**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of facility recorded video footage with sound, observation of police officer body camera footage, medical record review, facility incident review, review of a self-reported incident, interview, dementia training curriculum review, facility assessment review and policy review the facility failed to ensure Resident #145, who was cognitively impaired and had a diagnosis of dementia, was provided adequate, necessary kind, appropriate and dignified dementia care to meet his total care needs. This resulted in immediate jeopardy and the potential for serious harm and injury on 07/06/25 at 5:46 A.M. when the resident began to wander throughout the facility secured dementia unit. Certified Nursing Assistant (CNA) #800 and CNA #568 were observed on video to yell at the resident to get out of other resident rooms, to go back to his room, the facility was not his home and to stop hitting staff or they would call the police, and he would go to jail. The lack of planned and appropriate intervention, lack of appropriately trained staff to care for the residents (including Resident #145), on the specialty unit, and lack of staff supervision resulted in police being called to the facility to assist with the resident. The CNAs falsely reported to the police resident behaviors, and the resident was unnecessarily transferred to the hospital emergency room and returned to the facility the same day. The facility consultant psychiatrist then implemented the use of Depakote (an anti-seizure medication that can be used as a psychotropic medication), to the resident's treatment plan to manage the resident's behaviors. This affected one resident (Resident #145) of three residents reviewed. The facility census was 141.On 07/16/25 at 1:45 P.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing were notified Immediate Jeopardy began on 07/06/25 at 5:46 A.M. when Resident #145 began to wander on the facility secured dementia unit. CNA #800 and CNA #568 were observed on video to yell at the resident to get out of other resident rooms, to go back to his room, the facility was not his home and to stop hitting staff or they would call the police, and he would go to jail. The police were contacted to assist in the care of Resident #145 and the resident was unnecessarily transferred to the hospital after CNA #585 and CNA #800 falsely reported resident behaviors to the police department and facility nursing staff. Facility Administration failed to complete a thorough investigation of the incident, failed to review the facility recorded security camera video footage with sound from the secured dementia unit common area, failed to ensure staff responded appropriately to a population in their facility requiring specialized training and permitted CNA #585 and #800 to return to work on 07/06/25 to provide care to the residents on the secured dementia unit, including Resident #145.The Immediate Jeopardy was removed on 07/18/25 when the facility implemented the following corrections: On 07/16/25 (no time provided) Certified Nursing Assistant (CNA) #568 and #800 were suspended and a full internal investigation was initiated. CNA #800 was placed on the do not return list and CNA #568 will remain on suspension pending the outcome of the investigation. On 7/16/25 (no time provided) Pharmacist #300 completed a medication regimen review for Resident #145 and no changes were recommended. On 07/16/25 at 4:00 P.M. Social Services #400 contacted Resident #145's wife to discuss the facility's plan to involve the resident's family in future behavioral interventions such as notifying the resident's spouse anytime, day or night, of behaviors and/or incidents. The resident's wife plans to spend some nights with the resident and the staff will ask the resident's spouse to assist and/or be present during any behaviors. On 07/16/25 Social Services #502 implemented the facility Notification Protocol for Resident #145 which required staff to immediately notify Resident #145's wife of significant behaviors or interventions. If immediate notification was unable to be made, the resident's wife/family would be notified within 12 hours. The spouse's input would be incorporated into the resident's care plan to reduce reliance on restrictive interventions. Beginning 07/16/25 and continuing until all 105 nursing staff (18 Registered Nurses, 22 licensed practical nurses and 65 CNA) are educated prior to their next scheduled shift on the secured unit, in-person by the DON or designee related to