**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately provide basic life support, including cardiopulmonary resuscitation (CPR) to a resident requiring emergency care for 1 of 3 residents (R1) reviewed for code status. This has the potential to affect 12 full code residents that reside in the facility. R1 is a full code and was found on the floor of his room unresponsive on [DATE]. A Registered Nurse (RN) failed to initiate CPR immediately, the facility failed to ensure that staff were competent in using basic life support equipment, and failed to ensure that there was always a CPR-certified staff member in the building.The facility's failure to provide immediate life saving measures to a resident who wished to have basic life support measures initiated such as CPR, failure to ensure that a CPR certified staff member was in the building at all times, failure to ensure all staff were aware of where lifesaving equipment was located and were able to demonstrate competency of basic lifesaving equipment in a code blue situation created a finding of immediate jeopardy that began on [DATE]. Surveyors notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on [DATE] at 4:33 PM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a severity/scope level of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. This is evidenced by:Per CMS (Centers for Medicare and Medicaid Services) Cardiopulmonary resuscitation (CPR) memo 14-01 revised [DATE], CPR refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. When addressing full-code residents: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition,) facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services.Facility policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE] with revision date of [DATE], states in part, .1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and. 3. CPR certified staff will be available at all times. R1 was admitted to the facility on [DATE] with diagnoses that include Pneumonia due to Pseudomonas, Other Non-specific Abnormal finding of lung field, Chronic Obstructive Pulmonary Disease unspecified, Weakness Unspecified, Essential Primary Hypertension, Malignant Neoplasm of the Prostate, and Anemia.R1's most recent Minimum Data Set (MDS) dated [DATE] states that R1 has a Brief Interview for Mental Status (BIMS) of 13, indicating that R1 was cognitively intact. The MDS also indicates that R1 required substantial/maximum assistance for all mobility and transfer needs.R1's Advance Directives dated [DATE] state that R1 chose to remain a full code. If found unresponsive, pulseless and not breathing, R1 wished to have CPR performed.R1's Care Plan dated [DATE] with revision date of [DATE] states, in part: I have emphysema/COPD (Chronic Obstructive Pulmonary Disease) related to history of smoking. Interventions include: Monitor for signs/symptoms of acute respiratory insufficiency, Anxiety, confusion, restlessness, Shortness of Breath (SOB) at rest, cyanosis (bluish discoloration of the skin), somnolence (excessive drowsiness) . I have oxygen therapy related to acute hypoxic respiratory failure (lack of oxygen), history of mass of right lung and COPD. Interventions include: Monitor for signs/symptoms of respiratory distress and report to MD (Medical Doctor) PRN (as needed): Respirations, Pulse oximetry, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (collapsed lung), hemoptysis (coughing up blood), pleuritic pain (chest pain due to inflammation of the lining of the lung), cough accessory muscle usage, skin color. Oxygen settings: O2 via nasal cannula at 1L/min at rest and 3L/min with activity. R1's Physician Orders include, in part:--CPR (Cardiopulmonary Resuscitation). Order Date: [DATE]. No end date.--Facility parameters for vital signs include O2 less than 88%. Order Date [DATE]. No end date.--Oxygen 1L/min at rest and 3L/min with activity via nasal cannula every shift. Order Date: [DATE]. No end date.--Portable oxygen for activities as tolerated. Order Date: [DATE]. No end date. R1's Progress Notes include:On [DATE] at 1:40 PM, RN/NCC M (Registered Nurse/Nursing Care Coordinator) Nursing Note: Per NP (Nurse practitioner): Resident at (Facility name). Resident developed hypoxemia while working with therapy today. He reported shortness of breath with standing and pivoting. Therapy checked his oxygen level and it was 73%. Oxygen via nasal cannula was increased to 4L, but still stating 74-76% . He denies any dizziness, lightheadedness, chest pain. He does have wheezing and edema. He has an appointment with oncology today and both resident and son really want to get him there. Ordered a one-time DuoNeb treatment and sats (oxygen saturation in blood) improved to 92%. Son transported him to appointment with portable oxygen. Electronically signed by NP G (Nurse Practitioner) on [DATE] at 12:10 PM. On [DATE], Physical Therapy Note: . Pt attempts stand transfer X2 (times two) attempts however pt. (patient) unable to come to full stand. Writer retrieves second assist. On 3rd stand pt. performs sit to stand moderate Assist X2 with pt. putting hands on walker. Pt stands with BUE (bilateral upper extremity) support on walker CGA (contact guard assist) while CNA (Certified Nursing Assistant) holds urinal for pt. to urinate. When pt. is done urinating writer cues pt. to pivot to w/c (wheelchair) with 4WW (four wheeled walker), pt. has difficulty picking up and pt. reports having a hard time breathing. Writer has pt. sit down in recliner chair. SPO2 (saturation of peripheral oxygen) taken 72%-76% on 3.5 L increased to 4L (liters oxygen). Writer does not leave pts room and asks CNA to notify NCC (Nursing Care Coordinator) regarding low O2 sats NP and NCC enter pts room. NP assess pt., son enters room while assessing pt. NP explains to son regarding O2 sats and offers breathing treatment before leaving for doctor appointment. Pt agreeable. Response to Tx: Pt reports severe exertion with transfers and standing. Pt assessed by NP during session for low O2 sats. Electronically signed by PTA P (Physical Therapist Assistant) at 3:54 PM. On [DATE], Occupational Therapy Note: Pt (patient) on 4L O2, had just received a breathing tx. (treatment) which increased his PO2 (pulse oximetry) from 72% to 92%. Pt required AX 2-3 (assist of 2-3) to transfer into vehicle with his son to go to oncology appointment. Electronically signed by OT Q (Occupational Therapist) at 2:41 PM. On [DATE], R1 was seen for an office visit at the (Name of oncology clinic.) R1's Oncology Note includes, in part: . Exam: Lungs have decreased air filling in the right upper lobe otherwise with good breath sounds bilaterally on 4L (4 liters) NC (nasal cannula) O2 (supplemental oxygen). Assessment: RUL (right upper lobe) bronchial narrowing that is likely the source of his respiratory difficulties and increased O2 needs. tenuous respiratory status. Vital signs: SpO2 87% .On [DATE] at 8:24 AM, Surveyor interviewed NP G (Nurse Practitioner) and asked if R1's hypoxic episode on [DATE] was a change in condition. NP G stated yes, R1 had not been that hypoxic before. Surveyor asked if an assessment should have been done following R1's return from oncology appt. NP G stated that NP G had not ordered further assessments, as NP G did not believe that R1 would return to the facility following the appointment. Surveyor asked if NP G felt that an assessment should have been performed by staff when R1 did return from the appointment. NP G stated yes, given what R1 was like before R1 left, NP G would hope so.Of note: There is no documentation of what time R1 arrived back to the facility after his oncology appointment. There is no documentation that any respiratory assessments or monitoring was completed upon R1's return to the facility.On [DATE] at 5:07 AM (Late Entry), RN D (Registered Nurse) Nursing Note: I last saw resident when I came over to. unit at 11:30 PM on [DATE]th. Around 2:00 AM-2:30 AM, CNAs answered residents call light he needed to use the bathroom. He sat on the edge of the bed and used his urinal. I was on break from 2:30AM - 3:00 AM. I started passing meds at 4:15 AM. I got to R1's room at 5:07 AM, his door was shut. I walked in to him face down laying right next to his bed on the floor. His head was at the base of the bed and feet at the top of the bed. He was slightly turned on his left shoulder. Arms were straight down next to his side. I walked over to him yelling his name and tried to flip him over onto his back. I noticed right away he had a laceration on his forehead. His face was slightly blueish in color. I immediately yelled for help. CNA R (Certified Nursing Assistant) came from another resident's room. I then ran to LPN E (Licensed Practical Nurse) who was the supervisor. to come up because the resident was on the floor and not breathing. As she ran down to his room I looked up on the computer his code status which was CPR. LPN E started CPR right away, CNA F dialed 911, the call went out at 5:13 AM. We did CPR until the police, fire dept, and ambulance showed up around 5:22 AM.Of note: per RN D's documentation above, RN D did not check R1's code status or initiate CPR immediately upon finding R1 down with his face slightly blueish in color. On [DATE] at 10:04 PM, LPN E (Licensed Practical Nurse) Nursing Note: Late entry for [DATE] at 0500 (5:00 AM). Writer was. starting 0600 (6:00 AM) medication pass. Second Floor RN (Registered Nurse) came to writer frantically stating that resident was on the floor in his room unresponsive. Writer immediately locked medication cart and came to the resident's room. Resident was face down on floor with top of head towards window next to his bed. Writer felt for a pulse. No pulse was found. Second Floor RN stated that he was a full code. Writer immediately rolled patient from prone to supine position and initiated CPR. CNA called 911 about PNB (pulseless non-breather) with CPR in progress. (Town name) . EMT (Emergency Medical Team) entered room and began prepping resident. [NAME] Deputy immediately followed EMT and took over compressions from writer. EMS (Emergency Medical Services) followed within 2 minutes. EMS continued lifesaving efforts. Writer let the EMS and (Town name) Fire Department continue with life saving measures at that time. Writer went to first floor and contact [sic] DON B (Director of Nursing) at 0536 (5:36 AM) to inform her of PNB and CPR in progress for resident. Efforts to continue lifesaving efforts for resident were ceased. Coroner called. On [DATE] at 2:20 PM, Surveyor interviewed CNA F who indicated that on [DATE] at a little past 5:00 AM, CNA F was working with a resident when RN D came to the room and said that R1 was on the floor. CNA F indicated leaving the resident and going to R1's room and noting R1 on the floor face down. CNA F indicated RN D stated RN D needed to get LPN E and left the room. Surveyor asked if RN D gave any instructions prior to leaving the room. CNA F stated no. CNA F indicated CNA F remained with R1, checking for responsiveness by rubbing R1's back. CNA F indicated CNA F recalls hearing that R1 was a full code, turning R1 over onto his back, and LPN E starting compressions. CNA F called 911. Surveyor asked