**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 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to protect Resident #1 from abuse when four facility staff (LVN A, RN B, NA C and Laundry Staff D) grabbed Resident #1 and forcibly carried him by his extremities and dragged him on the floor to his room. The staff placed Resident #1 in his room and held the door closed so that he could not leave his room. An Immediate Jeopardy was identified on 8/25/25. The IJ template was provided to the facility on 8/25/25 at 5:07 PM While the IJ was removed on 8/26/25, the facility remained out of compliance at a scope of isolated, and a severity level of no actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk of physical injury, psychological trauma, and severe emotional distress. Findings include: Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life that can lead to a range of behavioral symptoms), anxiety disorder ( a nervous disorder that significantly impairs daily life by causing constant, debilitating fear and worry that make every day activities difficult to complete), unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain). Record review of Resident #1's Quarterly MDS, dated [DATE] revealed in Section C that he had a BIMS score of 5 which indicated severe cognitive impairment. Section E behavior indicated no psychosis, no presence of physical behavioral symptoms directed toward others, no presence of verbal behavioral symptoms directed toward others, and he had no behaviors such as wandering, pacing, or rummaging. Section N indicated the resident did not take an antipsychotic or an antidepressant since admission, re-entry or the last OBRA assessment. Record review of a skin assessment dated effective 8/17/25 and signed by the ADON on 8/18/25 reflected a 2-centimeter x 2-centimeter skin tear of Resident #1's Left pinky finger and a 2-centimeter x 2- centimeter skin tear to his left upper arm. Record review of Resident #1's skin assessment dated effective 8/19/25 and signed by the ADON on 8/19/25 reflected a 2-centimeter x 2-centimeter skin tear of Resident #1's Right ring finger and a 2-centimeter x 2- centimeter skin tear to his left upper arm. Record review of Resident #1's active physician orders dated 8/20/25 reflected Resident #1 had an order dated 10/17/24 which reflected: Admit to secure unit due to history of elopement with exit seeking behavior. admit date [DATE], and an order dated 9/9/23 : Admit to Hospice, and order dated 8/19/25 cleanse skin tear to left arm with normal saline and pat dry . Apply steri strips, cover with xeroform gauze and a padded dressing. Wrap with Kerlix daily and prn. There was no order for physical restraints. There was a one-time order for Haldol 5 mg/ml 1 time only for 1 day ordered on 8/17/25 by the Hospice physician. Record review of the MAR dated 8/1/25 reflected that Haldol 5mg was administered at 6:49 PM on 8/17/25. Record Review of Resident #1's Care Plan dated revised 8/18/25 reflected Focus: Resident has an actual impairment of skin integrity . Intervention : use caution during transfers and bed mobility to avoid striking arms, hands, and legs against any sharp or hard surface (dated initiated 8/18/25). Record review of Resident #1's care plan last dated revised on 8/18/25 included: Focus: The resident has a behavior problem - will become aggressive with staff and residents pushing and hitting. Purposely places himself on the floor. Interventions: Caregivers to provide for positive interaction, attention, stop and talk with him as they pass by (1/3/24); Hospice to evaluate medication list with psych. (3/17/25); If a resident becomes aggressive towards another resident remove him from the situation. Take him to a quiet area to talk. Resident likes to talk, walk outside and sit on the couch in the lobby (4/22/25); Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate location as needed (12/5/23); Resident enjoys prayers. When resident is combative ask him if he needs to pray (3/13/25); When resident has increased confusion and or combativeness call his family member and let him speak to her (3/13/25) Focus: Resident is at risk of feelings of isolation due to being on a secure unit because of high risk of elopement Revised 5/24/25.Interventions: Admit to secure unit per Dr orders.Assist and monitor resident for off unit activities if possibleInvolve resident in secure unit activitiesNotify physician and family of changes Focus: The resident has a history of trauma that may have a negative impact. Created 8/11/25 by DON and interventions initiated on 8/11/25. Interventions: Monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, physician, and mental health provider.Perform the following de-escalation techniques (there were no de-escalation techniques listed for staff to follow). Record review of Residents #1's Nurse's Progress Notes revealed: Author: LVN EEffective Date: 08/17/2025 3:30 PM Type: Nursing NoteNote Text : Resident was being combative with staff and was escorted back to room, Resident started throwing things at the window in his room and broke his window, Police and EMS was called to deescalate the situation. Will continue to monitor, Hospice gave new orders for Haldol 5mg/1ml. Resident has been given Haldol 5mg/1ml, POA notified. Interventions: 1 on 1 monitoring, Directed to the resident's room to decrease stimulation, Assess for pain. During an interview with N/A C on 8/18/25 at 4:20 PM. NA C stated she worked 6 AM to 6 PM on 8/17/25 and they had an incident occur between 2:00 PM and 4 PM when the Nurses had to call the police due to Resident #1's behaviors. She stated he broke glass in his room and the police came and they had to handle the situation, and the police had to restrain him by holding him down. She stated she was unable to leave him because he was so violent . She stated they did not have enough help at times to deal with the behavior, and stated 4 people was not enough to watch people with wandering and combative behavior. She stated she thought the Nurse notified the DON of the resident's behavior, but no one else came to help them. She did not mention that the resident was restrained, carried to his room and she prevented him from opening his room door by holding the door knob during this interview . During an interview on 8/19/25 at 9:24 AM RN B stated that on Sunday, 08/17/ 2025, Resident #1 was sitting in a chair near the nurses station. She stated she noticed he seemed withdrawn, which was not like him. She stated another staff member told her he is like that sometimes. She stated she had always seen him friendly, verbal, confused, and smiling. She stated he suddenly became violent toward other patients near him and attempted to strike them. She stated she tried to assist him to a standing position and called for help. She stated she tried to guide him to his room, but he was very resistant and extremely strong. She stated he tried to strike at her with his fists. She stated other staff members responded, and they continued to make their way down the hall while he continued to attempt to break lose, kick, and punch the staff. Resident #1 did manage to break free ahead of them, and grabbed a bedside table, picked it up, and threw it at them. She stated it struck her hard on her shins and left bruises on both legs. She stated she was afraid for herself and the other residents. She stated they were struggling to hold Resident #1 but were finally able to get him through the door of his room and close it, with one aide having to brace herself against the wall to hold it shut by the doorknob. Resident #1 was throwing things very hard against the door, trying to open it. She stated the staff outside Resident #1's door heard several loud bangs on the door and banging in the room and then they heard glass breaking. They did not enter the room to check on the resident. She stated LVN A had notified the DON by phone, after which she stated she (RN B) instructed LVN A to call the police and EMS. She stated they heard intermittent loud bangs continue on the door. They continued to hold the door closed . She stated it was determined after the police arrived and the door was open he had removed the toilet tank lid and threw it through the window and possibly at the door. She stated, We were all afraid for our own safety and that of other residents. She stated several police officers arrived and were able to lay him on the bed and hold him so that Resident #1 could not move. She stated a hospice nurse that had been called to come to the facility by LVN A was then able to administer an injectable behavioral medication. She stated Resident #1 was not transported to the hospital by the EMS. During an Interview on 8/20/25 at 10:33 AM with Laundry Staff D, she stated she worked in the laundry and was there on 8/17/25 and witnessed the incident with Resident #1 . She stated she saw him physically hitting her coworkers and trying to hit residents. She stated he was trying to hit a lady sitting in the chairs across from the nursing station and then four of the staff including herself restrained him. She stated Resident #1 was on the floor, he had a cord in his hand, and she was afraid he was going to use it to swing at them and hurt other people. She stated she took the cord away and picked up his legs and feet . She stated she picked up his feet and then 4 staff carried him down to his room and they shut the door and left him in there so he wouldn't hurt anybody. An aide was holding on to the doorknob to keep him in the room and prevent him from opening the door. An observation of the electronic monitoring system video dated 8/17/25, showed these events: At 2:20 PM Resident #1 began showing behaviors which included: wandering into other resident's rooms, taking items from other resident's rooms, dropping clothing items in the hallway, and pulling a bedside table down the hallway. At 2:44 PM Resident #1 went into another residents' room and took a small fan out of that room and carried it down the hallway. Resident #1 became agitated when housekeeping staff took the fan away from him. At 2:53 PM Resident #1 walked out of his room with a bedside table. Resident #1 pushed the bed side table forcefully into RN B and hit her in the shins of both legs. RN B and NA C walked away towards the nurses station and Resident #1 walked after them. At 2:55 PM Resident #1 started running toward N/A C down the hallway towards the nurses station with a call light cord which resembled an outdoor extension cord in his hand. It had an approximately 1.5-inch metal prong on one end and the other end was plastic with a red call button on the end in his hand. N/A C started running away from Resident #1 toward the nurses station. Resident #1 swung the call light cord while he ran toward the nurses station following staff. He bumped into Laundry Staff Member D as he ran, and she held her hands up in the air. Resident #1 continued to run and chase the staff and was swinging the cord . Resident #1 tripped on a chair and fell to the floor. There were four other residents in the vicinity. RN B motioned with her hand to two unidentified residents that were sitting in the row of chairs at the nurses station to go down the hallway away from Resident #1. The two residents walked away. N/A C removed another resident away from Resident #1 down the other hallway. An unidentified 4th resident stood back and watched. Laundry Staff D held onto the cord and sat in a nearby chair as Resident #1 held the cord and sat on the floor. RN B and LVN A walked around Resident#1 as he tried to kick Laundry Staff D. RN B and LVN A grabbed Resident #1 by the arms and twisted his body to lay on his back. They pulled him approximately 5 feet on the floor. Resident #1 tried kicking and resisting staff as the laundry staff got up and hung on to the cord and walked beside them down the hall as they continued to drag him. Resident #1 continued to kick with both feet to resist the staff. LVN A moved to his right leg as he tried to kick her. N/A C held on to his left arm. Resident #1 kicked with both feet as LVN A moved to his left leg and laundry staff grabbed his right leg. The 4 Staff picked him up off the floor by his extremities with no support to his back or midsection and carried Resident #1 to his room. Staff carried him into the room, ran out of the room, and closed the door of his room. The staff took turns holding his door closed and did not allow him to come out of the room. While other staff stood nearby, NA C placed her foot up against the wall or door frame to allow her to keep the door closed as the resident pulled on the door from the inside. At 3:11PM the police arrived and stood outside the door with the staff. At 3:12 PM the EMS arrived, and the police and EMS went into Resident #1's room. During an interview with LVN E on 8/20/25 at 11:51AM, she stated she worked on 8/17/26, and was coming out of the med room and turned to the right and saw the Resident #1 had a cord in his hand, and he was swinging it around. All the others were trying to get it out of his hands. Two of the nurses had grabbed his arms, and 2 other people grabbed his legs and carried him back to the room because he was fighting. They ended up putting him in his room and closed the door. They kept the door closed by holding the doorknob. One of the aides was holding the door and he was grabbing stuff in his room and throwing it and broke the window. She stated she had asked NA C if she could open the door because he was pushing on the door and hitting the door trying to get out. The EMS and the police had arrived by this time. After that he settled down. She stated she had tried to call the DON, but she didn't answer, and she told the other nurse (LVN A) to call the DON. She said they were all trying to call to see what we could do in that situation. LVN E stated she was concerned about the way the incident was handled because of him acting out like that. She stated that with Alzheimer's it was just kind of tricky on how they respond, and things were getting worse. She stated the Administrator was the abuse coordinator. She stated the types of abuse were physical. mental, sexual, verbal. She stated during the incident with Resident #1 on 8/17/25, she didn't like that they had to restrain him. She stated, I was trying to tell them (the other staff present) that I felt uncomfortable. She stated she didn't like how it was done by the staff or the police restraining him. She said, I didn't like the situation because I don't think I've had to restrain a patient in a long time, so it just didn't make me feel comfortable. To my knowledge I thought that the Administrator and the DON knew about it, but when I talked to them they had told me they did not know about it. During an observation on 8/20/25 at 12:30 PM Resident #1 had dressings to his right arm and was awake and alert, but unable to answer direct questions regarding the incident. He had no recall of an incident and was not interviewable at the time. He did not realize why he had a dressing on his arm or that he had one. He appeared quiet and calm. During an interview on 