**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect the resident's right to be free from abuse and neglect for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for abuse and neglect. 1. The facility failed to prevent Resident #1 from abusing Resident #3 on Hall 400 (male secured locked unit) that led to an emergency room visit resulting in head laceration requiring 3 staples for Resident #3 on 05/25/2025. 2. The facility failed to ensure Hall 400 (male secured locked unit) had sufficient staffing to prevent Resident #1 from abusing Resident #4 that led to hospitalization of Resident #1 and a fall resulting in a skin tear to Resident #4's left elbow, while Resident #1 was supposed to be on 1:1 monitoring on 05/25/2025. 3. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #5 resulting in a skin tear to her arm for Resident #5 on 06/04/2025. 4. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #5 by slapping her across the face on 06/08/2025. 5. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #6 resulting in a skin tear to the cheek for Resident #6, while Resident #2 was supposed to be on 1:1 monitoring on 06/08/2025. 6. The facility failed to ensure Hall 400 (male secured unit) had sufficient staff to provide 1:1 monitoring for Resident #1 on 05/25/2025 from 10:00pm-6:00am. 7. The facility failed to ensure Hall 500 (female secure unit) had sufficient staffing to provide 1:1 monitoring for Resident #2 on 06/04/2024 from 2:00pm-10:00pm, and from 10:00pm-6:00am. 8. The facility failed to ensure Hall 500 (male secure unit) had sufficient staffing to provide 1:1 monitoring for Resident #2 on 06/08/2024 from 2:00pm-10:00pm, and from 10:00pm-6:00am. An Immediate Jeopardy (IJ) situation was identified on 06/22/2025. The IJ template was provided to the facility at 4:05 pm. While the IJ was removed on 06/24/2025 at 10:30 am, the facility remained out of compliance at a scope of pattern with no actual harm with a potential for more than minimal harm at a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for resident-to-resident altercations and serious harm in the event of an emergency, hospitalizations, and even death. Findings included: Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 12/15/2023, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, heart failure, and alcohol dependence. Review of Resident #1's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: no antipsychotic, antianxiety, or antidepressant medications. Review of Resident's #1's Care Plan, last review 06/10/2025, revealed in part: Focus: Resident demonstrates physical behaviors hits other residents and staff, revised on 04/14/2025. Goal: Resident will not harm self or others through the review date, revised on 06/10/2025. Interventions: 1:1 supervision as needed, revised on 12/13/2024. Further review of care plan revealed no interventions added since 12/13/2024. Review of Resident #1's progress notes revealed: 05/25/2025 10:35 pm, signed by DON: .Resident saw another resident enter his room, he walked to his room and yelled at the other resident. When other resident did not move out fast enough, he punched other resident in the face. Another resident was walking backward, and this resident shoved him causing a fall. No injuries to Resident #1. Stated not in pain. Other resident was sent to the emergency room after hitting head on floor. Initial Treatment/New Orders: skin assessed. 1:1 monitoring, referral to impatient psyc notified: psych center 05/25/2024 at 4:45pm .Interventions 1 on 1 supervision, Redirection. 05/25/2025 10:45 pm, signed by DON: .CMA-A walking into the dining room, heard two residents having a verbal altercation then saw Resident #1 hit another resident in the face. When the other resident was swinging back, he slid out of his chair onto the floor .Initial Treatment/New orders: skin assessed, 1:1 monitoring, send referral to inpatient psych . notified psych center 05/25/2025 at 6:50pm .Interventions 1 on 1 supervision, Redirection. 05/27/2025 at 1:00 pm, signed by ADON: Resident #1 was transferred to a hospital on [DATE] at 1:00 PM related to resident had aggressive behaviors and was sent to psych facility for evaluation and treatment. Resident #3 Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted on [DATE] with initial admit date of 02/20/2024, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, depression, and dementia. Review of Resident #3's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. E0900. Wandering: behavior not exhibited. Section N: Medications: antidepressant medications. Review of Resident's #3's Care Plan, last review 05/29/2025, revealed in part: Focus: Resident is at risk for wandering, revised on 02/21/2024. Goal: Resident's safety will be maintained through the review date, revised on 05/29/2025. Interventions: Distract him from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, revised on 02/21/2024. Identify pattern of wandering, revised on 02/21/2024. Further review of care plan revealed no interventions regarding wandering added since 02/21/2024. Review of Resident #3's progress notes revealed: 05/25/2025 4:53 pm, signed by RN-B: Resident #3 was transferred to a hospital on [DATE] PM related to resident altercation on another resident. Resident was knocked to the ground and hit his head on the found resident sent out for further Evaluation. 05/25/2025 10:58 pm, signed by DON: .Resident wandered into another resident's room. Other resident came in starting verbal altercation. When this resident did not move fast enough the other resident punched him in the face. The resident was backing up trying to exit room and fell landing on left lateral. 911 was called immediately. Skin assessed and previous left elbow skin tear was bleeding and noted to be bigger in size. No pain .Physician notified on 05/25/2025 6:45 PM . Review of the Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 4:20 pm, Resident #3 went into Resident #1's room. Staff heard yelling and saw Resident #1 hit and push Resident #3. Resident #3 fell to the floor and hit his head on the floor and sent to emergency room to be further evaluated. Resident #3 had laceration to back of heat with hematoma, no bleeding, no signs of infection, closed with 3 staples, measurements 1.5x2x0.5cm, hematoma measures 4x5x0.5cm, hematoma to left side of head measurements 3x3cm, bruises to bilateral upper extremities, reopened skin teas to left elbow with part of skin fold missing, no bleeding, no signs of infection, measurements 2x2.5x0.1cm, no other skin issues noted at this time. Facility initiated one on one monitoring with Resident #1. Contacted psych services. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed 2 CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the 2 CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Resident #4 Review of Resident #4's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 03/25/2024, to Hall 400 (male secured locked unit) with diagnoses which included: personality change, depression, and dementia. Review of Resident #4's Quarterly MDS assessment, dated 05/30/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 physical behavioral symptom directed towards others. Section N: Medications: antidepressant medications. Review of Resident's #4's Care Plan, last review 06/19/2025, revealed in part: Focus: Resident has a potential for trauma that may have a negative impact. The trauma is related to physical altercation, revised on 05/26/2025. Goal: Staff will assist in avoiding triggers through next review date. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediate to the nurse. Record review of Resident #4's progress notes revealed: 05/25/2025 11:09 pm, signed by DON: .The fall caused a skin tear to left elbow. Size of the skin tear in cm: 0.5 x 0.5. New/bleeding, a verbal altercation between this resident and another resident was overheard. CMA- A walked into dining room and saw another resident hit this resident in the face, when Resident #4 tried to swing back he slid out of his chair. Upon assessment a skin tear to the left elbow was noted. Stated it did not hurt . Review of the Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 6:30 pm, Resident #1 slapped Resident #4 and when Resident #4 tried to swing back he slid out of his chair. Upon his assessment a skin tear to the left elbow was noted, measurements 0.8x0.7x0.1cm. Facility initiated one on one monitoring with Resident #1. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed (2) CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the (2) CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. During an interview on 06/19/2025 at 1:35 pm, the DON stated that both secure units were always staffed with 2 CNA's each on all shifts except night shift which had 1 CNA per unit. She stated that if a resident was placed on 1:1 monitoring, an additional staff was added making 3 CNAs or 2 CNAs on 10:00pm-6:00am shift. During an interview on 06/20/2025 at 12:45 pm, CNA- C stated she was on shift on Secure Hall 400 at the time of these incidents with Resident #1. She stated on 05/25/2025, there was only herself and 1 other staff to supervise the 19 residents plus provide 1:1 monitoring with Resident #1 that required the resident to always be within arm's reach. She stated the locked unit was also having issues with the locked doors on the unit not functioning; therefore, they also had to monitor the doors, the residents, and provide 1:1 of Resident #1 within arm's reach. She stated that Resident #1 was placed on 1:1 monitoring but no extra staff was sent. She stated that at the time of the second incident Resident #1 was in the dining room and no staff was present. She stated she worked the secure unit alone often and had never been given extra staff when residents were placed 1:1 monitoring requiring residents to be within arm's reach. During an interview on 06/20/2025 at 8:00 pm, LVN-G stated she was responsible for Secure Hall 400 and Secure Hall 500 on 05/25/2025 from 2pm-10pm. She stated she was on Secure Hall 500 at the time of the first incident. She stated she was back on Secure Hall 500 when the 2nd incident happened. She stated Resident #1 was supposed to be on 1:1 monitoring because of the previous incident, when the 2nd incident happened, and she did not know why he was not. She stated there were only 2 CNAs covering Secure Hall 400 at the time and that there was no way that the LVN could help with 1:1 monitoring because she was responsible for both secure halls. During an interview on 06/20/2025 at 8:15 pm, MA-A stated he was working on 05/25/2025 at time of both incidents and stated that he was in a resident's room during the 1st incident with Resident #3 and did not see that incident, but he knew that he was placed on 1:1 monitoring. He stated that he was walking down the hall, when the 2nd incident happened and heard Resident #1 yelling then he spotted Resident #1 in the dining room with no staff present and saw him slap Resident #4. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 02/09/2024, to Hall 500 (female secured locked unit) with diagnoses which included: traumatic brain injury, anxiety, depression, and dementia. Review of Resident #2's Quarterly MDS assessment, dated 05/20/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 other behavioral symptom not directed towards others. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #2's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors attempts to hit other residents, revised on 04/09/2025. Goal: Resident will not harm self or others through the review date, revised on 05/22/2025. Interventions: When she becomes agitated: intervene before agitation escalates; guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later, revised on 11/18/2024. Record review of Resident #2's progress notes revealed: 06/04/2025 11:13 am, signed by LVN-E: .resident started being anxious and agitated. resident grabbed another resident arm causing a skin tear . resident is currently on 1:1 for monitoring .: 06/08/2025 12:19 pm, signed by LVN-F: . nurse was called by resident in hallway, that resident has just slapped another resident across the face. psych facility contacted, and 1:1 supervision. 06/08/2025 1:09 pm, signed by LVN-F . resident was grabbing another female resident by her cheeks and would not let her go, staff intervened but resident would not let other resident go. Resident #5 Review of Resident #5's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 06/10/2020, to Hall 500 (female secured locked unit) with diagnoses which included: anxiety, Alzheimer's, and mood disorder. Review of Resident #5's Annual MDS assessment, dated 06/04/2025, revealed a BIMS score of 99 which indicated resident was unable to complete the interview. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #5's Care Plan, last review 04/10/2025, revealed in part: Focus: Resident has a history of trauma that may have a negative impact. The trauma is related to getting scratched, revised on 06/05/2025. Goal: Maintain resident safety and integrity during post trauma episode, using appropriate interventions, revised on 06/05/2025. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse, revised on 06/05/2025. Record review of Resident #5's progress notes revealed: 06/05/2025 10:38 am, signed by LVN-E: . resident received a skin tear due to another resident grabbing her arm. Physician notified on 06/04/2025 at 10:10am. 06/08/2025 12:29pm, signed by LVN-F: . Resident voices she was slapped across the face by the other female resident. Review of the Provider Investigation Report, dated 06/11/2025, revealed: On 06/04/2025 at 10:00am, Residents were sitting at the table in dining room when Resident #2 reached over and grabbed Resident #5's arm causing a skin tear. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/04/2025 at the time of the incident, revealed (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 10:15am-2:00pm, was signed by the (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. During an interview on 06/19/2025 at 2:00pm, CNA-J said she was on shift on Secure Hall 500 at the time of this incident with Resident #2 on 06/04/2025. She stated there was supposed to always be 2 CNAs, but she worked many times by herself. She stated that when a resident is placed on 1:1 monitoring the 2 CNAs on shift rotated and monitored them as close as possible. She stated it was very rare that a third CNA was sent. She stated she had worked on the floor multiple times alone with a resident on 1:1 monitoring. She stated when a resident was 1:1 the staff was supposed to be within arm's length of them at all times and must follow them wherever they go. She stated she could not remember specific dates or incidents because there were so many incidents and 1:1 monitoring that she couldn't remember them all. Resident #6 Review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] to Hall 500 (female secured locked unit) with diagnoses which included: explosive disorder, Alzheimer's, and seizures. Review of Resident #6's Quarterly MDS assessment, dated 05/26/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms- Presence and Frequency: 1 physical behavioral symptom director towards others. Section N: Medications: no antianxiety, antipsychotic, or antidepressant medications. Review of Resident's #6's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors, revised on 02/16/2024. Goal: Resident will demonstrate effective coping skills through the review date, revised on 05/22/2025. Interventions: Assess and anticipate her needs: food, thirst, toileting needs, comfort level, body positioning, pain, revised on 08/29/2023. Record review of Resident #6's progress notes revealed: 06/08/2025 1:28pm, signed by LVN-F: . Resident was in her wheelchair looking outside, when the other female resident came up to her and grabbed her face and started being combative, nurse/aide intervened but other resident would not let her go. Review of the Provider Investigation Report, dated 06/13/2025, revealed: On 06/08/2025 at 12:00pm, Resident #2 hit Resident #5 with no injuries. She then grabbed Resident #6 by the face causing a very small scratch to her cheek. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/08/2025 at the time of the incident, revealed (1) CNA (CNA-M) and a float CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the 1:1 monitoring sheet for Resident #2 on 06/08/2025 revealed 1:1 monitoring was not initiated until 1:00 pm after the 2nd incident. 1:1 monitoring sheet was signed by RN-B who was assigned as a nurse for Hall 100 and Hall 200. During an interview on 06/21/2025 at 9:00 am, LVN-F stated she was responsible for Secure Hall 500 on 06/08/2025 from 2pm-10pm. She stated that Resident #2 was supposed to have been placed on 1:1 monitoring after the 1st incident but there was no staff available. She stated Resident #1 and Resident #6 were in the dining room alone when she heard Resident #6 screaming. She stated the LVNs cannot provide 1:1 monitoring because they were responsible for multiple halls. Review of the facility daily staff schedule, dated 05/25/2025, revealed during the 10:00pm to 6:00am shift, there was (1) CNA (CNA-H) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with one (1) of the 36 requiring 1:1 monitoring. Review of the 1:1 monitoring sheet for Resident #1 on 05/25/2025 from 10:00pm-6:00am, revealed it was signed LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 2:00pm-10:00pm, was signed by one of the CNAs (CNA-K) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the facility daily staff schedule, dated 06/04/2025, revealed during the 10:00pm to 6:00am shift, there was (1) CNA (CNA-H) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with (2) of the 36 requiring 1:1 monitoring. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 10:00pm-6:00am, revealed it was signed by LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. Review of the facility daily staff schedule dated 06/08/2025 from 2:00pm-10:00pm, revealed (2) CNA (CNA-N and CNA-L) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/08/2025 from 2:00pm-10:00pm, was signed by one of CNAs (CNA-L) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the facility daily staff schedule, dated 06/08/2025, revealed during the 10:00pm to 6:00am shift, there was (2) CNA (CNA-O and CNA-P) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with (2) of the 36 requiring 1:1 monitoring. Review of 1:1 monitoring sheet for Resident #1 on Secure Hall 400 and Resident #2 on Secure Hall 500 on 06/04/2025 from 10:00pm-6:00am, revealed it was signed by LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. During an interview on 06/20/2025 at 10:15pm, with CNA-O who worked 10pm-6am stated that he worked many shifts alone and he was responsible for covering Secure Hall 400 and Secure Hall 500 at the same time. He stated he also worked alone when residents were on 1:1 monitoring. He stated 1:1 monitoring should be where the staff was within arm's length of the resident, but that was not possible when he was the only CNA and was responsible for both halls. During an interview on 06/20/2025 at 12:30pm, the ADON stated the secured units were supposed to be staffed with 2 CNAs each during the day and 1 CNA each on 10pm-6 am shift. She stated when a resident was placed 1:1 monitoring, and additional staff member was supposed to be designated for that resident. She stated they pull staff from other departments such as dietary and housekeeping to perform 1:1 monitoring. She stated 1:1 meant that 1 staff was with that resident at all times. The ADON stated that on the night shift, if there was only 1 CNA assigned to both secure units, the LVN would stay on the opposite unit and monitor it. She stated resident were usually asleep on that shift, so she felt that 1 person on each unit was enough even when a resident was on 1:1 monitoring. During an interview on 06/20/2025 at 3:30pm, the DON stated that she was not aware of any times that there was not a designated staff for residents on 1:1 monitoring. She stated did not know how Resident # 1 and Resident #2 were able to get into 2nd altercations while on 1:1 monitoring. She stated she felt the facility was doing a good job preventing altercations and injuries. She stated that she did not feel that the facility was short staffed. Review of the facility document dated 05/25/2025 titled In-service training report, reflected: Subject: 1:1 Monitoring. When a resident is on 1:1 monitoring, the person designated to monitor has to be with that resident at all times. Not just with in eyesight. Not in the same room as them. Not having him in an area where all employees can keep an eye out. There needs to be one designated person who will be filling out the monitoring sheet that is within arm's length. This is so we can quickly intervene, if needed. Review of facility policy titled, Abuse/Neglect; not dated, revealed, in part: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the residents medical symptoms . This was determined to be an Immediate Jeopardy (IJ) on 06/22/2025 at 4:05pm. The Regional Compliance Nurse, Director of Nurses, and Assistant Director of Nurses were notified. The Regional Compliance Nurse was provided with the IJ template on 06/22/2022 at 4:05 PM. The following Plan of Removal was accepted on 06/23/2025 at 6:20 PM and included: Interventions: Any resident that resides in the secure unit that has the potential for resident-to-resident altercation can be affected by deficient practices. Alleged perpetrator Resident #2 was interviewed by DON on 06/22/26 @ 6:15pm with no concerns voiced by resident and placed on 15-minute checks for resident safety and the safety of other resident in the secure unit and continued for at least 