CNA F who can perform CPR. CNA F stated everyone is supposed to, but staff looks to the nurses to do it. CNA F stated CNA F is not current in CPR certification. Surveyor asked how much time elapsed between CNA F arriving in R1's room and LPN E starting compressions. CNA F stated about 4-5 minutes.On [DATE] at 12:11 PM, Surveyor interviewed LPN E and asked about low oxygen levels. LPN E stated LPN E would check orders, turn up the oxygen level and notify the provider. LPN E indicated need to go back and recheck oxygen levels within 30 minutes to ensure resident is doing OK and then performing follow up assessments. Surveyor asked about R1. LPN E stated on [DATE], LPN E was the supervisor and RN D was working on the second floor. LPN E stated RN D came to the first floor where LPN E was about to pass medications, and RN D stated R1 was on the floor and unresponsive. LPN E indicated both nurses went up to the second floor to R1's room and LPN E checked for a carotid pulse and found none, then asked for R1's code status. LPN E stated RN D left the room to go to the computer and returned stating full code. LPN E then began compressions and told a CNA in the doorway to call 911. LPN E stated they needed an ambu bag, so RN D took over compressions. LPN E stated LPN E couldn't recall where the ambu bag would be, so looked around and found one in the locked medication room. LPN E stated on return to R1's room, LPN E tried giving breaths, but it wasn't working properly, so they did another switch and LPN E resumed compressions. LPN E stated EMS arrived and took over care. LPN E left the room, called DON B to report, and went back to first floor. Surveyor asked about emergency supplies. LPN E stated LPN E did not call for or obtain the AED or the emergency bag by elevator 2. LPN E indicated having no knowledge of what is contained in the emergency bag and stated there was never really any education on that.On [DATE] at 10:25 AM, DON B (Director of Nursing) Nursing Note: Resident was found by nursing staff on the floor next to his bed around 5:00 AM this morning. Resident was unresponsive, CPR was initiated, and 911 was notified. Coroner was contacted, investigated, and pronounced death at 0642 (6:42 AM) . The Emergency Medical Services (EMS) report dated [DATE] states in part: Response Time: EMS notified at 5:15 AM, the unit was enroute to the facility at 5:18 AM, arrived at the facility at 5:20 AM, was with the patient at 5:23 AM, and conducted first exam of patient at 5:24 AM. Resuscitation efforts were discontinued at 5:49 AM. The EMS Note states, in part: EMS responded immediately to a 911 call for an [AGE] year-old male found pulseless and not breathing by staff at 5:02 AM. Last known well time was 1:30 AM. The pt. was found in a supine position on the floor with bystander CPR in progress. CPR was continued by (Town name) Rural First Response throughout the call. There is dried blood on the patient's head appears he fell where found and hit his head. The defibrillator was placed on the pt. The rhythm was interpreted as asystole by paramedic. Possible lividity was noted. No vital signs noted. Assessment Summary, Skin Description: cold, lividity, dry. Mental status: unresponsive. Disposition: Dead at Scene.On [DATE] at 2:44 PM, Surveyor interviewed EMSC I (Emergency Medical Services Chief) and asked about the EMS report comment of possible lividity. EMSC I stated it means that it could have been lividity, but it could have been something else. CPR was active on arrival and we continued. Surveyor asked, if CPR had not already been started, would EMS have started CPR. EMSC I stated yes. R1's Death Notification Note, states, in part: Resident was found unresponsive and bleeding from the right side of his forehead, on the floor of his bedroom this morning around 5:00 AM when nursing staff went to give him his medication. Resident was last seen around 3:00 AM by CNA and he was sleeping at that time. CPR was initiated due to resident's full code status and 911 contacted. (county name) Coroner came, investigated, and pronounced death at 0642. Coroner advised that it appeared to be an accidental death related to unwitnessed fall.On [DATE] at 10:36 AM, Surveyor interviewed RN D (Registered Nurse) and asked about residents with low oxygen levels. RN D indicated that oxygen would be applied / turned up, a nebulizer treatment would be given per order, and oxygen level would be rechecked. If the resident's level was back up to 90%, the oxygen level would be lowered and the resident would be reassessed in a couple of hours to ensure their level was sufficient. Surveyor asked how staff was aware of a resident's code status. RN D stated that recently the room name plate was changed to green for a full code. RN D stated that some of the DNRs (Do Not Resuscitate) wear bracelets, otherwise the information was in the computer in the banner of the electronic health record. Surveyor asked who is able to perform CPR (cardiopulmonary resuscitation) in the facility. RN D stated that anyone who is certified can perform CPR; all of the nurses have to be certified. Surveyor asked about R1's status on [DATE]. RN D indicated that RN D had walked into R1's room about 5:10 AM and found R1 face down on the floor, parallel to the bed, with feet by the head end of bed. RN D rolled him over and R1 was limp. RN D felt R1's neck for a carotid pulse for about 5 seconds and watched R1's chest for breaths for about 5 seconds and determined R1 was pulseless and non-breathing. RN D yelled for the CNAs on the unit, and when they arrived, RN D left R1's room, took the elevator at the far end of the hall down to level 1 and found LPN E (Licensed Practical Nurse) midway up the hallway. RN D told LPN E that R1 was on the floor pulseless, and they went back up the elevator to level 2 to R1's room. RN D indicated that LPN E asked about R1's code status and RN D went into the computer to find the information. RN D noted that R1 was a full code and yelled the information to LPN E. RN D indicated that LPN E initiated compressions and told a CNA to call 911. RN D told LPN E that RN D could take over compressions. RN D indicated that LPN E then left to get an Ambu bag (artificial manual breathing unit). RN D indicated that compressions were done for about 5 minutes prior to EMS (Emergency Medical Services) arrival and on arrival, EMS took over and RN D went back to passing morning medications. RN D stated that following the event, the facility provided RN D with education on CPR and disciplined RN D for going to get LPN E.On [DATE] at 2:19 PM, Surveyor interviewed CNA S and asked if she had received any education on code status or CPR. CNA S indicated that they had received education after the incident with R1, but that was the first time receiving education that she could remember. Surveyor asked CNA S if she was aware of where the bag with emergency supplies for a code blue was located. CNA S stated no, she did not know where the emergency supplies were kept.On [DATE] at 2:03 PM, Surveyor interviewed LPN U, who reviewed the contents of the emergency supply bag with Surveyor on the 1st floor. Surveyor asked LPN U where additional emergency supplies were located, such as oxygen and suctioning. LPN U stated she wasn't 100% sure, but that she didn't believe that they did those things at the facility, that they would have to wait for EMS to arrive. Surveyor asked LPN U if she had done any code drills prior to the incident involving R1. LPN U stated she had not done any code drills.On [DATE] at 9:46 AM, Surveyor interviewed DON B (Director of Nursing) and asked who can perform CPR. DON B stated anyone that is certified. Surveyor asked when CPR is to be started. DON B stated if the resident is a full code, CPR is started as soon as they are found unresponsive. Surveyor asked how help is summoned in an emergency. DON B stated call light activation and unit cell phones carried by nurses. Surveyor asked if there is emergency equipment for use in a code. DON B stated yes, an AED (Automated External Defibrillator) and an emergency bag. DON B indicated there is oxygen in the storage room. Surveyor asked if CPR was expected to be initiated at the time that R1 was found unresponsive. DON B stated if the code status was known. DON B indicated the code status was located in the computer.On [DATE] at 10:43 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked who is expected to perform CPR. NHA A stated anyone who is CPR certified. Surveyor asked if any staff are required to have certification. NHA A stated no, the policy states that someone who is certified needs to be on duty. Surveyor asked how the facility ensures that a CPR certified staff member is on duty. NHA A stated when making the schedule, the scheduler looks. Surveyor asked when CPR is expected to begin. NHA A stated as soon as they realize the code status. Surveyor asked if staff is expected to know the code status. NHA A stated staff should be knowledgeable of the code status. Surveyor asked about emergency equipment. NHA A stated staff are shown the location of the equipment during orientation, and they are expected to know where it is located. Surveyor asked if there was a delay in starting CPR for R1. NHA A stated cannot confirm nor deny. Surveyor asked if RN D was expected to know R1's code status prior to leaving R1 and getting LPN E. NHA A stated yes, RN D should have known. Surveyor asked if facility would expect RN D to begin CPR when finding R1 unresponsive and pulseless. NHA A stated would expect someone who is CPR certified to start CPR upon finding the code status.On [DATE] at 10:55 AM, Surveyor interviewed SC H (Staffing Coordinator) and asked if SC H completes the nursing schedule. SC H stated yes. Surveyor asked if SC H considers CPR certification when making the schedule. SC H stated no, I don't look at that. Surveyor asked about CPR certifications at the facility. SC H stated the nurses are certified and some of the CNAs. Surveyor asked for documentation of certification for LPN K and ADON L (Assistant Director of Nursing). SC H stated ADON L did at times work PM shift but has been off work since [DATE]. LPN K was on schedule for [DATE]. No documentation of certification for LPN K or ADON L was provided. Of note, per Scheduler H she does not look at CPR certification when scheduling staff, though NHA A indicated the scheduler ensures a CPR certified staff member is always on duty. Therefore, there is no system in place to ensure there is a CPR certified staff member on duty each shift in case of an emergency. On [DATE] at 11:03 AM, Surveyor interviewed DON B and CCO J (Corporate Compliance Officer) about their mock code drills. DON B stated that they were not able to find any documentation of the previous administration doing mock drills. Surveyor asked when she started in the DON role. DON B stated she started in [DATE] as the DON. Surveyor asked DON B if there had been any mock code drills from [DATE] to the incident with R1 on [DATE]. DON B stated there had not been any mock code drills since she had been the DON. CCO J indicated that they are conducting mock code drills routinely now, and that they did one on [DATE], one