8/21/25 at 1:04 pm with the DON she stated she did not know how her staff handled the incident with Resident #1 until she watched the video on 8/19/25. The DON stated her expectation of them was to fully inform her of the situation on 8/17/25 and the severity of the behaviors and the interventions they had used when they called her. She stated she was aware that he was agitated, and he had broken his bedroom window and that was all she was told. She stated she would have liked to have seen RN B, LVN A, Laundry staff D, and N/A C put the safety of the other residents first and remove them from the situation. She further stated she would have liked to have seen them keep him in eyes view and not congregated around him. She stated that she could see that he could feel threatened by the staffs' actions. She stated in that situation she would have gotten down on the ground on the resident's level and asked him in a calm voice what can I do to make you feel safe. She stated she felt the staff acted the way that they did because they felt threatened and needed more education . During an interview on 8/21/25 at 1:24 PM with the Administrator, she stated she would have liked to see an attempt at de-escalation of the situation by her staff first. She stated she did not expect them to move him down the hall by picking him up by his arms and legs and taking him to his room. She stated she would have preferred to have her staff step back and not take items away from Resident #1, if the items were not doing any harm to him or the other residents. She stated she would have expected that they would not pick Resident #1 up and take him to the room, shut the door and then hold the door closed so he could not get out. She stated they could not see him. She stated she would have liked to have seen the staff keep Resident #1 in eyes view, because the video showed the resident was obviously upset and angry. She stated she would have preferred that the staff did not congregate around Resident #1. She stated she was notified by the DON on 3/17/25 at 4:58 PM that the resident had broken the window out in the room. She stated that is all she was told until 8/19/25 when she viewed the video after the surveyor asked to see the video footage. The administrator stated she was notified at 4:58 PM by the DON that Resident #1 was agitated and punched out the window in his room. She stated she called Maintenance to go to the facility to fix the window at that time. She wasn't aware of anything else. During an interview on 8/21/25 at 2:18 PM LVN A stated it was a collective decision of the 4 staff to forcibly carry Resident #1 to his room and hold the door shut. She stated they did it this way because it was easier for them to carry him down there, put him in his room and hold the door shut, than it was to get the other residents out of the way. She stated she went outside to see if she could see what Resident #1 had done after she heard glass break. She stated the housekeeper came out and relieved her and stayed until the police entered the room. She stated she saw a drawer on the floor and a lot of broken glass in the room and the resident was still agitated. She stated she had called the police when she heard the window break. She stated the police handcuffed the resident and restrained him until he was given the Haldol (antipsychotic) by the hospice nurse. During an interview on 8/21/25 at 4:30 PM with Resident #1's POA she stated the facility did not notify her of the behaviors Resident #1 was exhibiting and that they had restrained him, or that he had broken the window out in his room. She stated she did not give consent for restraints or Haldol to the facility. She stated the person that notified her was a Hospice nurse after it was all said and done. She stated she did not know why she was not notified sooner in the day. She stated she got mixed reports from the facility on how and when this had all happened , but stated she was told by Hospice that it had started earlier in the day, and she felt she should have been called then. She said if she had known she would have come up to the facility and helped calm him down. She stated : I don't understand why the police were called on a [AGE] year-old man that has dementia and was placed in a facility that specializes with Alzheimer's and dementia Record review of the facility policy titled Abuse/Neglect dated revised 9/9/24 reflected the following in part: The resident has the right to be free from abuse neglect misappropriation of property and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment and involuntary seclusion, and any physical or chemical restraint not required to treat the residents medical symptoms. Residents should not be subjected to abuse by anyone, including but not limited to facility staff, other residents consultants or volunteers, staff of other agencies serving the resident family members or legal guardians friends or other individuals. Abuse is the willful infliction of injury unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents irrespective of any mental or physical condition can cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting slapping pinching and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation, mistreatment means inappropriate treatment or exploitation of a resident. This was determined to be an Immediate Jeopardy (IJ) on 8/25/25 at 5:07 PM. The Interim Administrator, Corporate Nurse, Corporate Regional [NAME] president, DON, and Corporate Clinical Leader RN were informed of the IT. The interim Administrator was provided with the IJ template on 8/25/25. The following Plan of Removal was accepted on 8/26/25 at 9:54 AM: Please see the attached POR for F600. Please note that our dates will reflect 8/19, when our POR was completed after facility identified correction needed. Plan of Removal: Interventions: On 8/19/25, staff members LVN A, RN and NA were immediately suspended by the administrator. Completed 8/19/25. All three staff members remain suspended as of 8/25/25. On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25. On 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25. The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25. On 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25. On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. Completed 8/19/25. On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/25 The medical director was notified of the immediate threat by the Administrator on 8/25/25. On 8/19/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the Immediate Jeopardy and plan of removal. Completed 8/19/25. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25.o Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse.o Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent.o Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. o Trauma informed Care (an approach to care that recognized the widespread prevalence of trauma and its impact on individuals and promotes creation of a safe and supportive environment on residents that promotes healing and recovery from traumatic experiences, and Abuse and Neglect),to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. o Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily.In-services: The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25.o Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse.o Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent.o Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. o Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma. o Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. Monitoring of the facility's Plan of removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 8/26/25 at 9:58 AM to 5:30 PM as follows: During an interview with LVN F (6AM- 6PM shift) on 8/26/25 at 9:59 AM, he stated he was Inserviced on 8/19/25 and 8/26/25 on the abuse and neglect policy, trauma informed care assessments, the restraint policy for the facility, behavior management. He stated a restraint is holding their arms down or holding their door shut would be isolation. He stated restraints, involuntary seclusion, and unreasonable confinement were not tolerated and prohibited in this facility. During an interview with LVN G (6AM - 6PM shift) on 8/26/25 at 10:10 AM, she stated she was Inserviced on 8/19/25, and 8/26/25 by the Corporate Nurse. She stated, neglect is not doing things for patients intentionally and just let them sit all day in their chair, not changing them, not making sure that they've eaten. Abuse can be verbal, it can be physical, it can be mental. She stated, I have my Cheat Sheets with the highlights of the Inservice on it. You can't use restraints, secluding them involuntarily and unreasonable confinement is abuse. You report everything to the Administrator. The Administrator is the abuse coordinator, and you should report it immediately when it happens. That way you've reported it because you realize it could be wrong or considered abuse.She stated, We are actually a no restraint facility. That is a big No, no. You use Behavior management which would be doing every single thing that we're supposed to do first. Make sure that they've been to the toilet, see if they need a drink or if they are wet, go for a walk, start an activity. During an interview with CNA H (6AM - 6PM shift) on 8/26/25 at 10:15 AM, she stated that she was Inserviced on abuse and neglect, restraints, and seclusion today, 8/26/25 and on 8/19/25. She stated examples of abuse were: posting on social media about residents, talking bad or loud and screaming, or body harm that is sexual or physical or mental health. She stated, Resident restraining it's like from having something on them to keep them from moving or that the physician doesn't know that they are doing. Even if the physician does know, then is it still a restraint and you shouldn't do that. She stated, I would have to report it to the Administrator immediately. Resident rights means that residents have the right to ask for snacks or anything they need . They have the right to our respect and to be free from abuse or seclusion. Behavior management is to distract them from the things that upset them before they get upset if you can by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first. Never do it without the permission of the physician. She stated she would look in the or care plan for resident specific interventions. During an interview with CNA I (6 PM to 6 AM shift) on 8/26/25 at 10:30 AM, she stated the types of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms, sexual and stealing from residents. She stated you report abuse immediately. She stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility . She stated they learned about rights. They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to. She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention. She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types of behavior management required you to step back and give them some s[TRUNCATED]

**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 involuntary seclusion for 1 of 7 residents (Resident #1) reviewed for involuntary seclusion. The facility failed to ensure LVN A, RN B, N/A C, and Laundry Staff D did not isolate Resident #1 as a method of addressing his behaviors. The staff placed Resident #1 in his room and held the door closed by the doorknob so that he could not leave his room as he struggled to get the door open and leave the room. An Immediate Jeopardy was identified on 8/25/25. The IJ template was provided to the facility on 8/25/25 at 5:07 PM While the IJ was removed on 8/26/25, the facility remained out of compliance at a scope of isolated, and a severity level of no actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure affected Resident #1 and could place residents with behavior healthcare needs at risk of injury and isolation, leading to a decreased quality of life, severe emotional distress and trauma leading to distrust of staff.Findings include: Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life that can lead to a range of behavioral symptoms), anxiety disorder ( a nervous disorder that significantly impairs daily life by causing constant, debilitating fear and worry that make every day activities difficult to complete), unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain), and Alzheimer's Disease. Record review of Resident #1's Quarterly MDS, dated [DATE] revealed in Section C that he had a BIMS score of 5 which indicated severe cognitive impairment. Section E behavior indicated no psychosis, no presence of physical behavioral symptoms directed toward others, no presence of verbal behavioral symptoms directed toward others, and he had no behaviors such as wandering, pacing, or rummaging. Section N indicated the resident did not take an antipsychotic or an antidepressant since admission, re-entry or the last OBRA assessment. Record review of Resident #1's active physician orders dated 8/20/25 reflected Resident #1 had an order dated 10/17/24 which reflected: Admit to secure unit due to history of elopement with exit seeking behavior. There was no order for physical restraints . There was a one-time order for Haldol 5 mg/ml 1 time only for 1 day ordered on 8/17/25 by the Hospice physician. There was an order dated 8/19/25 cleanse skin tear to left arm with normal saline and pat dry . Apply steri strips, cover with xeroform gauze and a padded dressing. Wrap with Kerlix daily and prn. Record review of the MAR dated 8/1/25 reflected that Haldol 5mg was administered at 6:49 PM on 8/17/25. Record review of Resident #1's care plan last revised on 8/18/25 included: Focus The resident has a behavior problem - will become aggressive with staff and residents pushing and hitting. Purposely places himself on the floor. Interventions: Caregivers to provide for positive interaction, attention, stop and talk with him as they pass by initiated 1/3/24. Hospice to evaluate medication list with psych initiated 3/17/25. If resident becomes aggressive towards another resident remove him from the situation. Take him to a quiet area to talk. Resident likes to talk, walk outside and sit on the couch in the lobby initiated 4/22/25. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate place location as needed initiated 12/5/23. Resident enjoys prayers. When resident is combative ask him if he needs to pray (3/13/25); When resident has increased confusion and or combativeness call his family member and let him speak to her initiated 3/13/25.Focus: Resident is at risk of feelings of isolation due to being on a secure unit because of high risk of elopement Revised 5/24/25.Interventions: Admit to secure unit per Dr orders.Assist and monitor resident for off unit activities if possibleInvolve resident in secure unit activitiesNotify physician and family of changes Focus: The resident has a history of trauma that may have a negative impact. Created 8/11/25 by DON and interventions initiated on 8/11/25.Interventions: Monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, physician, and mental health provider. Perform the following de-escalation techniques (there were no de-escalation techniques listed). An observation of the electronic monitoring system video dated 8/17/25, showed these events: At 2:20 PM Resident #1 began showing behaviors which included: wandering into other resident's rooms, taking items from other resident's rooms, dropping clothing items in the hallway, and pulling a bedside table down the hallway. At 2:44 PM Resident #1 went into another residents' room and took a small fan out of that room and carried it down the hallway. Resident #1 became agitated when housekeeping staff took the fan away from him. At 2:53 PM Resident #1 walked out of his room with a bedside table. Resident #1 pushed the bed side table forcefully into RN B and hit her in the shins of both legs. RN B and NA C walked away towards the nurses station and Resident #1 walked after them. At 2:55 PM Resident #1 started running toward N/A C down the hallway towards the nurses station with a call light cord which resembled an outdoor extension cord in his hand. It had an approximately 1.5-inch metal prong on one end and the other end was plastic with a red call button on the end in his hand. N/A C started running away from Resident #1 toward the nurses station. Resident #1 swung the call light cord while he ran toward the nurses station following staff. He bumped into Laundry Staff Member D as he ran, and she held her hands up in the air. Resident #1 continued to run and chase the staff and was swinging the cord . Resident #1 tripped on a chair and fell to the floor. There were four other residents in the vicinity. RN B motioned with her hand to two unidentified residents that were sitting in the row of chairs at the nurses station to go down the hallway away from Resident #1. The two residents walked away. N/A C removed another resident away from Resident #1 down the other hallway. An unidentified 4th resident stood back and watched. Laundry Staff D held onto the cord and sat in a nearby chair as Resident #1 held the cord and sat on the floor. RN B and LVN A walked around Resident#1 as he tried to kick Laundry Staff D. RN B and LVN A grabbed Resident #1 by the arms and twisted his body to lay on his back. They pulled him approximately 5 feet on the floor. Resident #1 tried kicking and resisting staff as the laundry staff got up and hung on to the cord and walked beside them down the hall as they continued to drag him. Resident #1 continued to kick with both feet to resist the staff. LVN A moved to his right leg as he tried to kick her. N/A C held on to his left arm. Resident #1 kicked with both feet as LVN A moved to his left leg and laundry staff grabbed his right leg. The 4 Staff picked him up off the floor by his extremities with no support to his back or midsection and carried Resident #1 to his room. Staff carried him into the room, ran out of the room, and closed the door of his room. The staff took turns holding his door closed and did not allow him to come out of the room. While other staff stood nearby, NA C placed her foot up against the wall or door frame to allow her to keep the door closed as the resident pulled on the door from the inside. At 3:11PM the police arrived and stood outside the door with the staff. At 3:12 PM the EMS arrived, and the police and EMS went into Resident #1's room. Record review of a skin assessment dated effective 8/17/25 and signed by the ADON on 8/18/25 reflected a 2-centimeter x 2-centimeter skin tear of Resident #1's Left pinky finger and a 2-centimeter x 2- centimeter skin tear to his left upper arm. Record review of a skin assessment dated effective 8/19/25 and signed by the ADON on 8/19/25 reflected a 2-centimeter x 2-centimeter skin tear of Resident #1's Right ring finger and a 2-centimeter x 2- centimeter skin tear to his left upper arm. During a telephone interview with N/A C on 8/18/25 at 4:20 PM via phone regarding another incident NA C stated she worked 6 AM to 6 PM on 8/17/25 and an incident had occurred with Resident #1 between 2:00 PM and 4 PM when the Nurse had to call the police due to Resident #1's aggressive behaviors. She stated he broke the window glass in his room and the police were called. She stated the staff, and the police had to restrain him by holding him down. During an interview on 8/19/25 at 9:24 AM RN B stated on Sunday, 08/17/ 2025, Resident #1 was sitting in a chair near the nurses station. She stated Resident # 1 suddenly became violent toward other residents that were near him and attempted to strike them. She stated she tried to assist him to a standing position and called for help. She stated she tried to guide him to his room, but he was resistant. She stated he tried to strike at her with his fists. She stated other staff members responded, and they continued to attempt to make their way to take him down the hall while he continued to attempt to break lose, and kick, and punch the staff. She stated Resident #1 did manage to break free and grabbed a bedside table, picked it up, and threw it at them. She stated it struck her hard on her shins and left bruises on both legs. She stated she was afraid for herself and the other residents. She stated they struggled to hold Resident #1 but were finally able to get him through the door of his room and close it. She stated one aide had to brace herself against the wall to hold it shut by the doorknob while Resident #1 was throwing things against the door. She stated the staff outside Resident #1's door heard several loud bangs on the door and banging in the room, and then they heard glass break. She stated they did not enter the room to check on the resident. She stated LVN A had notified the DON by phone, after which she stated she (RN B) instructed LVN A to call the police and EMS. She stated they heard intermittent loud bangs continue on the door. They continued to hold the door closed. She stated it was determined after the police arrived and the door was open he had removed the toilet tank lid and threw it through the window and possibly at the door. She stated, We were all afraid for our own safety and that of other residents. She stated several police officers arrived and were able to lay him on the bed and hold him so that Resident #1 could not move. She stated a hospice nurse that had been called to come to the facility by LVN A was then able to administer an injectable behavioral medication During an Interview with Laundry Staff D at 10:33 AM on 8/20/25 she stated she worked in the laundry and was there on 8/17/25 and witnessed the incident with Resident #1 . She stated she saw him physically hitting her coworkers and trying to hit residents. She stated he was trying to hit an unidentified lady sitting in the chairs across from the nursing station. She stated 4 staff restrained him. She stated Resident #1 was on the floor and had a cord in his hand. She stated she took the cord away and picked up his legs and feet . She stated 4 staff carried him down to his room and they shut the door and left him in there so he wouldn't hurt anybody. An aide (name unknown) was holding on to the doorknob to keep him in the room and prevent him from opening the door. In an interview with LVN E on 8/20/25 at 11:51AM, she stated she worked on 8/17/26, and was coming out of the med room and turned to the right and saw the Resident #1 had a cord in his hand, and he was swinging it around. All the others were trying to get it out of his hands. Two of the nurses had grabbed his arms, and 2 other people grabbed his legs and carried him back to the room because he was fighting. They ended up putting him in his room and closed the door. They kept the door closed by holding the doorknob. One of the aides was holding the door and he was grabbing stuff in his room and throwing it and broke the window. She stated she had asked NA C if she could open the door because he was pushing on the door and hitting the door trying to get out. The EMS and the police had arrived by this time. After that he settled down. She stated she had tried to call the DON, but she didn't answer, and she told the other nurse (LVN A) to call the DON. She said they were all trying to call to see what we could do in that situation. LVN E stated she was concerned about the way the incident was handled because of him acting out like that. She stated that with Alzheimer's it was just kind of tricky on how they respond, and things were getting worse. She stated the Administrator was the abuse coordinator. She stated the types of abuse were physical. mental, sexual, verbal. She stated during the incident with Resident #1 on 8/17/25, she didn't like that they had to restrain him. She stated, I was trying to tell them (the other staff present) that I felt uncomfortable. She stated she didn't like how it was done by the staff or the police restraining him. She said, I didn't like the situation because I don't think I've had to restrain a patient in a long time, so it just didn't make me feel comfortable. To my knowledge I thought that the Administrator and the DON knew about it, but when I talked to them they had told me they did not know about it. During an observation on 8/20/25 at 12:30 PM Resident #1 had dressings to his right arm and was awake and alert, but unable to answer direct questions regarding the incident. He had no recall of an incident and was not interviewable at the time. He did not realize why he had a dressing on his arm or that he had one. He appeared quiet and calm. During an interview on 8/21/25 at 1:04 pm with the DON she stated she did not know how her staff handled the incident with Resident #1 until she watched the video on 8/19/25. The DON stated her expectation of them was to fully inform her of the situation and the severity of the behaviors and the interventions they had used when they called her. She stated she was aware that he was agitated, and he had broken his bedroom window and that was all she was told. She stated she would have liked to have seen RN B, LVN A, Laundry staff D, and N/A C put the safety of the other residents first and remove them from the situation. She further stated she would have liked to have seen them keep him in eyes view and not congregated around him. She stated that she could see that he could feel threatened by the staffs' actions. She stated in that situation she would have gotten down on the ground on the resident's level and asked him in a calm voice what can I do to make you feel safe. She stated she felt the staff acted the way that they did because they felt threatened and needed more education . During an interview with the Administrator on 8/21/25 at 1:24 PM she stated she would have liked to see an attempt at de-escalation of the situation by her staff first. She stated she did not expect them to move him down the hall in the manner that they did. She stated would have preferred to have her staff step back and not take items away from Resident #1 if the items were not doing any harm to him or the other residents. She stated she would have expected that they would not pick Resident #1 up and take him to the room, shut the door and then hold the door closed so he could not get out . She stated they could not see him. She stated she would have liked to have seen the staff keep Resident #1 in eyes view, because the video showed the resident was obviously upset and angry. She stated she would have preferred that the staff did not congregate around Resident #1. She stated she was notified by the DON on 3/17/25 at 4:58 PM that the resident had broken the window out in the room. She stated that is all she was told until 8/19/25 when she viewed the video. The administrator stated she was notified at 4:58 PM by the DON that Resident #1 was agitated and punched out the window in his room. She stated she called Maintenance to go to the facility to fix the window at that time. During an interview on 8/21/25 at 2:18 PM LVN A stated it was a collective decision of the 4 staff to forcibly carry the Resident #1 to his room and hold the door shut. She stated they did it this way because it was easier for them to carry him down there, put him in his room and hold the door shut, than it was to get the other residents out of the way. She stated she went outside to see if she could see what Resident #1 had done after she heard glass break. She stated the housekeeper came out and relieved her and stayed until the police entered the room. She stated she saw a drawer on the floor and a lot of broken glass in the room and the resident was still agitated. She stated she had called the police when she heard the window break. She stated the police handcuffed the resident and restrained him until he was given the Haldol (antipsychotic) by the hospice nurse. During an interview with Resident #1's POA on 8/21/25 at 3 :15 PM she stated the facility did not notify her of the behaviors Resident #1 was exhibiting and that they had restrained him, secluded him or that he was had broken the window out in his room. She stated she did not give consent for restraints or Haldol to the facility. She stated the person that notified her was a Hospice nurse after it was all said and done. She stated she did not know why she was not notified sooner in the day. She stated she got mixed reports from the facility on how and when this had all happened , but stated she was told by Hospice that it had started earlier in the day, and she felt she should have been called then. She said if she had known she would have come up to the facility and helped calm him down. She stated : I don't understand why the police were called on a [AGE] year-old man that has dementia and was placed in a facility that specializes with Alzheimer's and dementia. Record review of the facility policy titled Abuse/Neglect dated revised 9/9/24 reflected the following in part: The resident has the right to be free from abuse neglect misappropriation of property and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment and involuntary seclusion, and any physical or chemical restraint not required to treat the residents medical symptoms. Residents should not be subjected to abuse by anyone, including but not limited to facility staff, other residents consultants or volunteers, staff of other agencies serving the resident family members or legal guardians friends or other individuals. Abuse is the willful infliction of injury unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents irrespective of any mental or physical condition can cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting slapping punching and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation, mistreatment means inappropriate treatment or exploitation of a resident. An Immediate Jeopardy was identified on 8/25/25. The IJ template was provided to the facility on 8/25/25 at 5:07 PM While the IJ was removed on 8/26/25, the facility remained out of compliance at a scope of isolated, and a severity level of no actual harm, due to the facility's need to evaluate the effectiveness of their corrective action Please see the attached POR for F603 Please note that our dates will reflect 8/19, when our POR was completed after facility identified correction needed. Plan of Removal Interventions: On 8/19/25, staff members LVN A, RN and NA were immediately suspended by the administrator. Completed 8/19/25. All three staff members remain suspended as of 8/25/25. On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25. On 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25. The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25. On 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25. On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. Completed 8/19/25. On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/25 The medical director was notified of the immediate jeopardy by the Administrator on 8/25/25. On 8/19/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 8/19/25. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. In-services: The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. The surveyor monitored the facility's plan of removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews 8/26/25 from 9:58 AM to 5:50 PM. Interviews with Facility staff members from 9:58 AM on 2:10 PM revealed they had been educated on abuse, neglect, behavior management, Resident Rights, Trauma Informed Care, and the facility restraint policy. During an interview with LVN F 6AM- 6PM shirt on 8/26/25 at 9:59 PM. He stated he was Inserviced on 8/19/25 and 8/26/25 on the abuse and neglect policy, trauma informed care assessments, the restraint policy for the facility, behavior management, H stated a restraint is holding their arms down or holding their door shut would be isolation, He stated restraints, involuntary seclusion, and unreasonable confinement were not tolerated and prohibited in this facility. During an interview with LVN G 6AM - 6PM shift on 8/26/25 at 10:10 AM - she stated she was Inserviced on 8/19/25, and 8/26/24 by the Corporate Nurse. She stated neglect is not doing things for patients intentionally and just let them sit all day in their chair, not changing them , not making sure that they've eaten, Abuse can be verbal it can be physical it can be mental. She stated have my Cheat Sheets with the highlights of the Inservice on it. You can't use restraints, secluding them involuntary and unreasonable confinement is abuse. You report everything to the administrator. The administrator is the abuse coordinator, and you should report it immediately when it happens. That way you've reported it because you realize it could be wrong or considered abuse. Restraint policy - We are actually a no restraint facility. That is a big No, no . you use Behavior management which would be do every single thing that we're supposed to do first. Make sure that they've been to the toilet, see if they need a drink or if they are wet, go for a walk, start an activity. During an interview with CNA H 6AM - 6PM shift on 8/26/25at 10:15 AM She stated that she was Inserviced on abuse and neglect, restraints, and seclusion today. 8.26.25 and on 8/19/25. She stated examples of abuse were: posting on social media about residents, talking bad or loud and screaming , or body harm that is sexual or physical or mental health . She stated Resident restraining it's like from having something on them to keep them from moving or that that the physician doesn't know that they are doing. Even if the physician does know, then is it still a restraint and you shouldn't do that. She stated :I would have to report it to the to the administrator immediately. Resident rights means that residents have the right to ask for snacks or anything they need . They have the right to our respect and to be free from abuse or seclusion. Behavior management is to distract them from the things that upset them before they get upset if you can.by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first. Never do it without the permission of the physician . She stated she would look in the Kardex or care plan for resident specific interventions. During an interview with CNA, I 6 PM to 6 AM shift on 8/26/25 at 10:30 AM stated the typers of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms , sexual and stealing from residents. She stated you report abuse immediately. Stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other resident's she would make sure whoever's causing the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, we have to report it to the administrator or abuse coordinator for the facility . We learned about rights. They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to. We have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior manage you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with the AD she stated some types of behavior management required you to step back and give them some space. She said when you see a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. I would give them space provide one-on-one food and snacks go a long way you could take them to the bathroom start an activity just go down the list basically until something works you could look in their care plan and see if there's any interventions in there.- check to see if they are wet or hungry or thirsty. She stated the facility is a restraint free facility. She stated she was inserviced8/26/25 and earlier in the week by the RN corporate Nurse and she has a handout to keep in her pocket at all times for reference. During an interview with CNA K on 8/26/25 at 11:10 AM. She stated she was Inserviced on 8/19/.25 and 8/26/25 on abuse and Neglect, resident rights, Trauma Informed Care ( an approach to care that recognized the widespread prevalence of trauma and its impact on individuals and promotes creation of a safe and supportive environment on residents that promotes healing and recovery from traumatic experiences, and Abuse and Neglect. She stated she learned about isolation. She stated the corporate Nurse Inserviced all the staff again this morning and gave them a handout over the material to fold and keep in their pockets. She stated all allegations of possible abuse must be reported immediately to the administrator, whether it's an interim or permanent administrator . She stated abuse is to be reported immediately at the time it happens. She stated residents have the right to be abuse free. She stated that meant no restraints or involuntary seclusion and unnecessary confinement Trauma informed care assessment should be done on residents after incidents unauthorized restraint seclusion unreasonable confinement can cause unnecessary trauma. She stated they learned to be sure that residents having aggressive b[TRUNCATED]

**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 physical or chemical restraints imposed for purposes of discipline or convenience, and that are not required to treat the resident's medical symptoms for 1 of 7 residents (Resident #1) reviewed for physical restraint/chemical restraints. The facility failed to protect Resident #1 from physical restraint when LVN A, RN B, N/A C, and Laundry Staff D grabbed Resident #1 by his arms and legs which restricted his movement and dragged the resident across the floor and carried him by holding onto his arms and legs down to his room. The staff placed Resident #1 in his room and held the door closed so that he could not leave his room. An Immediate Jeopardy was identified on 8/25/25. The IJ template was provided to the facility on 8/25/25 at 5:07 PM While the IJ was removed on 8/26/25, the facility remained out of compliance at a scope of isolated, and a severity level of no actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk of physical injury, psychological trauma, and severe emotional distress.Findings include:An observation on 8/20/25 of the electronic monitoring system video dated 8/17/25, showed these events: At 2:20 PM Resident #1 began showing behaviors which included: wandering into other residents rooms, taking items from other residents rooms, dropping clothing items in the hallway, and pulling a bedside table down the hallway. At 2:44 PM resident number one went into another residents' room and took a small fan out of that room and carried it down the hallway. Resident #1 became agitated when housekeeping staff took the fan away from him. At 2:53 PM resident number one walked out of his room with a bedside table. Resident #1 pushed the bed side table forcefully into Rn B and hit her in the shins of both legs. RN B and NA C walk away towards the nurses station and resident number one walk after them. 2:55 PM incident number one started running toward N/A C down the hallway towards the nurses station with a call light cord which resembled an outdoor extension cord in his hand it had an approximately 1.5-inch metal prong on one end and the other end was plastic with a red call button on the end in his hand. N/A C started running away from Resident #1 toward the nurses station. Resident #1 swung the call light cord while he ran toward the nurses station following staff. He bumped into laundry staff member D as he ran, and she held her hands up in the air. Resident #1 continued to run and chase the staff and was swinging the cord . Resident number one tripped on a chair and fell to the floor. There were four other residents in the vicinity. Rn B motioned with her hand to two unidentified residents that were sitting in the row of chairs at the nurses station to go down the hallway away from resident #1. The two residents walked away. N/A C removed another resident away from resident #1 down the other hallway. An unidentified 4th resident stood back and watched. Laundry staff D held onto the cord and sat in a nearby chair as resident #1 held the cord and sat on the floor. Rn B and LVN A walked around Resident#1 as he tried to kick laundry staff D. RN B and LVN A grabbed resident number one by the arms and twisted his body to lay on his back. They pulled him approximately 5 feet on the floor. Resident #1 tried kicking and resisting staff as the laundry staff got up and hung on to the cord and walked beside them down the hall as they continued to drag him. Resident #1 continued to kick with both feet to resist the staff. LVN A moved to his right leg as he tried to kick her. N/A C held on to his left arm. Resident #1 kicked with both feet as LVN A move to his left leg and laundry staff grabbed his right leg. The 4 Staff picked him up off the floor by his extremities with no support to his back or midsection and carried resident number one to his room. Staff carried him into the room ran out of the room and closed the door of his room. During a telephone interview with N/A C on 8/18/25 at 4:20 PM via phone regarding another incident NA C stated she worked 6 AM to 6 PM on 8/17/25 and an incident had occurred with resident #1 between 2:00 PM and 4 PM when the Nurse had to call the police due to Resident #1's aggressive behaviors. She stated he broke the window glass in his room and the police were called. She stated the staff, and the police had to restrain him by holding him down. She stated she was only involved in this incident. During an interview on 8/19/25 at 9:24 AM RN B stated on Sunday, 08/17/ 2025, Resident #1 was sitting in chair near the nurses station. She stated Resident # 1 suddenly became violent toward other residents that were near him and attempted to strike them. She stated she tried to assist him to a standing position and called for help. She stated she tried to guide him to his room, he was resistant. She stated he tried to strike at her with his fists. She stated other staff members responded, and they continued to attempt to make their way to take him down the hall while he continued to attempt to break lose, and kick, and punch the staff. She stated Resident #1 did manage to break free and grabbed a bedside table, picked it up, and threw it at them. She stated it struck her hard on her shins and left bruises on both legs. She stated she was afraid for herself and the other residents. She stated they struggled to hold Resident #1 but were finally able to get him through the door of his room and close it. She stated one aide had to brace herself against the wall to hold it shut by the doorknob while Resident #1 was throwing things against the door. She stated the staff outside Resident 1's door heard several loud bangs on the door and banging in the room, and then they heard glass break. She stated they did not enter the room to check on the resident. During an Interview with laundry staff D at 10:33 AM on 8/20/25 she stated she worked in the laundry and was here on 8/17/25 and witnessed the incident with Resident #1 . She stated she saw him being physically hitting coworkers and trying to hit residents. She stated he was trying to hit an unidentified lady sitting in the chairs across from the nursing station. She stated 4 staff restrained him. She stated Resident #1 was on the floor and had a cord in his hand. She stated she took the cord away and picked up his legs and feet . She stated 4 staff carried him down to his room and they shut the door and left him in there so he wouldn't hurt anybody. An aide (name unknown) was holding on to the doorknob to keep him in the room and prevent him from opening the door. Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life that can lead to a range of behavioral symptoms), anxiety disorder ( a nervous disorder that significantly impairs daily life by causing constant, debilitating fear and worry that make every day activities difficult to complete), unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain), And Alzheimer's Disease . Record review of Resident #1's Quarterly MDS, dated [DATE] revealed in Section C that he had a BIMS score of 5 which indicated severe cognitive impairment. Section E behavior indicated no psychosis, no presence of physical behavioral symptoms directed toward others, no presence of verbal behavioral symptoms directed toward others, and he had no behaviors such as wandering, pacing, or rummaging. Section N indicated the resident did not take an antipsychotic or an antidepressant since admission, re-entry or the last OBRA assessment. Record review of Resident #1's active physician orders dated 8/20/25 reflected Resident #1 had an order dated 10/17/24 which reflected: Admit to secure unit due to history of elopement with exit seeking behavior. There was no order for physical restraints . There was a one-time order for Haldol 5 mg/ml 1 time only for 1 day. Record review of the MAR dated 8/1/25 reflected that Haldol 5mg was administered at 6:49 PM on 8/17/25. Record review of Resident #1's care plan last dated revised on 8/18/25 included : Focus The resident has a behavior problem - will become aggressive with staff and residents pushing and hitting. Purposely places himself on the floor. Interventions: Caregivers to provide for positive interaction, attention, stop and talk with him as they pass by (1/3/24); Hospice to evaluate medication list with psych. (3/17/25); If resident becomes aggressive towards another resident remove him from the situation. Take him to a quiet area to talk. Resident likes to talk, walk outside and sit on the couch in the lobby (4/22/25); Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate place location as needed (12/5/23); Resident enjoys prayers. When resident is combative ask him if he needs to pray (3/13/25); When resident has increased confusion and or combativeness call his granddaughter and let him speak to her( 3/13/25)During an interview at 1:04 pm on 8/21/25 with the DON she stated she did not know how her staff handled the incident with Resident #1 until she watched the video on 8.19.25. The DON stated her expectation of them was to fully inform her of the situation and the severity of the behaviors and the interventions they had used when they called her. She stated she was aware that he was agitated, and he had broken his bedroom window and that was all I was told. She stated she would have like to have seen RN B, LVN A, Laundry staff D, and N/A C put the safety of the other residents first and remove them from the situation. She further stated she would have liked to have seen them keep him in eyes view and not congregated around him. She stated that she could see that he could feel threatened by the staffs actions. She stated in that situation she would have gotten down on the ground on the Residents level and asked him in a calm voice what can I do to make you feel safe. She stated she felt the staff acted the way that they did because they felt threated and needed more education . During an interview with the Administrator on 8/21/25 at 1:24 PM she stated she would have would like to see an attempt at de-escalation of the situation by her staff first. She stated she did not expect them to move him down the hall in the manner that they did. She stated would have preferred to have her staff step back and not take items away from Resident #1 if the items were not doing any harm to him or the other residents. She stated she would have expected that they would not pick Resident #1 up and take him to the room, shut the door and then hold the door closed so he could not get out . She stated they could not see him. She stated she would have liked to have seen the staff keep Resident #1 in eyes view, because the video showed the resident was obviously upset and angry. She stated she would have preferred that the staff did not congregate around Resident #1. She stated she was notified by the DON at 4:58 PM that the resident had broken the window out in the room. She stated that is all she was told until 8/19/25 when she viewed the video. The administrator stated she was notified at 4:58 PM by the DON that Resident #1 was agitated and punched out the window in his room. She stated she called maintenance to go to the facility to fix the window at that time. During an interview on 8/21/25 at 2:18 PM LVN A stated it was a collective decision of the 4 staff to forcibly carry the Resident #1 to his room and hold the door shut. She stated they did it this way because it was easier for them to carry him down there, put him in his room and hold the door shut, than it was to get the other residents out of the way. She stated she went outside to see if she could see what Resident #1 had done after she heard glass break. She stated the housekeeper came out and relieved her and stayed until the police entered the room. She stated she saw a drawer on the floor and a lot of broken glass in the room and the resident was still agitated. She stated she had called the police when she heard the window break. She stated the police handcuffed the resident and restrained him until he was given the Haldol (antipsychotic) by the hospice nurse. During an interview with the resident POA on 8.21.25 at 3 :15 PM she stated the facility did not notify her of the behaviors her grandfather was exhibiting and that they had restrained him, or that he had broken the window out in his room. She stated she did not give consent for restraints or Haldol to the facility. She stated the person that notified her was a Hospice nurse after it was all said and done. She stated she did not know why she was not notified sooner in the day by the facility. She stated she got mixed reports from the facility on how and when this had all happened , but stated was told to her by Hospice that it had started earlier in the day, and she felt she should have been called then. She said if she had known she would have come up to the facility and helped calm him down. She stated : I don't understand why the police were called on a [AGE] year-old man that has dementia and was placed in a facility that specializes with Alzheimer's and dementia. During an interview at 4:32 PM on 8.21.25 with the Hospice phy 8.21.25 he stated I do believe that the situation with Resident #1 was handled appropriately by calling Hospice, and I do believe that they attempted preventative measures prior to chemical sedation and physical restraints according to the information the facility relayed to the Hospice RN who notified him. He stated The fact that two faculty staff had been assaulted, and I believe the chair had been thrown into a window damaging property. This could also potentially harm the resident as well. I do think that they managed it appropriately. During an interview with The Primary physician of Resident #1 on 8/21/25 at 4:50 PM he stated he was not informed of the incident with resident #1 until he was notified by the DON on 8/19/25. He stated he couldn't comment on whether he thought the situation was handled appropriately because he was not informed at the time of the incident. He stated he felt the DON was trying to make some positive changes at the facility. Record review of the facility policy titled Abuse/Neglect dated revised 9/9/24 reflected the following in part: The resident has the right to be free from abuse neglect misappropriation of property and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment and involuntary seclusion, and any physical or chemical restraint not required to treat the residents medical symptoms. Residents should not be subjected to abuse by anyone, including but not limited to facility staff, other residents consultants or volunteers, staff of other agencies serving the resident family members or legal guardians friends or other individuals. Abuse is the willful infliction of injury unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents irrespective of any mental or physical condition can cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting slapping pinching and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation, mistreatment means inappropriate treatment or exploitation of a resident. Record review of the facility policy titled Restraints not dated, reflected the following in part: It is the policy of this facility to maintain an environment that prohibits the use of restraints for discipline or convenience restraint usage should be limited to circumstances in which the resident has medical symptoms that warrant the use of restraints a resident assessment committee will evaluate the facilities is committed to nurturing the autonomy and independence of our residents by attempting to provide a restraint free environment. Definitions physical restraint- any manual method or physical mechanical device material or equipment attached or adjacent to the residence body that the resident cannot remove easily which restricts freedom of movement or normal access to 1's body physical restraints include but are not limited to leg restraints arm restraints hand mitts soft tire best wheelchair safety bars [NAME] chairs lap cushions and trays that residents cannot move. Procedure restraints will only be applied after it has been determined that a medical symptom requiring restraint usage exists and only after all other alternatives have been tried unsuccessfully a physicians order shall be necessary to begin a restraint assessment evaluation for the resident, the restraint assessment committee shall meet to assess the necessity of restraints for a resident by completing a pre-restraining assessment worksheet the restraint assessment committee will identify an alternate method, or the type of restraint needed, when and how often a restraint is to be used, and why the restraint is to be used. Contact the resident and our family member responsible party to discuss the plan of care and obtain informed consent if needed. Obtain A physicians order for the restraint to specify type of restraint and length of time the resident is to be in the restaurant facility staff will develop a care plan for the alternate method identified and or the restraint usage. Physical restraints for behavior control shall only be used in an emergency which threatens to bring immediate injury to the resident or others. In such an emergency an order may be received by telephone and shall be signed by the physician within 48 hours. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, and the length of time, effectiveness of the physical restraint time and the name of the individual applying the restraint. Such measures shall be entered in the residents medical record . Every effort shall be made to calm the resident first , however personal safety must be considered. There should be no prn order for behavioral restraints. Residents requiring restraints for behavioral control on more than one occasion shall be considered for alternate placement to a facility that can meet their needs without the use of restraints. This was determined to be an Immediate Jeopardy (IJ) on 8/25/25 at 5:07 PM. The Interim Administrator, Corporate Nurse, Corporate Regional [NAME] president, DON, and Corporate Clinical Leader RN were informed of the IJ. The interim Administrator was provided with the IJ template on 8/5/25. Please see the attached POR for F604 Please note that our dates will reflect 8/19, when our POR was completed after facility identified correction needed. Plan of Removal Interventions: On 8/19/25, staff members LVN A, RN and NA were immediately suspended by the administrator. Completed 8/19/25. All three staff members remain suspended as of 8/25/25. On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25. On 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25. The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25. On 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25. On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. Completed 8/19/25. On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/25 The medical director was notified of the immediate jeopardy by the Administrator on 8/25/25. On 8/19/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 8/19/25. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. In-services: The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. The surveyor monitored the facility's plan of removal and confirmed it was sufficient to remove the IJ t Monitoring of the facility's Plan of removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 8/26/25 at 9:58 AM to 5:30 PM as follows: During an interview with LVN F (6AM- 6PM shift) on 8/26/25 at 9:59 AM, he stated he was Inserviced on 8/19/25 and 8/26/25 on the abuse and neglect policy, trauma informed care assessments, the restraint policy for the facility, behavior management. He stated a restraint is holding their arms down or holding their door shut would be isolation. He stated restraints, involuntary seclusion, and unreasonable confinement were not tolerated and prohibited in this facility. During an interview with LVN G (6AM - 6PM shift) on 8/26/25 at 10:10 AM, she stated she was Inserviced on 8/19/25, and 8/26/25 by the Corporate Nurse. She stated, neglect is not doing things for patients intentionally and just let them sit all day in their chair, not changing them, not making sure that they've eaten. Abuse can be verbal, it can be physical, it can be mental. She stated, I have my Cheat Sheets with the highlights of the Inservice on it. You can't use restraints, secluding them involuntarily and unreasonable confinement is abuse. You report everything to the Administrator. The Administrator is the abuse coordinator, and you should report it immediately when it happens. That way you've reported it because you realize it could be wrong or considered abuse. She stated, We are actually a no restraint facility. That is a big No, no. You use Behavior management which would be doing every single thing that we're supposed to do first. Make sure that they've been to the toilet, see if they need a drink or if they are wet, go for a walk, start an activity. During an interview with CNA H (6AM - 6PM shift) on 8/26/25 at 10:15 AM, she stated that she was Inserviced on abuse and neglect, restraints, and seclusion today, 8/26/25 and on 8/19/25. She stated examples of abuse were: posting on social media about residents, talking bad or loud and screaming, or body harm that is sexual or physical or mental health. She stated, Resident restraining it's like from having something on them to keep them from moving or that the physician doesn't know that they are doing. Even if the physician does know, then is it still a restraint and you shouldn't do that. She stated, I would have to report it to the Administrator immediately. Resident rights means that residents have the right to ask for snacks or anything they need . They have the right to our respect and to be free from abuse or seclusion. Behavior management is to distract them from the things that upset them before they get upset if you can by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first. Never do it without the permission of the physician. She stated she would look in the or care plan for resident specific interventions. During an interview with CNA I (6 PM to 6 AM shift) on 8/26/25 at 10:30 AM, she stated the types of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms, sexual and stealing from residents. She stated you report abuse immediately. She stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility . She stated they learned about rights. They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to. She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention. She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types of behavior management required you to step back and give them some space. She said when you see a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. she said she would give them space, provide one-on-one, and food and snacks go a long way. She said you could take them to the bathroom, start an activity, just go down the list basically until something works. She said you could look in their care plan and see if there's any interventions in there. She said check to see if they are wet or hungry or thirsty. She stated the facility is a restraint free facility. She stated she was inserviced 8/26/25 and earlier in the week by the RN Corporate Nurse and she has a handout to keep in her pocket at all times for reference. During an interview with CNA K on 8/26/25 at 11:10 AM, she stated she was Inserviced on 8/19/25 and 8/26/25 on abuse and Neglect, resident rights, Trauma Informed Care She stated she learned about isolation. She stated the Corporate Nurse Inserviced all the staff again this morning and gave them a handout over the material to fold and keep in their pockets. She stated