24 hours. Resident #1 was interviewed on 06/23/25 by DON and voiced no concerns and did not recall being aggressive with any other resident. Resident #7 was interviewed on 06/23/25 by DON and resident did not voice any concerns and could not recall being aggressive with any other resident. Resident #8 is not at the facility for an interview on 06/23/25 and Resident #9 is not at the facility for an interview on 06/23/25. Abuse prevention in-service for all facility staff initiated in house and completed by Admin/DON/Compliance Nurse on 06/22/2025 and for staff that is not present during the in-services will be sent the in-service via staffing application and they be not be allowed to assume duties until in-service prior to them clocking in for their shift and all new staff or agency staff will be in-services on abuse prior to them starting their position. All in services to be completed by 6/23/2025. Immediate psychiatric services on call for residents that trigger through trauma informed assessments on the secure unit completed on 06/22/2025. Referrals sent out by DON and will be followed up by DON for Resident #2 have been sent out to other skilled nursing facility and Behavioral Hospitals. and Resident #8 referral was sent to a facility and accepted and admitted [DATE], Resident #9 referred to a facility and accepted and admitted on [DATE]. Resident #1 referral sent to psych hospital and accepted and admitted 05/2725 and return 06/03/25. All direct care staff that were work at the time of the incident in the secured unit working with Resident #2 have been interviewed by DON on 06/22/25 and no root cause could be determined for her behaviors. Staff was able to state regarding Resident #1 resident is very territorial and does not like resident entering his room and resident was transition to long term community in a private room and have decrease behaviors and for Resident #9 no root cause was determined for his behavior. For Resident #7 no root cause was determined for his behavior. Resident #8 no root cause was determined for his behaviors. Facility will ensure adequate staffing to manage acuity based on the 24-hour report in Point Click Care, Real Time systems monitoring and current census. The administrator will maintain adequate staff for resident safety per acuity. Staffing will be reviewed during stand-up Meetings at 8:30 AM and stand-down meetings at 4PM to ensure there is adequate staffing for the secure units. During both meetings the team will review, and the Administrator/designee will adjust staffing to maintain resident safety based on acuity based on the 24-hour report in PCC, Real Time Systems monitoring and current census. If one on one is required additional staff member will be added and not substituted with the current staff in the units to ensure adequate staffing to protect residents from further incidents. The facility administrator/designee will decide and assure staff are assigned to the 1:1 resident. The Administrator/DON will check in with assigned staff frequently to assure that 1:1 monitoring is ongoing. Resident interviews on the secure units have been completed by DON, compliance, ADON, on 06/22/25. No concerns from residents were voiced. On 6/23/2025 Skin assessments were completed, and no visible signs of physical abuse were noted. We will continue [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for resident-to-resident altercations. 1. The facility failed to prevent supervision of Resident #1 from abusing Resident #3 on Hall 400 (male secured locked unit) that led to an emergency room visit resulting in head laceration requiring 3 staples for Resident #3 on 05/25/2025. 2. The facility failed to ensure Hall 400 (male secured locked unit) had sufficient supervising staff to prevent Resident #1 from abusing Resident #4 that led to hospitalization of Resident #1 and a fall resulting in a skin tear to Resident #4's left elbow, while Resident #1 was supposed to be on 1:1 monitoring on 05/25/2025. 3. The facility failed ensure Hall 500 (female secured unit) had sufficient supervising staff to prevent Resident #2 from abusing Resident #5 resulting in a skin tear to her arm for Resident #5 on 06/04/2025. 4. The facility failed ensure Hall 500 (female secured unit) had sufficient supervising staff to prevent Resident #2 from abusing Resident #5 by slapping her across the face on 06/08/2025. 5. The facility failed ensure Hall 500 (female secured unit) had sufficient supervising staff to prevent Resident #2 from abusing Resident #6 resulting in a skin tear to the cheek for Resident #6, while Resident #2 was supposed to be on 1:1 monitoring on 06/08/2025. An Immediate Jeopardy (IJ) situation was identified on 06/22/2025 at 4:05 pm. While the IJ was removed on 06/24/2025 at 10:30 am, the facility remained out of compliance at a scope of pattern with no actual harm with a potential for more than minimal harm at a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for resident-to-resident altercations and serious harm in the event of an emergency, hospitalizations, and even death. Findings included: Review of the facility document dated 05/25/2025 titled In-service training report, reflected: Subject: 1:1 Monitoring. When a resident is on 1:1 monitoring, the person designated to monitor has to be with that resident at all times. Not just with in eyesight. Not in the same room as them. Not having him in an area where all employees can keep an eye out. There needs to be one designated person who will be filling out the monitoring sheet that is within arm's length. This is so we can quickly intervene, if needed. During an interview on 06/19/2025 at 1:35 pm, the DON stated that both secure units were always staffed with 2 CNA's each on all shifts except night shift which had 1 CNA per unit. She stated that if a resident was placed on 1:1 monitoring, an additional staff was added making 3 CNAs or 2 CNAs on 10:00pm-6:00am shift. Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 12/15/2023, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, heart failure, and alcohol dependence. Review of Resident #1's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: no antipsychotic, antianxiety, or antidepressant medications. Review of Resident's #1's Care Plan, last review 06/10/2025, revealed in part: Focus: Resident demonstrates physical behaviors hits other residents and staff, revised on 04/14/2025. Goal: Resident will not harm self or others through the review date, revised on 06/10/2025. Interventions: 1:1 supervision as needed, revised on 12/13/2024. Further review of care plan revealed no interventions added since 12/13/2024. Review of Resident #1's progress notes revealed: 05/25/2025 10:35 pm, signed by DON: .Resident saw another resident enter his room, he walked to his room and yelled at the other resident. When other resident did not move out fast enough, he punched other resident in the face. Another resident was walking backward, and this resident shoved him causing a fall. No injuries to Resident #1. Stated not in pain. Other resident was sent to the emergency room after hitting head on floor. Initial Treatment/New Orders: skin assessed. 1:1 monitoring, referral to impatient psyc notified: psych center 05/25/2024 at 4:45pm .Interventions 1 on 1 supervision, Redirection. 05/25/2025 10:45 pm, signed by DON: .CMA-A walking into the dinning room, heard two residents having a verbal altercation then saw Resident #1 hit another resident in the face. When the other resident was swinging back, he slid out of his chair onto the floor .Initial Treatment/New orders: skin assessed, 1:1 monitoring, send referral to inpatient psych . notified psych center 05/25/2025 at 6:50pm .Interventions 1 on 1 supervision, Redirection. 05/27/2025 at 1:00 pm, signed by ADON: Resident #1 was transferred to a hospital on [DATE] at 1:00 PM related to resident had aggressive behaviors and was sent to psych facility for evaluation and treatment. Resident #3 Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted on [DATE] with initial admit date of 02/20/2024, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, depression, and dementia. Review of Resident #3's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. E0900. Wandering: behavior not exhibited. Section N: Medications: antidepressant medications. Review of Resident's #3's Care Plan, last review 05/29/2025, revealed in part: Focus: Resident is at risk for wandering, revised on 02/21/2024. Goal: Resident's safety will be maintained through the review date, revised on 05/29/2025. Interventions: Distract him from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, revised on 02/21/2024. Identify pattern of wandering, revised on 02/21/2024. Further review of care plan revealed no interventions regarding wandering added since 02/21/2024. Review of Resident #3's progress notes revealed: 05/25/2025 4:53 pm, signed by RN-B: Resident #3 was transferred to a hospital on [DATE] PM related to resident altercation on another resident. Resident was knocked to the ground and hit his head on the found resident sent out for further Evaluation. 05/25/2025 10:58 pm, signed by DON: .Resident wandered into another resident's room. Other resident came in starting verbal altercation. When this resident did not move fast enough the other resident punched him in the face. The resident was backing up trying to exit room and fell landing on left lateral. 911 was called immediately. Skin assessed and previous left elbow skin tear was bleeding and noted to be bigger in size. No pain .Physician notified on 05/25/2025 6:45 PM . Review of Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 4:20 pm, Resident #3 went into Resident #1's room. Staff heard yelling and saw Resident #1 hit and push Resident #3. Resident #3 fell to the floor and hit his head on the floor and sent to emergency room to be further evaluated. Resident #3 had laceration to back of heat with hematoma, no bleeding, no signs of infection, closed with 3 staples, measurements 1.5x2x0.5cm, hematoma measures 4x5x0.5cm, hematoma to left side of head measurements 3x3cm, bruises to bilateral upper extremities, reopened skin teas to left elbow with part of skin fold missing, no bleeding, no signs of infection, measurements 2x2.5x0.1cm, no other skin issues noted at this time. Facility initiated one on one monitoring with Resident #1. Contacted psych services. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed 2 CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the 2 CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Resident #4 Review of Resident #4's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 03/25/2024, to Hall 400 (male secured locked unit) with diagnoses which included: personality change, depression, and dementia. Review of Resident #4's Quarterly MDS assessment, dated 05/30/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 physical behavioral symptom directed towards others. Section N: Medications: antidepressant medications. Review of Resident's #4's Care Plan, last review 06/19/2025, revealed in part: Focus: Resident has a potential for trauma that may have a negative impact. The trauma is related to physical altercation, revised on 05/26/2025. Goal: Staff will assist in avoiding triggers through next review date. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediate to the nurse. Record review of Resident #4's progress notes revealed: 05/25/2025 11:09 pm, signed by DON: .The fall caused a skin tear to left elbow. Size of the skin tear in cm: 0.5 x 0.5. New/bleeding, a verbal altercation between this resident and another resident was overheard. CMA- A walked into dining room and saw another resident hit this resident in the face, when Resident #4 tried to swing back he slid out of his chair. Upon assessment a skin tear to the left elbow was noted. Stated it did not hurt . Review of Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 6:30 pm, Resident ##1 slapped Resident #4 and when Resident #4 tried to swing back he slid out of his chair. Upon his assessment a skin tear to the left elbow was noted, measurements 0.8x0.7x0.1cm. Facility initiated one on one monitoring with Resident #1. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed (2) CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the (2) CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. During an interview on 06/20/2025 at 12:45 pm, CNA- C stated she was on shift on Secure Hall 400 at the time of these incidents with Resident #1. She stated on 05/25/2025, there was only herself and 1 other staff to supervise the 19 residents plus provide 1:1 monitoring with Resident #1 that required the resident to always be within arm's reach. She stated the locked unit was also having issues with the locked doors on the unit not functioning; therefore, they also had to monitor the doors, the residents, and provide 1:1 of Resident #1 within arm's reach. She stated that Resident #1 was placed on 1:1 monitoring but no extra staff was sent. She stated that at the time of the second incident Resident #1 was in the dining room and no staff was present. She stated she worked the secure unit alone often and had never been given extra staff when residents were placed 1:1 monitoring requiring residents to be within arm's reach. During an interview on 06/20/2025 at 8:00 pm, LVN-G stated she was responsible for Secure Hall 400 and Secure Hall 500 on 05/25/2025 from 2pm-10pm. She stated she was on Secure Hall 500 at the time of the first incident. She stated she was back on Secure Hall 500 when the 2nd incident happened. She stated Resident #1 was supposed to be on 1:1 monitoring because of the previous incident, when the 2nd incident happened, and she did not know why he was not. She stated there were only 2 CNAs covering Secure Hall 400 at the time and that there was no way that the LVN could help with 1:1 monitoring because she was responsible for both secure halls. During an interview on 06/20/2025 at 8:15 pm, CMA-A stated he was working on 05/25/2025 at time of both incidents and stated that he was in a resident's room during the 1st incident with Resident #3 and did not see that incident, but he knew that he was placed on 1:1 monitoring. He stated that he was walking down the hall, when the 2nd incident happened and heard Resident #1 yelling then he spotted Resident #1 in the dining room with no staff present and saw him slap Resident #4. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 02/09/2024, to Hall 500 (female secured locked unit) with diagnoses which included: traumatic brain injury, anxiety, depression, and dementia. Review of Resident #2's Quarterly MDS assessment, dated 05/20/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 other behavioral symptom not directed towards others. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #2's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors attempts to hit other residents, revised on 04/09/2025. Goal: Resident will not harm self or others through the review date, revised on 05/22/2025. Interventions: When she becomes agitated: intervene before agitation escalates; guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later, revised on 11/18/2024. Record review of Resident #2's progress notes revealed: 06/04/2025 11:13 am, signed by LVN-E: .resident started being anxious and agitated. resident grabbed another resident arm causing a skin tear . resident is currently on 1:1 for monitoring .: 06/08/2025 12:19 pm, signed by LVN-F: . nurse was called by resident in hallway, that resident has just slapped another resident across the face. psych facility contacted, and 1:1 supervision. 06/08/2025 1:09 pm, signed by LVN-F . resident was grabbing another female resident by her cheeks and would not let her go, staff intervened but resident would not let other resident go. Resident #5 Review of Resident #5's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 06/10/2020, to Hall 500 (female secured locked unit) with diagnoses which included: anxiety, Alzheimer's, and mood disorder. Review of Resident #5's Annual MDS assessment, dated 06/04/2025, revealed a BIMS score of 99 which indicated resident was unable to complete the interview. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #5's Care Plan, last review 04/10/2025, revealed in part: Focus: Resident has a history of trauma that may have a negative impact. The trauma is related to getting scratched, revised on 06/05/2025. Goal: Maintain resident safety and integrity during post trauma episode, using appropriate interventions, revised on 06/05/2025. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse, revised on 06/05/2025. Review of the facility daily staff schedule, dated 06/04/2025 at the time of the incident, revealed (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Record review of Resident #5's progress notes revealed: 06/05/2025 10:38 am, signed by LVN-E: . resident received a skin tear due to another resident grabbing her arm. Physician notified on 06/04/2025 at 10:10am. 06/08/2025 12:29pm, signed by LVN-F: . Resident voices she was slapped across the face by the other female resident. Review of Provider Investigation Report, dated 06/11/2025, revealed: On 06/04/2025 at 10:00am, Residents were sitting at the table in dinning room when Resident #2 reached over and grabbed Resident #5's arm causing a skin tear. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/04/2025 at the time of the incident, revealed (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 10:15am-2:00pm, was signed by the (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. During an interview on 06/19/2025 at 2:00pm, CNA-J she was on shift on Secure Hall 500 at the time of this incident with Resident #2 on 06/04/2025. She stated there was supposed to always be 2 CNAs, but she worked many times by herself. She stated that when a resident is placed on 1:1 monitoring the 2 CNAs on shift rotated and monitored them as close as possible. She stated it was very rare that a third CNA was sent. She stated she had worked on the floor multiple times alone with a resident on 1:1 monitoring. She stated when a resident was 1:1 the staff was supposed to be within arm's length of them at all times and must follow them wherever they go. She stated she could not remember specific dates or incidents because there were so many incidents and 1:1 monitoring that she couldn't remember them all. Resident #6 Review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] to Hall 500 (female secured locked unit) with diagnoses which included: explosive disorder, Alzheimer's, and seizures. Review of Resident #6's Quarterly MDS assessment, dated 05/26/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms- Presence and Frequency: 1 physical behavioral symptom director towards others. Section N: Medications: no antianxiety, antipsychotic, or antidepressant medications. Review of Resident's #6's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors, revised on 02/16/2024. Goal: Resident will demonstrate effective coping skills through the review date, revised on 05/22/2025. Interventions: Assess and anticipate her needs: food, thirst, toileting needs, comfort level, body positioning, pain, revised on 08/29/2023. Record review of Resident #6's progress notes revealed: 06/08/2025 1:28pm, signed by LVN-F: . Resident was in her wheelchair looking outside, when the other female resident came up to her and grabbed her face and started being combative, nurse/aide intervened but other resident would not let her go. Review of Provider Investigation Report, dated 06/13/2025, revealed: On 06/08/2025 at 12:00pm, Resident #2 hit Resident #5 with no injuries. She then grabbed Resident #6 by the face causing a very small scratch to her cheek. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/08/2025 at the time of the incident, revealed (1) CNA (CNA-M) and a float CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/08/2025 revealed 1:1 monitoring was not initiated until 1:00 pm after the 2nd incident. 1:1 monitoring sheet was signed by RN-B who was assigned as a nurse for Hall 100 and Hall 200. During an interview on 06/21/2025 at 9:00 am, LVN-F stated she was responsible for Secure Hall 500 and Secure Hall 400 on 06/08/2025 from 2pm-10pm. She stated that Resident #2 was supposed to have been placed on 1:1 monitoring after the 1st incident but there was no staff available. She stated Resident #1 and Resident #6 were in the dining room alone when she heard Resident #6 screaming. She stated the LVNs cannot provide 1:1 monitoring because they are responsible for multiple halls. During an interview on 06/20/2025 at 12:30pm, the ADON stated the secured units were supposed to be staffed with 2 CNAs each during the day and 1 CNA each on 10pm-6 am shift. She stated when a resident was placed 1:1 monitoring, and additional staff member was supposed to be designated for that resident. She stated they pull staff from other departments such as dietary and housekeeping to perform 1:1 monitoring. She stated 1:1 means that 1 staff is with that resident at all times. The ADON stated that on the night shift, if there was only 1 CNA assigned to both secure units, the LVN would stay on the opposite unit and monitor it. She stated resident were usually asleep on that shift, so she felt that 1 person on each unit was enough even when a resident was on 1:1 monitoring. During an interview on 06/20/2025 at 3:30pm, the DON stated that she was not aware of any times that there was not a designated staff for residents on 1:1 monitoring. She stated did not know how Resident # 1 and Resident #2 were able to get into 2nd altercations while on 1:1 monitoring. She stated she felt the facility was doing a good job preventing altercations and injuries. She stated