**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when another resident hit the resident in the face, resulting in a black eye and the need for sutures (Residents #1 and #2). The census was 138. The sample was 20. The administrator was notified on 1/9/25, of the past non-compliance. The facility responded appropriately when the incident occurred. The residents were separated and were sent to the hospital for evaluation. Care was provided to injuries and the rooms were changed so the residents no longer resided on the same hall. Continued education on abuse and neglect provided to staff. The deficiency was corrected on 1/2/25. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations; -Physical abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Review of the facility's Resident's Rights policy, revised 7/5/23, showed: -Purpose: To ensure that resident rights are protected; -Resident has a right to a dignified existence, self-determination, and communication with and access to persons and serves inside and outside the facility. Facility must protect and promote rights of each resident, including each of the following rights; -Freedom from abuse: Resident has the right to be free form verbal, sexual, mental, and physical abuse, corporal punishment and involuntary seclusion. Review of the facility's investigation report, dated 1/2/25, showed: -Date of incident 12/31/24; -Persons involved: Resident #2 and Resident #1; -Date and time notified: 12/31/24 at 9:00 A.M.; -During a code green (code called when there is a resident exhibiting aggressive behaviors), Resident #1 was attempting to propel towards the incident the code green was called on despite being redirected and told to go to his/her room. A staff propelled the resident into Resident #2's room to remove him/her from harm's way. Moments later Resident #1 was wheeled out of the room backwards by a different staff and was noted with blood coming form above left eye. Resident #2 then came to the doorway yelling. He/She was aware there was a code being called but wanted Resident #1 out of his/her room. Licensed Practical Nurse (LPN) B said he/she was already on the hall dealing with another resident. He/She state while he/she was turning to walk down the hall, he/she saw Resident #1 in the doorway of Resident #2's room being cursed at loudly. When the resident was removed from the doorway, blood noticed coming from Resident #1's left eye. Review of Resident #2's medical record, showed: -A quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 10/11/24, showed the resident cognitively intact with no behaviors; -A progress note dated 12/31/24 at 11:37 A.M., multiple staff were on the hall dealing with an altercation when incident occurred. Resident noted standing in front of another resident using a very selective choice of words after punching him/her in his/her face. (Laceration noted to opposed residents left eye). Residents separated immediately. Resident stated he/she was kicked, which caused him/her to punch resident in the face. When assessed no injuries to aggressor noted. Stated he/she was not hit, but he/she knocked the shit out of him/her. 911 called. Two emergency medical services (EMS) staff and two police arrived and transported the resident to the hospital for evaluation. Review of Resident #2's medical record, showed: -A quarterly MDS, dated [DATE], showed severe cognitive impairment. No behaviors. Uses a wheelchair; -A progress note dated 12/31/24 at 12:07 P.M., staff present at the time of incident, dealing with an altercation when incident occurred. Resident noted in a peers doorway, with blood coming from his/her left eye and being cursed at by aggressor. Residents separated immediately. When asked what happen, resident stated he/she hit me. Laceration noted to left eye when assessed, 911 called by writer. Vitals obtained, within normal limits according to prior assessments before altercation occurred. Two EMS and police arrived for transport to the hospital; -A progress note dated 12/31/24 at 10:15 P.M., resident remains at hospital emergency room (ER) at this time awaiting ambulance for transport back to facility. Sutures placed at ER to be removed in 3 to 5 days. No other orders received during report from ER nurse; -A progress note on 1/1/25 at 8:17 A.M., resident returned to facility. Appears to be 4 to 5 sutures below the left eyebrow, orders to remove in 3-5 days. Resident moved to a different room for protective oversite. States he/she is in no pain. Observation and interview on 1/9/25 at 7:49 A.M., showed Resident #2 sat in a wheelchair in his/her room. He/She said Resident #1 entered his/her room during a code green. He/She told Resident #1 to get out of his/her room and Resident #1 began to yell and then kicked him, so he/she punched him/her. He/She does realize what he/she did was wrong because not every resident in the facility is alert. Observation and interview on 1/9/25 at 7:55 A.M., showed Resident #1 lay in bed on his/her back. A dark bruise visible under the residents left eye. No sutures visible. He/She said he/she did not remember much but knows he/she got punched in the eye. He/She does not remember who did it or why. It does not hurt anymore. During an interview on 1/9/25 at 8:52 A.M., with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the ADON said she did complete the investigation into the incident between Resident #1 and Resident #2, but