preventing and responding to catastrophic reactions, trauma-informed dementia care, use of calm, kind, respectful tone: zero tolerance for threats or intimidation, communication and behavioral de-escalation during high stress situations via training materials and using sign in sheets. Information packets will be available for agency staff to review and sign prior to working on the secured unit. Beginning 07/16/25 incident review by the charge nurse and DON is required before calling external authorities. The medical director or on-call physician's input is also required unless there is an immediate life-threatening emergency. De-escalation and resident specific interventions must be exhausted first. This will be included in the all-staff education provided by the DON/designee. On 07/17/25 Psychiatry Services re-evaluated the resident and reviewed appropriateness of medications. At the request of the resident's spouse, Depakote was discontinued. On 07/17/25 (no time provided) the resident's care plan was updated to provide the staff with behavioral triggers, calming interventions and redirection methods. An escalation protocol was also added for potential catastrophic reactions and non-pharmacologic interventions will be exhausted prior to any medication intervention. Beginning 07/17/25 and concluding 07/18/25, Social Worker #400 audited the other 34 residents on the secured unit to ensure they were not affected by the deficient practice. No concerns were identified. Any new or concerning resident behaviors will be discussed in the morning clinical meetings. On 07/17/25 the Assistant Director of Nursing posted the facility Code [NAME] Protocol on the dementia unit. This informed the staff of overhead paging capability from any facility phone to request assistance on the secured unit. A written escalation plan was also placed on the secured unit to clarify when Code [NAME] should be used and how. Administrative staff (the DON and/or Administrator) will be notified of any behavioral code or help request on the secured unit after the Code [NAME] incident is resolved. On 07/18/25 (no time provided) the Administrator and DON conducted a video review of the incident, confirming inappropriate staff behavior and identifying failure points in staff training, communication protocols and response procedures. On 07/18/25 (no time provided) the Administrator, DON and Social Services #400 conducted a root cause analysis that highlighted an inappropriate tone and approach by staff, failure to follow non-threatening dementia care practices, the facility protocol was not followed to notify the Administrator/designee and poor communication between nursing staff, medical providers and family. On 07/18/25 (no time provided) a self-reported incident was submitted to the state survey agency. On 07/21/25 (no time provided) the Administrator contacted the North [NAME] Police Department and made them aware of the new information received regarding 07/06/25. An officer at the police department would follow-up with the CNAs and amend the report to reflect what he found. On 07/21/25 new expectations were established to ensure contracted and primary care physicians received complete and accurate information regarding behavioral changes, medication responses, incidents or staff interventions using the eInteract Change in Condition Evaluation. Communication measures will be monitored through the weekly audits completed by the DON/designee for two months and findings will be shared with Quality Assurance Performance Improvement. Beginning 07/21/25 the Administrator or designee will observe, three times a week for 60 days, the secured/dementia unit to ensure all staff interventions reflecting the new dementia training Weekly review of the video footage in the secured unit common area totaling one hour of footage on random shifts for 60 days completed by the DON or Administrator. Weekly audit of all incident reports to confirm accurate behavior documentation, appropriate communication with family and physicians, interventions align with the resident's care plan for 60 days Social Worker #400 will observe/interview all dementia unit residents weekly to assess psychosocial well-being and monitor for staff misconduct or resident fear for 60 days. All findings will be reviewed in the QAPI Committee with any follow-up actions documented.Although the Immediate Jeopardy was removed on 07/18/25 the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include:Review of the medical record revealed Resident #145 was admitted on [DATE] with