**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide immediate and adequate supervision after a resident's family member notified facility staff of a resident voicing R1 was going to escape out of his window and implement 15-minute visual checks as directed by the plan of care, for a cognitively impaired resident at risk for elopement for one (R1) of three residents reviewed for elopement in a sample of three. These failures resulted in (R1) a cognitively impaired resident with a previous elopement attempt from the facility, exiting the facility through his room window without staff knowledge or supervision on 9/3/25. (R1) was found across the road from the facility, a block away and close to active railroad tracks. These failures resulted in an Immediate Jeopardy.While the immediacy was removed on 9-11-25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:The facility's Elopements and Wandering Residents Policy, dated 2025, documents Policy: The facility ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering: is random or repetitive locomotion that may be goal-directed (example: the person appears to be searching for something such as an exit) or not-goal directed or aimless. Elopement: Occurs when a resident leaves the premises or a safe area without authorization (an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: A. Resident will be assessed for risk of elopement and unsafe wandering upon admission throughout their stay by the interdisciplinary care plan team. B. The interdisciplinary Team will evaluation the unique factors contributing to risk in order to develop a person-centered care plan. C. Interventions to increase staff awareness of the resident's risk, modify the residents' behaviors, or to minimize risk associated with hazards will be added to the resident's care plan and communicated to appropriate staff. D. Adequate supervision will be provided to help prevent accidents or elopements. E. Charge Nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly.R1's current Face Sheet documents R1 is a [AGE] year-old male admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Alzheimer's Disease, Restlessness and Agitation, Essential Hypertension, Congestive Heart Failure, Peripheral Vascular Diseases, Acute Respiratory Failure with Hypoxia, Muscle Wasting/Atrophy, and Other Abnormalities of Gait and Mobility.R1's MDS (Minimum Data Set), dated 6/30/25, documents R1 is severely cognitively impaired.R1's Care Plan, dated 6/27/25 documents, Cognition/Disorientation: (R1) experiences disorientation to place, time. My memory is similarly impaired. I have problems with decision making, insight, logic, reasoning, social skills, judgment. This problem is related to my cognitive deficits.R1's Progress Notes, dated 8/22/25 and signed by V7/RN (Registered Nurse) documents, (V7) called (V11/R1's Physician Assistant) and reported that (R1) is not being cooperative to reenter the facility.R1's BIMS (Brief Interview of Mental Status) Assessments dated 8/22/25 and 9/4/25 documents R1 is cognitively impaired.R1's Elopement Evaluation, dated 8/22/25, documents R1 is at risk of Elopement. This same evaluation documents Focus: Risk for Wandering/Elopement Identified. Goal: (R1) will not leave facility unattended. Goal: (R1's) safety will be maintained.R1's Community Survival Skills, dated 8/22/25, documents, The resident sufficiently alert, oriented, and knowledgeable allowing him/her to be considered for independent outside pass privileges? No. This same form documents R1 requires supervision to be out in the community.R1's Care Plan, dated 9/3/25, documents Focus: Risk for Wandering/Elopement Identified (Date initiated 8/22/25). Interventions: 8/22/25 Wander guard to right ankle. 8/22/25 15-minute checks initiated, 9/3/24 (R1) was moved to memory care unit, 9/3/25 Engage (R1) in purposeful activity, 9/3/25 Provide clear, simple instructions, Provide reorientation to surroundings, environment.R1's 15-Minute Checks, dated 8/22/25 through 9/4/25, does not document any safety concerns under safety concerns located on the top right corner of the 15-minute checks.R1's Illinois Department of Public health First and Final Report, dated 9/4/25, documents on 9/3/25 R1 left the building through his room window. A phone call was made to the facility at 7:34 PM by Local Police Department. Staff located R1 at 7:41 PM.R1's Police Report, dated 9/3/25, documents at 7:28 PM V4/R1's Family Member notified the police department advising that R1 had taken off from the local nursing facility. At 7:34 PM the police department attempted to call the facility with no answer. At 7:38 PM the police department spoke with V7/RN. V7 advised they would look for R1. In the background while V7 had set the phone down the police officer could hear employees stating they could not locate R1. On 9/3/25 at 7:55 PM the police department called the facility and spoke with V7. V7 advised the police department they (facility staff) had located R1 a block away from the facility.R1's Progress Note, dated 9/3/25 and signed by V7/RN, documents, (V7) received a call from (Local Police Department) at 7:33 PM to report that (R1) may have left facility through (R1's) window. Per Local Police Officer, (R1) is on the phone with (V4/R1's Family Member). (V7) and another CNA (Certified Nursing Assistant) identified as (V5), went to (R1's) room and observed that (R1) was not in the room or personal bathroom. (V7) did observed window opened about 14 inches and screen was missing. (V5) went through window to search for (R1) and this nurse informed the other staff on the floor to begin a search in the building. This nurse called (V12/Sister Facility Administrator) at 7:38 PM to report that (R1) had possibly left from facility exiting through windows. (V7) went out the back door and searched in the parking lot. (V7) met up with (V5) and got into (V7's) car and began to search for (R1). (V7) went around the corner and one-half block from facility and observed (R1) walking with a steady gait carrying a plastic bag with a small number of belongings at 7:41 PM. (V7) parked vehicle and approached (R1). (R1) was observed by (V7) that (R1) was on the phone with (V4) when (V7) approached (R1). (R1) agreed to get into vehicle and (R1) was returned to the facility.On 9/8/25 at 10:32 AM R1 was on the memory care unit lying in his bed. R1 was unable to answer questions appropriately but did state he was able to continually work on sliding his window over little by little and hit the window stopper until it would move. R1 stated he would do it a little every day until he knew it was wide enough to get through. R1 denies knowing where he went when he got out the window, speaking to V4/R1's Family Member, or how he got back to the facility on 9/3/25.On 9/8/25 at 3:05 PM this surveyor and V1/Administrator watched the video surveillance on the hallway R1 resided the night R1 left the facility unattended through his window on 9/3/25. At 7:04 PM a male with a meal tray cart (identified as V10/Cook) was observed slightly opening R1's room and grabbing R1's meal tray. At 7:36 PM two females (identified as V5/CNA and V6/CNA) were observed running down the hallway towards R1's room. Once they arrived to R1's room, they both look into (R1's) room and immediately started running back up the hallway. At 7:46 PM two females (identified as V5 and V7) were observed walking (R1) back into the facility's back door. (R1) was observed to have pants, shoes, and a t-shirt on. V1/Administrator confirmed at this time that R1 was on 15-minute checks and that no staff was observed on the camera going in R1's room and checking on R1 every 15 minutes. V1 stated staff should have been implementing R1's 15-minute checks and staff should have physically gone into R1's room and checked on R1 when performing the 15-minute checks. On 9/9/25 at 1:50 PM this surveyor, V1/Administrator, V2/Interim Director of Nursing, and V20/Regional Director of operations watched the video surveillance on the hallway R1 resided the night R1 left the facility unattended on 9/3/25 between 6:00 PM and 7:00 PM. From 6:00 PM to 6:28 PM R1's door is slightly cracked open. At 6:29 PM R1 is observed opening his door and standing slightly in the doorway. At that time V6/CNA is observed walking down the hallway and goes into a different resident's room, next to R1's room. At 6:31 PM V5/CNA is observed going into R1's room to deliver R1's meal tray and then immediately leaves R1's room. From 6:32 PM to 7:00 PM no other staff is observed checking on R1. During this time V1/Administrator and V2/Interim Director of Nursing both verify that R1 was not physically being checked on every 15-minutes as implemented and should have been.On 9/9/25 at 6:38 PM V17/Prior Administrator-in-Training stated she was the administrator in the building when R1 attempted to elope from the facility on 8/22/25. V17 stated, After (R1) attempted to elope, (R1) was determined to be a risk for elopement, so I placed a wander guard on (R1) and implemented 15-minute checks. (R1) was ambulatory and when he attempted to elope on 8/22/25, staff could not get him to come back into the facility. (R1) walked at least five blocks across main roads and railroad tracks (with staff present) and then finally agreed to get back into the facility van and come back to the facility with us. (R1) is not safe to be out in the community by himself. On 9/8/25 at 11:59 AM V7/RN (Registered Nurse) stated, The past two weeks prior to (R1) getting out of the facility on 9/3/25, he was verbalizing that he wanted to go home, or he wanted to get out. (R1) never stated how he was going to get out and rarely ever left his room. I didn't start work on the night of 9/3/25 until around 6:00 PM. While I was getting report between 6:00 PM and 6:15 PM, (V4/R1's Family Member) had called the facility and told me (R1) was wanting to leave and said he was