on [DATE], and one today ([DATE]).Surveyor reviewed the Mock Code Evaluation Checklist provided by the facility and noted that CNA/CMA V had indicated on her evaluation form, no oxygen tank in the building.On [DATE] at 2:04 PM, Surveyor interviewed CCO J (Corporate Compliance Officer) and asked if when completing the facility PIP (Performance Improvement Plan), if the facility found there was a delay in treatment / delay in starting CPR for R1. CCO J stated yes, we did.On [DATE] at 4:33 PM, Surveyor interviewed DON B and EVS T (Environmental Services). Surveyor asked DON B about the Mock Code Evaluation Checklists that were provided to Surveyor, noting that 5 of them had the date of survey ([DATE]) but were only signed by one participant. Surveyor asked DON B if all the things indicated on the mock code checklist had included a return demonstration to ensure skills competency. DON B stated those were skills evaluations, that they had discussed all the items on the list and answered questions, but there had been no return demonstration. Surveyor asked DON B about CNA/CMA V's checklist form that indicated no oxygen tank in the building. DON B stated they have oxygen concentrators. Surveyor asked DON B what oxygen source had been used in R1's incident. DON B stated R1 had an oxygen concentrator. Surveyor asked DON B if an oxygen concentrator could be used with an Ambu bag. DON B stated she would have to get back to Surveyor on that. EVS T confirmed they did not have any oxygen cylinders in the building but they had them at the HR (Human Resources) building and he could get one.On [DATE] at 4:34 PM, Surveyor interviewed RN M and asked about training on codes. RN M stated a mock code had been completed and RN M had to check the scene, check pulse and respirations, call for help, check the code status, start compressions, call for 911 and AED/code bag, and call the DON. RN M stated the Ambu bag was used, but that in a real code there are masks for mouth to mask respirations. Surveyor asked about supplemental oxygen. RN M stated there was no discussion or demonstration of use of oxygen with the Ambu bag. Surveyor noted that the Mock Code Evaluation Checklist provided by the facility stated, Handheld resuscitation bag attached to oxygen source (O2 concentration minimum flow rate of 10 to 12 L/min). A review of the oxygen concentrators used by the facility indicated a maximum flow rate of 5L/min.Of note, the oxygen concentrators used by the facility would not provide a high enough flow rate to be used with an Ambu bag in an emergency situation. The facility did not have any oxygen cylinders in the building that have the capacity to go to 10 to 12L/min. On [DATE] at 5:03 PM, EVS T brought an oxygen cylinder to Surveyor and indicated he would be keeping it at the facility to be used in emergency situations.The failure to provide life saving measures immediately to a resident who wished to be provided with CPR, the failure to ensure that a CPR certified staff member was in the building at all times, and the failure to ensure all staff were aware of where lifesaving equipment was located and able to demonstrate competency of basic lifesaving equipment in a code blue situation, led to serious harm for R1 which created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], when it completed the following: Staff across all departments to receive education on the location of suction machine; date initiated [DATE], percentage completed: 55% Staff across all departments to receive education on location of crash cart, date initiated [DATE], percentage completed: 1% Staff across all departments to receive education on the CPR policy and Communication of Code Status policy which includes, but is not limited to, the expectation that CPR is to be conducted immediately upon discovery of a resident in cardiac arrest who is full code, CPR staff will be available at all times, checking code status utilizing new color-coded system; date initiated [DATE], percentage completed: 56% Pleasant View Nurses will complete a competency for initiating CPR per current standards of practice which includes, but is not limited to, checking code status, grabbing the emergency cart, calling 911, conducting chest compressions, utilizing the AED machine and Ambu bag, and conducting compressions until EMS arrive; date imitated [DATE], percentage completed: 45% All IDT staff received education on updated system to ensure CPR certified staff are available at all times. This system entails the scheduler to have access to a list of individuals who are CPR certified and, while creating schedules, accessing the list and ensuring everyone listed is CPR certified. Additionally, the facility has ensured every working nurse has their CPR certification ; date initiated [DATE], percentage completed: 100% Nurses who did not have an active CPR on record with the facility received education that they would be unable to return to work without an active CPR certification, ensuring all nurses are certified; date initiated [DATE], percentage complete: 100%. On [DATE], facility implemented a new color-coded system which ensured the code status of each resident was communicated to staff in an expedited manner. This entails each resident's nameplate displaying either a red (DNR) or green (Full-code) color. Additionally, assistive devices (if applicable) also have tags with the associated colors. Code status is still located under Special Instructions in the facility's EMAR for reference. On [DATE], system was updated to ensure CPR staff are available at all times and education provided. On [DATE], crash carts equipped with oxygen tanks and additional items potentially needed in an emergency were established on both the first and second floors. On [DATE], the facility implemented an assigned individual to frequently check the crash carts to confirm adequate supplies available and functionality of equipment. On [DATE], the facility implemented regular Code Blue drills with staff across all three shifts. On [DATE], CPR and CPR Communication Policies were reviewed and updated as needed to ensure appropriateness. On [DATE], the CPR and CPR Communication Policies were uploaded to the agency portal, prohibiting agency staff from working at the facility unless the policies are signed by the agency staff member. The Medical Director was updated about the incident on [DATE] DON and/or designee will complete audits daily x 2 weeks, weekly x 5 weeks and monthly x 3 months confirming that new staff have reviewed / signed off on the CPR and Communication of Code Status policies and that all Nurses have completed a competency training prior to their first shift of work. Code blue drills across all three shifts will occur weekly x5 weeks. A performance improvement plan was created on [DATE] and brought to the QAPI committee for review. As part of that performance improvement plan, audits were being conducted to ensure staff were knowledgeable regarding the color-coded system that was implemented and that the color coded system was effectively implemented. Those audits will continue on a weekly basis x 5 weeks. On [DATE], an audit was completed of all residents in-house verifying code status was correct in the medical record. All results of audits will be submitted to QAPI for review and determination of substantial compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 1 residents reviewed for elopement (R58), 6 of 17 sampled residents (R2, R40, R59, R1, R66, R48) and 6 of 13 supplemental residents (R10, R31, R39, R45, R35, R50) reviewed for wandering, and 1 of 13 supplemental residents reviewed for accidents (R6). R58 has a history of multiple falls, exit seeking behaviors, and elopement. Facility staff did not provide adequate supervision to prevent elopement when R58 was exit seeking. R58 exited through an alarmed door, took his wheelchair down a stairwell, and was found at the bottom of a flight of stairs. Although the door alarm activated and would have sounded for 15 seconds before the stairwell door opened, staff did not respond because there was no staff in the immediate area. When a staff person heard the alarm, the alert board, which indicates to staff which door was alarming, was not functioning, leading to a delay in locating R58. The facility's failure to provide adequate supervision and maintain a functioning alarm system created a finding of Immediate Jeopardy that began on 5/13/2024. Surveyor notified the NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the Immediate Jeopardy on 6/27/2024 at 2:25 PM. The Immediate Jeopardy was removed on 6/27/24; however, the deficient practice continues at a scope/severity of an E (potential for minimal harm/pattern) as evidenced by the following examples: R51 wanders into other resident rooms. R1, R66, R39, R45, and R35 stated they did not want R51 in their room. The facility provided them with stop signs across their doors, but did not care plan these, nor did they monitor them for effectiveness. R1 stated that she was afraid of R51. R48, who is not cognitively intact and unable to voice concerns, was not offered a stop sign or other protections from R51 entering her room. R31, R39, R10, and R40 voiced concerns at a Resident Council meeting regarding wandering residents entering their room uninvited. R2, R50, and R59 voiced concerns during individual interviews regarding wandering residents entering their room uninvited. Staff reported they were aware of concerns voiced by R2, R50, R59, R40, R10, R39, and R31 and aware the interventions in place were not working to keep uninvited wandering residents out of their rooms. Staff did not place foot pedals on R6's wheelchair causing R6's leg to get caught under the wheelchair. This is evidenced by: Facility Falls-Clinical Protocol Policy, dated 2001 with last revision date of September 2012, states in part: As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling .The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk .For an individual who has fallen, staff will attempt to define possible cause within 24 hours of the fall .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling .If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions . Facility Wandering and Elopements Policy, dated 2001 with last revision date of March 2019, states in part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . R58 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, adjustment disorder with anxiety, chronic pain, other lack of coordination, repeated falls, vascular dementia unspecified. R58's most recent MDS (Minimum Data Set) dated 3/5/2024 states that R58 has a BIMS (Brief Interview of Mental Status) of 8/15 indicating that R58 has moderate cognitive impairment. R58's baseline care plan dated 5/30/2023 states in part, . I am an elopement risk/wanderer related to disoriented to place, impaired safety awareness. Distract me from wandering into other resident rooms by offering pleasant diversions, structured activities, food, conversation, television, book. I prefer country music, working on a horse ranch . I have limited physical ability related to Alzheimer's and frequent falls. I am able to move about the unit with an assistance of 1 person in my wheelchair. I can propel by wheelchair independently but do need supervision to prevent exit seeking. R58 had a wander guard bracelet placed on 6/23/2023. R58's care plan was updated on 8/14/2023 to include the intervention: When wandering and busy on the unit, keep me active and in dayroom for closer supervision to prevent attempts of self-transfers. R58's progress notes list the following: 1/2/2024 at 9:04 PM: Resident busy this pm, exit seeking. Unable to redirect with conversation, 1:1, food, toileting, or snacks. Resident did eventually settle down and is sitting in wheelchair, no distress observed. Resident was offered a non-alcoholic beer and resident appeared to content with that and a tractor book, 1:1 with staff. 