diagnoses that included ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive. A care plan dated 06/25/25 revealed Resident #145 had inappropriate behavior and was resistive to care. Interventions to allow flexibility in the activities of daily living routine to accommodate mood, elicit family input for best approaches to Resident #145, and leave and return in five to ten minutes if Resident #145 refuses care. A nurse note dated 06/25/25 at 10:41 P.M. revealed Resident #145 arrived at the facility at 7:56 P.M. Resident #145 appeared to be in a good mood and was happy to be closer to home. Review of Certified Nursing Assistant (CNA) documentation from 06/26/25 through 07/06/25 revealed on 07/01/25 and 07/04/25 there was documentation of Resident #145 wandering. There were no other behaviors documented. A dietary note dated 06/26/25 at 11:05 A.M. revealed Resident #145 was hospitalized for paranoid behavior from 06/17/25 to 06/25/25. Resident #145 was 73 inches (six feet) tall and weighed 211 pounds on 06/20/25. Resident #145 was ordered Seroquel (antipsychotic) prior to hospitalization. Resident #145 was started on Remeron (antidepressant) at the hospital. Resident #145 had been refusing medication at home, would not eat the food his wife prepared at home, was refusing medications at home, and was wandering and leaving the home. It was noted that Resident #145 had advancing dementia.Review of the physician orders revealed olanzapine 2.5 milligrams (mg) daily as needed for anxiety.Review of the medication administration record (MAR) dated 06/28/25 at 11:30 P.M. revealed Resident #145 received olanzapine (antipsychotic) 2.5 milligrams as needed for anxiety. A nurse's progress note dated 06/29/25 at 2:39 A.M. revealed Resident #145 was walking up and down the halls. Resident #145 had a skin tear to his left elbow that measured one centimeter (cm) long and 3 cm wide. Resident #145 was unable to describe what happened. Resident #145 had been observed leaning on the walls and bumping on the side boards (handrails) along the hallways. The physician and nursing coordinator were notified and Resident #145's family would be notified in the morning. A nurse progress note dated 06/29/25 at 4:42 A.M. revealed Resident #145 had been up most of the night pacing halls and trying to go into other resident rooms. Resident #145 was very difficult to redirect and as needed medication was administered. A medication administration note dated 06/29/25 at 7:43 A.M. revealed olanzapine 2.5 mg was ineffective. There was no documentation following the ineffective medication.A nurse progress note dated 06/29/25 at 2:51 P.M. revealed Resident #145's wife would like to be notified anytime day or night and stated she did not mind being awakened for incidents or information of importance. A nurse progress note dated 07/01/25 at 3:49 P.M. revealed Resident #145 was seen by the physician and a new order was received for Resident #145 to have a psychiatric consult. Review of facility recorded video footage (with sound) of the hall and common area outside Resident #145's room revealed on 07/06/25 at 5:46 A.M. Resident #145 walked out into the hallway wearing only a disposable incontinence brief. Resident #145 had a slow gait and was looking down at the floor. Resident #145 stopped and rubbed his face and looked around. At 5:47 A.M. Resident #145 walked down the hall and entered the next room on the left (Resident #67). CNA #568 can be seen entering the bottom left hand corner of the video and stated, Honey, that is a woman's room, and you cannot go in there. CNA #568 entered the room and told Resident #145 that his room was over there and pointed in the direction of the resident's room. CNA #800 informed the resident he must come out of that room as she stood in the doorway with her arms crossed at her chest. At 5:48 and nine seconds A.M. Resident #145 exited Resident #67's room and walked slowly back towards his room. At 5:48 and 15 seconds CNA #800 stated your room is right there and that is where you need to go. At 5:48 and 20 seconds Resident #145 stated something about court. At 5:48 and 22 seconds CNA #586 stated we will meet you there, but I suggest if we go to court, you put some clothes on which are in your room. At 5:48 and 33 seconds, Resident #145 turned away from his room and started toward Resident #51's room which was located directly across the hall from Resident #145's room. At 5:48 and 34 seconds CNA #586 raised her voice and told Resident #145 do not go into a patient's room. At 5:48 and 35 