she was not witness to the incident. There were no staff present at the time. It was not found out until the resident was found to have an injury and staff began to ask questions, that there was an altercation. The DON said the investigation depended on what the residents involved had to say about the incident. The resident did get sutures, but they had already been removed. He/She only need two or three of them for a few days. During an interview on 1/9/25 at 12:10 P.M., the Administrator said residents have the right to be free from abuse, to include abuse from other residents. At the time the altercation took place, there was another altercation occurring on the hall. Resident #1 kept propelling towards the other altercation and was at risk, so a split decision was made to place him/her in a different resident's room. His/Her room was on the other side of the hall, and it was not possible to get the resident to his/her room without getting in the middle of the other altercation. Staff did what they felt was best at the time. MO00247310 and MO00247336

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate, in accordance with their policies and procedures, a staff-to-resident incident which resulted in an allegation of abuse from Resident #506. Per facility policy, nursing staff also failed to thoroughly assess the resident, who experienced difficulty breathing, after two staff members witnessed Administrator-in-training (AIT) X lying on top of the resident (who was supine/lying face up on the floor) while holding the resident's arms on the floor. The resident's face was covered by the resident's shirt. In addition, the facility failed to keep one resident free from abuse when one resident (Resident #69), who resided on a secured behavior unit, obtained, ingested and tested positive for Fentanyl (a powerful synthetic opioid analgesic for severe pain that is similar to morphine but is 50 to 100 times more potent) on 5/28/21. The sample was 26. The census was 132. Review of the facility's policy titled Abuse and Neglect Policy, reviewed 7/8/20, showed every resident had the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. Every resident also had the right to be free from verbal, sexual, physical or mental abuse, corporal punishment, and involuntary seclusion. Mistreatment, neglect or abuse of residents was prohibited by the facility. Physical abuse was defined as purposefully beating, striking, wounding or injuring any consumer or any manner whatsoever of mistreating or maltreating a consumer in a brutal or inhumane manner. Physical abuse included handling a consumer with any more force than was reasonable for a consumer's proper control, treatment or management. Upon learning of a report of abuse or neglect, the administrator was to initiate an incident investigation. If the resident complained of physical injuries or if harm was suspected, then staff was to contact the resident's physician for further instructions. The facility was to immediately call 911 to involve the police department, when there was physical abuse involving physical injury inflicted on a resident by a staff member or visitor. Review of the facility's policy titled Behavioral Emergency Policy reviewed 2/26/21, showed the purpose was to provide safe treatment and humane care to the resident in a behavioral crisis and outline steps to follow in order to correctly care for the resident in a behavioral crisis, to ensure that the resident was not being coerced, punished or disciplined for staff convenience. If the resident exhibited extreme behaviors such as suicidal, homicidal, self-mutilation, elopement or resident-to-resident altercations, then the licensed nursing staff/team leader/resident care coordinator (RCC) would assess the resident exhibiting such behaviors. Ensuring the safety of the resident and others was the first priority. A one-to-one monitoring of the resident was to be initiated by staff under the direction of the licensed nurse. In the event that the resident was unable to be redirected or was requesting an as needed (PRN) medication for mood stabilization, the resident would receive the PRN medication per physician's orders. Staff was to notify the resident's guardian and physician. Documentation of the behavior emergency in the registered nurse investigation was to include evaluation of the resident's behavior with consideration for precipitating events or environmental triggers and other related factors in the medical record, with enough specific detail of the actual situation to permit underlying cause identification to the extent possible. If the resident required medication or the utilization of approved crisis allevations lessons and methods (CALM, a system of de-escalation, prevention and safety procedures designed for use in nursing homes, hospitals and schools) techniques, then staff was to assess the resident, closely monitor his/her vital signs and notify the physician of any changes or concerns regarding the resident's condition. Behavioral emergency=code green. The licensed practical nurse (LPN) or registered nurse (RN) must be present during the entire use of approved CALM hold techniques. There were only two reasons that staff was to utilize approved CALM hold techniques; when a resident was in imminent danger of harming him/herself or when a resident was in imminent danger of harming others. Approved CALM hold techniques were never