1/3/2024 at 07:21 AM: Resident did not sleep this NOC (overnight) shift. Resident was adamant to go pick up [NAME]. Resident was exit seeking from 1:00 AM to 4:30 AM. 1/6/2024 at 9:27 PM: Resident busy this pm, intermittent exit seeking, redirectable this pm. Compliant with medications. R58's care plan was updated on 1/30/2024 to include the intervention: Do not leave resident alone if he verbalizes the need to move. R58's progress notes list the following: R58's care plan was updated on 3/6/2024 to include the intervention: Distract me from wandering into other resident rooms by offering pleasant diversions, structured activities, food, conversation, television, book. I prefer country music, working on a horse ranch. R58's progress notes list the following: 3/7/2024 at 7:22 PM: Exit seeking, just going to the exits not through them or setting off alarms at this time. Resident is re directable at this time. No behaviors observed. R58's Elopement assessment dated [DATE] with score 4, meaning at risk for elopement is as follows: History of elopement while at home: Yes. History of attempting to leave the facility without informing staff: Yes. Verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Wanders: Yes. Wandering behavior, a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: No. Wandering behavior likely to affect the safety or well-being of self/others: No. Wandering behavior likely to affect the privacy of others: Yes. Recently admitted or re-admitted (within the past 30 days) and has not accepted the situation: No. R58's Wandering assessment dated [DATE] scored him at an 11, meaning High risk to Wander. R58's progress notes list the following: 4/14/2024 at 10:31 PM: Resident was actively exit seeking this pm, not going through the doors, but setting the alarms off and when staff attempted to redirect resident became agitated and attempted to swing hands at staff. No contact with staff made. Resident was re-directed finally with snacks and activities. 4/22/2024 at 2:12 PM: Epic (electronic record system) sent to Doctor of Nursing Practice (DNP) notifying of resident's unwitnessed fall this morning at 7:25 AM Resident has been awake for over 24 hours straight and is not redirectable. Resident found sitting on floor in his room with many of his clothes packed since he is leaving. No injuries noted. Vital signs stable and neurological checks normal. R58's care plan was updated on 4/23/2024 to include the intervention: Provide structured activities: toileting, reorientation strategies including signs, pictures and memory boxes. R58's progress notes list the following: 4/26/2024 at 9:23 PM: Resident exit seeking and looking for my car. Staff attempted to redirect resident; resident became agitated with staff, swinging arms at staff. Resident was redirected with balloon game briefly. Resident is watching a movie and 1:1 with Resident Assistant (RA) at this time. 5/4/2024 at 8:41 PM: Resident exit seeking after supper. Needed frequent redirection. I have livestock to care for. RA sitting with resident part of shift attempting to redirect him. 5/13/2024 at 6:45 PM: Elopement attempt made by resident; alarms sounded. Staff reported a 911 situation, resident had gone through door and down one flight of stairs in wheelchair; chair was on stairway tilted, resident was standing at bottom of landing holding onto both railings; staff assisted resident to chair on landing. Resident description: adamant several times that he did not fall, did not hit anything; denies pain. Immediate action taken: Assisted with 3 staff to bottom of 2nd stairs, then to wheelchair and back to unit via elevator; 1:1 staff assistance at this time, administrator Power of Attorney (POA) and Director of Nursing (DON) updated. Predisposing factors: Door alarm sounding light up alert board not functioning, staff found resident at bottom of 1st stairwell, standing on landing with wheelchair on stairs behind him. (It is important to note: There is a kiosk at both ends of the hallway which displays call lights and door alarms that have been activated. There are doors at both ends of the hallway leading to the stairs. The door is alarmed, but it does not have a wander guard unit on it. When the door is pressed an alarm will sound and then the after 15 seconds the door releases and opens. This means the alarm sounded for 15 seconds before the stairwell door opened, during which time staff did not respond.) R58 had a new wander guard placed on 5/27/2024 with expiration date of 3/19/2025. R58's care plan was updated on 5/27/2024 to include the following: Goal: I will not leave facility unattended through the review date. Interventions: My safety will be maintained through the review date. I will demonstrate happiness with daily routine through the review date. If I am talking about leaving the building. Try the following interventions, in part: Explain I do not have to work today. Try calling significant other .line of sight staff attendance when exit seeking .Provide structured activities: toileting, reorientation strategies including signs, pictures and memory boxes. R58's progress notes list the following: On 6/24/24 from 4:03PM-4:05 PM, Surveyors observed R58 by an exit door, running his hand along it, running his hand along the wall, and trying to stand up independently. R58 was stating he had to get out of here and had to get to his truck. Surveyors tried to interview resident about waiting for a staff member to help. Surveyor looked down hallway to find a staff member but did not see one. Resident insisted, stating he has his truck parked outside and needed to get home. Life Enrichment Aide came down the length of the hallway and intervened with conversation and they went together to the center of the hallway. On 6/26/2024 at 08:52 AM, Surveyors observed R58 on the end of the hall in dining room sitting in his wheelchair at the table. There were no staff present and he could not be seen coming down the hallway. Surveyors greeted resident and looked his wheelchair over for anti-tip bars. On 6/26/2024 at 2:38 PM, RN K (Registered Nurse) indicated R58 was known to exit seek and try to self-transfer. She stated on 5/13/2024 there were 2 CNAs (Certified Nursing Assistant) in the two farthest rooms down the hall providing cares while the nurse on the unit went down to the kitchen to take the dirty dishes, leaving R58 unsupervised. One CNA came out of the room and heard the door alarm. When she looked at the lighted alarm system it was blank. This means the door that was activated did not read across the lighted board. The CNA went to the center of the two halls and listened where the sound was coming from. She went toward the sound. CNA found the R58 and his wheelchair at the bottom of the flight of stairs. RN K indicated staff are to have R58 in line of sight so they can supervise him when he is out of his room. RN K indicated resident still talks about leaving and still tries to self-transfer. On 6/26/2024 at 2:44 PM, CNA L indicated that from time-to-time R58 has exit seeking behaviors. On 5/13/2024 at approximately 3:30 PM, R58 was exhibiting exit seeking behaviors, but he calmed down and ate supper. CNA L stated she and her partner thought the nurse was supervising him, but she left the unit to take down the dirty dishes and did not communicate this. CNA L indicated staff were to supervise him and she thinks this means he should have been in a staff member's line of sight. CNA L stated since the incident R58 still tries to self-transfer and still tries to elope. CNA L stated staff are to keep him in the line of sight, but they can't always if they are in a room. On 6/26/2024 at 3:40 PM, LPN J (Licensed Practical Nurse) indicated resident R58 is to be in line of sight of staff at all times, but no one staff is assigned to him. They all just try to keep him in the common areas. On 6/26/2024 3:59 PM, CNA G indicated she is supposed to make sure R58 is always within where staff can see him, but no one staff is specifically assigned to supervise him. CNA G indicated she works night shift, and they can't always keep an eye on him because they have others to attend to. Sometimes they have an RA who will sit with him and do activities. On 6/26/2024 at 4:04 PM, RA H indicated she tries to meet R58 where he is and talk about things that are important to him like farming, tractors, and milking cows. RA H indicated resident is to be supervised. RA H indicated to supervise you have to have your eyes on him and be near him to make sure he is safe. On 6/26/2024 at 4:10 PM, Life Enrichment Aide I indicated on Monday 6/24/2024 around 4:00 PM she was gathering residents for an activity when she saw R58 near an exit door on the opposite end of the hallway from where he lives. Resident was trying to self-transfer and was talking about leaving, finding his truck, and going home. Life Enrichment Aide I stated she knows he is supposed to be supervised or in the line of sight of someone, but it was not her and she did not see staff around. Life Enrichment Aide I indicated she intervened, so he did not attempt to go out the exit door or fall. On 6/26/2024 at 5:07 PM, NHA A (Nursing Home Administrator) stated on 5/13/2024 they were changing their call light system out. NHA A indicated the lighted alert board malfunctioned, but the door functioned appropriately. NHA A indicated staff were to supervise R58 and didn't, they knew he was exit-seeking, and the plan was to have someone with him. The nurse was supposed to be in the lobby, and she went to the kitchen to drop off dishes and came back up, leaving R58 unattended. NHA A stated it is her expectation that there would always be someone on the floor with R58 in their line of sight. NHA A indicated since the event, R58 continues to exit seek, talk about leaving, talk about getting to his truck, and tries to self-transfer. NHA A indicated R58 is to be in the line of sight of a staff member but no one staff is specifically assigned to this task. The facility's failure to adequately supervise a resident who had been identified as a high risk for elopement and had a known history of exit-seeking behaviors created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 6/27/24 when they completed the following: - On 6/26/24, staff in nursing, life enrichment, housekeeping, and maintenance were educated regarding the intervention to have line of sight supervision when resident indicates