all allegations of possible abuse must be reported immediately to the Administrator, whether it's an interim or permanent Administrator. She stated abuse is to be reported immediately at the time it happens. She stated residents have the right to be abuse free. She stated that meant no restraints or involuntary seclusion and unnecessary confinement. She stated Trauma informed care assessments should be done on residents after incidents of unauthorized restraint or seclusion. She said unreasonable confinement can cause unnecessary trauma. She stated they learned to be sure that residents having aggressive behaviors are in an area where they will not harm themselves and redirect other residents from the area where the resident is being physically aggressive. She stated, I know that you cannot restrain a resident, you cannot put them in a wheelchair and put the locks on if they can't get the lock off. She stated the Abuse Coordinator is the Administrator. During an interview with the DM on 8/26/25 at 11:15 AM, she stated she had an inservice on 8/19/25 by the administrator, and again today on 8/26/25. She stated No restraints, involuntary seclusion, or unreasonable confinement are allowed. All allegations of possible abuse must be reported immediately to my administrator right whether it's an interim or permanent administrator. The restraint policy is no restraints. We learned about resident rights that they have the right to be abuse free. Restraints, involuntary seclusion, and unnecessary confinement are all different types of abuse . Trauma assessment should be done after any incident of abuse or aggression, an incident of abuse can cause mental trauma. We were given a little cheat sheet to keep in our pocket. During an interview with the ADON on 8/26/25 at 11:40 AM, she stated she was inse[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to implement policies and procedures for reporting when the administrator and the State Survey Agency were not notified immediately notified of abuse on 8/17/25 when 4 facility staff (LVN A, RN B, NA C, and Laundry attendant D) grabbed Resident #1 and forcibly carried him by his extremities to his room. The staff placed Resident #1 in his room and held the door closed so that he could not leave his room. The abuse was not reported to the administrator until 8/19/25. This failure could place residents at risk of physical injury, psychological trauma, and severe emotional distress.An Immediate Jeopardy was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 5:07 PM While the IJ was removed on 9/14/25, the facility remained out of compliance at a scope of isolated, and a severity level of actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. Findings include: A record review of the facility policy Abuse/Neglect, dated as revised 9/9/24, revealed the following [in part]: Policy Statement: Reporting any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse neglect or exploitation must report this to the Don, administrator, state, and our adult Protective Services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated. Employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury and unknown source to the facility administrator. The facility administrator or designee will report to HSC all incidents that meet the criteria of provider letter 2024-14 dated 8/29/24. A record review of Provider Letter No. 2024-14, dated 8/29/24 revealed the following [in part]: 1. Abuse: A NF must report incidents a nursing facility must report to CII the following types of incidents in accordance with applicable state and federal requirements: abuse, neglect, exploitation, due to unusual circumstances, a missing resident misappropriation drug theft, suspicious injuries of unknown sources, fire emergency situations that pose a threat to resident health and safety, communicable disease, situations that are an unusual or abnormal event that possess a threat to resident health and safety. Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life that can lead to a range of behavioral symptoms), anxiety disorder ( a nervous disorder that significantly impairs daily life by causing constant, debilitating fear and worry that make every day activities difficult to complete), unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain). Record review of Resident #1's Quarterly MDS, dated [DATE] revealed in Section C that he had a BIMS score of 5 which indicated severe cognitive impairment. Section E behavior indicated no psychosis, no presence of physical behavioral symptoms directed toward others, no presence of verbal behavioral symptoms directed toward others, and he had no behaviors such as wandering, pacing, or rummaging. Record review of Residents #1's nursing progress note Author: LVN EEffective Date: 08/17/2025 3:30 PM Type: Nursing NoteNote Text: Resident was being combative with staff and was escorted back to room, Resident started throwing things at the window in his room and broke his window, Police and EMS was called to deescalate the situation. Will continue to monitor, Hospice gave new orders for Haldol 5mg/1ml. Resident has been given Haldol 5mg/1ml, POA notified. Interventions: 1 on 1 monitoring, Directed to the resident's room to decrease stimulation, Assess for pain. Record review of the Incident Investigation Worksheet, dated 8/19/25, revealed the following [in part]: It was reported to the DON on 8/17/25 that Resident #1 threw a drawer through his window. During the course of investigation, it was discovered on 8/19/25 that the resident had previously thrown an over bed table out of a room at the staff and that the staff carried Resident #1 to his room, put him in his room and held the door closed. The staff members were suspended pending investigation. Inservice on abuse/neglect. Family notified; physician notified. An observation on 8/19/25 at 12:24 PM of the electronic monitoring system video dated 8/17/25, showed these events: -At 2:20 PM Resident #1 began showing behaviors which included: wandering into other residents' rooms, taking items from other residents rooms, dropping clothing items in the hallway, and pulling a bedside table down the hallway. -At 2:44 PM Resident #1 went into another residents' room and took a small fan out of that room and carried it down the hallway, Resident #1 became agitated when housekeeping staff took the fan away from him. -At 2:53 PM Resident #1 walked out of his room with a bedside table and pushed the bed side table forcefully into RN B and hit her in the shins of both legs. RN B and NA C walked away towards the nurses station and Resident #1 walked after them. -At 2:55 PM Resident #1 started running toward NA C down the hallway towards the nurses station with a call light cord which resembled an outdoor extension cord in his hand, it had an approximately 1.5-inch metal prong on one end and the other end was plastic with a red call button on the end in his hand. NA C started running away from Resident #1 toward the nurses station. Resident #1 swung the call light cord while he ran toward the nurses station following staff. He bumped into laundry staff D as he ran, and she held her hands up in the air. Resident #1 continued to run and chase the staff and was swing the cord. Resident #1 tripped on a chair and fell to the floor. There were four other residents in the vicinity, RN B motioned with her hand to two unidentified residents that was sitting in the row of chairs at the nurses station to go down the hallway away from Resident #1. The two residents walked away. NA C removed another resident away from Resident #1 down the other hallway. An unidentified 4th resident stood back and watched. Laundry staff D held on to the cord and sat in a nearby chair as Resident #1 held the cord and sat on the floor. RN B and LVN A walked around Resident #1 as he tried to kick laundry staff D. RN B and LVN A grabbed Resident #1 by the arms and twisted his body to lay on his back. They pulled him approximately 5 feet on the floor. Resident #1 tried kicking and resisting staff as the laundry staff got up and hung on to the cord and walked beside them down the hall as they continued to drag him. Resident #1 continued to kick with both feet to resist the staff. LVN A moved to his right leg as he tried to kick her. NA C held on to his left arm. Resident #1 kicked with both feet as LVN A move to his left leg and laundry staff grabbed his right leg. The 4 Staff picked him up off the floor by his extremities with no support to his back or midsection and carried Resident #1 to his room. Staff carried him into the room ran out of the room and closed the door of his room. During an interview on 8/21/25 at 1:04 p.m., the DON stated she did not know how her staff handled the incident with Resident #1 until she watched the video on 8/19/25. The DON stated her expectation of them was to fully inform her of the situation on 8/17/25 and the severity of the behaviors and the interventions they had been used when they called her. She stated she was aware that he was agitated, and he had broken his bedroom window and that was all I was told. She stated abuse should have been reported immediately to the administrator and all staff were responsible to do this. During an interview on 8/21/25 with the Administrator at 1:24 p.m., she stated she was notified by the DON at 4:58 p.m., that the resident had broken the window out in the room. She stated that is all she was told until 8/19/25 when she viewed the video. The administrator stated she was notified at 4:58 p.m., by the DON that Resident #1 was agitated and punched out the window in his room. She stated she called maintenance to go to the facility to fix the window at that time. During an interview on 8/21/25 at 2:18 p.m., LVN A stated it was a collective decision of the 4 staff to forcibly carry the Resident #1 to his room and hold the door shut. She stated they did it this way because it was easier for them to carry him down there, put him in his room and hold the door shut, than it was to get the other residents out of the way. She stated she told the DON that they forcibly carried the resident down the hall and held the door in his room closed so that he could not get out and the DON was aware of what all occurred on 8/17/25 on that date. During an interview on 8/20/25 at 11:51 a.m., LVN E stated she worked on 8/17/25. and was coming out of the med room and turned to the right and saw Resident #1 had a cord in his hand. He was swinging it around and all the other staff was trying to get it out of his hands. Two of the nurses had grabbed his arms, and 2 other people grabbed his legs and carried him back to the room because he was fighting. They ended up putting him in his room and closed the door. They kept the door closed by holding the doorknob. One of the aides was holding the door and he was grabbing stuff in his room and throwing it and broke the window. She stated she had asked NA C if she could open the door because he was pushing on the door and hitting the door trying to get out. The EMS and the police had arrived by this time. After that he settled down. She stated she had tried to call the DON, but she didn't answer, and she told the other nurse (LVN A) to call the DON. We were all trying to call to see what we could do in that situation. LVN E stated she was concerned about the way the incident was handled because of him acting out like that. She stated that with Alzheimer's it was kind of tricky on how they respond, and things were getting worse. She stated the administrator was the abuse coordinator. She stated the types of abuse are physical. mental, sexual, verbal. She stated during the incident with Resident #1 on 8/17/25, she didn't like that they had to restrain him. She stated, I was trying to tell them (the other staff present) that I felt uncomfortable. She stated she didn't like how it was done by the staff or the police restraining him. I did not like the situation because I don't think I've had to restrain a patient in a long time, so it just did not make me feel comfortable. To my knowledge I thought that the Administrator and the DON knew about it, but when I talked to them, they had told me they did not know about it. This was determined to be an Immediate Jeopardy (IJ) on 9/12/25 at 2:04 PM. The Interim Administrator, Corporate Compliance Nurse, Corporate Regional [NAME] President, DON, and were informed of the IJ. The interim Administrator was provided with the IJ template on 9/12/25 2:04 PM. The following Plan of Removal was accepted on 9/13/25 at 1:15 PM: Please see the attached POR for F609. Please note that our dates will reflect 8/19, when our POR was completed after facility identified correction needed. Plan of Removal:Facility: Peach Tree Date: 9/12/25Plan of RemovalProblem: F609 Reporting of Alleged ViolationsAll residents had the potential to be affected by this deficient practice. Interventions:1. The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on the following topic as of 9/12/25. The Administrator will report to the State immediately or within 2 hours any incidents in accordance with state and federal requirements of abuse in situations that are an unusual or abnormal event that poses a threat to residents' health and safety. A post-test was provided to the Administrator and DON by the Regional Compliance Nurse. Completed 9/12/25.2. On 8/19/25, staff members NA, LVN and Laundry Aide were immediately suspended by the administrator. LVN returned 9/5/25 and the Laundry Aide returned 8/25/25. NA was terminated on 8/30/25. Completed 9/5/253. 1:1 in-service was conducted with both employees by the secure care consultant and Regional Compliance Nurse. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician.4. On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25.5. On 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25.6. The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25.7. On 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25.8. On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. Completed 8/19/25.9. On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/2510. The medical director was notified of the immediate jeopardy by the Administrator on 9/12/25.11. On 9/12/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 9/12/25.12. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician.Inservices:The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. All staff will report abuse immediately to abuse coordinator (administrator). If the abuse coordinator is not available, the DON will be notified immediately. Examples of abuse are physical, verbal, sexual, and emotional. Specific examples are mentioned on the policy. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include unauthorized restraints, seclusion, and unreasonable confinement can cause unnecessary trauma. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician.Monitoring: Administrator/DON/Designee will ask 15-20 staff members per week situational questions related to abuse. Any corrective action needed from situational questions will be addressed immediately with a 1:1 written in-service prior to returning to work. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will ask 5 residents per week how staff treat them. Any corrective action needed from resident interviews will be immediately reported to the Abuse Preventionist and an internal investigation will be conducted. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will complete incident/event reviews in daily standup to ensure the facility is free of any potential abuse/neglect. Monitoring will occur 7 days per week beginning 8/25/25 and will continue indefinitely. The ADO/Compliance Nurse/Designee staff are at the facility 7 days a week interviewing staff for comprehension and reviewing facility monitoring tools and video footage of any new incidents reported that may require state reporting. 15- 20 staff members are asked situational questions per week related to abuse and neglect.13. Upon return, staff members brought back from suspension were given secure care dementia training on crisis vs. non crisis, The role of the care plan, and abuse reporting by the Director of Secure Care Services. Videos were reviewed on how to de-escalate residents with difficult behavior, with a return demonstration of understanding. LVN returned 9/05/25 and the Laundry Aide returned 8/25/25. 14. Risk management is reviewed on a daily risk call with the DON and Administrator to review all events to rule out Abuse and Neglect.15. The Administrator/DON review all events on the video surveillance system immediately upon notification of events and report findings to the risk management IDT to determine state reportable within 2 hours. Abuse and any incident that results in serious bodily injury is reportable within 2hrs.16. There is a daily 3 o'clock call with the ADO/RCN reviewing risk management, any incidents of behaviors or allegations for reportable purposes to ensure timely reporting. The facility's plan of removal monitored and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 8/26/25 at 9:58 AM to 5:30 PM and on 9/14/25 from 6:00 AM to 1:00 PM as follows: During an interview with LVN F (6AM- 6PM shift) on 8/26/25 at 9:59 AM, he stated he was Inserviced on 8/19/25 and 8/26/25 on the abuse and neglect policy, trauma informed care assessments, the restraint policy for the facility, behavior management. He stated a restraint is holding their arms down or holding their door shut would be isolation. He stated restraints, involuntary seclusion, and unreasonable confinement were not tolerated and prohibited in this facility. During an interview with LVN G (6AM - 6PM shift) on 8/26/25 at 10:10 AM, she stated she was Inserviced on 8/19/25, and 8/26/25 by the Corporate Nurse. She stated, neglect is not doing things for patients intentionally and just let them sit all day in their chair, not changing them, not making sure that they've eaten. Abuse can be verbal, it can be physical, it can be mental. She stated, I have my Cheat Sheets with the highlights of the Inservice on it. You can't use restraints, secluding them involuntarily and unreasonable confinement is abuse. You report everything to the Administrator. The Administrator is the abuse coordinator, and you should report it immediately when it happens. That way you've reported it because you realize it could be wrong or considered abuse. She stated, We are actually a no restraint facility. That is a big No, no. You use Behavior management which would be doing every single thing that we're supposed to do first. Make sure that they've been to the toilet, see if they need a drink or if they are wet, go for a walk, start an activity. During an interview with CNA H (6AM - 6PM shift) on 8/26/25 at 10:15 AM, she stated that she was Inserviced on abuse and neglect, restraints, and seclusion today, 8/26/25 and on 8/19/25. She stated examples of abuse were: posting on social media about residents, talking bad or loud and screaming, or body harm that is sexual or physical or mental health. She stated, Resident restraining it's like from having something on them to keep them from moving or that the physician doesn't know that they are doing. Even if the physician does know, then is it still a restraint and you shouldn't do that. She stated, I would have to report it to the Administrator immediately. Resident rights means that residents have the right to ask for snacks or anything they need . They have the right to our respect and to be free from abuse or seclusion. Behavior management is to distract them from the things that upset them before they get upset if you can by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first. Never do it without the permission of the physician. She stated she would look in the Kardex or care plan for resident specific interventions. During an interview with CNA I (6 PM to 6 AM shift) on 8/26/25 at 10:30 AM, she stated the types of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms, sexual and stealing from residents. She stated you report abuse immediately. She stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility . She stated they learned about rights. They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to. She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention. She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types of behavior management required you to step back and give them some space. She said when you see a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. she said she would give them space, provide one-on-one, and food and snacks go a long way. She said you could take them to the bathroom, start an activity, just go down the list basically until something works. She said you could look in their care plan and see if there's any interventions in there. She said check to see if they are wet, hungry, or thirsty. She stated the facility is a restraint free facility. She stated she was inserviced 8/26/25 and earlier in the week by the RN Corporate Nurse and she has a handout to keep in her pocket at all times for reference. During an interview with CNA K on 8/26/25 at 11:10 AM, she stated she was Inserviced on 8/19/25 and 8/26/25 on abuse and Neglect, resident rights, Trauma Informed Care She stated she learned about isolation. She stated the Corporate Nurse Inserviced all the staff again this morning and gave them a handout over the material to fold and keep in their pockets. She stated all allegations of possible abuse must be reported immediately to the Administrator, whether it's an interim or permanent Administrator. She stated abuse is to be reported immediately at the time it happens. She stated residents have the right to be abuse free. She stated that meant no restraints or involuntary seclusion and unnecessary confinement. She stated Trauma informed care assessments should be done on residents after incidents of unauthorized restraint or seclusion. She said unreasonable confinement can cause unnecessary trauma. She stated they learned to be sure that residents having aggressive behaviors are in an area where they will not harm themselves and redirect other residents from the area where the resident is being physically aggressive. She stated, I know that you cannot restrain a resident, you cannot put them in a wheelchair and put the locks on if they can't get the lock off. She stated the Abuse Coordinator is the Administrator. During an interview with the DM on 8/26/25 at 11:15 AM, she stated she had an inservice on 8/19/25 by the administrator, and again today on 8/26/25. She stated No restraints, involuntary seclusion, or unreasonable confinement are allowed. All allegations of possible abuse must be reported immediately to my administrator right whether it's an interim or permanent administrator. The restraint policy is no restraints. We learned about resident rights that they have the right to be abuse free. Restraints, involuntary seclusion, and unnecessary confinement are all different types of abuse . Trauma assessment should be done after any incident of abuse or aggression, an incident of abuse can cause mental trauma. We were given a little cheat sheet to keep in our pocket. During an interview with the ADON on 8/26/25 at 11:40 AM, she stated she was inserviced one on one with the Corporate Nurse on 8/19/25. She stated the following topics were discussed by the RN Consultant: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy - restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights - that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care - the use of unauthorized restraints, seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management - how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. During an interview with the MDS Nurse on 8/26/25 at 11:40 AM, she stated she was Inserviced on 8/19/25. She stated she had a sheet to keep with her at all times. She stated the Inservice covered the following areas: Restraint Policy - restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights - that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care - the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management - how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. During an interview with the ADON on 8/26/25 at 11:40 AM, she stated she was inserviced one on one with the Corporate Nurse on 8/19/25. The topics included: Restraint Policy - restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. She showed a copy of the handout to the surveyor that she was given to keep in her pocket and it . Resident Rights -[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident , consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment which were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to implement de-escalation techniques listed on the care plan were not implemented when 4 facility staff , (LVN A RN B, NA C and Laundry staff D) grabbed Resident #1 and forcibly carried him by his extremities to his room. The staff placed Resident #1 in his room and forcibly held the door closed so that he could not leave his room. An Immediate Jeopardy was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 5:07 PM While the IJ was removed on 9/14/25, the facility remained out of compliance at a scope of isolated, and a severity level of actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. These deficient practices could place residents at risk of not receiving the necessary care or services and having personalized plans developed to address their needs and maintain their highest level of well-being mentally and physically. Findings include: Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life that can lead to a range of behavioral symptoms), anxiety disorder ( a nervous disorder that significantly impairs daily life by causing constant, debilitating fear and worry that make every day activities difficult to complete), unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain). Record review of Resident #1's Quarterly MDS, dated [DATE] revealed in Section C that he had a BIMS score of 5 which indicated severe cognitive impairment. Section E behavior indicated no psychosis, no presence of physical behavioral symptoms directed toward others, no presence of verbal behavioral symptoms directed toward others, and he had no behaviors such as wandering, pacing, or rummaging. Section N indicated the resident did not take an antipsychotic or an antidepressant since admission, re-entry or the last OBRA assessment. Record review of Resident #1's care plan last revised on 8/18/25 included: Focus The resident has a behavior problem - will become aggressive with staff and residents pushing and hitting. Purposely places himself on the floor. Interventions: Caregivers to provide for positive interaction, attention, stop and talk with him as they pass by initiated 1/3/24. Hospice to evaluate medication list with psych initiated 3/17/25. If resident becomes aggressive towards another resident remove him from the situation. Take him to a quiet area to talk. Resident likes to talk, walk outside and sit on the couch in the lobby initiated 4/22/25. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate place location as needed initiated 12/5/23. Resident enjoys prayers. When resident is combative ask him if he needs to pray (3/13/25); When resident has increased confusion and or combativeness call his granddaughter and let him speak to her initiated 3/13/25.Focus: Resident is at risk of feelings of isolation due to being on a secure unit because of high risk of elopement Revised 5/`4/25.Interventions: Admit to secure unit per Dr orders.Assist and monitor resident for off unit activities if possible.Involve resident in secure unit activities.Notify physician and family of changes.Focus: The resident has a history of trauma that may have a negative impact. Created 8/11/25 by DON and interventions initiated on 8/11/25.Interventions: Monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, physician, and mental health provider.Perform the following de-escalation techniques (there were no de-escalation techniques listed for staff to implement). An observation on 8/19/25 at 12:24 PM of the electronic monitoring system video dated 8/17/25, showed these events: -At 2:20 PM Resident #1 began showing behaviors which included: wandering into other residents' rooms, taking items from other residents rooms, dropping clothing items in the hallway, and pulling a bedside table down the hallway. -At 2:44 PM Resident #1 went into another residents' room and took a small fan out of that room and carried it down the hallway, Resident #1 became agitated when housekeeping staff took the fan away from him. -At 2:53 PM Resident #1 walked out of his room with a bedside table and pushed the bed side table forcefully into RN B and hit her in the shins of both legs. RN B and NA C walked away towards the nurses station and Resident #1 walked after them. -At 2:55 PM Resident #1 started running toward NA C down the hallway towards the nurses station with a call light cord which resembled an outdoor extension cord in his hand, it had an approximately 1.5-inch metal prong on one end and the other end was plastic with a red call button on the end in his hand. NA C started running away from Resident #1 toward the nurses station. Resident #1 swung the call light cord while he ran toward the nurses station following staff. He bumped into laundry staff D as he ran, and she held her hands up in the air. Resident #1 continued to run and chase the staff and was swing the cord. Resident #1 tripped on a chair and fell to the floor. There were four other residents in the vicinity, RN B motioned with her hand to two unidentified residents that was sitting in the row of chairs at the nurses station to go down the hallway away from Resident #1. The two residents walked away. NA C removed another resident away from Resident #1 down the other hallway. An unidentified 4th resident stood back and watched. Laundry staff D held on to the cord and sat in a nearby chair as Resident #1 held the cord and sat on the floor. RN B and LVN A walked around Resident #1 as he tried to kick laundry staff D. RN B and LVN A grabbed Resident #1 by the arms and twisted his body to