to be utilized for punitive reasons, discipline or for staff convenience. Staff was never to threaten the use of CALM as a scare tactic or a threat. A code green did not denote that approved CALM hold techniques were automatically utilized. After every code green which required utilization of approved CALM hold techniques, the director of nursing (DON) or designee was to complete a RN investigation of the occurrence regarding the resident's behavior and staff responses. All behavioral emergency code green reviews filled out by the responding staff were to become part of the RN investigation to ensure that the behavioral crises was handled professionally, that it could not have been avoided and was handled by CALM certified staff using appropriate techniques following the policies of the facility. Any resident who requires approved CALM hold techniques must have complete skin assessment with vital signs monitored for 72 hours. The physician and legal guardian were to be notified of assessment findings and other concerns regarding the resident's behavior emergency crisis. 1. Review of Resident #506's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/21, showed the following: -Cognitively intact; -Weight: 148 pounds, 63 inches tall; -Required supervision of personal hygiene and bathing; -No mobility devices; -Diagnoses included other neurological conditions, seizure disorder, paranoid schizophrenia (mental illness characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations), diabetes mellitus, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), hypoglycemia (a condition in which the blood sugar (glucose) level is lower than normal), other seasonal rhinitis (hay fever, an inflammatory condition of the upper airways which occurs in response to exposure to airborne allergens) and COVID-19. Review of the resident's care plan, updated 12/10/20, showed the following: -The resident is alert and oriented times three (person, place and time), able to make his/her needs known, has impaired cognition and decision-making with limited judgment/insight; -The resident had a diagnosis of schizophrenia. He/she had periods of restlessness with repetitive pacing, verbal/physical aggression and demanding behavior; -The resident experiences paranoia which impacts his/her behavior. The resident will act out aggressively against staff or other residents, while in a paranoid state; -During periods of agitation, staff is to allow the resident to vent his/her fears and frustrations; -When addressing the resident, get his/her attention using a calm tone and volume. Speak in short simple statements and instructions. Allow him/her time to process and respond; -Do not argue with the resident. Speak to the resident in a calm tone. Attempt to redirect him/her, when he/she is exhibiting a behavior. Approach the resident with his/her permission, in a gentle manner and explain what you are trying to do; -The resident takes antipsychotics for management of mood/behavioral symptoms which may affect his/her cognitive ability. He/she is at risk for falls and adverse drug reactions. Review of the facility's undated investigation summary, showed on 5/15/21, at approximately 10:00 P.M., the resident got upset with AIT X. The resident wanted AIT X to take him/her to the laundry area to get clean linen. AIT X told the resident that he/she would take the resident in a little bit. The resident got upset, after seeing another staff member take a peer off of the hall, before the resident got to leave. The resident yelled at AIT X, calling AIT X a no good motherfucker, went into his/her room and slammed the door. AIT X knocked on the resident's door, entered the room to check on the resident and noted that the resident was in the restroom. AIT X did not indicate that the resident was further agitated. AIT X went back out into the hallway and a few moments later, the resident came out of his/her room yelling at AIT X, calling him/her a piece of shit. AIT X attempted to de-escalate and redirect the resident, who continued to yell and advanced toward him/her. The resident then started to swing at AIT X, who called for a code green to be announced. AIT X attempted to block the resident's right arm from hitting him/her. The resident made contact with AIT X's face with the left arm. While the code green was being called, AIT X continued to try and block the resident from striking him/her. During this event, the two of them fell to the floor. As they fell, the Hall Monitor (Dietary Aide FF) responded to the code green to assist with redirection. The resident continued to try to kick, hit and spit on staff. AIT X was able to secure one of the resident's arms, while the Hall Monitor secured the other arm. More staff members responded to the code green and the charge nurse took over as team leader. AIT X was tapped out of the code green, in an attempt to de-escalate the resident. AIT X went to the front conference area to await further instruction. Staff assisted the resident off of the floor and provided 1:1 attention for the resident to verbalize and ventilate his/her feelings, which enabled him/her to calm down. The charge nurse completed a head-to-toe assessment and neurochecks with no injuries noted. The nurse did not note any pain. The resident's vital signs were as follows: temperature 98.6 (normal range: 97.8-99.1 degrees Fahrenheit), pulse 95 (normal range: 60-100 beats per