that she did not feel that the facility was short staffed. During an interview on 06/23/2025 at 8:00pm, the ADO stated the facility did not have a policy regarding accidents and hazards. This was determined to be an Immediate Jeopardy (IJ) on 06/22/2025 at 4:05pm. The Regional Compliance Nurse, Director of Nurses, and Assistant Director of Nurses were notified. The Regional Compliance Nurse was provided with the IJ template on 06/22/2022 at 4:05 PM. The following Plan of Removal was accepted on 06/23/2025 at 6:20 PM and included: Interventions: Any resident that resides in the secure unit that has the potential for resident-to-resident altercation can be affected by deficient practices. Alleged perpetrator Resident #2 was interviewed by DON on 06/22/26 @ 6:15pm with no concerns voiced by resident and placed on 15-minute checks for resident safety and the safety of other resident in the secure unit and continued for at least 24 hours. Resident #1 was interviewed on 06/23/25 by DON and voiced no concerns and did not recall being aggressive with any other resident. Resident #7 was interviewed on 06/23/25 by DON and resident did not voice any concerns and could not recall being aggressive with any other resident. Resident #8 is not at the facility for an interview on 06/23/25 and Resident #9 is not at the facility for an interview on 06/23/25. Abuse prevention in-service for all facility staff initiated in house and completed by Admin/DON/Compliance Nurse on 06/22/2025 and for staff that is not present during the in-services will be sent the in-service via staffing application and they be not be allowed to assume duties until in-service prior to them clocking in for their shift and all new staff or agency staff will be in-services on abuse prior to them starting their position. All in services to be completed by 6/23/2025. Immediate psychiatric services on call for residents that trigger through trauma informed assessments on the secure unit completed on 06/22/2025. Referrals sent out by DON and will be followed up by DON for Resident #2 have been sent out to other skilled nursing facility and Behavioral Hospitals. and Resident #8 referral was sent to a facility and accepted and admitted [DATE], Resident #9 referred to a facility and accepted and admitted on [DATE]. Resident #1 referral sent to psych hospital and accepted and admitted 05/2725 and return 06/03/25. All direct care staff that were work at the time of the incident in the secured unit working with Resident #2 have been interviewed by DON on 06/22/25 and no root cause could be determined for her behaviors. Staff was able to state regarding Resident #1 resident is very territorial and does not like resident entering his room and resident was transition to long term community in a private room and have decrease behaviors and for Resident #9 no root cause was determined for his behavior. For Resident #7 no root cause was determined for his behavior. Resident #8 no root cause was determined for his behaviors. Facility will ensure adequate staffing to manage acuity based on the 24-hour report in Point Click Care, Real Time systems monitoring and current census. The administrator will maintain adequate staff for resident safety per acuity. Staffing will be reviewed during stand-up Meetings at 8:30 AM and stand-down meetings at 4PM to ensure there is adequate staffing for the secure units. During both meetings the team will review, and the Administrator/designee will adjust staffing to maintain resident safety based on acuity based on the 24-hour report in PCC, Real Time Systems monitoring and current census. If one on one is required additional staff member will be added and not substituted with the current staff in the units to ensure adequate staffing to protect residents from further incidents. The facility administrator/designee will decide and assure staff are assigned to the 1:1 resident. The Administrator/DON will check in with assigned staff frequently to assure that 1:1 monitoring is ongoing. Resident interviews on the secure units have been completed by DON, compliance, ADON, on 06/22/25. No concerns from residents were voiced. On 6/23/2025 Skin assessments were completed, and no visible signs of physical abuse were noted. We will continue to monitor with random interviews and weekly skin assessments, and address if issues are identified. Primary contact for each resident on the secure unit to be contacted on 6/23/2025 by the DON/Compliance Nurse to inquire about any concerns related to resident safety/abuse. These will be reviewed by the DON/Facility Administrator, Regional Compliance Nurse, and ADO for follow up and to address concerns identified. All resident responsible party contacts will be initiated/completed by 6/23/2025. Trauma informed assessment (to determine historical or present trauma based on resident perspective) completed by Compliance, DON and ADON on residents in the secured unit with history of physical aggression and assessment were completed on 06/22/2025. No trauma was identified during these assessments. On 6/23/2025, skin assessments were completed by DON and Compliance Nurse to assess for signs of physical trauma. Off cycle QAPI done with Dr. medical director via telephone on 06/22/25 by facility DON. No recommendation made by the medical director at this time. The following in-services were initiated by Facility DON on 06/22/25. Any staff member who is not present during the in-service will not be allowed to assume their duties until in-service. All in-services sent via staffing application to all staff on 06/22/25. o All Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to Management of aggressive behavior One-to-one monitoring Prevention of Resident-to-Resident physical Abuse On 6/23/2025, 1:1 in-service for Administrator by ADO regarding staffing adjustment as needed based on acuity to maintain resident safety. After receiving education, a handout is given to the staff members to have on their person in case a question arises and random interviews with staff members are ongoing to assess understanding. These will be completed by DON/Compliance team/ADO. Monitoring of facilities Plan of Removal through observations, interviews, and record reviews from 06/23/2022 at 7:00 PM through 06/24/2022 at 10:30 AM revealed: Review of facility documents revealed written interviews by the DON with Resident #2, Resident #1, and Resident #7, with no concerns voiced. Review of facility fax receipts revealed referrals were faxed on 06/21/2025 to 6 different facilities for Resident #2. Review of facility documents revealed 9 staff were interviewed by DON for Resident #2, 5 staff were interviewed for Resident #7, 4 staff were interviewed for Resident #1, and 2 staff were interviewed for Resident #9. The questions asked where: Are you aware of any triggers for resident? What time of day are her behaviors worst? Is there anything they like? Are there any recommendations to improve care? And are there any co[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 5 (Resident #1, Resident #2, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for sufficient staffing related resident-to-resident altercations and 1:1 monitoring. 1. The facility failed to ensure Hall 400 (male secured locked unit) had sufficient staffing to prevent Resident #1 from abusing Resident #4 that led to hospitalization of Resident #1 and a fall resulting in a skin tear to Resident #4's left elbow, while Resident #1 was supposed to be on 1:1 monitoring from a previous altercation on 05/25/2025. 2. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #5 resulting in a skin tear to her arm for Resident #5 on 06/04/2025. 3. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #5 by slapping her across the face on 06/08/2025. 4. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #6 resulting in a skin tear to the cheek for Resident #6, while Resident #2 was supposed to be on 1:1 monitoring on 06/08/2025. 5. The facility failed to ensure Hall 400 (male secured unit) had sufficient staff to provide 1:1 monitoring for Resident #1 on 05/25/2025 from 10:00pm-6:00am. 6. The facility failed to ensure Hall 500 (female secure unit) had sufficient staffing to provide 1:1 monitoring for Resident #2 on 06/04/2024 from 2:00pm-10:00pm, and from 10:00pm-6:00am. 7. The facility failed to ensure Hall 500 (male secure unit) had sufficient staffing to provide 1:1 monitoring for Resident #2 on 06/08/2024 from 2:00pm-10:00pm, and from 10:00pm-6:00am. An Immediate Jeopardy (IJ) situation was identified on 06/22/2025 at 4:05 pm. While the IJ was removed on 06/24/2025 at 10:30 am, the facility remained out of compliance at a scope of pattern with no actual harm with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for resident-to-resident altercations and serious harm in the event of an emergency, hospitalizations, and even death. Findings included: Review of the facility document dated 05/25/2025 titled In-service training report, reflected: Subject: 1:1 Monitoring. When a resident is on 1:1 monitoring, the person designated to monitor has to be with that resident at all times. Not just with in eyesight. Not in the same room as them. Not having him in an area where all employees can keep an eye out. There needs to be one designated person who will be filling out the monitoring sheet that is within arm's length. This is so we can quickly intervene, if needed. During an interview on 06/19/2025 at 1:35 pm, the DON stated that both secure units were always staffed with 2 CNA's each on all shifts except night shift which had 1 CNA per unit. She stated that if a resident was placed on 1:1 monitoring, an additional staff was added making 3 CNAs or 2 CNAs on 10:00pm-6:00am shift. Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 12/15/2023, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, heart failure, and alcohol dependence. Review of Resident #1's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: no antipsychotic, antianxiety, or antidepressant medications. Review of Resident's #1's Care Plan, last review 06/10/2025, revealed in part: Focus: Resident demonstrates physical behaviors hits other residents and staff, revised on 04/14/2025. Goal: Resident will not harm self or others through the review date, revised on 06/10/2025. Interventions: 1:1 supervision as needed, revised on 12/13/2024. Further review of care plan revealed no interventions added since 06/20/2024. Review of Resident #1's progress notes revealed: 05/25/2025 10:45 pm, signed by DON: .CMA-A walking into the dining room, heard two residents having a verbal altercation then saw Resident #1 hit another resident in the face. When the other resident was swinging back, he slid out of his chair onto the floor .Initial Treatment/New orders: skin assessed, 1:1 monitoring, send referral to inpatient psych . notified psych center 05/25/2025 at 6:50pm .Interventions 1 on 1 supervision, Redirection. 