a bed against the bathroom door. She (Resident 2) stated the resident (Resident 1) had disappeared while the bed was against the door. CNA 2 stated she entered the room and witnessed LVN 1 and CNA 1, placing the bed against the bathroom door with the resident (Resident 1) already in the bathroom. She (CNA 2) stated they told her to turn her head and act like she did not see anything. A review of Resident 1's acute hospital's records indicated Resident 1 was admitted to the acute psychiatric hospital on [DATE] timed at 2:49 PM, with chief complaints of psychosis (used to describe conditions that affect the mind, where there has been some loss of contact with reality), acute (sudden onset) anxiety (the mind and body's reaction to stressful, dangerous, or unfamiliar situations), depression, and agitation (a state of excitement, disturbance, or worry). The acute hospital record's Psychiatric Evaluation dated [DATE], indicated Resident 1 was placed on 5150 (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) for DTO (danger to others) and transferred to the acute hospital for inpatient psychiatric treatment. The evaluation stated Resident 1 was irritable and guarded. On [DATE] at 9:25 AM, during an interview with the Director of Nursing (DON), the DON stated during the interviews with CNA 2 and Resident 2, both stated that LVN 1 and CNA 1 locked (confined) Resident 1 in the bathroom on [DATE], by pushing the bed in front of the bathroom door. The DON stated that the incident was witnessed by CNA 2 and Resident 1's roommate, Resident 2. The DON stated involuntary seclusion is not right because it is a form of abuse and can cause emotional stress, trauma, and the incident can occur in the victim's mind, time and again. The DON stated if staff were unable to redirect residents from leaving the facility, the appropriate intervention for staff to do is to place the resident on one-to-one supervision (closely monitor), provide as needed medications such as Ativan (anti-anxiety medication) as ordered by the physician, inform the attending physician (Physician 1), and the resident's responsible party, complete an SBAR (Situation, Background, Assessment and Recommendation. The DON stated if any of the implemented interventions did not work, the facility staff should call 9-1-1 emergency services. An Observation of the facility's surveillance video on [DATE] at 10:20 AM, in the presence of the ADM indicated the following information dated [DATE]: a. Timestamped at 5: 21 AM: Resident 1 attempted to exit the facility's front door (wheeling herself). b. Timestamped at 5:23 AM: LVN 1, accompanied by CNA 1 was seen wheeling Resident 1 in her wheelchair back to her room. c. Timestamped at 5:24 AM: CNA 2 was seen walking towards Resident 1's room and went inside the room. d. Timestamped at 5:26 AM: LVN 1, CNA 1, and CNA 2 was seen going out of Resident 1's room. e. Timestamped at 6 AM: CNA 1 and CNA 2 was seen walking back towards Resident 1's room and went back inside Resident 1's room. f. Timestamped at 6:02 AM: LVN 1 was seen walking towards Resident 1's room and entered Resident 1's room. g. Timestamped at 6:03 AM: LVN 1, CNA 1, and CNA 2 was seen exiting Resident 1's room together (40 minutes from 5:23 AM when LVN 1 and CNA 1 was seen wheeling Resident 1 to her room). h. Timestamped at 6:10 AM: Resident 1 was seen wheeling herself out of the room. On [DATE] at 10:35 AM, during the observation of the facility's surveillance video and concurrent interview of the ADM, the ADM stated that the incident of Resident 1 being confined in the bathroom inside Resident 1's room happened on [DATE] between the hours of 5:23 AM and 6:03 AM. On [DATE] at 11:05 AM, during an interview with Resident 1, Resident 1 stated one of her family members died and she was going to a funeral on that day ([DATE]). Resident 1 stated before going to her family member's funeral, during the early morning of [DATE], LVN 1 locked her in the bathroom, inside her room. Resident 1 stated, It was dark, very dark. Resident 1 stated she was inside the bathroom for a long time. Resident 1 stated she was scared while inside the bathroom and was banging on the door several times. Resident 1 stated she was crying while she was yelling and calling for help to get out, inside the bathroom. Resident 1 stated she could not remember who opened the door and when the door opened Resident 1 stated she was scared. Resident 1 stated ever since LVN 1 locked her in the bathroom, she did not like to see any doors being closed and did not like to be inside dark places. Resident 1 stated she could not sleep at night because it was very dark, It's terrifying. 