lay on his back. They pulled him approximately 5 feet on the floor. Resident #1 tried kicking and resisting staff as the laundry staff got up and hung on to the cord and walked beside them down the hall as they continued to drag him. Resident #1 continued to kick with both feet to resist the staff. LVN A moved to his right leg as he tried to kick her. NA C held on to his left arm. Resident #1 kicked with both feet as LVN A move to his left leg and laundry staff grabbed his right leg. The 4 Staff picked him up off the floor by his extremities with no support to his back or midsection and carried Resident #1 to his room. Staff carried him into the room ran out of the room and closed the door of his room. During an interview on 8/21/25 at 1:04 p.m., the DON stated she did not know how her staff handled the incident with Resident #1 until she watched the video on 8/1925. The DON stated her expectation of them was to fully inform her of the situation and the severity of the behaviors and the interventions they had used when they called her. She stated she was aware that he was agitated, and he had broken his bedroom window and that was all I was told. She stated she would have liked to have seen RN B, LVN A, Laundry staff D, and NA C put the safety of the other residents first and remove them from the situation. She further stated she would have liked to have seen them keep him in eyes view and not congregated around him. She stated that she could see that he could feel threatened by the staffs actions. She stated in that situation she would have gotten down on the ground on the residents level and asked him in a calm voice what can I do to make you feel safe. She stated she felt the staff acted the way that they did because they felt threated and needed more education. She stated it was the responsibility of the nurses to update care plans and monitor to see that interventions were followed. She stated she felt the failure occurred because the staff needed education. She stated she expected staff to follow the care plan She stated an adverse outcome for the resident was that he did not receive the behavioral interventions he needed to de-escalate. During an interview with the Administrator on 8/21/25 at 1:24 p.m., she stated she would have liked staff to follow the resident's care plan and make an attempt at de-escalation of the situation first. She stated she did not expect them to move him down the hall in the manner that they did. She stated she would have preferred to have her staff step back and not take items away from Resident #1 if the items were not doing any harm to him or the other residents. She stated they could not see him. She stated she would have liked to have seen the staff keep Resident #1 in eyes view, because the video showed the resident was obviously upset and angry. She stated she would have preferred that the staff did not congregate around Resident #1. During an interview on 8/21/25 at 2:18 p.m., LVN A stated it was a collective decision of the 4 staff present to forcibly carry the Resident #1 to his room and hold the door shut. She stated they did it this way because it was easier for them to carry him down there, put him in his room and hold the door shut, than it was to get the other residents out of the way. She stated they did not try any other interventions because they knew it would not do any good. During an interview with Resident #1's POA on 8/21/25 at 3 :15 p.m., she stated the facility did not notify her of the behaviors Resident #1 was exhibiting and that they had restrained him, secluded him or that he had broken the window out in his room. She stated she did not give consent for restraints or Haldol to the facility. She stated the person that notified her was a Hospice nurse after it was all said and done. She stated she did not know why she was not notified sooner in the day. She stated she got mixed reports from the facility on how and when this had all happened , but stated was told to by Hospice that it started earlier in the day, and she felt she should have been called then. She said if she had known she would have come up to the facility and helped calm him down. She stated: I don't understand why the police were called on a [AGE] year-old man that has dementia and was placed in a facility that specializes with Alzheimer's and dementia. She stated she had discussed with staff and asked that she be called when he had behavioral issues. She stated so much more could have been done to prevent the incident if they followed the intervention to call her before his behavior escalated. Record review of the facility policy Comprehensive Care Planning, not dated stated in part: The facility will develop and implement the comprehensive person-centered care plan for each resident consistent with the residents rights that includes measurable objectives and time frames to meet a resident medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the services that are to be furnished to attain or maintain the highest practicable physical, mental and psychosocial well-being, and the right to refuse treatment. The following Plan of Removal was accepted on 9/13/25 at 1:15 PM:Peach Tree September 12, 2025 Plan of RemovalF656 Develop/Implement Comprehensive Care Plans Intervention:All residents care plans reviewed by Regional Compliance Nurse and DON to ensure proper interventions are in place for all residents with behaviors on 9-12-25. 40/40 residents care plans identified to have behavior care plan in place with interventions. All care plans were verified to have the appropriate interventions for behaviors.The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on care plan policies and procedures, Comprehensive Care plans of residents with behaviors with interventions to implement for resident overall mental, physical, and psychological health on 9/12/25. Post test was completed for the comprehension of the in-service.All staff will be in-serviced on 9/12/25 by the DON/designee regarding the following and all staff not in-serviced by 9/12/25 will not be allowed to work in their assigned position until completion of these in-services. All new hires, PRN, and agency staff will be in-services prior to the start of their assignment: This will be ongoing. Comprehensive Care Plan- Clinical staff were educated on how to access the resident care plan/Kardex for residents with behaviors to review the interventions to implement for residents overall mental, physical, and psychological health on 9/12/25. The IDT will review and reassess care plans and interventions quarterly, and as needed for changes of condition in the resident by the IDT. On 8/19/25 the staff involved in the incident were suspended, they were educated upon suspension and upon return to the facility. The Secure Care Specialist had additional Dementia and Secure care training with staff. On 9/8/25 staff were given education, by Secure Care Specialist, along with a scripted scenario of the actual event that took place then they were asked questions after she gave the scenario to ensure comprehension. She also educated staff on their responsibility to protect residents and themselves, to include what is abuse and neglect, and exploitation, Reporting steps, who to tell, why reporting matters, and how to de-escalate. Resident #1 has rummaging boxes added on 8/25/25 to his care plan as an intervention to distract him when he is wandering looking for his items. On 8/19/25, staff members LVN A, RN and NA were immediately suspended by the administrator. Completed 8/19/25. All three staff members remain suspended as of 8/25/25.On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25.On 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25.The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25.On 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25.On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. Completed 8/19/25.On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/25The medical director was notified of the immediate jeopardy by the Administrator on 9/12/25.On 9/12/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 9/12/25.The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de- escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove al residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician. Inservices: The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma. Behavior management to include how to manage behaviors and de- escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician. Monitoring: Administrator/DON/Designee will ask 15-20 staff members per week situational questions related to abuse. Any corrective action needed from situational questions will be addressed immediately with a 1:1 written in-service prior to returning to work. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will ask 5 residents per week how staff treat them. Any corrective action needed from resident interviews will be immediately reported to the Abuse Preventionist and an internal investigation will be conducted. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will complete incident/event reviews in daily standup to ensure the facility is free of any potential abuse/neglect. Monitoring will occur 7 days per week beginning 8/25/25 and will continue indefinitely. Compliance nurse/designee will monitor weekly for care plan behavioral intervention implementation; findings will be addressed immediately. Interventions:On 8/19/25, staff members LVN A, RN and NA were immediately suspended by the administrator. Completed 8/19/25. All three staff members remain suspended as of 8/25/25. Verified 8/26/25 @ 3:53 PM.On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25. (Completed by [NAME] LVN) Verified 8/26/25 @ 4:13 PMOn 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25. Verified 8/26/25 @ 4:13 PM The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25. Verified 8/26/25 @ 3:40 PMOn 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25. Verified 8.26.25 @ 4:00 PM On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. 8.19.25 Verified 8.26.25 @ 4:20 PM On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/25 Verified 8.26.25 @ 4:20 PM The medical director was notified of the immediate jeopardy by the Administrator on 8/25/25. On 8/19/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 8/19/25.Verified 8/26/25 @ 4:26 PM The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25.Verified 8.26.25 4:27 PMAbuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician. In-services: The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25. Verified 8.26.25 from 10 :07 AM to 12:00 Noon. Horn RN Interviews completedAbuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician.Monitoring: Administrator/DON/Designee will ask 15-20 staff members per week situational questions related to abuse. Any corrective action needed from situational questions will be addressed immediately with a 1:1 written in-service prior to returning to work. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will ask 5 residents per week how staff treat them. Any corrective action needed from resident interviews will be immediately reported to the Abuse Preventionist and an internal investigation will be conducted. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will complete incident/event reviews in daily standup to ensure the facility is free of any potential abuse/neglect. Monitoring will occur 7 days per week beginning 8/25/25 and will continue indefinitelyThe facility's plan of removal monitored and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 8/26/25 at 9:58 AM to 5:30 PM and on 9/14/25 from 6:00 AM to 1:00 PM as follows: During an interview with LVN F (6AM- 6PM shift) on 8/26/25 at 9:59 AM, he stated he was Inserviced on 8/19/25 and 8/26/25 on the abuse and neglect policy, trauma informed care assessments, the restraint policy for the facility, behavior management. He stated a restraint is holding their arms down or holding their door shut would be isolation. He stated restraints, involuntary seclusion, and unreasonable confinement were not tolerated and prohibited in this facility. During an interview with LVN G (6AM - 6PM shift) on 8/26/25 at 10:10 AM, she stated she was Inserviced on 8/19/25, and 8/26/25 by the Corporate Nurse. She stated, neglect is not doing things for patients intentionally and just let them sit all day in their chair, not changing them, not making sure that they've eaten. Abuse can be verbal, it can be physical, it can be mental. She stated, I have my Cheat Sheets with the highlights of the Inservice on it. You can't use restraints, secluding them involuntarily and unreasonable confinement is abuse. You report everything to the Administrator. The Administrator is the abuse coordinator, and you should report it immediately when it happens. That way you've reported it because you realize it could be wrong or considered abuse. She stated, We are actually a no restraint facility. That is a big No, no. You use Behavior management which would be doing every single thing that we're supposed to do first. Make sure that they've been to the toilet, see if they need a drink or if they are wet, go for a walk, start an activity. During an interview with CNA H (6AM - 6PM shift) on 8/26/25 at 10:15 AM, she stated that she was Inserviced on abuse and neglect, restraints, and seclusion today, 8/26/25 and on 8/19/25. She stated examples of abuse were: posting on social media about residents, talking bad or loud and screaming, or body harm that is sexual or physical or mental health. She stated, Resident restraining it's like from having something on them to keep them from moving or that the physician doesn't know that they are doing. Even if the physician does know, then is it still a restraint and you shouldn't do that. She stated, I would have to report it to the Administrator immediately. Resident rights means that residents have the right to ask for snacks or anything they need . They have the right to our respect and to be free from abuse or seclusion. Behavior management is to distract them from the things that upset them before they get upset if you can by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first. Never do it without the permission of the physician. She stated she would look in the Kardex or care plan for resident specific interventions. During an interview with CNA I (6 PM to 6 AM shift) on 8/26/25 at 10:30 AM, she stated the types of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms, sexual and stealing from residents. She stated you report abuse immediately. She stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility . She stated they learned about rights. They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to. She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention. She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types of behavior management required you to step back and give them some space. She said when you see a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. she said she would give them space, provide one-on-one, and food and snacks go a[TRUNCATED]