05/27/2025 at 1:00 pm, signed by ADON: Resident #1 was transferred to a hospital on [DATE] at 1:00 PM related to resident had aggressive behaviors and was sent to psych facility for evaluation and treatment. Resident #3 Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted on [DATE] with initial admit date of 02/20/2024, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, depression, and dementia. Review of Resident #3's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. E0900. Wandering: behavior not exhibited. Section N: Medications: antidepressant medications. Review of Resident's #3's Care Plan, last review 05/29/2025, revealed in part: Focus: Resident is at risk for wandering, revised on 02/21/2024. Goal: Resident's safety will be maintained through the review date, revised on 05/29/2025. Interventions: Distract him from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, revised on 02/21/2024. Identify pattern of wandering, revised on 02/21/2024. Further review of care plan revealed no interventions regarding wandering added since 02/21/2024. Review of Resident #3's progress notes revealed: 05/25/2025 4:53 pm, signed by RN-B: Resident #3 was transferred to a hospital on [DATE] PM related to resident altercation on another resident. Resident was knocked to the ground and hit his head on the found resident sent out for further Evaluation. 05/25/2025 10:58 pm, signed by DON: .Resident wandered into another resident's room. Other resident came in starting verbal altercation. When this resident did not move fast enough the other resident punched him in the face. The resident was backing up trying to exit room and fell landing on left lateral. 911 was called immediately. Skin assessed and previous left elbow skin tear was bleeding and noted to be bigger in size. No pain .Physician notified on 05/25/2025 6:45 PM . Review of Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 4:20 pm, Resident #3 went into Resident #1's room. Staff heard yelling and saw Resident #1 hit and push Resident #3. Resident #3 fell to the floor and hit his head on the floor and sent to emergency room to be further evaluated. Resident #3 had laceration to back of heat with hematoma, no bleeding, no signs of infection, closed with 3 staples, measurements 1.5x2x0.5cm, hematoma measures 4x5x0.5cm, hematoma to left side of head measurements 3x3cm, bruises to bilateral upper extremities, reopened skin teas to left elbow with part of skin fold missing, no bleeding, no signs of infection, measurements 2x2.5x0.1cm, no other skin issues noted at this time. Facility initiated one on one monitoring with Resident #1. Contacted psych services. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed 2 CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the 2 CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Resident #4 Review of Resident #4's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 03/25/2024, to Hall 400 (male secured locked unit) with diagnoses which included: personality change, depression, and dementia. Review of Resident #4's Quarterly MDS assessment, dated 05/30/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 physical behavioral symptom directed towards others. Section N: Medications: antidepressant medications. Review of Resident's #4's Care Plan, last review 06/19/2025, revealed in part: Focus: Resident has a potential for trauma that may have a negative impact. The trauma is related to physical altercation, revised on 05/26/2025. Goal: Staff will assist in avoiding triggers through next review date. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediate to the nurse. Record review of Resident #4's progress notes revealed: 05/25/2025 11:09 pm, signed by DON: .The fall caused a skin tear to left elbow. Size of the skin tear in cm: 0.5 x 0.5. New/bleeding, a verbal altercation between this resident and another resident was overheard. CMA- A walked into dining room and saw another resident hit this resident in the face, when Resident #4 tried to swing back he slid out of his chair. Upon assessment a skin tear to the left elbow was noted. Stated it did not hurt . Review of Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 6:30 pm, Resident ##1 slapped Resident #4 and when Resident #4 tried to swing back he slid out of his chair. Upon his assessment a skin tear to the left elbow was noted, measurements 0.8x0.7x0.1cm. Facility initiated one on one monitoring with Resident #1. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed (2) CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the (2) CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. During an interview on 06/20/2025 at 12:45 pm, CNA- C stated she was on shift on Secure Hall 400 at the time of these incidents with Resident #1. She stated on 05/25/2025, there was only herself and 1 other staff to supervise the 19 residents plus provide 1:1 monitoring with Resident #1 that required the resident to always be within arm's reach. She stated the locked unit was also having issues with the locked doors on the unit not functioning; therefore, they also had to monitor the doors, the residents, and provide 1:1 of Resident #1 within arm's reach. She stated that Resident #1 was placed on 1:1 monitoring but no extra staff was sent. She stated that at the time of the second incident Resident #1 was in the dining room and no staff was present. She stated she worked the secure unit alone often and had never been given extra staff when residents were placed 1:1 monitoring requiring residents to be within arm's reach. During an interview on 06/20/2025 at 8:00 pm, LVN-G stated she was responsible for Secure Hall 400 and Secure Hall 500 on 05/25/2025 from 2pm-10pm. She stated she was on Secure Hall 500 at the time of the first incident. She stated she was back on Secure Hall 500 when the 2nd incident happened. She stated Resident #1 was supposed to be on 1:1 monitoring because of the previous incident, when the 2nd incident happened, and she did not know why he was not. She stated there were only 2 CNAs covering Secure Hall 400 at the time and that there was no way that the LVN could help with 1:1 monitoring because she was responsible for both secure halls. During an interview on 06/20/2025 at 8:15 pm, CMA-A stated he was working on 05/25/2025 at time of both incidents and stated that he was in a resident's room during the 1st incident with Resident #3 and did not see that incident but he knew that he was placed on 1:1 monitoring. He stated that he was walking down the hall, when the 2nd incident happened and heard Resident #1 yelling then he spotted Resident #1 in the dining room with no staff present and saw him slap Resident #4. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 02/09/2024, to Hall 500 (female secured locked unit) with diagnoses which included: traumatic brain injury, anxiety, depression, and dementia. Review of Resident #2's Quarterly MDS assessment, dated 05/20/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 other behavioral symptom not directed towards others. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #2's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors attempts to hit other residents, revised on 04/09/2025. Goal: Resident will not harm self or others through the review date, revised on 05/22/2025. Interventions: When she becomes agitated: intervene before agitation escalates; guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later, revised on 11/18/2024. Record review of Resident #2's progress notes revealed: 06/04/2025 11:13 am, signed by LVN-E: .resident started being anxious and agitated. resident grabbed another resident arm causing a skin tear . resident is currently on 1:1 for monitoring .: 06/08/2025 12:19 pm, signed by LVN-F: . nurse was called by resident in hallway, that resident has just slapped another resident across the face. psych facility contacted, and 1:1 supervision. 06/08/2025 1:09 pm, signed by LVN-F . resident was grabbing another female resident by her cheeks and would not let her go, staff intervened but resident would not let other resident go. Resident #5 Review of Resident #5's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 06/10/2020, to Hall 500 (female secured locked unit) with diagnoses which included: anxiety, Alzheimer's, and mood disorder. Review of Resident #5's Annual MDS assessment, dated 06/04/2025, revealed a BIMS score of 99 which indicated resident was unable to complete the interview. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #5's Care Plan, last review 04/10/2025, revealed in part: Focus: Resident has a history of trauma that may have a negative impact. The trauma is related to getting scratched, revised on 06/05/2025. Goal: Maintain resident safety and integrity during post trauma episode, using appropriate interventions, revised on 06/05/2025. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse, revised on 06/05/2025. Review of the facility daily staff schedule, dated 06/04/2025 at the time of the incident, revealed (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Record review of Resident #5's progress notes revealed: 06/05/2025 10:38 am, signed by LVN-E: . resident received a skin tear due to another resident grabbing her arm. Physician notified on 06/04/2025 at 10:10am. 06/08/2025 12:29pm, signed by LVN-F: . Resident voices she was slapped across the face by the other female resident. Review of Provider Investigation Report, dated 06/11/2025, revealed: On 06/04/2025 at 10:00am, Residents were sitting at the table in dining room when Resident #2 reached over and grabbed Resident #5's arm causing a skin tear. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/04/2025 at the time of the incident, revealed (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 10:15am-2:00pm, was signed by the (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. During an interview on 06/19/2025 at 2:00pm, CNA-J she was on shift on Secure Hall 500 at the time of this incident with Resident #2 on 06/04/2025. She stated there was supposed to always be 2 CNAs, but she worked many times by herself. She stated that when a resident is placed on 1:1 monitoring the 2 CNAs on shift rotated and monitored them as close as possible. She stated it was very rare that a third CNA was sent. She stated she had worked on the floor multiple times alone with a resident on 1:1 monitoring. She stated when a resident was 1:1 the staff was supposed to be within arm's length of them at all times and must follow them wherever they go. She stated she could not remember specific dates or incidents because there were so many incidents and 1:1 monitoring that she couldn't remember them all. Resident #6 Review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] to Hall 500 (female secured locked unit) with diagnoses which included: explosive disorder, Alzheimer's, and seizures. Review of Resident #6's Quarterly MDS assessment, dated 05/26/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms- Presence and Frequency: 1 physical behavioral symptom director towards others. Section N: Medications: no antianxiety, antipsychotic, or antidepressant medications. Review of Resident's #6's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors, revised on 02/16/2024. Goal: Resident will demonstrate effective coping skills through the review date, revised on 05/22/2025. Interventions: Assess and anticipate her needs: food, thirst, toileting needs, comfort level, body positioning, pain, revised on 08/29/2023. Record review of Resident #6's progress notes revealed: 06/08/2025 1:28pm, signed by LVN-F: . Resident was in her wheelchair looking outside, when the other female resident came up to her and grabbed her face and started being combative, nurse/aide intervened but other resident would not let her go. Review of Provider Investigation Report, dated 06/13/2025, revealed: On 06/08/2025 at 12:00pm, Resident #2 hit Resident #5 with no injuries. She then grabbed Resident #6 by the face causing a very small scratch to her cheek. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/08/2025 at the time of the incident, revealed (1) CNA (CNA-M) and a float CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/08/2025 revealed 1:1 monitoring was not initiated until 1:00 pm after the 2nd incident. 1:1 monitoring sheet was signed by RN-B who was assigned as a nurse for Hall 100 and Hall 200. During an interview on 06/21/2025 at 9:00 am, LVN-F stated she was responsible for Secure Hall 500 and Secure Hall 400 on 06/08/2025 from 2pm-10pm. She stated that Resident #2 was supposed to have been placed on 1:1 monitoring after the 1st incident but there was no staff available. She stated Resident #1 and Resident #6 were in the dining room alone when she heard Resident #6 screaming. She stated the LVNs cannot provide 1:1 monitoring because they are responsible for multiple halls. Review of the facility daily staff schedule, dated 05/25/2025, revealed during the 10:00pm to 6:00am shift, there was (1) CNA (CNA-H) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with one (1) of the 36 requiring 1:1 monitoring. Review of 1:1 monitoring sheet for Resident #1 on 05/25/2025 from 10:00pm-6:00am, revealed it was signed LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. Review of the facility daily staff schedule dated 06/04/2025 from 2:00pm-10:00pm, revealed (2) CNA (CNA-K and CNA-L) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 2:00pm-10:00pm, was signed by one of the CNAs (CNA-K) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the facility daily staff schedule, dated 06/04/2025, revealed during the 10:00pm to 6:00am shift, there was (1) CNA (CNA-H) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with (2) of the 36 requiring 1:1 monitoring. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 10:00pm-6:00am, revealed it was signed by LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. Review of the facility daily staff schedule dated 06/08/2025 from 2:00pm-10:00pm, revealed (2) CNA (CNA-N and CNA-L) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/08/2025 from 2:00pm-10:00pm, was signed by one of CNAs (CNA-L) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the facility daily staff schedule, dated 06/08/2025, revealed during the 10:00pm to 6:00am shift, there was (2) CNA (CNA-O and CNA-P) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with (2) of the 36 requiring 1:1 monitoring. Review of 1:1 monitoring sheet for Resident #1 on Secure Hall 400 and Resident #2 on Secure Hall 500 on 06/04/2025 from 10:00pm-6:00am, revealed it was signed by LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. During an interview on 06/20/2025 at 10:15pm, with CNA-O who worked 10pm-6am stated that he worked many shifts alone and he was responsible for covering Secure Hall 400 and Secure Hall 500 at the same time. He stated he also worked alone when residents were on 1:1 monitoring. He stated 1:1 monitoring should be where the staff is within arm's length of the resident, but that was not possible when he was the only CNA and was responsible for both halls. During an interview on 06/20/2025 at 12:30pm, the ADON stated the secured units were supposed to be staffed with 2 CNAs each during the day and 1 CNA each on 10pm-6 am shift. She stated when a resident was placed 1:1 monitoring, and additional staff member was supposed to be designated for that resident. She stated they pull staff from other departments such as dietary and housekeeping to perform 1:1 monitoring. She stated 1:1 means that 1 staff is with that resident at all times. The ADON stated that on the night shift, if there was only 1 CNA assigned to both secure units, the LVN would stay on the opposite unit and monitor it. She stated resident were usually asleep on that shift, so she felt that 1 person on each unit was enough even when a resident was on 1:1 monitoring. During an interview on 06/20/2025 at 3:30pm, the DON stated that she was not aware of any times that there was not a designated staff for residents on 1:1 monitoring. She stated did not know how Resident # 1 and Resident #2 were able to get into 2nd altercations while on 1:1 monitoring. She stated she felt the facility was doing a good job preventing altercations and injuries. She stated that she did not feel that the facility was short staffed. During an interview on 06/23/2025 at 8:00pm, the ADO stated the facility did not have a staffing policy. This was determined to be an Immediate Jeopardy (IJ) on 06/22/2025 at 4:05pm. The Regional Compliance Nurse, Director of Nurses, and Assistant Director of Nurses were notified. The Regional Compliance Nurse was provided with the IJ template on 06/22/2022 at 4:05 PM. The following Plan of Removal was accepted on 06/23/2025 at 6:20 PM and included: Interventions: Any resident that resides in the secure unit that has the potential for resident-to-resident altercation can be affected by deficient practices. Alleged perpetrator Resident #2 was interviewed by DON on 06/22/26 @ 6:15pm with no concerns voiced by resident and placed on 15-minute checks for resident safety and the safety of other resident in the secure unit and continued for at least 24 hours. Resident #1 was interviewed on 06/23/25 by DON and voiced no concerns and did not recall being aggressive with any other resident. Resident #7 was interviewed on 06/23/25 by DON and resident did not voice any concerns and could not recall being aggressive with any other resident. Resident #8 is not at the facility for an interview on 06/23/25 and Resident #9 is not at the facility for an interview on 06/23/25. Abuse prevention in-service for all facility staff initiated in house and completed by Admin/DON/Compliance Nurse on 06/22/2025 and for staff that is not present during the in-services will be sent the in-service via staffing application and they be not be allowed to assume duties until in-service prior to them clocking in for their shift and all new staff or agency staff will be in-services on abuse prior to them starting their position. All in services to be completed by 6/23/2025. Immediate psychiatric services on call for residents that trigger through trauma informed assessments on the secure unit completed on 06/22/2025. Referrals sent out by DON and will be followed up by DON for Resident #2 have been sent out to other skilled nursing facility and Behavioral Hospitals. and Resident #8 referral was sent to a facility and accepted and admitted [DATE], Resident #9 referred to a facility and accepted and admitted on [DATE]. Resident #1 referral sent to psych hospital and accepted and admitted 05/2725 and return 06/03/25. All direct care staff that were work at the time of the incident in the secured unit working with Resident #2 have been interviewed by DON on 06/22/25 and no root cause could be determined for her behaviors. Staff was able to state regarding Resident #1 resident is very territorial and does not like resident entering his room and resident was transition to long term community in a private room and have decrease behaviors and for Resident #9 no root cause was determined for his behavior. For Resident #7 no root cause was determined for his behavior. Resident #8 no root cause was determined for his behaviors. Facility will ensure adequate staffing to manage acuity based on the 24-hour report in Point Click Care, Real Time systems monitoring and current census. The administrator will maintain adequate staff for resident safety per acuity. Staffing will be reviewed during stand-up Meetings at 8:30 AM and stand-down meetings at 4PM to ensure there is adequate staffing for the secure units. During both meetings the team will review, and the Administrator/designee will adjust staffing to maintain resident safety based on acuity based on the 24-hour report in PCC, Real Time Systems monitoring and current census. If one on one is required additional staff member will be added and not substituted with the current staff in the units to ensure adequate staffing to protect residents from further incidents. The facility administrator/designee will decide and assure staff are assigned to the 1:1 resident. The Administrator/DON will check in with assigned staff frequently to assure that 1:1 monitoring is ongoing. Resident interviews on the secure units have been completed by DON, compliance, ADON, on 06/22/25. No concerns from residents were voiced. On 6/23/2025 Skin assessments were completed, and no visible signs of physical abuse were noted. We will continue to monitor with random interviews and weekly skin assessments, and address if issues are identified. Primary contact for each resident on the secure unit to be contacted on 6/23/2025 by the DON/Compliance Nurse [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #44) of four residents reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident #44 who resided in the secure unit. As a result, he eloped from the facility and was located approximately 20 minutes later after he had crossed a 5-lane street. Resident #44, who was diagnosed with dementia, had attempted on 2 other occasions to elope from the secure unit through a resident room window. On the third attempt he went out a resident's window and out the back gate of the secure unit due to the gate magnetic locking mechanism not aligning up correctly. It was determined a past non-compliance Immediate Jeopardy existed from 09/18/22 to 09/19/22. The Immediate Jeopardy was determined to have been removed due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure could place residents at risk for elopement that could result in injury, impairment or even death. Findings included: Review of Resident #44's admission record dated 09/27/22 revealed he was an [AGE] year old male admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and dementia. Record review of Resident #44's MDS dated [DATE] indicated in part: BIMS = 12 indicating the resident was moderately impaired. Disorganized Thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? Indicated the resident Behavior present, fluctuates (comes and goes, changes in severity) Wandering - Presence & Frequency =. 