2. A review of Resident 2's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including COPD and paraplegia (a type of paralysis that affects a person's ability to move the lower half of the body). A review of Resident 2's MDS indicated dated [DATE], indicated Resident 2 had intact cognition and memory recall. The MDS indicated Resident 2 required extensive assistance for bed mobility, totally dependent on staff for locomotion on and off units and could not walk. On [DATE] at 11:25 AM, during an interview with Resident 2, Resident 2 stated she remembered approximately two weeks ago, during the early morning (unable to recall exact date) she woke up to the noise of two people (LVN 1 and CNA 1) inside her room. Resident 2 stated she saw LVN 1 and CNA 1 pushed the bed (pointed to Resident 1's bed) in front of the bathroom door and blocked the bathroom door with the bed. Resident 2 stated that Resident 1 was not in her bed during that time. Resident 2 stated she recalled hearing a noise coming from the inside of the bathroom and Resident 2 thought she heard that someone was banging on the door, yelling, and crying. Resident 2 stated the yelling, crying and the banging on the door would stop for a while, and then continue again. Resident 2 stated that she was still awake when in about an hour, the two CNAs (CNA 1 and CNA 2) came back inside the room and pushed the bed back towards the wall. Resident 2 stated after that, she saw Resident 1 coming out of the bathroom in her wheelchair and wheeled herself to bed. Resident 2 stated the incident that happened to Resident 1 made her feel uncomfortable and anxious and thought that it could happen to her too, especially that she is bed bound and could not walk. On [DATE] at 12:13 PM, during an interview with the Social Services Director (SSD), the SSD stated prior to the incident, she informed Resident 1 that the resident's family member passed away and that she would accompany the resident to the funeral that was scheduled to be held on [DATE] in the afternoon. The SSD stated she came to the facility early that morning ([DATE]) to get Resident 1 ready for the family member's funeral when Resident 1 informed her that LVN 1 and CNA 1 locked her in the bathroom earlier that same day ([DATE]). The SSD stated she informed the DSD and the police. During the same interview with the SSD and concurrent interview of the SSD's psychosocial notes, on [DATE] at 12:13 PM, indicated no documented evidence addressing the resident's fears from being confined and secluded in the bathroom by facility staff. The SSD stated she did not ask questions or talked to Resident 1 about the incident that happened on [DATE] or offered additional psychosocial support because the resident was more focused on the death of the family member. The SSD stated that after the resident's family member's death, the Psychologist she had referred Resident 1 to was not able to come and visit. The SSD stated that Physician 1 had ordered for Resident 1 to be transferred to the acute psychiatric hospital for further evaluation due to sadness. The SSD stated Resident 1 was transferred on [DATE] to the acute psychiatric hospital. On [DATE] at 12:58 PM, during an interview with the DSD, the DSD stated Resident 1 is alert and oriented to person, time, and place. The DSD stated that sometimes Resident 1 would go to other residents' room, but Resident 1 can be easily redirected back to her room. The DSD stated that on [DATE], at 7:09 AM, Resident 1 informed him that LVN 1 confined her in a dark room for a long time and Resident 1 stated she was trying and trying to get out, but she could not get out. On [DATE] at 1:35 PM, during another interview with the SSD, the SSD stated that confining Resident 1 in the bathroom was not acceptable because it is a form of abuse. The SSD stated it can negatively affect and cause trauma to Resident 1. The SSD stated Resident 1 was having some anxiety issues. The SSD stated that she had noticed since Resident 1 was readmitted back to the facility (on [DATE]), Resident 1 had showed fear of closed doors and the lights in her room being off or dark. On [DATE] at 2 PM, during an interview with LVN 2, LVN 2 stated Resident 1 tends to go to other residents' room but can be easily redirected back to her room. LVN 2 stated that confining Resident 1 in bathroom is a type of abuse that could lead to serious mental and physical injuries, even dying. LVN 2 stated that involuntary seclusion can lead to PTSD (post-traumatic stress disorder- a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). On [DATE] at 2:14 PM, during an interview with CNA 3, CNA 3 stated that she was assigned to Resident 1 on [DATE], during the morning shift (7 AM to 3 PM shift). CNA 3 stated that on [DATE], during the morning shift, she assisted Resident 1 in getting ready for the family member's funeral. CNA 3 stated Resident 1 attempts to go to other resident's rooms but can easily be redirected back to her room. CNA 3 stated she had observed Resident 1 sad and crying that day ([DATE]). On [DATE] at 2:43 PM, during an interview with ADM, the ADM stated involuntary seclusion is against