that he is exit-seeking and the need to call maintenance immediately if there are issues identified with the Wander Guard or call light system prior to their next shift. -On 6/26/24, all resident care plans were reviewed for individuals with identified wandering/elopement concerns. All elopement assessments are up to date as are all of the assessments for new residents that would have put them into this category. -On 6/26/24, the interventions were reviewed for adequacy to meet safety needs and to determine if all increased supervision needs were being met. No other care plans were identified where increased supervision was listed as an intervention. -On 6/26/24, the policy for managing care plan interventions regarding wandering and exit-seeking was changed to include monthly reviews of all plans, or sooner if elopement occurs, by the clinical team which includes DON, nursing management, and social services. -As of 6/26/24, daily audits of the delayed egress door system functionality were implemented. -As of 6/26/24, the procedure for notifying maintenance regarding the failure of the elopement prevention system has been updated to include notification immediately to prevent elopement. On 6/27/24, education was provided on the facility has an elopement prevention program listing the names and pictures of the individuals who are high risk for elopement on each unit. Staff have been educated/reeducated on the program and their roles. -DON or DON designee will audit the care plan interventions for proper practice and implementation on a daily basis for one week, then weekly for a month, then monthly for three months, then quarterly. -Action and reeducation will take place promptly upon discovery if it is discovered that interventions are not being properly employed. -Maintenance supervisor will review the WorxHub system for work orders regarding the elopement prevention system that are not being reported promptly on a daily basis for one week, then weekly for one month, and monthly for three months, then quarterly. Action and education will take place promptly if policy is not followed. -Results will be presented to QAPI. Example 15: R6 admitted to the facility on [DATE]. R6 has diagnosis including emphysema, chronic obstructive pulmonary disease (COPD), type 2 diabetes, chronic heart failure (CHF), atrial fibrillation, and malignant neoplasm of bladder. R6's Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/14/24, indicates a Brief Interview of Mental Status (BIMS) of 15, indicating R6 is cognitively intact. Section GG indicates he utilizes a walker and wheelchair for mobility, he is dependent on staff for putting on and taking off footwear, supervision or touching assistance to walk 10 feet, supervision or touching assistance to walk 50 feet with two turns, and R6 could not attempt walking 50 feet due to safety concerns. Section GG also indicates the resident requires supervision or touching assistance to wheel 50 feet with two turns in a manual wheelchair, and partial/moderate assistance to wheel 150 feet in a manual wheelchair. On 6/25/24 at 1:35 PM, Surveyor was standing in the hallway of the Sugar River Trail unit, in the middle of the hallway between two nurses' stations. Surveyor observed a resident, later identified as R6, roll past in a wheelchair with no foot pedals. R6 was holding his legs up while PTA O (Physical Therapy Assistant) pushed his wheelchair. Surveyor heard R6 yell out. PTA O immediately stopped the wheelchair and stated, Why did you put your foot down on me, [Resident Name]?. PTA O ensured clinical staff were aiding the resident. Surveyor observed several other staff members approach the resident to assist. On 6/25/24 at 3:48 PM, Surveyor interviewed LPN T (Licensed Practical Nurse) and MT U (Medication Technician). Surveyor asked if anything had happened with R6 earlier today. LPN T and MT U state that R6 has knee pain due to an incident earlier with his foot dropping while someone was pushing him. LPN T and MT U state that a therapist was pushing him down the hallway without his foot pedals. LPN T and MT U don't know why the therapist was not using the foot pedals because they should have been using the foot pedals. On 6/25/24 at 4:09 PM, Surveyor interviewed OT Q (Occupational Therapist). OT Q reports that she is familiar with R6. Surveyor asked OT Q who was working with R6 today. OT Q reported that PTA O was working with him today. Surveyor asked OT Q if PTA O should have foot pedals on his wheelchair. OT Q states that he should have had foot pedals on his wheelchair and did not know why he didn't. On 06/26/24 at 9:45 AM, Surveyor interviewed PTA O with DOR P (Director of Rehab) also present. Surveyor asked PTA O if she was working with R6 yesterday (6/25/24). PTA O confirms that she was working with R6 and was the one pushing R6 in his wheelchair down the hall. PTA O reports that she was pushing R6 down the hall when R6 put his foot down and she didn't notice and kept pushing the wheelchair and he yelled out and his leg was under the wheelchair. R6 reported pain so PTA O notified UM D (Unit Manager) immediately to assess the patient. PTA O reports that following the incident, PTA O also states that R6 never has his foot pedals on as he is able to self-propel when his wheelchair is not getting pushed by a staff member. Surveyor asked PTA O if R6 refused or has ever refused to have his foot pedals placed on his wheelchair. PTA O reports that he has not and that he has never put his feet down before yesterday. DOR P states that PTA O offered them to him today and he was agreeable to having his foot pedals on his wheelchair. DOR P reports that R6 was ordered physical therapy for strengthening after an RSV (respiratory syncytial virus) diagnosis that caused a significant physical decline. Surveyor asked PTA O and DOR P if foot pedals are readily available in the facility. PTA O and DOR P confirm that foot pedals are readily available in the facility. Surveyor asked PTA O if she should have used foot pedals while pushing R6 down the hallway. PTA O states that she should have had the foot pedals attached to the wheelchair. DOR P and PTA O state that they are changing the policy to ensure all residents have foot pedals attached to wheelchairs prior to transporting residents. Example 8: R31 admitted to the facility on [DATE]. R31's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 4/23/24 indicates R31's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 13 out of 15. On 6/24/24 at 1:30 PM during the Resident Council Meeting, R31 indicated R24 enters his room uninvited and at times takes his belongs out of his room. Example 9: R10 admitted to the facility on [DATE]. R10's most recent MDS with ARD of 4/23/24 indicates R10's cognition is intact with a BIMS score of 15 out of 15. On 6/24/24 at 1:30 PM during the Resident Council Meeting, R10 indicated R24 comes into her room uninvited. R10 indicated staff sometimes come in and redirect her but not always. R10 also indicated that at times R24 takes her belongings with her when she exits her room. R10 stated that she voices concerns to the nurses and the CNAs (Certified Nursing Assistant) about R24. On 6/25/24 at 3:48 PM LPN T (Licensed Practical Nurse) indicated R10 has voiced concerns of R24 coming in her room and taking her things. Example 10: R39 admitted to the facility on [DATE]. R39's most recent MDS with ARD of 5/14/24 indicates R39's cognition is moderately impaired with a BIMS score of 9 out of 15 and it indicates R39 makes herself understood and understands others. On 6/24/24 at 1:30 PM during Resident Council Meeting, R39 indicated she has reported to staff that R24 comes in and uses her bed. R39 indicated this has happened more than once and the staff are doing nothing about it. Example 11: R2 admitted to the facility on [DATE]. R2's most recent MDS with ARD of 5/21/24 indicate R2's cognition is intact with a BIMS score of 14 out of 15. On 6/25/24 at 11:14 AM Surveyor observed a hanging stop sign next to R2's door. R2 indicated the stop sign is supposed to be strung across the door and secured with Velcro straps, but the staff do not always remember to put it up. R2 indicated the sign's purpose is to keep R24 out of her room. R2's eyes began to drop tears and she bowed her head as she explained, (Named wandering resident) comes in my room. She bothers me a lot. She was in my room a couple days ago. She taunts me, saying I can lift this up and just come in when I want to (referring to the stop sign). She goes in the fridge and gets whatever she wants. She takes things out of my room. She bothers me a lot. Surveyor observed R2 visibly crying. R2's shoulders were moving up and down as she cried with a Kleenex covering her face. R2 continued, She has to go pass my door how many times a day and just stops in my doorway to taunt me. I can see her socks and legs when she is just parked outside of the doorway, and she sits there and listens in when I am on the phone. Surveyor asked if R2 has told anyone about this. R2 stated, I am reporting this to nurses, CNA, Social Services Supervisor V, life enrichment department and everyone knows I am upset about this. I always have my eyes open. I can't get up to defend my things. I can't even get up to shut the door. I use a machine to get up. All I can do is sit here and watch her. I use the call light, but staff can't come right away. Surveyor asked R2, How does this make you feel? R2 replied, I would feel safe and happy if she wasn't coming in my bedroom or sitting by my doorway. This is my home. I don't have a home anywhere else. This is it. Upon exiting the room Surveyor observed R24's and R2's rooms were next to each other on a dead-end hallway. R24 would have to pass R2's room to go to the dining room, to the kitchenette, to the activity room, and to the nurse's station. On 6/25/24 at 3:48 PM LPN T (Licensed Practical Nurse) indicated R24 goes into other people's rooms all the time . LPN T indicated R2 has voiced concerns about R24 coming into her room uninvited. LPN T indicated they put up stop signs on some of the doors of residents who have voiced concerns, but they don't work as R24 just lifts them up or removes them altogether and enters. LPN T indicated she has observed R24 yell through R2's door to her and that R24 is light fingered, meaning she takes things that do not belong to her from R2's room and others. On 6/25/24 at 3:52 PM Medication Technician U indicated R2 has voiced concerns to her related R24 coming in her room uninvited and removing items from her room. Medication Technician U indicated she has observed R24 in R2's room despite the stop sign being up. Medication Technician U indicated R24 removes the sign or goes underneath it. Medication Technician U stated, The stop sign is not working. On 6/26/24 at 7:58 AM CNA W (Certified Nursing Assistant) indicated she has observed R24 in R2's room and she has observed R24 take items out of R2's room. CNA W indicated she has found R2's items in the R24's room too. CNA W indicated R2 has voiced concerns to her related to R24 entering her room without being invited and removing items from her room. On 6/26/24 at 8:01 AM CNA R stated, The stop