going to get out through his window. I then told (V5/CNA and V6/CNA) to keep an eye on him and check on him periodically through the night. I didn't go down and look at the window myself to see if he could get out at that point. The windows never open very far so I didn't figure there was any way he could get out through his window. Around 7:30 PM the police department called the facility. I was doing my medication pass and had gone to answer the phone. The police department told me that (V4) had called them and stated (R1) had left the building. I then yelled to (V5) and (V6) to go check on him. (V5) ran down to (R1's) room and noticed (R1) was not in the room. (V5) jumped out the window to go look for (R1) and I told staff to start looking for (R1), and then I went outside to look for (R1). I was in the back parking lot looking for (R1) when I saw (V5). We both jumped in my car to go look for (R1). There are railroad tracks, and he was half a block from the tracks when we found (R1). We found (R1) approximately a block away from the facility. (R1) agreed to get in the car and allowed me to drive him back to the facility. We arrived back to the facility around 7:45 PM. On 9/10/25 at 12:25 PM V22/LPN (Licensed Practical Nurse) stated, (V4/R1's Family Member) called on 9/3/25 while I was giving report to (V7/RN). It would have been approximately between 6:00 PM and 6:15 PM. (V4/R1's Family Member) told me (R1) and (V4) had been arguing and that (R1) had told (V4) he was going to escape out of his window tonight. I assured (V4) that we would keep an eye on (R1), I then reported what (V4) had stated to (V7). I did not go down to (R1's) room and assess (R1) or his window. I would have never thought (R1) would have been able to get through his window. The windows usually only open four inches. On 9/8/25 at 1:33 PM V4/R1's Family Member stated, (R1) had called me between 5:00 PM and 6:00 PM the night of 9/3/25 and told me he wanted to leave the facility and that he was almost able to get through his window. I got off the phone and called the facility and spoke to some nurse and told them what (R1) had stated. They told me they would check on (R1). Later, that night around 7:30 PM (R1) had called me and stated he had got out his window and was walking down the street. We then got disconnected so I attempted to call the facility and could not get anyone to answer so I called the local police department and let them know. I was told by the facility (R1) was found around a block away. On 9/8/25 at 11:01 AM V5/CNA stated she was working on the unit where R1 resided when R1 got out of the building on 9/3/25. V5 stated, I do remember (V7/RN) stating (V4/R1's Family Member) had called and told (V7) (R1) was saying he was going to escape out his window and to check on (R1) periodically. It was around 6:15 PM. I did not go down there immediately to check on (R1) but do know I had checked on (R1) at some time, I just don't remember the time. I did not frequently check on (R1) because his room is at the end of the hallway, and I didn't figure there was any way for (R1) to escape since (R1) would have to walk past the nurse's station or try to go through an exit (which he had a wander guard on). I did not look at (R1's) window though to see if he could get through it and should have. I worked with (V6/CNA) that night on that hallway. I was the one in charge of the 15-minute checks. I was not sure why (R1) was on the 15-minute checks. It does not say anywhere. If I had known, I would have kept a better eye on him. I do physically go down and check on (R1) when I am completing the 15-minute checks, but I may not get down there every 15 minutes. I did not know (R1) had attempted to get out of the facility prior to 9/3/25 or that he was a high-risk wanderer. I have never been trained on how to access a resident's care plan or if I even have access. V5 stated the night R1 got out his window on 9/3/25 V5 was sitting at the nurse's station charting. V7 had told V5 she received a phone call that R1 had escaped from the building. V5 reported she immediately ran down to R1's room, noticed R1's window was wide open and R1 was not in his room. V5 stated she immediately told V7 and V5 jumped through the window in an attempt to locate R1. V5 reported she did not notice anything broken on the window. V5 noticed V7 out in the parking lot and got in the car with V7 to go locate R1. V5 stated, I got in (V7's) car in the back parking lot. We took a right out of the parking lot. Then at the stop sign we took another right, then a left at the following stop sign. (R1) was observed to be right at the corner of that block by the stop sign about a half block from the railroad tracks. (R1) was cooperative and did get back in the car with us. On 9/8/25 12:30 PM V6/CNA stated she had no means to check on R1 that night and that she did not know anything about him. V6 denies V7/RN telling her to keep an eye on R1 or that R1 was