minute), blood pressure 125/94 (normal range: 90/60 millimeters/Hg (millimeters of mercury)-120/80 mm/Hg), and oxygen saturation on room air 99% (normal range: 95%-100%). Summary of incident investigation findings: The resident had a history of impulsive behavior related to his/her diagnosis. He/she could become easily agitated and strike out, when his/her expectations were not met. AIT X attempted to redirect the resident without success. The resident took an aggressive approach toward staff, by attempting to hit AIT X, who then tried to block the resident from making contact. While AIT X was trying to block the resident's strikes, they both fell to the floor. Staff notified the administrator of the altercation at approximately 10:30 P.M. The administrator went to the facility and began the investigation. Staff notified the police department. AIT X wrote his/her statement and was suspended, pending an investigation. Staff contacted the resident's physician, did not receive any new orders and placed the resident under 1:1 supervision for protective oversight. Staff attempted to reach the resident's legal guardian and left a voicemail message. Administration provided a self-reporting of the incident to the Missouri Department of Health and Senior Services within two hours of the altercation. Plan of action: educational needs- educate staff on the behavior emergency policy, CALM techniques, resident triggers. AIT X was removed from his/her assignment at the facility. Review of the resident's progress note, dated 5/16/21 at 6:33 A.M., showed the resident was displaying increased agitation related to a resident-to-staff altercation. Staff called a code green. Upon entering the unit, LPN EE saw the resident lying on the floor in the doorway of his/her room with AIT X on top of the resident holding the resident down. LPN EE stepped in and asked AIT X to remove him/herself from the situation, so LPN EE could intervene. Staff helped the resident off of the floor. The resident was able to vent the frustrations and concerns, which led to the aggression. LPN EE completed a full body assessment, did not note any bruising or bleeding and educated the resident on asking to speak to LPN EE when upset. Staff was educated on proper CALM techniques. Review of the resident's undated written statement, regarding the incident, showed he/she was talking to AIT X about going to get his/her clothes. A staff person from the laundry department happened to open the door to the locked unit and another resident went with him/her, instead of Resident #506. Resident #506 and AIT X started arguing, because AIT X would not allow Resident #506 to go. The resident was arguing that it was not fair. AIT X got really smart with the resident and said that the resident could wait until the next day. When the resident got sarcastic, AIT X called a code green and took him/her to the floor. The resident started struggling with AIT X, who pulled the resident's shirt over the resident's face, slapped him/her in the face and stuck a finger in the resident's throat. AIT X kept the shirt over his/her face, until the nurse entered the unit. Review of Resident #517's undated written statement showed, when Resident #506 was on the floor, Resident #517 saw AIT X strike Resident #506 twice. Review of LPN EE's written statement, dated 5/16/21, showed staff called a code green for 600 hall. LPN EE entered the unit. AIT X was on top of the resident. The two of them were yelling back and forth. As LPN EE got closer, he/she saw that AIT X was stuffing the resident's shirt into his/her mouth. LPN EE asked AIT X to tap out and allow the other staff present to take control, in order to defuse the situation. Review of Certified Medication Technician (CMT) GG's written statement, dated 5/16/21, showed he/she responded to the code green called for 600 hall on 5/15/21. The resident was face up on the floor, held down by two staff members. One of them was holding the resident's shoulders down and the other was holding down the resident's legs. The resident's shirt was covering his/her face. The staff members holding the resident down said it was because the resident was spitting on them. The resident said that staff (AIT X) hit him/her. The resident was cursing at staff and saying that he/she would get the staff person fired. They tapped the staff person out and asked him/her to leave the unit. Further review of the facility's incident investigation and the resident's medical records, did not show documentation of 72 hour vital signs on the resident per the behavioral emergency policy. The investigation summary did not indicate that the issues of AIT X covering the resident's face with the resident's shirt and/or stuffing the shirt into the resident's mouth, the resident's allegations of AIT X striking him/her and pressing a finger into the base of his/her neck or the appropriateness/risk for harm caused by the manner in which the CALM technique was utilized by staff were investigated. No findings regarding those issues were included in the investigation summary. Review of the administrator's e-mail, sent 7/20/21 at 2:12 P.M., showed she could not find an incident report or code green review sheets for this incident. According the administrator, AIT X completed his/her CALM training on 4/7/21. In response to a request for incident witness statements, she attached to the e-mail statements for all staff who witnessed