signs are not working always. I have seen her in rooms, especially R2's room. She does what she wants, and she takes items out of the rooms. CNA R indicated R2 has voiced concerns related to R24 coming in her room uninvited and removing items from her room. Example 12: R40 admitted to the facility on [DATE]. R40's most recent MDS with ARD of 6/4/24 indicates R40's cognition is intact with a BIMS score of 15 out of 15. On 6/24/24 at 1:30 PM during the Resident Council Meeting, R40 voiced concerns related to R24 coming in her room uninvited. R40 indicated the wandering resident removes items from her room and she has voiced her concerns to staff, and they aren't doing anything about it. Example 13: R50 admitted to the facility on [DATE]. R50's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/11/24 indicate R50's has a BIMS (Brief Interview of Mental Status) score of 11 out of 15 indicating moderate cognitive impairment. On 6/26/24 at 1:57 PM, Surveyor observed R50 tell CNA N to close her door if there's someone crazy walking around out there. CNA N indicated that R50 was referring to R56 who frequently wanders into her room uninvited. Example 14: R59 was admitted to the facility on [DATE]. R59's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/4/24, indicates R59 has a BIMS (Brief Interview of Mental Status) score of 9 out of 15 indicating R59 is moderately cognitively impaired. On 6/24/24 at 11:11 AM, Surveyor interviewed R59 who indicated that there R56 who often wanders into her room uninvited and takes her belongings. R59 stated she had told Life Enrichment Assistant I about the missing items. On 6/26/24 at 08:13 AM, Surveyor interviewed CNA N (Certified Nursing Assistant) who indicated she was aware R56 wanders into R59 and other resident's rooms and takes their belongings. CNA N indicated that the items are always found and returned. On 6/26/24 at 8:16 AM, Surveyor interviewed CNA M who stated she was aware of another resident who wandered into R59's room uninvited and takes items. On 6/26/24 at 2:05 PM, R59 said R56 came into R59's room [ROOM NUMBER] days prior, and she feels it is invasive. R59 stated that when she tells Life Enrichment Assistant I about this invasion of her privacy, she was told that she should just put up with it. On 6/26/24 at 2:42 PM, Surveyor interviewed Life Enrichment Assistant I who stated that R59 had told her about R56 who came into her room uninvited and took her belongings. On 6/26/24 at 4:19 PM DON B (Director of Nursing) refused to be interviewed. On 6/26/24 at 6:22 PM NHA A (Nursing Home Administrator) and Social Services Supervisor V indicated residents can voice concerns to staff and staff who receive these concerns should be following up on concerns and re-evaluating interventions that are not working. Example 2: R51 was admitted to the facility on [DATE] with the following diagnoses of Alzheimer's disease (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), unspecified, delusional disorders (a type of psychotic disorder that is an unshakable belief in something that's untrue), major depressive disorder (a severe and persistent low mood, profound sadness, or a sense of despair), generalized anxiety disorder (extremely worried or nervous more frequently even when there is little or no reason to worry about them), and adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life) with mixed anxiety and depressed mood. R51's most recent MDS (Minimum Data Set) dated 6/11/24, states that R51 has a BIMS (Brief Interview of Mental Status) score was not conducted indicating seve[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from physical abuse by a resident (R1). This affected 3 of 6 residents (R4, R5, and R6) reviewed for abuse. R1 has a history of resident-to-resident incidents including punching a resident in the back (R4), punching a resident in the face, putting a resident in a choke hold and banging her head on the wall, hitting the resident in the head and chest and pushing her into a chair and grabbing her wrist. The facility failed to update R1's care plan with new interventions after the incidents to prevent further abuse. The facility failed to ensure that R1's line of sight monitoring was completed to prevent further incidents. The facility was aware of R1's behaviors of hitting, punching, grabbing, yelling, and swearing at other residents and staff. The facility's failure to care plan interventions and ensure that increased supervision was completed resulted in R1 abusing R5 and R6 creating a finding of Immediate Jeopardy (IJ) that began on 2/3/24. Staff report that R6 comes out of her room less frequently now. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the Immediate Jeopardy on 3/1/24 at 2:00 PM. The immediate jeopardy was removed on 3/1/24; however, the deficient practice continues at a scope/severity of D (no actual harm with potential for more than minimal harm, isolated) as the facility continues to implement its action plan. Evidenced by: The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, includes, in part, the following: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. 6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 10. Protect residents from any further harm during investigations. Interventions can include increased supervision. The lowest level supervision should be used to meet immediate safety needs. b. 1:1 line of sight This means that the resident is in sight and the staff is able to intervene if necessary. R1 was admitted [DATE]. R1's diagnoses include late onset dementia/mixed dementia and traumatic brain injury (TBI). R1's Minimum Data Set (MDS), dated [DATE], indicates R1 has severe cognitive impairment, has delusions, and no identified behaviors. R1 ambulates with supervision. R1's Care Plan includes, in part, the following: Focus: I am dependent on staff for meeting emotional, intellectual, physical, and social needs, initiated 2/7/24. Interventions: All staff to converse with me. Encourage ongoing family involvement. Invite my family to attend special events, activities, meals. Establish and record my prior to level of activity involvement and interests by talking with me, caregivers, and family on admission and as necessary. I need assistance/escort to activity functions. Invite me to scheduled activities. My preferred activities are: small group activities, visiting with my family, talking about being an iron worker, walking outside when the weather is good, musical activities, etc. Provide me with materials for individual activities as desired. I like the following independent activities: 1 on 1 visits with staff and residents, looking through fishing, hunting and animal books/magazines, watching hunting, fishing and animals on the television/iPad, listening to music (country western, piano, soft music), enjoys the cast on the unit, etc. Provide with activities calendar. Notify me of any changes to the calendar of activities. Review my activity needs with the family/representative. Thank me for attendance at activity function, all care plan interventions initiated 2/7/24. Focus: The resident is/has potential to be physically aggressive towards staff r/t (related to) dementia, TBI (traumatic brain injury), History of harm to others, initiated 1/18.24, revised 2/12/24. Inventions: Analyze times of day, place, circumstances, triggers, and what de-escalates behavior and document. This may include sleep amount, previous negative contacts, pain in legs, initiated 1/18/24, revised 2/12/24. Assess and address for contributing sensory deficits, initiated 1/18/24. Give me as many choices as possible about care and activities, initiated 1/18/24. I will remain in the DSU (dementia stabilization unit) area for smaller area monitoring until I am able to transfer to a facility that is more appropriate for me with my brain injury. When I come out of the DSU to the larger part of the facility I can come out with 1:1 with staff member or family. I will be brought out of my room on the unit each night where I will sleep. If I get up during the night to wander, I will be returned to the DSU at that time. I will have my room door alarmed to notify staff of my awakening, initiated 2/26/24, revised 2/27/24. Monitor each shift. Document observed behavior and attempted interventions in behavior log, initiated 1/18/24. Monitor/document/report PRN (as needed) and s/sx (signs or symptoms) of me posing danger to self and others, initiated 1/18/24. Psychiatric/Psychogeriatric consult as indicated, initiated 1/18/24. Review behavior summary including triggers and approaches to be utilized. These may include but are not limited to: residents approaching him fast or in a manner that he feels he needs to protect self or persons who move fast or are loud, initiated 2/5/24, revised 2/23/24. When I become agitated: Intervene before agitation escalates; Guide me away from source of distress; Engage me calmly in conversation; If my response is aggressive, staff to walk calmly away, and approach me later, initiated 1/18/24. I can have a delusion that someone has hit me and that I should to [sic] retaliate physically. This may occur the first moments when I wake up before I am fully awake, initiated 1/19/24. Interventions: Assist me to develop more appropriate methods of coping and interacting seeking out staff. Encourage me to express feelings appropriately, initiated 2/23/24. Educate me/family/caregivers on successful coping and interaction strategies such as removed from environment and return to room. I need encouragement and active support by family/caregivers when I use these strategies, initiated 1/19/24, revised 2/21/24. If reasonable, discuss my behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to me, initiated 2/23/24. Intervene as necessary to protect the rights and safety of others. Approach/Speak to me in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, initiated 2/23/24. Minimize potential for my disruptive behaviors striking out by offering tasks which divert attention such as visiting with staff, initiated 2/23/24. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes, initiated 2/23/24. My triggers for striking out is belief someone is trying to harm me. My behavior is de-escalated by talking about where he is, initiated 2/23/24. Praise any indication of my progress/improvement in behavior, initiated 2/23/24. Provide a program of activities that is of interest and accommodates my status, initiated 2/23/24. Focus: I have impaired cognitive function/dementia or impaired thought process r/t (related to) brain surgery, initiated 1/18/24, revised 2/5/24. Communication: Use my preferred name Identify yourself at each interaction. Face me when speaking and make eye contact. Reduce any distractions - turn off TV (television), radio, close door, etc. I understand consistent, simple, directive sentences. Provide me with necessary cues - stop and return if agitated, initiated 1/18/24. Cue, reorient, and supervise as needed, initiated 1/18/24. Engage me in simple, structured activities that avoid overly demanding tasks, initiated 1/18/24. I need assistance with all decision making, initiated 1/18/24. Present just one thought, idea, question, or command at a time, initiated 1/18/24. Focus: I use Seroquel and Citalopram, r/t poor adjustment to communication deficits, psychosis (delusions/hallucinations, initiated 1/18/24, revised 2/5/24. Interventions: Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT (every shift) initiated 1/18/24. Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal, decline in ADL (activities of daily living) ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs (problems), movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt. (weight) loss, n/v (nausea/vomiting), dry mouth, dry eyes, initiated 1/18/24. R1's Certified Nursing Assistant (CNA) Kardex states in part . Behavior/Mood: If reasonable, discuss my behavior. Explain reinforce why behavior is inappropriate and/or unacceptable to me. Intervene as necessary to protect the rights and safety of others. Approach/speak to me in a calm manner. Divert attention. Remove from situation and take to alternate locations as needed. Monitor each shift. Document observed behavior and attempted interventions in behavior log. My triggers for striking out is belief someone is trying to harm me. My behavior is de-escalated by talking about where he is. Praise any indication of my progress/improvement in behavior. When I become agitated: Intervene before agitation escalates; Guide me away from source of distress; Engage me calmly in conversation; If my response is aggressive, staff to walk calmly away, and approach me later. R1's behavior monitoring states in part . 1/19/24 - Entering other resident's rooms/personal space, repetitive motions, anxious/restless, wandering. 1/20/24 - Grabbing others, pushing others, disrobing in public, entering other resident's rooms/personal space, rummaging, agitated, elopement/exit seeking, repetitive movements. 1/24/24 - disrobing in public, entering other resident's rooms/personal space, repetitive motions, rummaging, agitated, anxious, restless, elopement/exit seeking, insomnia/not sleeping, refusing care, wandering. 1/25/24 - Grabbing others, pushing others, physically aggressive towards others, express frustration/anger at others, entering other resident's room/personal space, agitated, pacing. 1/26/24 - entering others resident's rooms/personal space, rummaging, anxious, restless, elopement/exit seeking. 1/27/24 - entering others resident's rooms/personal space, refusing care. 1/28/24 - physically aggressive towards others, pacing, refusing care, disrobing in public, entering other residents' rooms/personal space, insomnia/not sleeping. 1/29/24 - physically aggressive towards others, anxious/restless, pacing, hitting others, physically aggressive towards others, agitated. 2/1/24 - pushing others, physically aggressive towards others, cursing at others, express frustration/anger at others, threatening others, agitated, anxious/restless, pacing and wandering. 2/7/24 - physically aggressive towards others, pacing and wandering. 2/8/24 - Express frustration/anger at others, agitated, anxious, restless, hallucinations. 2/9/24 - agitation, elopement/exit seeking, pacing, and wandering. 2/12/24 - wandering, withdrawn/isolating. 2/15/25 - anxious, restless, and pacing. 2/21/24 - hitting others and agitation. R1's Nurse's Note from 1/23/24 at 12:18 PM states, Behavior Note: Resident had a phone call with an attorney regarding a court proceeding that was occurring tomorrow. Resident was able to answer the attorney's questions but then became frustrated when he was trying to ask a question but couldn't find the words to say. Resident ended the conversation promptly and walked into the hallway. Resident was noted to be pacing up and down the hallway still frustrated. DON (Director of Nursing) walked with the resident and provided 1:1 conversation. This writer offered the resident a snack or something to eat and he responded, yeah I'll give you this kind of snack and put his fist up. Nursing staff tried calling the residents wife, and while it was ringing the residents was noted to be crying and put his head down on the nurses station. Resident them spoke with his wife, but then continued to be frustrated while he was listening then hung up the phone during the conversation. DON continued to provide 1:1 interaction with the resident as he started to pace the hall again but then he did sit down and eat lunch. Resident seemed to less frustrated after he was done eating lunch. R1's Nurses Note from 1/23/24 at 21:49 (9:49 PM) states, wandering in and out of rooms. Staff report did strike out at CNA. R1's Nurses Note from 1/23/24 at 21:49 (9:49 PM) states, Behavioral Note: After supper resident wandering and going in and out of other residents rooms. He was walking faster and faster, putting his body in front of other staff. Staff reports he did try to strike at CNA. He did not with this writer, I kept distance away from him, called supervisor. CNA familiar with resident did one on one with resident. Administrator came in and spent time with him. Now resident resting quietly. R1's Nurses Note from 1/24/24 at 22:37 (10:37 PM) states, wandering going in other resident rooms. Stop signs put up but he still going into resident rooms. Some other residents yelling at him to get out of room. Staff assisting him out. Ice cream offered. R1's Nurses Note from 1/25/24 at 11:59 AM states, R1 moved to Lane unit on admission. Room coming available on View unit and scheduled to move 1/29/24. Example 1 (This example does not rise to the level of immediate jeopardy): R4 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety and depression, and severe cognitive impairment. R4's care plan states in part . Focus: I have the potential to be physically aggressive r/t dementia, initiated 4/24/23, revised 8/15/23. Interventions: Monitor each shift. Document observed behavior and attempted interventions in behavior log, initiated 8/15/23. Monitor/document/report PRN any s/sx of me posing danger to self or others, initiated 8/15/23. When I become agitated: Intervene before agitation escalates; Guide me away from source of distress; Engage me calmly in conversation; If my response is aggressive staff to walk calmly away, and approach me later, initiated 8/15/23. Focus: I may have a history of behaviors of striking out at bedtime r/t dementia, initiated 4/24/23, revised 4/25/23. Interventions: I like my stuffed animal with me, initiated 8/08/23. R4's CNA Kardex states in part . Resident Care: Ensure I am safe from abuse due to being a vulnerable adult. If concerned abuse may have occurred I require a skin check to identify any signs of physical abuse. If I have a change in emotion evaluate for possible abuse. Monitor my whereabouts in relation to any individuals that may harm me or upset me. Behavior/Mood: When I become agitated: Intervene before agitation escalates; Guide me away from source of distress; Engage me calmly in conversation; If my response is aggressive staff to walk calmly away, and approach me later. The facility's Misconduct Incident Report includes in part the following: Date occurred, 1/29/24. Briefly Describe the incident: R1 came into the lounge on the Lane unit and walked by R4 striking her on the back. He then struck out at staff member hitting her on the back when she was trying to redirect him. He was running around the tables in the lounge and grabbed a can off of the housekeepers cart from behind the housekeeper throwing it across the room. He was then removed back to the View unit where his room is located and was watched by staff until he calmed down. Describe the Effect: No effect of R4. She was not injured and had no psychosocial affects. Repeated skin checks continued to show no injury. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: Staff removed R1 back to the View unit and staff on the View unit supervised him until he calmed down. A write up was completed stating what his triggers are and signs of anxiousness that will escalate to striking out. A list of interventions and approaches were completed, and care planned to help staff identify problems before they escalate to his striking out. The facility document titled Follow-up Investigation Report for Resident-to-Resident R1 and R4, undated, states in part . 4. Corrective Action(s) Taken. Describe any action(s) taken as a result of the investigation or allegation. Staff were provided with a write up discussing the interventions needed to help calm R1 and how to approach him to reduce his aggression. He is redirected to the View unit when he enters the Lane unit, and it appears he has been receptive to this. He has had no other incidents on the lane unit. The information sheet also includes triggers for R1 and what to watch for and when to intervene. Note: Care plan was not updated following this incident to prevent further abuse. R1's Nurses Note from 1/29/24 at 10:54 AM states, assisted with move from Lane to View unit. R1's Nurses Note from 1/29/24 at 22:53 (10:53 PM), Wandering on view unit at times this shift redirects but at times will show flashes of irritation towards staff - turns away suddenly, frowns, did raise arm x1 (times 1) to nurse. R1's Nurses Note dated 1/29/24 at 14:10 (2:10 PM) states, Following R1's move to the View unit this morning he was witnessed going into the lane unit lounge and running around tables and striking another resident on the back and striking a staff member on the back. He was also witnessed throwing a spray can. There were no injuries, and he was calmed down. Guardian was notified. R1's Nurse's Note dated 1/30/24 at 12:04 PM states, Note Text: Follow up to resident-to-resident concern. Staff has been monitoring residents behavior since knowing of incident. Resident did come over on the lane unit today, 1/30/24. However, the view unit was able to redirect resident back to the view unit successfully. R1's Nurses Note from 2/1/24 at 8:02 AM, Resident was up all night shift this NOC. He was trying to hit staff, throw objects at staff, pacing back and forth down halls, exit seeking, swearing at staff, trying to bite and elbow staff. He was also trying to pull the shadow boxes off the walls and banging on the windows. On 2/29/24 at 3:30 PM, Surveyor interviewed CNA O (Certified Nursing Assistant). Surveyor asked CNA O about any incidents she witnessed with R1. CNA O stated, I was in the dining room with the residents. R1 came by R4 and turned around and hit R4 in the back. I then went to redirect R1, and he turned on me and punched me in the back. R1 ran around the table and went after the housekeeper. I was able to intervene before R1 could hit the housekeeper. R1 then took an aerosol can off the housekeeping cart and threw it across the room. R1 then tried to get the broom off of the cart and I was able to redirect him from the unit. R1 was taken back to the view unit where his room was. There were 3 other residents in the dining room at the time of this incident. R4 did nothing to provoke R1 and I didn't see it coming. I have seen him angry before but never have seen him go after a resident before or after that. R1 still wanders the units a lot. There has been no education on R1's behaviors or dementia care. Surveyor asked CNA O if she has seen the document about R1's