seconds CNA #586 again stated in an even louder voice Do not go in a patient's room. At 5:48 and 40 seconds CNA #586 and CNA #800 entered Resident #51's room with Resident #145. CNA #800 stated in a firm voice, you cannot go in here that is a woman's room. At 5:48 and 43 seconds CNA #800 yelled stop and CNA #586 yelled don't touch her. At 5:48 and 45 seconds, CNA #586 exited the room and said that's it, I'm calling the cops. At 5:48 and 47 seconds, CNA #800 also exited the room. At 5:48 and 56 seconds, CNA #586 reentered the room and said, I will not let you near my patients. You will get out. At 5:49 AM CNA #586 said in a loud voice, yes, you will and then repeated yes you will in a louder voice. At 5:49 AM and seven seconds, CNA #586 yelled out, He's beating the (expletive) out of me. CNA #800 yelled, I'm coming. At 5:49 and 15 seconds CNA #800 entered the room and CNA #586 stated, he threw me on the floor. At 5:49 and 21 seconds yelling in loud voices from CNA #586 and CNA #800 included: you can get out, OUT, You are on a memory care unit, Get out, You need to go now, out. At 5:49 and 30 seconds can see Resident #145 slowly approach the doorway from Resident #51's room to the hallway. CNA #568 and CNA #800 can be heard telling Resident #145 it was not his house, and he was at a nursing facility. At 5:50 and 24 seconds, CNA #568 called 911. A CNA can be heard stating Resident #145 was a new resident, was combative, and staff had been injured, and Resident #145 was threatening other residents. CNA #568 stated there was not proper staffing and there was not a nurse on the unit. CNA #568 stated a police officer was needed if the facility was not going to staff properly. At 5:51 and 40 seconds AM CNA #800 walked out of the room and was on the phone standing in the hallway. CNA #568 was still in Resident #51's room and on the phone with 911. CNA #568 stated she did not need a medic yet but may if Resident #145 did not stop. CNA #800 spoke up and said Resident #145 had tossed both CNA's and was extremely combative. At 5:51 and 49 seconds, Resident #145 stepped out of view back into Resident #51's room. Both CNA's told Resident #145 to leave the room. CNA #568 stated she needed the police soon. At 5:52 and two seconds CNA #568 yelled ouch and in a firm voice stated you need to move. At 5:52 and 19 seconds CNA #568 stated there was no one at the front door to let the police in. CNA #800 stated (to Resident #145) you need to get out of this room. This is a woman's room, NOW! At 5:53 and 15 seconds CNA #568 was heard saying do not go near my patient in a loud voice and then again in a louder voice. At 5:53 at 23 seconds, CNA #800 stated let's go and CNA #586 stated Protect your license, protect your license. At 5:54 at 19 seconds, Resident #145 can be observed again standing at the doorway to Resident #51's room. At 5:55 and four seconds, Resident #145 stepped slowly back into Resident #51's room. A CNA can be heard saying Do not come any closer in a loud voice and then stating it again in a louder voice. At 5:55 and 14 seconds, a crash sound was heard and CNA #568 stated we wanted you to sit down the whole time.blow the place up too. At 5:57 and eight seconds, CNA #586 said You will go to jail if you touch anyone down here. CNA #586 exited the room. At 5:57 and 13 seconds CNA #800 left the room. At 5:57 and 18 seconds CNA #800 made a phone call and asked for a nurse to come to the unit. At 5:58 A.M. CNA #586 and #800 reentered the room. At 6:00 and ten seconds CNA #586 and CNA #800 left Resident #51's room while Resident #145 was still in Resident #51's room. At 6:00 and 44 seconds police arrive at the unit. CNA #586 told the police she did not know why Resident #145 was here. The CNA's told the police they gave all the grace in the world to Resident #145 and gently asked him to return to his room. Resident #145 tossed CNA #568 like a ragdoll. At 6:04 and 12 seconds CNA #586 told the police that they needed Resident #145 to understand (the CNA was unable to finish her sentence) but the police officer interrupted CNA #586 and stated they could not make Resident #145 understand. At 6:40 Emergency Medical Services (EMS) arrived and at 6:50 A.M. Resident #145 was sitting calmly on the transport cot and EMT's wheeled Resident #145 down the hall. The resident was transported to the hospital.A police report/incident #25-008748 dated 07/06/25 revealed an incident occurred around 5:50 A.M. The police responded to a call for a report of a combative patient. Employees reported a male patient became