the incident, with the exception of AIT X and Hall Monitor/Dietary Aide FF. Review of AIT X's abuse and neglect policy acknowledgement, dated 10/1/17, showed he/she acknowledged that he/she received, read, understood and had the opportunity to ask questions concerning the abuse and neglect policy. Review of AIT X's Missouri commercial driver's license showed he/she weighed 240 pounds and was 5 feet 11 inches tall. During interviews on 7/13/21 at 2:30 P.M. and 7/30/21 at 11:08 A.M., AIT X said on the day in question, he/she was sitting at the end of the hall in secured unit 600, when Resident #506 asked to go to the laundry. AIT X told him/her to wait until staff returned from assisting with snack time. A certified nurse aide (CNA) entered the unit and another resident asked if he/she could go and heat up some food. AIT X granted that resident permission to leave the unit with the CNA. Resident #506 got mad saying, that was our aide. He/she started cursing and went into his/her room. AIT X followed and asked if the resident was alright. The resident said, just leave me alone. I'll be fine. AIT X explained that the CNA was not assigned to unit 600 and promised the resident would be allowed to go to the laundry, when the assigned CNA returned. AIT X went back out into the hall. The resident came out, still angry and cursing while walking towards AIT X fast. Several times, AIT X asked the resident not to curse at AIT X. The resident suddenly swung his/her right arm, attempting to hit AIT X, who turned sideways, leaned back and caught the arm. The resident tried to pull away and AIT X shouted for someone to announce code green over the intercom. With his/her left hand, the resident slapped AIT X in the face twice. They fell down. AIT X believed that either the resident pulled them down or leaning backwards caused AIT X to lose his/her balance. AIT X was still holding the resident's right arm in both of AIT X's hands like a baseball bat. Hall Monitor/Dietary Aide FF and CMT GG entered the unit. The resident was lying on his/her back. Dietary Aide FF held the resident's left arm. AIT X then told Dietary Aide FF and CMT GG that they could not hold the resident on his/her back. The resident was wearing an oversized T-shirt. One arm had slipped out of the sleeve and the shirt had slid up over his/her face. AIT X did not pull the shirt over the resident's face or stuff it into his/her mouth. The resident never spit, but was talking crazy and threatening to spit. AIT X never laid on top of the resident, he/she was off to the side on the floor. At one point, he/she was up on his/her knees, holding the resident's right arm. Others came and told AIT X to leave the unit, because the resident was fixated on him/her. They said, you're the trigger. You need to leave. AIT X went out into the front lobby of the facility. AIT X never lost his/her temper, did not strike the resident or press a thumb into the base of the resident's neck. He/she was suspended and never called back to work at the facility. He/she completed CALM training during the first week in April of this year. AIT X had previously read the resident's care plan and was familiar with the interventions listed. AIT X had worked with the resident at several other facilities and was knowledgeable about the resident's care needs. During interviews on 7/7/21 at 9:30 A.M. and 7/16/21 at 7:03 A.M., the resident said on the day in question, he/she was sitting down, waiting to go and get his/her laundry. The resident had to wait for someone to return. It was taking a long time. He/she grew frustrated and stood up, complaining to AIT X, how long does it take to get your laundry and come back? AIT X ordered him/her sit back down. The resident refused. AIT X got into his face saying, you want me to call a code on you? I'll kick your ass! The resident still refused to sit down saying, come on in my room and do it. AIT X called a code green and performed a takedown on the resident without any other staff present. AIT X was lying on top of the resident and holding down the resident's arms. It was hard for the resident to breathe with AIT X on top of him/her. AIT X pulled the resident's shirt over his/her face and struck the resident on the side of the face. The resident swatted at AIT X, who then pressed a finger into the base of the resident's neck, in the front, so hard that it caused a bruise to form. The shirt was stretched so much that the resident could see shadows through it. He/she saw Dietary Aide FF approach, but Dietary Aide FF did not do much. He/she just held one of the resident's arms. Staff never turned the resident onto his/her stomach. The resident did not spit. He/she did not recall his/her shirt being stuffed into his/her mouth. During an interview on 7/30/21 at 1:11 P.M., Resident #517 said he/she witnessed the incident and saw AIT X bear down on Resident #506's throat and slap him/her a couple of times. Resident #517 could not recall any other details of the incident. The day after the incident, Resident #506 developed a bruise below the neck but above the upper sternum from being held. The bruise was a dark purple which looked black. In general, AIT X was not nice to residents in the unit. However, he/she was not mean to them. AIT X just did not have much patience with residents. During an interview on 7/15/21 at 3:08 P.M., Dietary Aide FF said on the day in question, he/she was returning from