wanting to escape on 9/3/25. V6 stated, I don't remember the last time I saw (R1) that night. I honestly didn't even know who (R1) was. On 9/8/25 at 2:05 PM V10/Cook stated, I didn't witness anything on 9/3/25 regarding (R1). They just said he was out of the building, and they were looking for him. I don't recall how (R1) got out his window. I would have picked up (R1's) room tray after 7:00 PM, but I don't even know if (R1) was in there. (R1) leaves his door cracked open and I just grabbed (R1's) tray. I didn't put my eyes on (R1). V10 stated no one interviewed him the night of 9/3/25 to ask if he had observed R1 that night or not.On 9/8/25 at 11:26 AM V3/Maintenance Director reports when he came into work on 9/4/25, V3 was told about R1 escaping out his window without staff knowledge. V3 stated, I went down to (R1's) room to observe his window. There are locks located on the bottom of the window seals, they only allow the windows to be open four inches. When I got down to his room, a visible scratch was observed along the bottom of the window seal, and the lock was observed to be next to the other four-inch lock. It looked like (R1) had been working on moving the bottom lock over for a while. I had to physically loosen the set screws and slide it back down to the original position and then set the screws again. I did put a new lock on it with the pointed screws. V3 stated it would have taken R1 a while to get the bottom lock to slide over, R1 would have had to use excessive force, and it was not something that could have happened quickly. V3 reported the only other way to get the bottom window locks to move is by utilizing a special tool to undo the locks. On 9/8/25 at 2:54 PM V1/Administrator stated she would have expected someone (a staff member) to immediately go down and assess R1's window at that time and then move R1 closer to the nurse's station to be monitored closely, after receiving a phone call that R1 was wanting to leave the facility and escape through his window. V1 stated, (R1) most definitely should have been checked on more than 15 minutes at that time if staff were aware he was voicing he was going to get out the window. The immediate jeopardy started on 9/3/25 when V7/RN and V22/LPN were made aware byV4/R1's Family Member of R1 voicing he was going to escape out his window and failed to immediately assess R1's window or immediately provide additional supervision. V1/Administrator and V20/Regional Director of Operations were notified of the Immediate Jeopardy on 9/10/25 at 11:35 AM. On 9/13/25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: R1's care plan was reviewed and update to reflect current wandering and elopement risk by V23/MDS Coordinator on 9/4/25.V20/Director of Operations reviewed all resident's MDS sections E and associated CAA (Care Area Assessment) on 9/4/25 and all concerns identified were addressed or updated on 9/4/25.V24/Social Service re-evaluated residents at risk for wandering/elopement, including R1, using the elopement risk assessment tool in PCC (Point Click Care) on 9/4/25.V1/Administrator in serviced all nursing staff on wandering, elopement, and resident safety on 9/4/25 and continued in-serving staff on leave by their next shift. R1 assessed for Memory Care Unit and moved to a room on Memory Care for safety. R1's window faces an interior courtyard. V1/Administrator, V2/Interim Director of Nursing, V20/Director of Operations, V24/Social Service Director, V20/Regional Director of Operations assessed all residents to determine if other residents should be placed in the memory care unit on 9/4/25.R1's room with the damaged window was repaired on 9/4/25 by V3/Maintenance Director.V7/RN completed a head-to-toe assessment on R1 upon his retorn to his room on 9/3/25.On 9/4/25 V25/Chief Nursing Officer audited all residents care plans and diagnosis to determine if any other resident needed to be placed in the locked dementia unit, needed a wander guard, or needed more frequent checks. On 9/4/24 V3/Maintenance director verified all window safety measure in place to ensure that window cannot be opened to a measurement where a resident can climb out the window. V3/Maintenance Director was in serviced by V20/Regional Director of Operation regarding the placement of these window safety measures, and to perform daily checks that the window safety measures are still in place and working properly. On 9/4/25 V1/Administrator in-serviced all staff regarding window safety measures and to alert maintenance or management if they identify a window safety component to be broken, out of place or missing. On 9/4/25 V1/Administrator in-serviced regarding safety and supervision policies and procedures, including but not limited to following resident care plan interventions pertaining to Wandering and Elopement (example: more frequent checks). On 9/4/25 V1/Administrator in-serviced all staff regarding the facility's Elopement Policies and Procedures. On 9/4/25 