combative towards them when he (Resident #145) wandered into other patients' rooms. CNA #568 and CNA #800 stated Resident #145 was a new patient and wandered into other resident's rooms. The CNA's stated it was a memory care unit, and residents were not allowed in other resident rooms. Resident #145 started to argue with CNA #568 and CNA #800. Resident #145 pushed CNA #800 and knocked her down. When CNA #568 tried to intervene, Resident #145 threw CNA #568 to the ground. Upon arrival of the police, Resident #145 was sitting in a chair in another resident's room. Resident #145 appeared confused and was not aware he was in a care facility. Resident #145 kept saying it was his house. The police attempted to get Resident #145 to return to his room, but Resident #145 refused. The facility director advised Resident #145 needed to be transported to the emergency room for an evaluation. EMS responded and Resident #145 was transported without incident. A nurse progress note authored by RN #578 dated 07/06/25 at 10:34 A.M. revealed at 6:15 A.M. Registered Nurse (RN) #578 received phone call from CNA #800. CNA #800 stated she needed a nurse NOW. Resident #145 had beaten up a couple of staff and was trying to get to another resident. RN #578 immediately rushed to the memory care unit. CNA #568 and CNA #800 had called the police, and the police arrived shortly after this nurse arrived. CNA #568 and CNA #800 reported Resident #145 woke up and was trying to go into multiple resident rooms. CNA #568 and CNA #800 stated they were gently trying to encourage Resident #145 not to go into another resident's room when Resident #145 suddenly struck CNA #800 in the chest and knocked CNA #568 to the floor. When RN #578 arrived, Resident #145 was sitting at the foot of the bed in a chair against the wall in Resident #51's room with no clothes on. The police officers tried to get Resident #145 to leave Resident #51's room and return to his own room. Resident #145 would not move and would not speak to the police. The police stated another plan was needed as they would not be able to do anything with Resident #145 at the police station. RN #578 called RN #704, who was the acting Director of Nursing (DON) at the time. RN #704 told RN #578 to call 911 and have Resident #145 taken to the emergency department so Resident #145 could be pink slipped (taken to the hospital for a mental evaluation) to a psychiatric facility. Emergency medical services (EMS) were called, and Resident #145 was placed on a stretcher without incident. Resident #145's wife was notified of the incident and Resident #145 being transferred to the hospital on [DATE] at 6:50 A.M. A statement by CNA #568 revealed CNA #568 and CNA #800 had been alone on the memory care unit since approximately 12:15 A.M. when the nurse left and went home. LPN #712 was notified around 12:30 A.M. that there were only two CNAs on the memory care unit and the nurse had left. LPN #712 stated there was no one available so they would be alone. CNA #568 did not have access to locked areas, residents did not get medications passed, and to call LPN #712 if there was an emergency. LPN #712 was called at the first verbal altercation to let LPN #712 know that CNA #568 and CNA #800 did not feel safe and Resident #145 would not cooperate or redirect and was threatening CNA #568 and CNA #800. This was around 5:00 A.M. and LPN #712 advised that one of the CNA's sit on the couch at the end of the hall to make sure Resident #145 (unable to read what was written) room. Before CNA #568 could get off the phone, Resident #145 entered Resident 67 room. The door to Resident #67's room was closed, and Resident #145 knew it was not his room. Despite Resident #145 being verbally abusive and threatening, CNA #568 and CNA #700 agreed Resident #145 was alert and oriented to person, place, and time. CNA #568 and CNA #800 went down the hall to Resident #67's room and reminded Resident #145 that his room was next door. Resident #145 stated he was going anywhere the (expletive) he wanted and then entered Resident #51's room. CNA #568 and CNA #800 calmly followed Resident #145 in Resident #51's room and attempted to redirect Resident #145 and asked Resident #145 not to approach Resident #51. Resident #145 purposefully did exactly what staff asked him not to do. CNA #568 offered to watch television in common area, a snack, and anything to redirect Resident #145. Resident #145 laughed maniacally and said he could do anything he wanted. Resident #145 then grabbed CNA #800, and the main assaults began. After