a break and about to continue his/her 1:1 supervision assignment, when he/she heard the code green announcement and entered unit 600. AIT X had already taken the resident down and was lying on top of the resident and holding the resident's arms down. The resident's shirt rode up as he/she struggled, attempting to free him/herself. LPN EE entered and moved to pull the shirt off of the resident's face. AIT X said, Don't move the shirt, because he'll spit at you. LPN EE urged AIT X to get up off of the resident. Dietary Aide FF assisted by holding down the resident's left arm. AIT X moved off to the side and held down the resident's right arm. With the shirt off of his/her face, the resident started spitting. They rolled the resident onto his/her stomach and CMT GG held the resident's head. The resident was arguing with AIT X, who was angry but not saying anything. Initially, AIT X did not want to leave. With urging from LPN EE, he/she left the unit. Dietary Aide FF did not see AIT X strike the resident, press his/her thumb into the resident's neck or stuff the shirt into the resident's mouth. During an interview on 7/15/21 at 11:35 A.M., CMT GG said prior to the incident, he/she was not on unit 600. CMT GG heard someone yelling, code green. When he/she entered the unit, AIT X was not lying on top of the resident. The resident was face up on the floor and AIT X was kneeling over the resident, holding down both arms. The resident was fighting and spitting. His/her shirt was not over his head or in his/her mouth. Dietary Aide FF was holding the resident's legs. The resident kept saying that AIT X had choked him/her, but there was no visible bruising. They turned the resident onto his/her stomach. Each of them held one part of the resident's body: one person held his arms, legs and head. They held the resident that way for five minutes and then released him/her. During an interview on 7/15/21 at 2:30 P.M., LPN EE said he/she was at the nurse's station on the day in question, when Dietary Aide FF came out of unit 600 and yelled, code green. LPN EE entered the unit and saw the resident lying on the floor, in the doorway of his/her room, with his/her legs out in the hallway. AIT X appeared to be angry and was on top of the resident, forcibly attempting to stuff the top portion of the resident's shirt (neck/collar) into the resident's mouth. The resident was not gagging, but tried turning away his/her face. AIT X and the resident were arguing, going back and forth. AIT X's actions were making the situation worse; he/she had the resident's arms pinned to the floor. The resident could not lift his/her arms. He/she was screaming and yelling, attempting to get up. Initially, AIT X refused to get off of the resident. When LPN EE attempted to pull the resident's shirt back down, AIT X said the resident would spit in LPN EE's face. LPN EE had to move between them and use an arm to urge AIT X, who had moved on the resident's left side, to get up. Dietary Aide FF was present in the room, but staff never turned the resident onto his/her stomach. Once AIT X got off of the resident, the resident got up and was completely calm. He/she had started to calm down, as soon as he/she saw LPN EE. The two of them had that kind of relationship. LPN EE told AIT X to let him/her talk to the resident. AIT X did not want to leave, so LPN EE had someone walk him/her off of the unit and took the resident into the resident room. Prior to that day, LPN EE had not wanted AIT X working with the resident, because AIT X was short-tempered and seemed to be on a power trip. One time, LPN EE needed to bring the resident off of the unit for something. AIT X said no, the resident was not coming off of my unit. LPN EE had to remind AIT X that LPN EE was the charge nurse for the unit. During an interview on 7/20/21 at 10:25 A.M., the administrator said it was not appropriate for a staff person to tell a resident that he/she would call a code green, if the resident did not sit down and be quiet. If an agitated resident walked away and went into his/her room, it was not appropriate for the staff person to follow him/her, unless the resident had a history of and/or appeared to be engaging in self-harm. It was never appropriate for a staff person to lie on top of a resident. Stuffing the resident's shirt into the resident's mouth was unacceptable, even if the resident was spitting at staff, because it could obstruct his/her breathing. The facility ensured all staff received CALM training, prior to working on locked resident units. After an incident in which staff employed CALM techniques, staff were to fill out an emergency code green review sheet. The administrator agreed to provide copies of witness statements for AIT X and the other staff who witnessed the incident as well as documentation of AIT X's CALM training. During an interview on 7/16/21 at 1:30 P.M., the DON said it was never acceptable for a single staff person to perform a CALM takedown without assistance from other staff trained in the technique. Doing so posed a high risk of harm to the resident. Lying on top of a resident could hinder his/her breathing. If a staff person observed another staff person engaging in those behaviors, then that staff person should tap out their co-worker and immediately report it to supervisory and/or administrative staff. Proper procedure was for the staff person who was the target of the code green