all staff involved regarding if a resident should be placed in the locked memory care unit, have a wander guard, or need more frequent checks, were in serviced by V20/Regional Director of Operation regarding the assessing the resident collaboratively to make the determination, and relaying to the staff why the determination was made.V20/Regional Director of Operations reviewed the Elopement and Wandering Residents Policy and Procedure with Interdisciplinary Team and V26/Medical Director on 9/4/25.V24/Social Service Director audited new admissions for elopement risk and ensure appropriate interventions were in place on 9/11/25.On 9/4/25 V23/MDS Coordinator audited all completed MDS's to ensure the care plan reflects needs/concerns identified in the CAA's.On 9/4/25 V20/Director of Operations updated all new hire packets with education regarding wandering, elopement, resident safety, and window safety. There have been no new hires since 9/4/25.On 9/4/25 V20/Regional Director of Operations held a QAPI meeting to review and interpret all audit findings, review all procedures, review investigation, review root cause analysis and all facts surrounding the incident IDT team and V26/Medical Director.On 9/4/25 V1/Administrator in-serviced all staff regarding following resident care plan pertaining to resident safety and supervision (Example: conducting 15-minute checks and looking for Elopement and Wandering behaviors). V1/Administrator and V20/Regional Director of Operations conducted an Audit on 9/5/25 and 9/12/25 regarding all policies and procedures pertaining to wandering and elopement, including resident care plans pertaining to wandering and elopement, weekly. Will continue weekly for weeks and then monthly for three months. On 9/11/25 V1 in-serviced all clinical staff on where to find/access the resident care plans. (Staff will not be allowed to return to work until education is completed. On 9/11/25 V1 provided education to clinical staff on the PCC dashboard identifying residents at risk, the intervention, and the reason for the intervention. (Staff will not be allowed to return to work until education is completed. On 9/11/25 V1 provided education to clinical staff on the need for safety interventions (Such as 15-minute checks-requiring actual visualization of resident identified with need for additional safety measures in place). Staff will not be allowed to return to work until education is completed. On 9/4/24 V20/Director of Operations reviewed/modified current policies to ensure appropriate procedures are in place to prevent harm/potential harm with IDT team and V26/Medical Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent resident physical abuse after (R1) displayed increased agitation and aggression and no interventions were implemented to prevent potential resident abuse for two (R2 & R3) of 23 residents reviewed for abuse in the sample of 26. These failures resulted in R1 throwing a walkie talkie at R2's head and R1 physically shoving a trash can in R3's face and R3 sustaining a bleeding laceration to upper and lower lips. These failures have the potential to affect all 19 residents (R2, R3, R9 through R25) residing in the facility's Dementia unit. These failures resulted in an Immediate Jeopardy that began on 4/13/25. While the Immediate Jeopardy was removed on 5/13/25, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits.Findings include:The Facility Abuse, Neglect and Exploitation Policy, reviewed/revised 2/1/25, documents, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility will develop and implement written policies and procedures that: prohibit ad prevent abuse, neglect, bribery, and exploitation of residents and misappropriation of resident property; Establish policies and procedures to investigate any such allegation; include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and establish coordination with the QAPI (Quality Assurance and Performance Improvement) program. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state agency and other officials in accordance with state law. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, bribery, misappropriation of resident property, and exploitation that achieves: The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which lead to conflict or neglect. The facility will make an effort to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; and revision of resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.The Facility Behavioral Health Services Policy, not dated, documents, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being. The facility will ensure that a resident who, upon admission was not assessed or diagnosed with a mental or psychosocial adjustment difficulty or a documented history of trauma and/or PTSD (Post Traumatic Stress Disorder) does not develop patterns of decreased social interaction and/or increased withdraw, angry, or depressive behaviors while residing in the facility. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Staff will: obtain history from medical records, the resident, and as appropriate the resident's family and friends, regarding mental, psychosocial, and emotional health; monitor closely for expressions or indications of distress; evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable; utilize MDS (Minimum Data Set) and care area assessments; assess and develop a person-centered care plan for concerns identified in the resident's assessment; share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes, including differential diagnosis; accurately document the changes, including the frequency of occurrences and potential triggers in the resident's record; ensure appropriate follow-up assessment, if needed; discuss potential modifications to the care plan; evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident. The resident, and as appropriate the resident's family, are included in comprehensive assessment process along with the interdisciplinary team and outside sources, as indicated. The care plan shall: have interventions that person-centered, evidenced-based, culturally competent, trauma-informed, and in accordance with professional standards of practice; provide for meaningful activities which promote engagement and positive, meaningful relationships; be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions.R1's admission record documents R1's date of admission to the facility was 2/22/25 and his diagnoses included: Cerebral Infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety, Depression, unspecified and Gastro-Esophageal Reflux Disease without Esophagitis.R1's Minimum Data Set (MDS) assessment, dated 2/28/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 5/15, indicating severe cognitive impairment and documents R1's transfers/ambulation as supervision or touching assistance.R1's progress notes dated 3/30/25, 3/31/25, 4/1/25, 4/2/25, 4/7/25, 4/12/25, 4/13/25 and 4/15/25 document behaviors of increased wandering, suspicion, agitation, and combativeness.R1's abuse investigation, Final Five-Day Report, dated 4/13/25, documents that R1 became agitated when staff attempted to redirect R1 from another resident room. V22 (Certified Nursing Assistant/CNA) was walking R1 to his room when R1 grabbed a handheld radio from nurse's station desk. V22 (CNA) asked R1 to give her the radio and R1 refused continuing to walk down the hall. V22 (CNA) noted R2 sitting in the hallway and moved her out of R1's way for safety. V22 (CNA) continued to redirect R1 at which time he threw the handheld radio in the hallway striking R2 in the back of the head. R2 assessed for injury with none sustained. Report also stated that R1 was sent to emergency room for a psychiatric evaluation. R1 returned to the facility later that evening with no new orders and facility initiated frequent checks with increase in agitation. No documentation of frequent checks noted in R1's medical record.On 5/7/25, V9 (LPN), V11 (LPN), and V8, V23, and V25 all Certified Nursing Assistants (CNA) stated that they were not educated on increasing supervision on R1 after altercation with R2. On 5/7/25 at 2:12pm, V8 (Certified Nursing Assistant/CNA) stated, I saw that R1 was agitated and (R1) grabbed a walkie talkie (handheld radio) off the nurse's station desk. We (V8, V9, V22) tried to get it from R1, but he got more agitated and kept walking down the hall, so we let him be. Next thing I (V8) know I heard Ow and saw the walkie talkie (handheld radio) hit R2 in the back of the head. R2 was sitting in her wheelchair by room [ROOM NUMBER] with her back to R1 who had just gotten by room [ROOM NUMBER]. I (V8) went and got the nurse (V9/Licensed Practical Nurse) and V9 took over after I told her what I saw. I (V8) had separated R1 from R2 by taking R1 to his room and then I left because my shift was over.On 5/7/25 at 2:15pm, V9 (Licensed Practical Nurse/LPN) stated, I was working when R1 grabbed the walkie (handheld radio) off my cart by the nurse's station. R1 was agitated that day. I (V9) did not know what had happened until V8 (CNA) told me R1 had threw the walkie (handheld radio) and it hit R2. I went and assessed R2 and R2 had no visible injuries. R1 was redirected away from R2. I don't think R1 threw the walkie (handheld radio) at R2 on purpose, I think R1 threw the walkie (handheld radio) to just get rid of it.On 5/8/25 at 3:30pm, V22 (Certified Nursing Assistant/CNA) stated, R1 was agitated prior to the incident with R2. R1 grabbed a walkie talkie (handheld radio) off the nurse's station, and I (V22) tried to get it from him, but he just got more agitated, so the nurse (V9/Licensed Practical Nurse) told me to leave R1 alone. I (V22) followed R1 down the hallway to redirect him and noted R2 was sitting in her wheelchair in the way, I moved R2 so R1 could get past to go to his (R1) room. As R1 went around the corner R1 tossed the walkie talkie (handheld