3. Behavior of this type occurred daily. Functional Limitation in Range of Motion. No impairment. Mobility Devices = None. Record review of Resident #44's care plan dated 09/19/22 indicated in part: FOCUS: Resident is at risk for wandering related to dementia. GOAL: Resident will not leave facility unattended through the review date. INTERVENTIONS: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Monitor location every 15 min. The resident will reside in the secure unit. Record review of the facility's provider investigation report dated 09/20/2022 and completed by the previous facility Administrator L indicated in part: Incident date 09/18/22, Resident involved: Resident #44. Description of allegation: Resident eloped from secure unit. Resident left out of another resident's room window and went out the back gate and left the facility grounds. Investigation summary: Resident left facility approx. 1345PM (1:45pm), resident exited the facility from another resident's room window. The resident pushed open the back gate and left the facility grounds. Facility gate was not appropriately secured due to the magnets not lined up and touching. Resident was identified walking across the street. Staff brought resident back to the facility at 14:05PM (2:05pm). Resident was combative with staff. The resident was placed 1:1 monitoring and referrals have been sent out to behavioral hospitals transfer. Investigation findings = confirmed. Record review of Resident #44's nurses notes indicated in part: 6/8/2022 22:20 (10:20pm) resident was found by staff trying to get out of his bedroom window. staff that witness stated that resident was about halfway out of the window. this nurse went into resident's room and resident had his window propped up. resident stating that it is too hot in his room right now that is why his window is open. window was closed and resident became upset at staff. 9/4/2022 17:00 (5:00pm) This nurse observed res walking outside in memory care courtyard, upon attempting to redirect res back inside, this nurse noted a window open, and screen removed, res refused to come back inside, attempted x3 to notify family member of elopement attempt. one on one care provided at this time, no injury noted. Record review of CNA B's undated statement indicated in part: I left the hall at 1:35pm [on 09/18/22] to throw my trash. Walked back at 1:40pm into hall 400 noticed another resident coming out of Resident #44's room I thought that was weird. I asked the resident what he was doing? He said he was checking to see if Resident #44 was in there. I checked to see if he was on his bed didn't see him, so I went to the dining room he wasn't there. I told CMA E what was going on. He got up fast we went back to check his room and bathroom he wasn't there. We started checking every room. Didn't find him. CMA E went report it to head of nursing I kept looking we checked back door. Back gate was open. Record review of CMA E's undated statement indicated in part: I did my last hourly check at before I took Resident #44 and other residents at 1:05pm [on 09/18/22]. We came back at 1:25 I went to the nurses station at 1:35, CNA B told me she was going to throw the trash I said ok. She came back at 1:40 and she told me should couldn't find Resident #44. I got up and started checking rooms from the opposite sides of the hall after we met, I went to the nurses station and told them I was missing Resident #44. I return to the hall and opened the emergency exit to check back gate. The alarm went off for the inside door but the gate going to the alley was not locked. I went back inside to turn off the alarm. And started double checking my hall. Then I called DON. During an observation and interview on 09/25/22 at 09:44 AM Resident #44 was in his room awake and alert and ambulating in his room. The resident was asked if he recalled getting out of the facility and he stated yes, he had done that because he wanted to go back home to Seminole. Resident said his family member had just dumped him here and did not want to come pick him up. The resident said none of his children wanted to come and take him home and that was the reason he had gotten out. The resident said he was going to contact the police for them keeping him here. Resident #44 said he had gotten out through a window and then opened the gate door and that was how he got out. During an interview on 09/26/22 at 12:02 PM, CMA D said at one time the back gate located outside the men's unit appeared to be secured with a plastic bag and was not working well, she said she did not recall reporting it. CMA D said the day (09/18/22) that Resident #44 had eloped from the facility she had last seen him at about 1:21 PM because that was when CMA E had brought the resident back inside from smoking in the back patio. CMA D said at about 1:45 PM she heard from facility staff the resident was missing and that some aides had spotted the resident outside by the school. CMA D said she and one of the nurses got in her car and went to assist with getting the resident into her car. CMA D said at the time they got the resident into her car he had already walked about 3 blocks away from the facility. During an interview on 09/27/22 at 11:42 AM, CNA B said she was working 6am-2pm on 09/18/2022 in the men's secure unit on the day Resident #44 had eloped from the facility. CMA B said before she left to take the trash out, she had seen Resident #44 sitting down in the secure unit dining room. CNA B said she told CMA E she was going to take the trash out, said CMA E was sitting at the nurses station when she told him she was leaving to take the trash out. CNA B said when she came back, she noticed another resident coming out of Resident #44's room so she asked him what he was doing and he said he was checking to see if Resident #44 was in his room. CNA B said she looked in the room and did not see Resident #44. She said she asked CMA E where Resident #44 was, and they started looking for him and that's when they noticed he was missing. CNA B said CMA E opened the back door and they noticed that the gate door could be opened by simply pushing it as it was not locked so they assumed the resident went out that way. During an interview on 09/28/22 at 03:02 PM, the DON and ADON, said that as far as they knew Resident #44 had gotten out through one of the resident's windows in the secure unit and had forced open the back gate [on 09/18/22]. They said that along with the regional compliance nurse they had checked the back gate on that day and found that it was not locking. They said they had aligned the locking magnets on the gate and it worked again. They said that as far as they knew the gate was working before Resident #44 eloped. The DON said there was no documentation or plan on checking the gate to make sure it was closing prior to the elopement on 09/18/2022 but that now they had implemented something to check it. The DON said the gate had been repaired the following day [on 09/19/22]. During an observation on 09/28/22 at 03:32 PM, the secure unit back gate was inspected and the gate was noted to have been replaced as the gate appeared new and was functioning properly when inspected with the facility maintenance man. During an observation on 09/28/22 at 03:42 PM, a video recording that was on file of the facility's video camera showed the day (09/18/22) when the Resident #44 eloped through the back gate. The video showed where Resident #44 approached the gate and started to push it open but then the video stopped and started again and at that time the resident was gone, later on the video CMA E is seen coming out to check the gate and pushes it open, the gate did not appear to be locked at the time CMA E came to check it. (Note: CMA E was not available for in person interview as he was not working. An attempt was made to interview via telephone on 09/28/22, but he did not return voice message.) During an observation on 09/28/22 at 03:54 PM, revealed the street the resident crossed before being found was a 5 lane street which was located in front of the facility. Facility implemented actions: The gate and magnets were replaced on 09/19/22. This was verified by surveyor during an observation on 09/25/22 and 10/10/22. All the windows in the men's secure unit have locks on them that allowed the windows to open only 6 inches. This was verified by surveyor during an observation on 09/25/22. The men's and women's secure unit initiated a resident head count on an hourly basis and kept a log where they document the count. This was verified by surveyor during an observation on 09/25/22. The facility conducted training and in-services on how monitor residents with exiting behaviors and what to do when a resident is missing. This was verified on 10/10/22 by surveyor during interviews of 2 LVNS, 4 CNAs and activity director and they understood the training. The facility placed Resident #1 on a one to one with a facility staff continuously with the resident. This was verified by surveyor during an observation on 09/25/22 and 10/10/22. The facility initiated back gate checks twice a day daily to make sure the gate was functioning correctly and documenting the checks. This was verified by surveyor during an observation and record review of the document which indicated the gate was checked twice a day daily by the Maintenance man on 10/10/22. The facility placed an aide in the hall to monitor the residents if they were not busy, they were to sit in the hall. This was verified by surveyor during an observation on 09/25/22 and 10/10/22. Facility Administrator, DON and ADON stated they had included Resident #1's elopement issues in their plans and QA meetings. Record review of the facility's policy titled Wandering and elopement and dated March 2019 indicated in part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. Record review of the facility's policy titled SecureCare environment admission criteria and process and dated February 2007 indicated in part: The goal of the SecureCare environment is to meet the individual needs of the residents with dementia related illnesses. The SecureCare environment will provide a safe environment that maximizes independence and provides an activity intensive atmosphere. The secured care unit may be used to keep residents who are a high risk for elopement safe from exiting the facility. On 10/10/22 at 4:45pm the Administrator and DON were notified of the Past Non-Compliance IJ existing from 09/18/22 - 09/19/22 and the template was provided.