needed to leave, so that his/her co-workers could de-escalate the resident. During an interview on 7/16/21 at 7:30 A.M., Facility Advisory Nurse/RN C said appropriate CALM technique consisted of the following: verbal de-escalation was the first step. If a resident required physical intervention, then staff was to perform a two-man hold with the resident standing or sitting between them. Each staff member was to exert pressure via a hand-over-hand hold on the he resident's arm and wrist. Taking a resident down to the floor required the participation of five staff. With the resident's arms extended and their joints intact, staff was to apply pressure to the resident's shoulders as other staff members held and supported each of the resident's leg with their hands on the thigh and lower leg/shin. Providing support, the group would then guide the resident down to the floor onto his/her stomach with a pillow under the resident's head, which should be turned to one side. Once the resident was on the floor, staff was to keep the resident's arms and legs spread. At no point was it appropriate for a staff member to be on top of the resident. That could result in bruising or occluding of the resident's airway. It was also inappropriate to hold the resident's head straight back, because that could also occlude his/her airway. Keeping the resident's head sideways would be an appropriate way to prevent him/her from banging his/her head on the floor. It was not appropriate to stuff the resident's shirt into his/her mouth, because it could occlude his/her airway. Appropriate CALM technique never involved covering the resident's face with his/her shirt. During an interview on 7/21/21 at 11:32 A.M., Physician W said a staff person should never lie on top of a resident or stuff a resident's shirt into his/her mouth. If lying on a resident resulted in pressure being applied to the resident's neck, then it could block his/her airway. Heavy pressure on the chest could lead to the resident experiencing difficulty breathing. No one should be on top of a resident, unless that resident was attempting to self-harm or kill him/herself. 2. Review of Resident #69's preadmission screening/resident review (PASARR) Level II screening (a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate), dated 3/7/19, showed a history of polysubstance abuse. Reports paranoid delusions and hallucinations. History of incarceration due to substance abuse and driving while intoxicated. Review of the resident's face sheet, showed the following: -admitted to a secured unit room in the facility on 4/24/21; -Had a legal guardian; -Diagnoses included hypertension (high blood pressure), paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves), bipolar disorder (manic depression, a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), personality disorder (a way of thinking, feeling and behaving that deviates from the expectations of the culture, causes distress or problems functioning, and lasts over time) and inhalant abuse. Review of the resident's departmental notes, dated 4/25/21 at 10:17 A.M., showed the facility admitted the resident. The resident was ambulatory, alert and oriented times three (to person, place and time), denied complaints of pain or discomfort, denied thoughts or feelings of harm to self or others. No suicidal, homicidal or elopement ideations. Resident is polite and smiling. Review of the resident's social service note, dated 4/30/21, showed the resident transferred from another facility. Resident had a long history of drug abuse and addiction. Resident stated he/she last used in 2017. Review of the resident's admission MDS, dated [DATE], showed diagnoses of hypertension, acid reflux, arthritis, manic depression and schizophrenia. Further review of the resident's departmental notes, dated 5/28/21 at 8:16 A.M., showed at approximately 6:15 P.M. on 5/27/21, code blue was called to resident's room. Resident noted to be laying in bed with the head of bed elevated, oxygen on per nasal cannula. Staff reported that they witnessed the resident kneeling down and then went unresponsive. 911 called. Pupils dilated and eyes rolled upwards. Resident did not respond to sternal rub or verbal stimuli. Resident given nasal Narcan (nasal spray, the first nasal formulation of naloxone to be FDA approved for the treatment of known or suspected opioid overdose). Nursing continues to monitor the resident while waiting for Emergency Medical Services (EMS). Approximately 6:25 (5 minutes after Narcan was administered), resident became responsive at approximately 6:30 P.M. Review of the hospital note, dated 5/28/21, showed EMS gave Narcan, after which he/she regained consciousness. The resident admitted to snorting unknown substance which he/she found on the floor at the facility. His/her urine toxic screen is consistent with Fentanyl intake. During an interview on 6/4/21 at 2:11 P.M., the resident said he/she paid a staff member, whose name he/she didn't remember, for two pills and a chunk of white powder. The resident said he/she made the purchase in his/her room. During an interview on 7/14/21 at 11:22 A.M., the social service director (SSD) said the resident has a history of substance abuse. The resident said he/she had a problem with drugs, and marijuana was his/her drug of choice. The SSD was familiar with the incident that occurred. The resident had been at the facility for approximately a