radio) and it hit R2 in the back of the head. I don't think he (R1) was aiming at R2; I think R1 threw the walkie (handheld radio) to get rid of it.R1's Health Status note dated 4/17/25, documents, R1 very agitated before supper. R1 was walking down the hall when this nurse (V9/Licensed Practical Nurse) heard what sounded like trash can being thrown down the hallway. This nurse went to investigate where noise came from and R1 was standing in hallway and trash can was sitting on the floor in front of R1. Another resident (R3) was sitting in his doorway. R1 then came running at this nurse (V9) trying to hit nurse. R1 then turned around and tried to run after resident (R3) sitting in his doorway. The nurse (V9) then looked at the other resident (R3) and he (R3) had a bloody lip. The other resident (R3) states that resident (R1) hit him. Resident (R1) was trying to speak with nurse (V9), but his words were making no sense. This nurse (V9) tried to get resident (R1) to go into his room to try and calm him (R1) down but very resistive and combative. Not able to redirect. MD (doctor) notified. Nurse Manager notified and administrator notified. Resident (R1) then sent to (local hospital emergency department) to eval and treat.R1's abuse investigation, Final Five-Day Report, dated 4/17/25, documents that R1 and R3 were involved in a physical altercation in the hallway. V9 (Licensed Practical Nurse/LPN) heard a waste basket tumble across the floor. V9 (LPN) noted R3 sitting in the doorway to his room and R1 standing a few feet away. R3 had a laceration to his lip and stated R1 hit him. R1 and R3 were separated. R3 was given first aid and R1 was sent to emergency department for further evaluation. Report also documents R3 was identified by a witness (V17/R26's spouse) as the initiator. V17's witness statement documents that R3 yelled at R1 and threw the trash can at R1 when he was walking toward R3. R1 threw trash can back at R3 and R3 threw it back at R1 again. R1 then picked up trash can and pushed it into R3's face, open side up, causing injury. Report also documents facility took the following action: Power of Attorney and Physician notified, R1 sent to emergency department for evaluation and then transferred to psychiatric hospital for further evaluation and treatment. R1's care plan will be updated per physician recommendations. R3's care plan updated, and staff educated on communication needs, redirection strategies and monitoring for signs of agitation.On 5/7/25 V9 (LPN), V11 (LPN), and V8, V23, and V25 all Certified Nursing Assistants (CNA) stated that they were not educated on communication, redirection strategies or monitoring for signs of agitation after altercation with R3. On 5/7/25 at 3:00pm, V9 (Licensed Practical Nurse/LPN) stated R1 became increasingly agitated during a conversation with V9. In R1's agitated state and without staff member supervision, R1 walked down the hallway out of V9's or any other staff members' view. V9 then reported hearing what sounded like a trash can hitting the floor and went to investigate. V9 reports seeing R1 standing in the hallway directly facing R3, who was in the doorway of his (R3) room. A trash can was noted on the hallway floor. V9 noted bleeding to R3's mouth. R3 reported to V9 that R1 had hit him with the trash can. V9 stated she felt the altercation was intentional because R1 and R3 do not seem to like each other, they make rude comments to each other all the time.On 5/8/25 at 3:20pm, V11 (Licensed Practical Nurse/LPN) stated, R1 and R3 do not like each other, they make rude comments to each other and I'm surprised that their (R1, R3) rooms are still next to each other after their altercation.On 5/6/25, 5/7/25, and 5/8/25 tour of the facility conducted. R1 and R3's rooms observed to be next to each other, R1 in room [ROOM NUMBER] and R3 in room [ROOM NUMBER].On 5/7/25 at 1:30pm, V11 stated that there are no specific individualized interventions to use for any of the residents on the dementia unit, we try what we can and utilize our dementia training but that's about it.R1's current care plan documents a behavior care plan for aggression initiated on 4/29/25, no previous behavior care plan for aggression in medical record. R3's current plan of care documents, Behaviors: I (R3) demonstrate verbally abusive behavior when agitated such as use of profanity/demeaning statements; racial, ethnic, religious, gender slurs; physically abusive behavior when agitated; attempting to push, shove, scratch, hit, slap, kick, grab, or otherwise harm another person related to ineffective coping skills, poor verbal skills and inability to express self, and dementia. Interventions include Ask (R3) to calmly explain what is causing this upsetting behavior; If talking to (R3) is not successful in stopping the behavior, try to take (R3) to a quiet area, away from other individuals, and intervene by speaking calmly and professionally in a soft tone of voice. Staff should avoid raising own voice, since this tends to make a resident more upset and may cause the situation to escalate. R3's current care plan also includes: Behaviors: I (R3) display behavioral symptoms such as verbal and physical aggression due to dementia diagnosis. 