diagnoses, interventions, likes and dislikes. CNA O stated, I have not seen that document. CNA O stated it would have been good for both units to see. On 2/29/24 at 11:15 AM, Surveyor interviewed HSK J. Surveyor asked HSK J if she ever saw any resident-to-resident interaction involving R1. HSK J stated R1 was on the Lane Unit and one morning HSK J came around the corner by the Lane Unit common area with her housekeeping cart; R1 was in a bad mood, a CNA was trying to get R1 away from the common area. R1 grabbed a can from HSK J's housekeeping cart and R1 threw the can at a door. The CNA told HSK J to keep going and R1 grabbed a mop handle, the CNA got the mop handle from R1 and HSK J moved on down the hall. Example 2: R5 was admitted to the facility on [DATE] with diagnoses that include acute respiratory failure with hypoxia, anxiety, trans ischemic attack (TIA), and congestive heart failure (CHF). R5 has a Brief Interview of Mental Status (BIMS) of 14 indicating she is cognitively intact. R5's care plan states in part . Focus: I have an ADL (activities of daily living) self-care performance deficit r/t (related to) impaired balance. Interventions: It is recommended that 2 staff care for me at all times, to help decrease risk of unjust accusations towards staff. Focus: I have a mood problem r/t I am ready to die, and it is not happening fast enough for me. This causes me anxiety at times. I will refuse care frequently which may cause me pain and discomfort which will increase my anxiety. Due to my anxiety, I have a history of getting upset with the staff and will at times yell at them due to things I perceive they have done to me. This at times will manifest as accusations against staff and at other times I will just yell at them. Interventions: Allow me to feel I have control of the conversation we are having, keep interactions brief if I am feeling tired or overwhelmed. Follow my lead for conversations. This helps me feel a sense of control and decreases my anxiety, initiated 4/27/23. Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.), initiated 4/22/23. Encourage her to take pain medication to keep pain under control and reduce anxiety feelings, initiated 10/17/23. I need support to maintain as much independence and control as possible. My strengths can ask for help, can express feelings, initiated 4/22/23, revised 4/22/23. I need time to talk upon request. Encourage me to express feelings, initiated 4/22/23, revised 4/22/23. Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity, initiated 10/17/23. R5's CNA Kardex states in part . Monitors: Monitor/record/report to MD prn (as needed) risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM (range of motion), withdrawal or resistance of care. Resident care: 2 staff must be present for all personal care. Encourage me to participate to the fullest extent possible with each interaction. Allow me to feel I have control of the conversation we are having, keep interactions brief if I am feeling tired or overwhelmed. Follow my lead for conversations. This helps me feel a sense of control and decreases my anxiety. I show this by: exhibiting fluctuations in my ability to perform ADL (activities of daily living), memory loss, appetite, pain and health status. It is recommended that 2 staff care for me at all times, to help decrease risk of unjust accusations towards staff. Behavior/Mood: I need support to maintain as much independence and control as possible. My strengths are: can ask for help, can express feelings. The facility's Misconduct Incident Report includes, in part the following: Date occurred 2/3/24. Briefly Describe the incident: R1 was witnessed striking R5 with an open hand on the right side of her head. Describe the Effect that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident. R5 was startled and had some tenderness on her jaw area following the incident. She was angry with the incident but has seemed to resolve her feeling with it due to it being addressed. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct. Immediately following the event R1 was taken to the DSU for 1:1 with staff. He remained 1:1 with DSU staff through the weekend and continues to work with them on addressing behaviors. Staff Statement, dated 2/3/24 written by CNA D states in part . As I got off the elevator around 6:30 AM on the View unit, I saw R1 have a tight hold on the NOC RA (Resident Assistant) (name unknown) arm, wouldn't let go and yelling in her face. Once he let go, she went back to Lane (unit). R1 walked down the halls on the View unit punching the wall and mailbox. That's when the NOC (night) CNA walked near him and tried redirecting him back to his room, as this was happening, I was getting report on residents from the NOC CNA, soon after we heard R1 yelling at NOC CNA and her telling him to let go. He had a tight hold on her arms, tried tripping her, and then R1 stuck the NOC CNA with a closed fist in the face. As the NOC CNA finally got let go, he started chasing towards us and the residents while his pants and brief were down by his ankles. Then a CNA from Lane unit came over to help and got him in his room for a few minutes. As I was getting residents up for breakfast, R1 was pacing the View unit, going into other residents' rooms playing with their belongings. As I was exiting a room, I heard a resident yell, when I ran over, the nurse was leading R1 out of R5's room, yelling and trying to fight against the nurse, then I was told to call the DON (Director of Nursing) and notify her. That's when she came up and R1 was lead [sic] back into the DSU. The facility document titled Follow-up Investigation Report for Resident-to-Resident R1 and R5, undated, states in part .Corrective Action(s) Taken. Immediately following the event R1 was taken to DSU for 1:1 treatment with staff. R1 is fully in agreement with working on the goals of 1) resisting the temptation to go into people's rooms and 2) learning the keys to calm down after getting angry. R1 remains living in the nursing home but received 1:1 treatment as well. Staff will receive further training as more successful interventions are discovered. R5 was offered support and an opportunity to move off of the dementia unit to a unit with less activity and fewer residents that wander. R5 again has refused to move at this time and wants to be left alone. R5 is angry and has refused traditional means of counseling or treatment, but it appears that by making a report and talking to family she is coming to peace with the event. R5 has a supportive family that talks with her frequently, and their talks help her with her anger and feelings of injustice over this event. R5 has felt validation by giving a report to the [County Name] Sheriff's Department. While she has no expectations of punishment, it was helpful for her to see that it was treated as an unacceptable event. R1's Nurses Note from 2/3/24 at 9:05 AM: Resident will stay in the DSU for a 2:1 with staff through the weekend. R1's Nurses Note from 2/3/24 at 10:04 AM: Resident punched another resident. Resident immediately removed from the unit and placed on DSU. Resident will stay in DSU for a 2:1 with staff through the weekend. On 2/28/24 at 3:30 PM, Surveyor interviewed R5. Surveyor asked R5 about an incident that happened a few weeks prior. R5 stated, I was in my room, R1 took down the Velcro stop sign across the doorway. R1 came in walked over to me and punched me on the right side of the face with a closed fist. There were no staff around when this happened. I did not yell or scream, I just said, Hey, and he came over and punched me one time. R1 just stood there and then 2 staff showed up and walked R1 away. I sat there stunned I couldn't get up and go after him, I was scared. I am scared of him and have had nightmares since this happened. No staff came in and talked with me or asked if anything happened until later. My niece and nephew came in later and I told them what happened. My niece left and went to the police station. When I asked why R1 was still walking around unsupervised I was told, He lives here. I would like to move back to my room on the second floor if R1 won't be able to come in again; I don't like this room. On 2/28/24 at 4:28 PM, Surveyor interviewed FM K (Family Member). Surveyor asked FM K about incident that happened with R5 that was reported to him by the facility. FM K stated, I was notified by the DON that R5 was hit, and they were still trying to get information. It was a very basic notification. I was assured that R5 had no injury but was offered pain medication and ER (emergency room) evaluation. I was also told that R1 was on a locked unit. I felt that this was just reassuring me. I contacted SW H to inquire about what the plan was, and SW H indicated that he had not seen anything about the incident yet and would get back to me. I went to the facility to visit R5 on Monday and SW H came in and indicated that R1 had other incidents needing to be looked at. SW H brought up R5 moving to another unit which R5 did not want to discuss at the time. R5 then later brought up moving, so staff moved her to the 1st floor. Since the move R5 has brought up wanting to move back to her old room. I let SW H know that we were concerned that R1 was still able to roam around freely. On 2/29/24 at 8:35 AM, Surveyor interviewed FM L. Surveyor asked FM L about the incident with R5. FM L stated, I was out of town. I was in meetings and my phone was ringing. I didn't answer the call, so they called FM K. When I came back to town, I talked with R5 and asked if she wanted to press charges and R5 stated, yes. I then called the police from home, no one called back so I went to the Sheriff's Department who then came to the facility and took pictures and R5's statement. On 2/29/24 at 9:20 AM, Surveyor interviewed SW H (Social Worker). Surveyor asked SW H about the incident between R1 and R5. SW H stated, I want to say that happened over the weekend and I was told on Monday. I then talked with R5. The IDT (Interdisciplinary Team) came up with a plan to move R5 to 1st floor to prevent this from happening again. Initially R5 refused to be moved but was later receptive. Surveyor asked SW H if he follows up with R5. SW H stated, I follow up with her on occasion. Surveyor asked SW H if he was aware that R5 was interested in moving back to her old room. SW H stated, I have heard she wants to move again but I have not asked her about wanting to move, she will tell you. I was not really involved with the aggressor but with R5 and the move. On 2/29/24 at 10:10 AM, Surveyor interviewed SSS C (Social Services Supervisor). Surveyor asked SSS C about the incident between R1 and R5. SSS C stated, R1 was seen by the RN going into the room but the RN never saw the incident with R5. R5 had been asked about moving in the past, would agree, then would cancel the move the day she was scheduled to move. Following the incident with R1, I took a video of the new room that we were considering moving R5 into, but she did not want to look at it and told me to get out. R5 then reported to staff that she wanted to move. SW H had been talking to R5, I had not. R5 was afraid R1 was going to come ba[TRUNCATED]