CNA #800 was pushed very hard, CNA #568 stepped between Resident #145 and Resident #51 and attempted to calm and redirect Resident #145. Resident #145 seemed like he wanted to physically fight and continued to threatened CNA #568 and CNA #800. Resident #145 took another step towards CNA #568 and Resident #145's feet were almost touching CNA #568's. CNA #568 took a step back and Resident #145 grabbed CNA #568's forearm and flung her to the side. Resident #145 then used his other hand/arm to punch CNA #568 in the face. CNA #568 flew on the floor and her ankle turned under CNA #568's weight and CNA #568 hit something with the left side of her face. CNA #568 wrote that she had multiple places that were badly bruised and neck and shoulder felt jarred. At some point, Resident #145 stomped on CNA #568's left foot after CNA #568 stood up. Because LPN #712 had been called when Resident #145 got out of bed and was verbally abusive in his own room during rounds and bed checks, CNA #568 knew Resident #145 was combative and threatened CNA #568 and CNA #800, and there was no way out of the room, and CNA #568 had been hit in the head and face, so CNA #568 called 911. As soon as Resident #145 heard CNA #568 call 911 he sat in a chair in Resident #51's room. Because of Resident #145's size and sitting down forcefully, Resident #145 shoved an oxygen tank standing between the chair and piece of furniture. The oxygen tank wobbled but the wheels kept the tank from falling over. CNA #568 explained calmly that the oxygen tank could not be touched due to safety concerns. Resident #145 stated he could do whatever he wanted. Resident #145 was purposefully blocking the doorway and CNA #568 and #800 were unable to get out of Resident #51's room until Resident #145 sat down. Resident #145 was observed by CNA #568 and CNA #800 to be seeking satisfaction from conflict. Resident #145 did everything CNA #568 and CNA #800 asked him not to do. An example: you can be in the hall, common areas or your room but please do not startle other residents by entering rooms that are not yours. Resident #145 immediately would enter a room he knew was not his to see what CNA #568 and CNA #800 would do about it. CNA #568 and CNA #800 quietly agreed not to tell Resident #145 not to do anything so to engage or escalate him. CNA #568 did not feel safe around Resident #145. It then occurred to CNA #568 that the police could not enter the building as the door was locked and required a staff member to answer the phone to unlock the door, but because of being so short staffed there was no one answering the phones. CNA #800 called the phone number the police would need to call to enter the building and verified no one answered the phone. An undated statement by CNA #800 revealed the nurse on the memory care unit had left around 12:15 A.M. or 12:30 A.M. LPN #712 was told the nurse on the memory care unit went home and left the keys with CNA #568 and CNA #800. LPN #712 was called again around 5:00 A.M. and told Resident #145 was awake and verbally abusive and threatening CNA #568 and CNA #800. LPN #712 advised that one CNA watch Resident #145, but CNA #568 and CNA #800 were not comfortable with doing that. But Resident #145 had already entered Resident #67's room. CNA #800 and CNA #568 calmly told Resident #145 to please leave Resident #67's room. Resident #145 stated he would do what he wanted. Resident #145 knew it was not his room. Even though Resident #145 was being verbally abusive, CNA #800 and CNA #568 agreed Resident #145 was alert and oriented to person, place, and time. CNA #800 and CNA #568 told Resident #145 where his room was, which he already knew. Resident #145 finally left Resident #67's room. CNA #800 and CNA #568 tried to redirect Resident #145 back to his room. Resident #145 started to verbally abuse CNA #568 and CNA #800 and then went towards Resident #51's room. Resident #145 then entered Resident #51's room. CNA #800 and CNA #568 calmly followed Resident #145 into Resident #51's room and tried to redirect Resident #145. Resident #145 was asked not to approach Resident #51, but Resident #145 purposefully continued to approach Resident #51. Resident #145 was offered a snack, to watch television in the common area, and anything to redirect him. Resident #145 laughed maniacally and said he could do what he wanted. CNA #800 was standing between Resident #145 and where Resident #51 was lying in bed. Resident #145 then grabbed CNA #800's right arm and the assault began. Resident #145 swung CNA #800 across the room. After