residents' rights, and it is a form of abuse. The ADM stated it can result in fear and can be viewed as a form of punishment physically and mentally. On [DATE] at 1:30 PM, during an observation in the resident's room, CNA 3 was assisting Resident 1 during toileting inside the bathroom with the door wide open. During a subsequent interview with CNA 3, CNA 3 stated Resident 1 told her a week ago that she did not want the bathroom door to be closed because it makes her anxious. CNA 3 stated she respected the request of Resident 1 to keep the bathroom door open during toileting. On [DATE] at 2:38 PM, during an interview with Registered Nurse (RN) 1, RN 1 stated involuntary seclusion is a form of abuse that can cause mental, physical harm, and stress to the resident. On [DATE] at 11:02 AM, during a telephone interview with CNA 1, CNA 1 stated she was familiar with Resident 1, and most of the time Resident 1 was assigned to her during the night shift (11 PM to 7 AM). CNA 1 stated she was assigned to Resident 1 on [DATE], during the 11 PM to 7 AM shift. CNA 1 stated Resident 1 was wheeling around the facility more than usual on [DATE] from 11 PM to 5AM ([DATE]). CNA 1 stated Resident 1 was restless and going to other residents' rooms. CNA 1 stated she did not know about Resident 1's family member's recent death. CNA 1 stated Resident 1 told CNA 1 she was going to miss the family member's funeral. CNA 1 stated she did not call Resident 1's responsible party and did not offer any activities to redirect Resident 1. CNA 1 declined to comment regarding the alleged incident of confining Resident 1 in the bathroom the morning of [DATE]. On [DATE] at 12:28 PM, during a telephone interview with CNA 2, CNA 2 stated that on [DATE] at around 5:20 AM, when she walked into Resident 1's room, she observed LVN 1 and CNA 1 pushing Resident 1's bed against the bathroom door. Resident 1 was unable to come out of the bathroom. CNA 2 stated she heard Resident 1's wheelchair hitting the door and Resident 1 screaming and banging on the door. CNA 2 stated that LVN 1 and CNA 1 told CNA 2 that she (CNA 2) did not see anything, as they walk out of the resident's room. CNA 2 stated she could hear Resident 1 screaming for help. CNA 2 stated that around 6:10 AM, she and CNA 1 went back to Resident 1's room. CNA 1 stated she saw Resident 2's (Resident 1's roommate) bed on a high fowler's (seated upright with their spine in straight position), wide awake with eyes wide and with shocked look on her face. CNA 2 stated that Resident 2 was looking at CNA 1 and CNA 2. CNA 2 stated she and CNA 1 moved the bed back towards the wall. CNA 2 stated when CNA 1 opened the bathroom door, Resident 1 was still sitting on her wheelchair, and that it was very dark in the bathroom because the light was off in the bathroom. CNA 2 stated she saw Resident 1's face was red, very angry, and at the same time very upset. CNA 2 stated Resident 1's hands were on the wheelchair as she wheeled herself out of the bathroom. CNA 2 stated CNA 1 told Resident 1 to lie down in bed. CNA 2 stated that she should have intervened and not let LVN 1 and CNA 1 confine Resident 1 in the bathroom and call 9-1-1. On [DATE] at 1:15 PM, during a telephone interview with Resident 1's responsible party (RP1), RP 1 stated Resident 1 informed her that LVN 1 confined her in the bathroom. Resident 1 told RP1 that after the incident, Resident 1 was terrified being in the dark and did not want the bathroom door to be closed. RP 1 stated that their family member passed away on [DATE] and Resident 1 was informed about it and the funeral was scheduled on [DATE] in the afternoon. On [DATE] at 5:02 PM, during a telephone interview with LVN 1, LVN 1 stated he was assigned to Resident 1 on [DATE] during the 11 PM to 7 AM shift. LVN 1 stated Resident 1 told him she wants to go to the family member's funeral. LVN 1 stated Resident 1 was restless during the whole night shift, wheeling around the facility and going to other resident's rooms. LVN 1 stated that around 5 AM, they found Resident 1 outside of the facility. LVN 1 stated he wheeled Resident 1 back to her room with CNA 1 and left Resident 1 sitting on the wheelchair. LVN 1 denied all allegations of confining Resident 1 in the bathroom in the early morning of [DATE]. A review of the facility's policy and procedure titled Abuse and Neglect Prohibition Policy updated in [DATE], indicated It is the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents . The policy indicated The purpose of the policy is to ensure that facility staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all residents . Abuse is defined as the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services which are necessary to maintain physical or mental health including the following: Involuntary seclusion is defined as separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident's legal representative.