4/17/25: (R3) became physically aggressive with another resident throwing a trash can at him. Interventions include: 4/17/25: Staff education provided to monitor for signs of agitation and re-direct away from others if agitation is noted; conduct an evaluation of the behavioral symptoms to determine what strengths or abilities and needs are communicated via behavior; use interventions that address the abilities and needs reflected in the specific symptom: (i.e. rummaging may be an indicator that s/he needs to be busy and work with their hands).On 5/7/25 at 1:41pm, V19 stated she is responsible for aggression assessments when residents are admitted to facility and then initiates the care plans from that assessment. V19 verified that R1's behavior care plan was not initiated until 4/29/25 when he returned from inpatient psychiatric stay.On 5/8/25 at 8:30am, V1 (Administrator in Training/AIT) stated that the facilities dementia unit just opened mid-April and verified that there are system failures regarding care plans, documentation, and communication on interventions with the floor staff.On 5/8/25 at 11:00am, V21 (Chief Nursing Officer/CNO) stated that V16 (Registered Nurse/RN/Former Director of Nursing) was told to educate the floor staff and initiate increased supervision of R1 with documentation of the supervision after R1's incident involving R2 but verified it was not done.R2's admission Record documents R2's date of admission to the facility was 4/2/25 and her diagnoses included: Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Anemia, Diabetes, Depression, Anxiety Disorder, Hypertension, and Insomnia.R2's Minimum Data Set (MDS) assessment, dated 4/8/25, documents R2 has a Brief Interview for Mental Status (BIMS) score of 8/15, indicating severe cognitive impairment.On 5/8/25 at 11:00am, R2 stated she does not remember being hit and feels safe. R2 also stated, If anyone was mean to me, I'd, (R2 shook her fist) then laughed.R3's admission Record documents R3's date of admission to the facility was 3/3/25 and his diagnoses included: Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Unspecified Dementia, unspecified severity, with agitation, Iron deficiency and Hypertension.R3's Minimum Data Set (MDS) assessment, dated 3/10/25, documents R3 has a Brief Interview for Mental Status (BIMS) score of 7/15, indicating severe cognitive impairment.R3's progress notes dated 4/13/25, 4/17/25, 4/23/25, 4/30/25, and 5/3/25 document behaviors of yelling, cussing, hitting, kicking, and biting during cares by staff.On 5/9/25 at 10:00am, R3 stated he does not remember the altercation with R1. R3 shook his head no and propelled wheelchair away from surveyor and down the hall.V1 (Administrator in Training/AIT) and V7 (Regional Director of Operations/Administrator) were notified of the Immediate Jeopardy on 5/13/23 at 12:55pm.The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 5/13/25 the DON/Director of Nursing, Social Services Director and designee assessed all residents in memory care to determine their level of risk with the Abuse assessments and Aggressive behavior assessment. 2. On 5/08/25 15-minute checks for R1 changed to 1:1 supervision3. R1 was evaluated by V13's team with inpatient hospital evaluation/treatment and review of medications from 4/17/25 through 4/28/25.4. On 5/13/25 R1's care plan updated with individualized interventions for aggressive behaviors.5. On 5/13/25 R1 is not to be seated by other residents with activities, dining etc. when agitated6. On 5/13/25 Social Services Director, DON and Administrator re-educated staff on Abuse/Neglect & Exploitation policy and Abuse Prevention.7. All Agency staff being in-serviced on Abuse/Neglect & Exploitation policy and Abuse Prevention prior to start of next shift.8. On 5/13/25 R1's abuse and aggression assessments completed/updated.9. On 5/13/25 R1's care plan reviewed and revised by facility interdisciplinary team and revisions and interventions communicated to front line staff caring for R1.10. On 5/13/25 abuse policies reviewed/revised to include resident to resident altercations.11. On 5/13/25 abuse investigation procedures and documentation process reviewed/revised, and Education provided to all staff.12. DON and designee educated Nurse Aids and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director/MDS/Minimum Data Set Coordinator or designee and care plans to be updated as indicated. Staff will be educated on new interventions either verbally or in writing by Care Plan Coordinator or designee. 13. On 5/13/25 an emergency QAPI (Quality Assessment Performance Improvement) meeting was held to develop and implement plans to prevent further resident abuse.