that, CNA #800 calmly told Resident #145 to please not put his hands on her. Resident #145 kept trying to get to Resident #51 and CNA #800 tried to block Resident #145 before he got to Resident #51. Resident #145 got very angry and hit CNA #800 on the chest with both of his hands so hard CNA #800 went flying to the ground and hit her neck and back. CNA #568 got between CNA #800 and Resident #145 and told Resident #145 not to touch CNA #800. Resident #145 grabbed CNA #568's arm and used his other arm to punch CNA #568 in the face. After that, Resident #145 grabbed CNA #568's arm and threw her to the ground. CNA #568's face slammed into the ground and CNA #568's left foot buckled under her and her arm hit the edge of the bed. After CNA #568's got up, both CNA's stood their ground to get Resident #145 to go to his room. Resident #145 would not move. CNA #800 and CNA #568 had no way to escape and were trapped because Resident #145 purposefully blocked the doorway. CNA #800 stated they were going to get help and Resident #145 stood in the doorway so CNA #568 and CNA #800 could not get out of the room. The CNA's tried to get out for a while and then CNA #568 called 911 and CNA #800 tried to call a nurse working on another unit. CNA #800 called the facility three times and finally got a nurse and CNA #800 yelled who she was, where she was, and needed help because a resident had beat up the CNA's and the CNA's could not get out of the room. The nurse hung up after CNA #568 was on the phone with 911. Resident #145 heard CNA #568 talking to the police so he flung himself into a chair which, because of Resident #145 ‘s size, the chair and oxygen tank wobbled. CNA #568 and CNA #800 told Resident #145 please do not touch the oxygen tank. Resident #145 stated he would do what the (expletive) what he wanted. The police could not get into the facility because there was not a staff member available to let them in. Panic and fear set in, but CNA #568 and CNA #800 stayed calm. CNA #800 and CNA #568 both observed Resident #145 to be seeking satisfaction from conflict and did literally everything he was asked not to do. Example: you can be in the hall or common areas but please do not enter other resident's rooms. Resident #145 immediately entered rooms that he knew were not his. He challenged CNA #568 and CNA #800. CNA #568 and CNA #800 agreed not to tell Resident #145 to do anything. CNA #800 wrote she did not feel safe around Resident #145. Review of hospital notes dated 07/06/25 revealed a [AGE] year-old male was brought to emergency department (ED) from a nursing home by ambulance for aggression. Resident #145 was alert to person only with a history of dementia. Resident #145's behavior was appropriate, and speech was appropriate for rate and volume. Resident #145 was mildly anxious and confused. Resident #145 would sometimes wander. A licensed professional counselor assessed Resident #145 face-to-face. Resident #145 was cooperative in the ED. Resident #145 thought he was in a video game, and someone was trying to take his identity. Resident #145 stated there was a fight downtown I think but denied being in the fights. The ED nurse and nursing home staff member stated Resident #145 got in another resident's face. The aides attempted to redirect Resident #145 and Resident #145 slammed the aid on the floor and threw another staff member against the nurse's station. The RN at the nursing home stated Resident #145's wife had requested Seroquel (antipsychotic) and olanzapine (antipsychotic) be discontinued on 06/01/25. Since the discontinuation of the medication Resident #145 had been more difficult to redirect. Resident #145's wife stated Resident #145 did not have a history of aggression with her. The nursing home staff reported Resident #145's wife had endorsed aggression as the reason for needing nursing care and stated she was no longer able to manage Resident #145 at home. Resident #145's wife expressed concern that Resident #145 had been looking for her and that was why he was wandering into rooms. A RN stated Resident #145 would become more confused and harder to redirect when family left. The mental status exam at the hospital revealed Resident #145 was alert to person only, was cooperative, and mildly anxious and confused. Resident #145 allegedly hit a nurse at the nursing facility and was at moderate risk to non-lethal harm to others. Resident #145 did not meet the criteria for inpatient psychiatric admission. It was recommended that Resident #145 follow up with outpatient providers [NAME][TRUNCATE